Lucan · Conditions

Paediatric asthma (6-11y)

Australian guidance: Australian Asthma Handbook v3.0 (NACA), Children section + RCH Melbourne CPG, Asthma in primary school-aged children (6-11 years) and Preschool asthma (1-5 years) (both captured 2026-09-05, added 2026-09-22)

1. Definition and epidemiology

Asthma is a chronic inflammatory disorder of the airways characterised by variable expiratory airflow limitation and episodic respiratory symptoms. Australia has one of the highest childhood asthma prevalences in the world, with approximately 1 in 9 children affected. Among school-aged children aged 6 to 11 years, the condition is a leading cause of school absence, emergency department presentation, and hospital admission.

2. Pathophysiology

Asthma in school-aged children involves two interrelated processes described in Robbins Ch 15. The first is chronic eosinophilic and Th2-driven airway inflammation, leading to subepithelial fibrosis, goblet cell hyperplasia, smooth muscle hypertrophy, and increased mucus production. The second is bronchial hyperresponsiveness, in which the thickened and inflamed airway wall contracts disproportionately to inhaled stimuli such as cold air, exercise, allergens, or viral upper respiratory infections. The net result is episodic, partially or fully reversible expiratory airflow limitation. In children with atopic disease, allergen sensitisation drives mast cell and IgE-mediated early-phase bronchoconstriction within minutes, followed by a late-phase response from recruited eosinophils and T-lymphocytes that sustains inflammation for hours. Remodelling begins early in life and progresses with ongoing poor control, potentially reducing lung function trajectories into adulthood.

3. Clinical presentation and diagnostic criteria

In school-aged children the cardinal symptoms are episodic wheeze, chest tightness, cough, and exertional dyspnoea. Wheeze is the most specific symptom for asthma in this age group compared with isolated cough or breathlessness. Symptoms are typically worse at night, provoked by viral respiratory infections, exercise, cold air, and aeroallergen exposure. On examination the chest is usually clear between episodes; expiratory polyphonic wheeze may be heard during symptomatic periods. A silent chest in the context of increased work of breathing signals severe airflow limitation requiring urgent intervention. Atopic features including eczema, allergic rhinitis, and periorbital darkening may be present. The Australian Asthma Handbook v3.0 defines confirmed asthma as variable expiratory airflow limitation demonstrated on spirometry and/or fractional exhaled nitric oxide (FeNO) greater than or equal to 25 ppb in a child with suggestive symptoms.

4. Investigations and AU-specific cutoffs

Spirometry with bronchodilator responsiveness testing is the first-line objective investigation; most children aged 6 to 11 years can perform it to acceptable quality standards in primary care [NACA Asthma Handbook — diagnosis-children-6-11-years.md]. Bronchodilator responsiveness is tested by measuring FEV1 before, and 10 to 15 minutes after, a rapid-acting bronchodilator (e.g. salbutamol), with at least three spirometry manoeuvres each time. Two criteria for a positive test are used in Australia, and differ between guidelines and spirometer software: (1) the Spirometry Handbook criterion — FEV1 increase of 12% or more compared with the pre-bronchodilator reading; or (2) the ERS/ATS criterion — FEV1 increase, by absolute volume, of at least 10% of the individual's predicted FEV1 (by sex, height and age). A positive bronchodilator responsiveness test confirms the diagnosis in a child with a history suggestive of asthma. FEV1 below 80% of predicted indicates abnormal lung function; a reduced FEV1/FVC ratio below the lower limit of normal indicates expiratory airflow limitation. Clinical diagnosis based on history alone leads to significant overdiagnosis of asthma, but normal spirometry when the child is asymptomatic does not exclude it. Peak expiratory flow measurements are not used to diagnose asthma in children under 12 years because they are highly variable [NACA Asthma Handbook — diagnosis-children-6-11-years.md].

If spirometry is arranged through an accredited respiratory function laboratory, request FeNO in the same session. Diagnose asthma if variable expiratory airflow limitation is confirmed by spirometry AND/OR FeNO is 25 ppb or above, in a child whose signs and symptoms suggest asthma and who has no features suggesting an alternative diagnosis. In children and adolescents aged 5 to 18 years, a FeNO level above 24 ppb has a reported sensitivity of 0.50 and specificity of 0.91 for the diagnosis. A normal FeNO does not rule out asthma; FeNO is also raised by other type-2 inflammatory conditions such as allergic rhinitis, and is suppressed by obesity and by treatment with ICS or systemic corticosteroids. The recommended reference values are the Global Lung Initiative (GLI) 2012 dataset (covering ages 3 to 95 years and relevant ethnic groups); for Aboriginal and/or Torres Strait Islander children, select the GLI-2012 "other/mixed" category — NHANES III is no longer recommended [NACA Asthma Handbook — diagnosis-children-6-11-years.md].

