Asthma management and assessment in very young children

The goals of asthma management are to prevent asthma deaths and reduce the burden of asthma on individuals, families and health systems and, for the individual, to achieve long-term asthma control, including:

• Few/no asthma symptoms
• No sleep disturbance due to asthma
• Unimpaired physical activity
• No exacerbations
• Improved or stable personal best lung function
• No requirement for maintenance oral corticosteroids, and
• No medication side-effects

Diagnosis

Failure to confirm a diagnosis of asthma risks unnecessary treatment for those who do not have the condition, or missed diagnoses of other serious conditions, the latest update to GINA asthma guidelines warns.

The diagnosis of asthma in young children is made by confirming a pattern of recurrent asthma-like symptoms, with careful consideration of the differential diagnosis (Table 1), and confirming treatment response. A structured approach is recommended, based on the presence of three criteria:

• Recurrent acute wheezing episodes OR at least 1 acute wheezing episode with asthma-like symptoms between episodes
• No likely alternative cause for the respiratory symptoms
• Timely response of respiratory symptoms or signs to asthma medications, e.g. short-term response during acute wheezing episode (at home or in the clinic) to short-acting beta agonist (SABA) within minutes; reduced frequency or severity of acute wheezing episodes and/or symptoms between episodes during 2-3 months’ trial for daily inhaled corticosteroids (ICS)

All three criteria must be met to confirm the diagnosis of asthma. If only 1 or 2 criteria are met, describe the child’s condition as ‘suspected asthma’.

Wheeze that can be heard without a stethoscope is the most common and specific sign associated with asthma in children 5 years or under. Wheeze that occurs during sleep or which is triggered by activity, laughing or crying is consistent with asthma. It is defined as a high-pitched sound on expiration, but parents may use the word to describe any noisy or difficult breathing.

Other typical symptoms include dry, recurrent or persistent cough (but may be due to allergic rhinitis, the common cold or other respiratory infections, including whooping cough), breathlessness and avoidance of strenuous play or exercise.

Assessing symptoms and 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 GINA has developed a set of questions for use in children aged 5 and under (Table 2).

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 adherence to ICS or incorrect inhaler technique.

Good control of asthma can be achieved in almost all young children.

Consider:

• The preferred medication option at each treatment step to control asthma symptoms and minimise future risk
• Response to previous treatment
• Patient characteristics that contribute to symptoms or risk of flare-ups, including
  • Clinical phenotype
  • Comorbidities including allergic rhinitis
  • Environment exposures, such as passive smoking
  • Parent/carer preferences (goals, beliefs and concerns about medications)
  • Practical issues such as inhaler technique and adherence

GINA recommends a stepwise approach, based on symptom control, risk of exacerbations and side effects, and response to initial treatment. Generally, treatment for preschool children includes long-term daily use of low-dose ICS to maintain good asthma control. Initially, treatment should be given for 2–3 months to establish effectiveness(See Table 3). Children aged 5 years or less should be provided with SABA for as-needed symptom relief, by pMDI with mouthpiece or face mask as appropriate (Table 4).

• If a child needs more than 4 puffs of salbutamol in less than 4 hours, urgent medical care should be sought.

Management

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

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

Once the diagnosis of asthma is confirmed, establish the minimal effective dose for each patient that controls their interval symptoms, and in combination with an action plan, reduces the risk of acute episodes and the need for oral corticosteroids. For dosing, consult the summary of product characteristics for each individual product.

In young children with persistent asthma, regular treatment with an LTRA may help to reduce symptoms, but daily ICS has been shown to be more effective in improving symptoms and reducing exacerbations than regular LTRA monotherapy. Parents/carers should be warned about the potential adverse effects on montelukast on sleep and behaviour.

Referral for specialist advice

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%)

Global Initiative for Asthma. Global strategy for asthma management and prevention, 2026. https://ginasthma.org/2026-gina-strategy-report/