Asma en niños

Key NICE recommendations on management

Please be aware that some of the following indications for medications may not be licensed by the manufacturer (i.e., the use of the medication is ‘off-label’). Refer to the full NICE guideline and your local drug formulary for further information - including cautions, contraindications, and monitoring - when prescribing.

Do not prescribe a short-acting beta-2 agonist (SABA) to children of any age with asthma without a concomitant prescription of an ICS.

Consider, and try to address, possible reasons for uncontrolled asthma before starting or adjusting medicines for asthma. These may include:

• Alternative diagnoses or comorbidities

• Suboptimal adherence or inhaler technique

• Smoking (active or passive), including vaping using e-cigarettes

• Psychosocial factors (e.g., anxiety, depression, relationships, social networks)

• Seasonal or environmental factors (e.g., air pollution, indoor mould exposure).

If possible, check the FeNO level when asthma is uncontrolled. If it is raised, this may indicate poor treatment adherence or the need for an increased dose of ICS.

After starting or adjusting medicines for asthma, review treatment response in 8 to 12 weeks.

See the NICE guideline for information on choosing inhalers, dosing recommendations and patient advice for use of their inhaler treatments.

Pharmacological management in children aged 5 to 11 years

Offer a paediatric low-dose ICS, with a SABA as needed, as initial treatment for children aged 5 to 11 years with newly diagnosed asthma.

If asthma is not controlled on paediatric low-dose ICS plus SABA as needed, consider one of the two following pathways depending on the child’s ability to manage a maintenance and reliever therapy (MART) regimen:

MART pathway:

• Consider paediatric low-dose MART as long as the child is able to manage a MART regimen

• Consider increasing to paediatric moderate-dose MART if asthma is not controlled on paediatric low-dose MART

• Refer to an asthma specialist if asthma is not controlled on paediatric moderate-dose MART.

Conventional pathway:

• Consider adding a leukotriene receptor antagonist (LTRA) to paediatric low-dose ICS plus SABA as needed if the child is unable to manage a MART regimen

  • Give the LTRA for an 8 to 12 week trial period (unless there are side effects), then stop it if it is ineffective

  • Note MHRA safety advice on neuropsychiatric reactions risk with montelukast

• Offer a paediatric low-dose ICS/long-acting beta-2 agonist combination inhaler plus SABA as needed if asthma is not controlled on paediatric low-dose ICS plus SABA as needed (with or without an LTRA depending on previous response)

• Offer a paediatric moderate-dose ICS/long-acting beta-2 agonist combination inhaler plus SABA as needed if asthma is not controlled on paediatric low-dose ICS/long-acting beta-2 agonist plus SABA as needed (with or without an LTRA depending on previous response)

• Refer to an asthma specialist if asthma is not controlled on paediatric moderate-dose ICS/long-acting beta-2 agonist maintenance treatment (with or without an LTRA depending on previous response).

Pharmacological management in children under 5 years

For children under 5 years with suspected asthma, consider an 8 to 12 week trial of paediatric low-dose ICS as maintenance therapy (with SABA reliever therapy) if:

• Symptoms at presentation indicate the need for maintenance therapy (e.g., interval symptoms in children with another atopic disorder),or

• The child has severe acute episodes of difficulty breathing and wheeze (e.g., requiring hospital admission, or needing ≥2 courses of oral corticosteroids).

If symptoms do not resolve during the trial period, take the following sequential steps:

• Check inhaler technique and adherence

• Check whether there is an environmental source of symptoms (e.g., mould in the home, cold housing, smokers, indoor air pollution)

• Review whether an alternative diagnosis is likely.

  If none of these explain failure to respond to treatment, refer to an asthma specialist.

If symptoms resolve during the trial period, consider stopping ICS and SABA treatment after 8 to 12 weeks, and review symptoms after a further 3 months.

If symptoms recur by the 3-month review or the child has an acute episode requiring systemic corticosteroids or hospitalisation:

• Restart regular ICS (begin at paediatric low-dose, titrating up to paediatric moderate-dose if needed) with SABA as needed,and

• Consider further trial without treatment after reviewing the child within 12 months.

If suspected asthma is uncontrolled on paediatric moderate-dose ICS as maintenance therapy (with SABA as needed), consider adding an LTRA for a trial period of 8 to 12 weeks (unless there are side effects), then stop it if it is ineffective.

• If still uncontrolled, and an LTRA trial has been unsuccessful or is not tolerated, stop the LTRA and refer to an asthma specialist for further investigation and management.

Monitoring asthma control, adherence and inhaler technique

In primary care, children with asthma should be reviewed at least annually and after any exacerbation. The review should incorporate a written personalised action plan.

• At annual review, discuss the potential risks and benefits of decreasing maintenance therapy when asthma has been well controlled on current maintenance therapy.

Monitor asthma control at every review. In addition to asking about symptoms, check:

• Time off school due to asthma

• Amount of reliever inhaler used (include a check of the prescription record)

• Number of courses of oral corticosteroids, and any admissions to hospital or attendance at an emergency department due to asthma.

Consider using a validated symptom questionnaire (e.g., the Asthma Control Questionnaire, the Asthma Control Test or the Childhood Asthma Control Test) at any asthma review.

Do not use regular PEF monitoring to assess control unless there are person-specific reasons for doing so (e.g., PEF monitoring is part of the personalised asthma action plan).

Observe inhaler technique (including use of any spacer) at every asthma review (routine or unscheduled) and asthma-related consultation, and when there is deterioration in asthma control or if the inhaler device is changed or the person requests it be checked/changed.

• If the child is assessed as being unable to use a device properly, find an alternative.

Check adherence, using prescription records, at every asthma-related healthcare review.

Ask adolescents about factors that may affect their inhaler use in real life settings (e.g., school, social situations), and ask them if they vape or smoke (encourage them to stop, give them advice, and signpost to local NHS stop smoking services).

See the NICE guideline for more information on how to define asthma control, how to decrease maintenance therapy, and risk-stratified care.

Self-management

For children aged 5 to 11 years with asthma (and their family or carers, if appropriate):

• Offer an asthma self-management programme (comprising a documented personalised action plan and education), including advice on seeking review if asthma control deteriorates. Symptom-based plans are usually preferred for children

• Explain about potential triggers for asthma symptoms and exacerbations (e.g., indoor and outdoor pollution). Include in the personalised action plan approaches for minimising exposure to air pollution and any other personal triggers.

Review the content of the personalised action plan, and check that the person understands it, at annual reviews, acute consultations (primary care or emergency department) and hospital admissions (including virtual wards).

Consider an asthma self-management programme (including approaches for minimising exposure to air pollution, and advice on seeking review if asthma control deteriorates) for the family or carers of children under 5 years with suspected or confirmed asthma.

© NICE (2024) All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England https://www.nice.org.uk/terms-and-conditions#notice-of-rights. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.