If spirometry (repeated on separate occasions with bronchodilator responsiveness testing) and FeNO are both normal, asthma is unlikely; reconsider the differential diagnosis and consider specialist referral (paediatrician, paediatric respiratory physician, or allergist) for a bronchial challenge test, a positive result of which also confirms the diagnosis. Corrected 2026-09-22: the previous draft stated that allergy testing with skin-prick testing or serum allergen-specific IgE is arranged when allergic triggers are suspected, to inform management. The captured RCH CPG contradicts this: allergy testing (RAST or skin prick testing) should not be performed if there is no history of an immediate reaction to the potential allergen, and a clear relationship between an allergen and asthma symptoms also does not require testing, because that should be treated as an allergic trigger and avoided where possible. The handbook's position on when to test is unchanged in this note; the RCH restriction is recorded alongside it. In children aged 1 to 5 years the captured RCH preschool page states that lung function tests cannot be used at all.

5. Management

Management in children aged 6 to 11 years follows a five-level stepwise approach, adjusted over time to maintain good symptom control and prevent exacerbations while minimising side effects; the optimal step for an individual child may change, and remission can occur [NACA Asthma Handbook — treatment-levels-children.md]. Level 1 is salbutamol as needed via pressurised metered-dose inhaler (pMDI) plus spacer for all children, and may be the sole treatment for children with mild, infrequent symptoms and no history of severe exacerbation or other exacerbation risk factors. Frequent reliever use signals the need for ICS: prescription of three or more salbutamol canisters per year is associated with at least double the risk of subsequent exacerbations in this age group. Level 2 adds maintenance low-dose ICS, which in a major 3-year trial in children aged 5 to 10 years with recently diagnosed asthma reduced serious exacerbations by 40%, improved lung function, increased symptom-free days, and reduced days lost from school, compared with salbutamol alone; most of the benefit of ICS occurs at low-to-medium doses, with high doses giving only small further gains in control at the cost of more local adverse effects. Daily montelukast is an alternative when parents decline ICS after discussion of benefits and risks, with a switch to ICS when possible. Level 3 is low-dose ICS-LABA in a single inhaler, TGA-approved from age 4 years: when asthma is not well controlled on low-dose ICS alone, adding a LABA is more likely to improve control than increasing the ICS dose or adding montelukast, and — contrary to historical concerns — does not increase exacerbation risk in children aged 4 to 11 years. An alternative at this level is maintenance medium-dose ICS. Level 4 is maintenance medium-dose ICS-LABA. Level 5 is specialist-directed treatment, which may include tiotropium, high-dose ICS, medicines approved for adolescents, or monoclonal antibody therapy; montelukast can also be added to ICS-based treatment at levels 3 and above. Tiotropium added to ICS-LABA reduces exacerbation risk and gives a small lung function improvement in children aged 6 to 11 years, with benefit that does not appear to depend on IgE or eosinophil phenotype. Maintenance-and-reliever therapy (MART) with ICS-formoterol is not TGA-approved for children under 12 years as of the handbook's 2025 note on this question, though limited evidence suggests very-low-dose budesonide-formoterol used this way is associated with a large reduction in exacerbation rate [NACA Asthma Handbook — treatment-levels-children.md].

Added 2026-09-22 from the captured RCH primary school-aged CPG, the RCH step structure and doses. RCH uses a four-step structure rather than the handbook's five levels, and gives explicit doses. Step 1 is SABA only, permitted only in children who have not required treatment for an exacerbation (systemic corticosteroid or hospital presentation) in the past 12 months, whose symptoms occur infrequently, and who have no other contributing factors. Step 2 is low-dose ICS via spacer: ciclesonide 80 microg once daily or fluticasone 50 microg twice daily, with montelukast 5 mg once daily as an alternative first-line preventer or an adjunct. Step 3 is moderate-dose ICS (fluticasone 100 microg twice daily or ciclesonide 160 microg once daily), or low-dose ICS plus montelukast, or ICS/LABA (budesonide/formoterol MDI 100 microg/3 microg, 2 puffs twice daily, or DPI 200 microg/6 microg, one inhalation twice daily). Step 4 is moderate-dose ICS plus montelukast, or ICS/LABA plus montelukast, or referral for expert advice. RCH also states that frequent use of SABA alone, more than 3 MDI canisters per year, together with infrequent use of preventer or anti-inflammatory therapy is associated with more severe exacerbation and death; note that RCH words this as more than 3 canisters, where the handbook figure above is three or more.

