SIGN treatment guidelines for 5s and over
Initial ‘add-on’ therapy – step 3 of the SIGN treatment guidelines
Brittle or very unstable asthma
In most children who have childhood asthma, asthma develops before the age of five years. However many children under five who are wheezy will grow out of it. In addition, children aged 5 and over can understand that they have asthma and comply with treatment to prevent symptoms. Treatments for the under 5s may be difficult because of the age related behaviour of the child; the over 5s will be able to comply with treatment. Wheeze in many children under five will have resolved and no excess care needs will be present.
Note: The table below should be used together with the age and dosage information in the Treatment page. See the link at the bottom of the page.
| SIGN step wise Asthma treatment guidelines for children aged 5 and over | |
|---|---|
| Mild to moderate asthma | |
| Step 1 | Mild intermittent asthma |
| Inhaled short-acting Beta agonist as required - ‘reliever’ therapy | |
| Step 2 | Regular ‘preventer’ therapy & ‘reliever’ therapy |
| Short-acting Beta agonist inhaler as required
and Low dose steroid inhaler twice daily | |
| Step 3 | Initial ‘add on’ therapy - medication is given in addition to regular
preventer and reliever inhaler from step 2 |
| Inhaled short-acting Beta agonist as required
and Low dose steroid inhaler twice daily AND at least one of the following:
| |
| Severe asthma | |
| Step 4 | Persistent poor control |
Plus continue other treatments from step 3:
| |
| Step 5 | Continuous or frequent use of oral steroids in addition to treatments listed in step 4.
|
Mild to moderate asthma
Children will be on steps 1-3 of the SIGN treatment guidelines. They may use bronchodilators (drugs that open the airways in spasm) for symptoms several times a week. They may have symptoms such as coughing at night and attend Accident and Emergency up to 3 times a year with asthma symptoms. They may have lost up to 10% of days off school with asthma. They may need to step up treatment regularly because of upper respiratory tract infection to control asthma. They may take up to 3 courses of oral steroids per year for asthma exacerbations. They will not be on long term high dose inhaled steroids. These children are likely to be well when not experiencing asthma exacerbations, able to exercise normally and sleep through the night. They may be under the care of the GP in primary care or under a hospital paediatrician.
Severe Asthma
Indicators of severe functional restriction
Indicators of severe functional restriction can only be applied to children aged 5 and over and are -:
- On step 4 or 5 of treatment guideline.
- >5 short courses oral steroids in one year.
- On any of the drugs listed under drug treatment only used in severe asthma.
- Admission to paediatric intensive care (PICU) with asthma in the last year.
- Poorly controlled asthma and previous episode of anaphylaxis.
These children will be under the care of a Consultant Paediatrician. They will have been identified in the medical evidence as having ‘severe’ or ‘unstable’ asthma. They are likely to be on Step 4 or 5 of the SIGN guidelines asthma treatment. They are likely to have symptoms of asthma most of the time and will often be wheezy during the day and cough at night. They are likely to have had significant time off school (more than 10% of days lost). They are likely to have had more than 3 admissions to hospital in the previous year or more than 5 Accident and Emergency attendances with asthma and more than 5 courses of oral steroids. This group of children will have had further investigations for their asthma and may do daily PEFR measurements and recording to guide asthma treatment.
Children with hard to control asthma as described above may be controlled by high dose inhaled steroids (see steroid inhaler dose information by age in treatment section) or other treatments such as long term low dose oral steroids. Either of these treatments requires daily input and close supervision from parents to ensure medication is taken correctly in addition to asthma monitoring even though asthma itself may be better controlled with high dose treatment. Children on a terbutaline subcutaneous pump are likely to have very severe asthma. Children with hard to control asthma on multiple medications are likely to continue to lose time from school during exacerbations and require extra care on school trips to ensure medication is taken as prescribed. Parents may be advised to check on children during the night when they have upper respiratory tract infections.
A very small number of children require 24 hour supervision for much of the time; there are very few children that would fall into this category because of asthma. Such children are likely to have been admitted to Paediatric Intensive Care (PICU) in the previous year. Such children are likely to have such unstable asthma that they are on a subcutaneous terbutaline pump 24 hours a day, oral steroids or other immunomodulating drugs such as azathioprine or ciclosporin.
Brittle or very unstable asthma
A very small number of children will require supervision out of doors because of rapid deterioration of asthma. They are likely to be on at least step 4 of the asthma guidelines and take high doses of medication for asthma control. These children can develop life threatening attacks of asthma within a few minutes of inhaling a trigger or on exercise. Parents will have been advised by the Consultant Paediatrician that the child should not go off alone on a bike or go swimming without supervision from another child of at least 14 or an adult. Written confirmation of such advice will always be available from the Clinical Nurse Specialist or treating Paediatrician.
