Asthma: management in children

The British Thoracic Society (BTS) updated their asthma guidelines in 2016 resulting in some significant changes in how asthma is diagnosed and managed. In terms of management of asthma in children, some of the key changes include:

• the previous numbered steps have been abandoned
• all patients should receive an inhaled corticosteroid, right from the point of assessment in patients with suspected asthma

In terms of management, the BTS suggest the following approach:

• 1. Start treatment at the level most appropriate to initial severity
• 2. Achieve early control
• 3. Maintain control by increasing treatment as necessary and decreasing treatment when control is good

The previous steps 1-5 of asthma management have been abandoned. Previously 'Step 1' of asthma management was the use of a short-acting beta agonist (SABA) as required. This is no longer suggested as the initial first step. Instead, all patients from the 'diagnosis and assessment' onwards should use a SABA as required. Having to use a SABA more than 3 times per week is considered a sign that further add-on therapy is needed.

Initial step

It is now recommended that a very low-dose inhaled corticosteroid (ICS) is started in all patients with a diagnosis, or suspected diagnosis, of asthma, right from the 'diagnosis and assessment' period prior to a formal diagnosis being made. The first step of asthma management is now a very low-dose inhaled corticosteroid.

Next step.

The next step depends on the age of the child

• >= 5 years: the addition of a long-acting beta agonist (LABA)
• < 5 years: add a leukotriene receptor antagonist

Next step..

At this point the advice is clear for children aged > 5 years - if poor control remains the next step depends on the response to the LABA:

• no response to LABA - stop LABA and increase dose of ICS to low-dose
• response to LABA - continue LABA and increase ICS to low-dose. An alternative to this is to continue with on the current treatment but consider a trial of a leukotriene receptor antagonist

The guidance is less clear for children aged < 5 years. Given their age and uncontrolled symptoms it would seem a reasonable step to refer to a paediatric specialist at this point, possibly increasing their inhaled steroids to low-dose whilst awaiting review. LABA are not licenced in this age group.

Next step...

Consider trials of either:

• increasing the ICS to medium-dose, or
• the addition of a fourth drug - SR theophylline
• the patient should be referred to specialist care at this point

Next step....

The consideration of regular oral steroids at the lowest dose providing adequate daily control.

Table showing examples of inhaled corticosteroid doses