Management of asthma in children under 5: GINA 2025

The 2025 GINA report confirms that a diagnosis of asthma can be made in children under 5, and provides clear advice on how it can be done. It also offers new advice on the treatment of asthma and exacerbations in this age group.

The Global Initiative for Asthma (GINA) has extensively revised its advice on the diagnosis and management of asthma in children under 5, a group in whom diagnosis is notoriously tricky.

GINA offers a pragmatic approach to diagnosis, focusing on three clear clinical criteria:

• Recurrent acute episodes of wheezing, with or without interval asthma-like symptoms
• Assessment that an alternative diagnosis is unlikely to be causing the symptoms or signs, and
• A timely response to asthma treatment, including symptomatic improvement within minutes of administration of a short-acting beta-2 agonist (SABA) (in a healthcare setting or at home), or during a diagnostic trial with daily inhaled corticosteroid (ICS) plus as-needed SABA for 2–3 months.

Asthma is the most common chronic disease in children, and the leading cause of childhood morbidity as measured by absences from school, emergency department visits and hospital admissions. It often begins in early childhood, and atopy is present in most children with asthma over the age of 3 years. Allergen-sensitisation is one of the main risk factors for the development of asthma.

Recurrent wheezing is common in children below the age of 5 years, but is typically associated with upper respiratory tract infections (URTI). Young children may have six or more such infections a year. Some of these, such as respiratory syncytial virus (RSV) and the common cold are associated both with recurrent wheeze and asthma throughout childhood. Bronchiolitis can also cause wheeze in children younger than 12 months but is usually accompanied by other signs that do not suggest asthma, e.g. crackles on chest auscultation. Therefore, careful observation is needed to determine whether wheeze in conjunction with URTI is also a presentation of asthma.

The newly-developed approach to diagnosis uses the same concepts of variable respiratory symptoms and variable expiratory airflow on which the diagnosis of asthma in older children and adults.

A structured, criterion-based approach is recommended, and all three criteria listed in Table 1 must be met to confirm the diagnosis.

TABLE 1. DIAGNOSTIC CRITERIA FOR ASTHMA IN CHILDREN AGED <5 YEARS

• Acute wheezing episode includes symptoms such as wheezing on expiration, accessory muscle use, or difficult, fast or heavy breathing, lasting for more than 24 hours.
• Asthma-like symptoms include:
  • dry cough, wheeze after running, laughing or crying, or during sleep that occur between acute wheezing episodes
  • signs consistent with lower airway obstruction, such as accessory muscle use, prolonged expiration, decreased air exchange (low oxygen saturation, cyanosis, increased CO2
• If only one or two criteria are met, describe as ‘suspected asthma’ and continue to follow up.
• A personal or family history of allergic disease may strengthen the diagnosis of asthma but is not necessary nor specific to asthma.
• Breathlessness during exercise is consistent with asthma. In infants and toddlers, crying and laughing require physical exertion equivalent to exercise in older children.
• Audible wheezing heard without a stethoscope means a high-pitched sound on expiration and should be observed by a trained HCP or from a recording. Be aware that parents may use the word ‘wheeze’ to describe any noisy or difficult breathing, so ask them to imitate the child’s respiratory sounds

TABLE 2. COMMON DIFFERENTIAL DIAGNOSES IN CHILDREN £5 YEARS

Any of the following features in a child <5 years should prompt referral for specialist advice

• Failure to thrive
• Neonatal/very early onset of symptoms
• Vomiting associated with respiratory symptoms
• Continuous wheezing, recurrent stridor or barking cough
• Failure to respond to asthma medications (ICS, oral steroids or SABA)
• No association of symptoms with typical triggers, e.g., viral URTI
• Focal lung or cardiovascular signs, finger clubbing
• Hypoxemia (<95%)

MANAGEMENT OF CHILDREN AGED <5 YEARS

• Day-to-day symptoms should be treated with an inhaled short-acting beta2-agonist (SABA) as reliever
• Daily controller treatment (ICS) should be started in children with asthma symptoms more than twice a week, or one or more severe exacerbations requiring emergency treatment in the previous year
• Response to treatment should be assessed before deciding whether to continue it or change it. If response is absent or incomplete, consider:
  • Inhaler technique
  • Adherence
  • Modifiable risk factors
  • Alternative diagnoses
  • Comorbidities
• If there is a good response to ICS for 2–3 months, consider a dose reduction
• Choice of inhaler device should be based on the child’s age and capability. A pressurised metered-dose inhaler (pMDI) with spacer (with face mask for childen <3 years and mouthpiece for children aged 3–5 years) is the preferred option
• Education and a written personalised asthma action plan should be given to parents/carers
• Reassess the need for treatment periodically, since symptoms may fluctuate or remit in young children. Advise parents/carers that asthma symptoms may recur

The goals of treatment in young children are similar to those in older patients:

1. To achieve the best possible control of symptoms and maintain normal activity levels
2. To minimise the risk of exacerbations, impaired lung development and medication side-effects

ASSESSING CONTROL

Assessing asthma control depends on reports from parents/carers, who may not always be aware of the frequency or severity of symptoms, or mistake them as tiredness, irritability or mood changes, not recognising that they represent uncontrolled asthma.

