Synopsis
Diagnose variable airflow obstruction with age-appropriate objective evidence, separate preschool wheeze and mimics, assess future attack risk as well as current symptoms, and use the current BTS, NICE and SIGN age-specific inhaled-corticosteroid pathways with technique, adherence and environmental review before escalation.
- Asthma is variable respiratory symptoms with variable expiratory airflow limitation. Typical patterns are wheeze, breathlessness, chest tightness or cough that vary over time and with exercise, viral infection, allergens, cold air or night.
- Do not diagnose from symptoms alone in a child able to test. Record objective evidence and the basis for diagnosis; examination may be normal between episodes.
- Age 5–16 first objective test: FeNO. A value at least 35 ppb confirms asthma in a compatible history; inhaled corticosteroid can suppress FeNO and make testing falsely normal.
Key red flags
Silent chest, cyanosis, altered consciousness, exhaustion, hypotension or poor respiratory effort indicates life-threatening asthma.
Investigation priorities
Identify type-2 airway inflammation within a suggestive history.
Management branches
A child aged at least 5 years has a suggestive variable symptom history.
- Treat urgent symptoms first and obtain FeNO before ICS where feasible.
- If unconfirmed, proceed through spirometry reversibility, peak-flow variability and allergy/eosinophil steps.
Key medicines
Paediatric low-dose inhaled corticosteroidUse a licensed age-appropriate ICS and the current BTS, NICE and SIGN paediatric dose table, generally twice daily for children 5–11; under 5 use an 8–12 week twice-daily low-dose trial when indicated.
MontelukastAge 6 months–5 years: 4 mg orally at night; age 6–14 years: 5 mg at night; age 15 years and over: 10 mg at night. For asthma step-up, use an 8–12 week monitored trial and stop if ineffective.