Management of chronic asthma in children under 5

NICE state (1):

• an 8 to12 week trial of twice-daily paediatric low-dose inhaled corticosteroid (ICS) as maintenance therapy (with a short-acting beta2 agonist [SABA] for reliever therapy) should be considered in children under 5 with suspected asthma and:
  • symptoms at presentation that indicate the need for maintenance therapy (for example, interval symptoms in children with another atopic disorder, or
  • severe acute episodes of difficulty breathing and wheeze (for example, requiring hospital admission, or needing 2 or more 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 their symptoms (for example mould in the home, cold housing, smokers or indoor air pollution)
  • review whether an alternative diagnosis is likely

• if none of these explain the failure to respond to treatment, refer the child to a specialist in asthma care (https://www.nice.org.uk/guidance/ng245/chapter/recommendations#specialist-in-asthma-care)

• consider stopping ICS and SABA treatment after 8 to 12 weeks if symptoms are resolved. Review the symptoms after a further 3 months
• if symptoms resolve during the trial period, but then:
  • symptoms recur by the 3-month review, or
  • the child has an acute episode requiring systemic corticosteroids or hospitalisation, restart regular ICS (begin at a paediatric low dose and titrate up to a paediatric moderate dose if needed) with SABA as needed and consider a further trial without treatment after reviewing the child within 12 months
• if suspected asthma is uncontrolled in children under 5 on a paediatric moderate dose of ICS as maintenance therapy (with SABA as needed), consider a leukotriene receptor antagonist (LTRA) in addition to the ICS
  • the LTRA should be given for a trial period of 8 to 12 weeks (unless there are side effects), then stop it if it is ineffective

If suspected asthma is uncontrolled in children under 5 on a paediatric moderate dose of ICS as maintenance therapy and a trial of an LTRA has been unsuccessful or not tolerated, stop the LTRA and refer the child to a specialist in asthma care for further investigation and management.

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):

Open Image in Modal

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 under 5 year olds