Corrected 2026-09-22, ICS/LABA in the 1 to 5 year age band. This note states above that low-dose ICS-LABA in a single inhaler is TGA-approved from age 4 years, citing the handbook's children treatment-level page (ages 1 to 11). The captured RCH preschool CPG (1 to 5 years) states that combination ICS/LABA inhalers are not recommended in that age group outside of specialist use. Both statements are recorded here rather than reconciled: the handbook treats age 4 as the TGA approval floor, while RCH does not recommend routine ICS/LABA use below school age. For a preschool child, follow the RCH position.

Added 2026-09-22 from the captured RCH pages, stepping, control and cessation. Step up after 6 weeks if further control is required, always checking technique and adherence and considering alternative diagnoses first. Good control for approximately 3 months suggests preventer treatment could be stepped down; continue the lowest treatment that controls symptoms. Only cease treatment after a period of 6 months symptom-free (RCH primary school-aged page; the preschool page gives 3 months), and review 4 to 6 weeks after stepping down. RCH defines good asthma control as daytime symptoms less than twice per week, reliever use less than twice per week, no limitation of activities, night-time waking less than twice per month, and no need for systemic corticosteroid, emergency department presentation or admission. RCH risk factors for exacerbation are previous intubation or ICU admission for asthma, two or more hospital presentations requiring asthma treatment, SABA use more than twice weekly or more than 3 MDI canisters per year, infrequent or poor preventer adherence, incorrect inhaler technique, exposure to smoke or vaping, and comorbidities such as obesity, sleep apnoea, chronic rhinosinusitis or confirmed food allergy.

For acute exacerbations in primary care, rapidly assess severity by observation and pulse oximetry (noting pulse oximetry may overestimate saturation in people with higher skin pigmentation) while preparing salbutamol and oxygen. Give salbutamol (100 micrograms per actuation) by pMDI plus spacer using tidal breathing technique: 4 to 12 actuations for a mild-to-moderately severe exacerbation, or 12 actuations for a severe exacerbation, repeated every 20 minutes for the first hour if breathing difficulty persists (nebulised alternative, if required: 5 mg for a severe exacerbation, or two 5 mg nebules for a life-threatening exacerbation). If dyspnoea or increased work of breathing has not resolved within 5 minutes, give an additional bronchodilator dose and arrange emergency department transfer. Start supplemental oxygen when saturation falls below 92% on room air and titrate to 92–96% (simple mask 5 L/min; nasal prongs 3 L/min). Contact ambulance services immediately, with bronchodilator and oxygen given concurrently, if respiratory distress prevents the child speaking in complete sentences or oxygen saturation is 94% or below. If anaphylaxis is identified or suspected — acute onset with skin/mucosal involvement, or acute hypotension, bronchospasm or laryngeal involvement after allergen exposure — give adrenaline before bronchodilator [NACA Asthma Handbook — acute-asthma-children-primary-care.md].

Added 2026-09-22 from the captured RCH pages, community acute management rules. The RCH primary school-aged reliever dose is salbutamol 100 microg MDI, 6 to 12 puffs via spacer with or without mask, which overlaps but is not identical to the handbook's 4 to 12 actuations for a mild-to-moderately severe exacerbation and 12 actuations for a severe exacerbation; the handbook figures above remain the source for the severity-stratified regimen. For preschool children the RCH reliever dose is up to 6 puffs. In children already taking daily ICS there is no role for increasing the dose of ICS during an exacerbation (stated on both RCH pages). The RCH preschool page adds that prednisolone should not be prescribed for preschool asthma outside the emergency department or hospital setting, unless an exacerbation is being managed in general practice and transfer to emergency is being arranged. RCH also directs an annual influenza vaccine, a written asthma action plan for home and childcare, adherence checks at every visit, and review of contributing factors including allergic rhinitis, obesity, obstructive sleep apnoea, gastro-oesophageal reflux, dysfunctional breathing, smoke and vaping exposure, damp or mouldy housing, aeroallergens and barriers to accessing healthcare. ICS-formoterol MART is worth considering in children nearing 12 years with poor preventer adherence or high SABA use; it may be prescribed off label or by private script, which is consistent with the handbook statement above that MART is not TGA-approved under 12 years.

