Childhood asthma diagnosis and stepwise treatment — Rapid

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.
If FeNO is not raised or unavailable, perform spirometry with bronchodilator reversibility. An FEV1 rise at least 12% from baseline, or at least 10% of predicted normal FEV1, supports diagnosis.
If spirometry is delayed, twice-daily peak flow for 2 weeks supports diagnosis when amplitude percentage mean variability is at least 20%. Persistent doubt requires allergy/eosinophil assessment then paediatric specialist review and possible bronchial challenge.
Under age 5 there is no reliable reference test. Use a clinical phenotype, exclude alternatives, trial treatment when indicated and retry objective testing every 6–12 months once feasible.
Before every step up, check diagnosis, inhaler and spacer technique, adherence, dose actually dispensed, smoke or vape exposure, allergen triggers and comorbidity.
Age 5–11 first-line maintenance is twice-daily paediatric low-dose inhaled corticosteroid plus short-acting beta2 agonist as needed.
If uncontrolled at age 5–11 and able to use it, consider paediatric low-dose MART, then moderate-dose MART. Licensing is device and age specific; current NICE notes only one 100/6 microgram budesonide/formoterol dry-powder inhaler licensed for MART age 6–11 in November 2025.
If unable to manage MART, consider an 8–12 week montelukast trial, stopping if ineffective; then step to low-dose and moderate-dose ICS/LABA plus SABA. Discuss the MHRA warning about neuropsychiatric reactions.
Under 5 with interval symptoms or severe recurrent episodes: trial twice-daily low-dose ICS plus SABA for 8–12 weeks. Stop and reassess response; add an LTRA trial only after technique, adherence and environment review, and refer when uncontrolled.
Give a personalised written action plan, spacer education and regular review. Step down after sustained control, one change at a time, while retaining an anti-inflammatory strategy and monitoring attacks.

Key red flags

Silent chest, cyanosis, altered consciousness, exhaustion, hypotension or poor respiratory effort indicates life-threatening asthma.

Stridor, drooling, sudden choking, unilateral signs or no response to bronchodilator suggests upper-airway obstruction or foreign body rather than asthma.

Persistent wet cough, clubbing, faltering growth, recurrent focal pneumonia or neonatal symptoms suggests cystic fibrosis, bronchiectasis or structural disease.

Previous intensive-care ventilation, recent severe attack, excessive reliever use and poor inhaled-corticosteroid adherence predict future fatal or near-fatal attacks.

Symptoms only with feeds, recurrent aspiration, cardiac signs or fixed monophonic wheeze requires an alternative pathway.

Adolescent smoking or vaping, psychosocial distress, medicine access and deliberate underuse must be assessed confidentially and without blame.

Investigation priorities

First-line age 5–16: fractional exhaled nitric oxideFirst stepFirst line

Identify type-2 airway inflammation within a suggestive history.

Management branches

DiagnoseBuild objective confirmation

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.
Refer for specialist opinion and challenge when doubt remains rather than applying an unsupported label.

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.Dose equivalence varies by molecule and device. Teach spacer use and mouth rinsing, monitor height and total steroid burden, and use the lowest effective dose after stable control.

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.Discuss MHRA neuropsychiatric warnings, including sleep, mood, behaviour and suicidal symptoms. Reassess benefit explicitly and do not continue an ineffective trial.

Open full textbook →Answer 2 questions