The Childhood Asthma Control Test (cACT) can be used for children aged 4–11 years, and the Test for Respiratory and Asthma Control in Kids (TRACK) questionnaire has been validated for use with the parents/carers of pre-school children.

GINA has developed a set of questions for use with parents/carers of children aged 5 and under.

TABLE 3. SYMPTOM CONTROL QUESTIONNAIRE

Risk factors for future asthma exacerbations include one or more severe acute episodes needing emergency visit, inpatient treatment or OCS in the past year; uncontrolled asthma symptoms; exposure to tobacco smoke, indoor or outdoor pollution, or indoor allergens; major psychological or socio-economic problems for the child or family; poor adhere to ICS or incorrect inhaler technique.

Severe asthma with several hospitalisations, and/or history of bronchiolitis put the child at risk of persistent airflow limitation, while frequent courses of OCS or high-dose and/or potent ICS may result in systemic medication side effects, and moderate-to-high dose or potent ICS, incorrect inhaler technique, and failure to protect skin or eyes when using ICS by nebuliser or spacer with face mask, can cause local side effects.

MEDICATION FOR SYMPTOM CONTROL AND RISK REDUCTION

Good control of asthma can be achieved with medication in almost all young children. The recommended asthma reliever for pre-school-age children is SABA given as needed when symptoms occur, by pMDI via a spacer with mouthpiece or mask according to the child’s age.

There is insufficient evidence to recommend a daily controller for all children with asthma in this age bracket, but low dose ICS can be considered as intermittent therapy at the onset of viral illness, or daily if symptoms are not well controlled (or one or more exacerbations in the past year). Alternatively, daily leukotriene receptor antagonist (LTRA) can be considered. If daily low-dose ICS is insufficient to control symptoms, double the low-dose ICS (medium-dose) can be administered, and specialist referral should be considered. Be aware of the recommended total daily dose for individual formulations of ICS. Before stepping up treatment, check for alternative diagnosis and inhaler skills, and review adherence and risk exposure.

MANAGEMENT OF WORSENING ASTHMA AND EXACERBATIONS IN CHILDREN >5 YEARS

Signs of an asthma attack in children of 5 years and under include worsening of symptoms such as cough, coughing fits with or without wheezing, breathing difficulties or breathlessness, especially during sleep or after activities such as laughing, crying or playing. Feeding may be affected, and symptoms may not respond well to reliever medication. Use of accessory muscles and/or audible wheezing are signs of a moderate attack.

Give the parents/carers of the child with asthma a written personalised action plan to help them recognise when asthma control is deteriorating, and so they know when to take the child to hospital.

Initial treatment at home is with SABA: same day medical attention should be sought if four or more puffs of SABA are needed in less than 4 hours, or more than three times in any 12-hour period.

In primary care, assess the severity of the attack and give SABA (4–6 puffs of salbumatol 100 mcg/actuation by pMDI with a spacer, or 0.25 by nebuliser, administered once for mild exacerbations and every 20 minutes up to a total of three doses in the first hour for moderate or severe exacerbations. For children with moderate or severe exacerbations give OCS (dose of prednisolone equivalent to 1–2mg/kg/day, maximum 20 mg/day for children under 2 years, and 30 mg/day for children aged 2–5 years).

Give oxygen to maintain an O2 saturation of 94% or higher. Arrange immediate transfer to hospital if there is no response to the repeated SABA within 1–2 hours, or if the child is unable to speak or drink, has a respiratory rate of >40/minute, or is cyanosed, or O2 saturation is <92% on room air. Note that O2 saturation may be overestimated by pulse oximetry in people with dark skin colour.

Children must be carefully monitored after discharge to ensure that the attack is over. Arrange early follow-up: tell the parent/carer to seek medical attention if there is no improvement or a deterioration over the next 24-48 hours, and arrange follow-up within 1–3 days of the attack, and again 1-2 months later to plan ongoing management.

Children who have had one exacerbation are at risk of further exacerbations, so they should be assessed and managed to reduce this risk.

Reference

Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention (2025 update); 5 May 2025.

https://ginasthma.org/wp-content/uploads/2025/05/GINA-Strategy-Report_2025-WEB-WMS.pdf