For moderate-to-severe exacerbations, start oral prednisone or prednisolone 1 mg/kg (maximum 50 mg) each morning for 3 days; corticosteroids are omitted when the exacerbation is assessed as mild. Giving systemic corticosteroids within 1 hour of presentation reduces the likelihood of hospital admission. After respiratory distress resolves, observe for a minimum of 4 hours, with instructions for the supervising parent/carer to call an ambulance if symptoms recur. Schedule follow-up at 3 to 5 days to verify corticosteroid adherence and inhaled corticosteroid compliance, and arrange a comprehensive asthma review at 2 weeks to identify exacerbation triggers and additional risk factors, review the written asthma action plan, assess reliever-use patterns, adjust maintenance ICS as indicated, and verify and correct inhaler technique. Consider specialist referral if the child has had more than one emergency health service visit for acute asthma, or multiple systemic corticosteroid courses, in the preceding 12 months [NACA Asthma Handbook — acute-asthma-children-primary-care.md].

6. Pharmacology and AU PBS notes

The captured Australian Asthma Handbook topics used for this note describe treatment by drug class (salbutamol, ICS, montelukast, ICS-LABA, tiotropium, oral corticosteroids) rather than by AU brand name or PBS item code, so specific brand names, PBS streamlined-authority wording and item numbers are not asserted here and should be checked against AMH or the PBS schedule directly before prescribing.

At recommended paediatric doses, ICS is generally well tolerated. Spacer use with pMDIs reduces oropharyngeal deposition and the local risk of candidiasis and dysphonia; mouth-rinsing and spitting after inhaling further reduces topical effects, and rinsing immediately (rather than after a delay) removes more residual medicine. Systemic ICS effects in children include rare HPA-axis suppression, short-term linear growth suppression, clinically non-significant effects on bone mineral density, and dose-dependent effects on glucose metabolism [NACA Asthma Handbook — treatment-levels-children.md].

Montelukast carries a TGA product information and consumer medicine information warning about potential neuropsychiatric adverse effects, and parents should be counselled about this risk before starting it; the most commonly reported events are sleep disorders in infants under 2 years and depression/anxiety in children aged 2 to 11 years. A large cohort study (Wintzell et al., JAMA Pediatr 2025) in children aged 6 to 17 years found no association between montelukast use and neuropsychiatric adverse event risk, but the warning label remains current [NACA Asthma Handbook, treatment-levels-children.md]. Corroborated 2026-09-22 by the captured RCH pages: RCH states that 1 in 6 children may develop side effects with montelukast including agitation, sleep disturbance and altered mood, and that if this occurs the medication should be ceased to see if symptoms resolve. Tiotropium at Level 5, added to ICS-LABA, reduces exacerbation risk with benefit that does not appear to depend on IgE or eosinophil phenotype in children aged 6 to 11 years [NACA Asthma Handbook, treatment-levels-children.md].

For acute exacerbations, when prescribing the oral prednisone/prednisolone course, write the PBS script for the exact tablet quantity needed for one course with no repeats, to minimise excess medication supply [NACA Asthma Handbook — acute-asthma-children-primary-care.md].

7. Complications and monitoring

Uncontrolled asthma in school-aged children is associated with cumulative lung function impairment, reduced final adult height, and increased risk of fixed airflow obstruction in adulthood. In the acute setting, life-threatening complications include respiratory failure, pneumothorax, and cardiorespiratory arrest; a silent chest on auscultation during an acute attack indicates near-complete airflow obstruction and mandates immediate transfer by ambulance with concurrent salbutamol and supplemental oxygen. ICS use at recommended paediatric doses causes modest short-term reduction in linear growth rate of approximately 0.48 cm per year in the first year of treatment, with less effect thereafter; uncontrolled asthma itself also impairs growth. Monitoring at each visit should include symptom frequency, nocturnal waking, reliever use, exercise tolerance, school attendance, spirometry at diagnosis and periodically during follow-up, and review of written asthma action plan and inhaler technique. Children with more than one emergency health service visit or multiple systemic corticosteroid courses in the preceding 12 months warrant specialist referral.

Written for Australian practice and grounded in the guidance named above. Study material only — not medical advice. Always check against current guidelines.