Management of chronic asthma in children aged 5 to 11

The aim of asthma management is control of the disease. Complete control is defined as

• no daytime symptoms
• no night-time awakening due to asthma
• no need for rescue medication
• no asthma attacks
• no limitations on activity including exercise
• normal lung function (in practical terms FEV1 and/or PEF >80% predicted or best)
• minimal side effects from medication

NICE state (1):

Initial management in children aged 5 to 11

• a twice-daily paediatric low-dose inhaled corticosteroid (ICS), with a short-acting beta2 agonist (SABA) as needed, should be offered as initial treatment for children aged 5 to 11 years with newly diagnosed asthma

Medicine combination and sequencing in children aged 5 to 11

Maintenance and reliever therapy (MART) definition:

• a form of combined ICS plus formoterol treatment in which a single inhaler containing ICS and formoterol is used for daily maintenance therapy and the relief of symptoms as needed
• terms low-dose MART and moderate-dose MART refer to the dosage of the maintenance component of MART
• people using MART do not normally need a SABA

MART pathway

• paediatric low-dose MART (maintenance and reliever therapy should be considered for children with asthma that is not controlled on paediatric low-dose ICS plus SABA as needed, as long as they are assessed to have the ability to manage a MART regimen

Conventional pathway

• adding a leukotriene receptor antagonist (LTRA) to twice daily paediatric low-dose ICS plus SABA as needed should be considered when a child has uncontrolled asthma and is assessed as unable to manage the MART regimen
  • the LTRA should be given for a trial period 8 to 12 weeks (unless there are side effects), then stop it if it is ineffective
• a twice daily paediatric low-dose ICS/LABA (long-acting beta2 agonist combination inhaler plus SABA as needed
  • should be offered to children assessed as unable to manage the MART regimen if their asthma is not controlled on paediatric low-dose ICS plus SABA as needed (with or without an LTRA depending on previous response)
• a twice daily paediatric moderate-dose ICS/LABA inhaler plus SABA as needed
  • should be offered to children with asthma that is not controlled on paediatric low-dose ICS/LABA plus SABA as needed (with or without an LTRA depending on previous response)

Refer children to a specialist in asthma care if their asthma is not controlled on paediatric moderate-dose MART or paediatric moderate-dose ICS/LABA maintenance treatment (with or without an LTRA, depending on previous response).

Decreasing maintenance therapy Principles:

When decreasing maintenance therapy:

• stop or reduce dose of medicines in an order that takes into account the clinical effectiveness when introduced, side effects and the person's preference.
• allow at least 8 to 12 weeks before considering a further treatment reduction
• if considering step-down treatment for people aged 12 and over who are using low-dose maintenance inhaled corticosteroid (ICS) plus a short-acting beta2 agonist (SABA) as needed or low-dose MART, step down to low-dose ICS/formoterol combination inhaler as needed (as-needed AIR therapy

A pragmatic summary of this guidance with practical suggested options has been stated as (2):

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Reference:

1. NICE (November 2024). Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN)
2. NHS Dumfries and Galloway (Accessed June 15th 2025). Asthma treatment for 5-11s