SIGN treatment guidelines for under 5s
Initial ‘add-on’ therapy – step 3 of the SIGN treatment guidelines
Children are unlikely to be diagnosed with asthma under the age of one. This is because many wheezy babies will grow out of their condition and not go on to develop chronic asthma. Children aged over 1 with persistent cough or wheeze may be diagnosed with and treated for asthma. There are four steps in the treatment guidelines for children under 5 with asthma.
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 under 5 | |
|---|---|
| Mild to moderate asthma | |
| Step 1 | Mild intermittent asthma |
| Inhaled short-acting Beta agonist as required – ‘reliever’ | |
| Step 2 | Regular ‘preventer’ therapy |
Inhaled short-acting Beta agonist inhaler as required and one of the following:
| |
| 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
| |
| Severe asthma | |
| Step 4 | Persistent poor control |
| Increase steroid inhaler dose (up to 400 mcg) beclomethasone | |
Mild to moderate Asthma
Symptoms of mild to moderate asthma are likely to include -:
- Coughing especially at night
- Wheezy sounds from the chest
- Shortness of breath and rapid breathing.
The symptoms may be reported by either the child or the parent, depending on the age of the child. Intermittent use of bronchodilator beta agonist inhalers may control symptoms sufficiently, if these have to be used more than twice a week to control symptoms or if there are exercise induced asthmatic symptoms or trips to Accident & Emergency with asthma then a low dose steroid inhaler may be used as ‘preventer’ treatment. The inhalers are likely to be given using either a ‘spacer device’ or more rarely a nebuliser. These are used to enable a child to take the drug without having to learn an inhaler technique like an adult or an older child. They are not an indictor of severe asthma or care needs. Asthma inhalers require co-ordination of both breathing in and pressing the inhaler to release the inhaler spray. This is difficult for small children, the use of spacers or nebulisers does not indicate severe asthma. Upper respiratory tract infections (URTI) such as coughs and colds are common in young children – they may have 6-8 URTIs each year, children with asthma are likely to cough more and wheeze during these infections unlike children without asthma. Children with asthma that is not controlled with the above measures are likely to have further tests and be referred to a paediatrician.
Severe Asthma
Severe asthma in young children is rare but is likely to result in frequent attendance at the GP and more than 3 attendances per year to Accident & Emergency with difficulty breathing due to acute asthma. Children with severe asthma are likely to have been admitted to hospital at least once in the previous year and to be under the care of a consultant paediatrician for their asthma. Severe asthma in young children is rare. These children are likely to still have poor control of their asthma despite all add on therapy in step 3 of the guidelines. These children are likely to be wheezy most of the time and to wake at night with frequent coughing. Frequent stepping up of treatment to control acute asthma especially with inter-current upper respiratory tract infection will be required. In younger children with severe asthma feeding may be difficult because of breathlessness and in older children exercise tolerance is likely to be limited by breathlessness. Those on high dose steroid inhalers are likely to have the most severe asthma. Missing doses of ‘preventer’ treatment in these children is likely to result in episodes of severe asthma and ensuring that medication is available and taken as prescribed will be particularly important in this group.
