Treating asthma in children

By NHS Choices 5

Personal asthma action plan

As part of the initial assessment, you and your child should be encouraged to draw up a personal asthma action plan with your GP or asthma nurse. The plan includes information about your child’s asthma medicines. If your child has been admitted to hospital because of an asthma attack, you should be offered a written action plan (or the opportunity to review an existing action plan) before you go home.

As your child gets older, it is important for them to be able to recognise the signs and symptoms of their asthma, and how to effectively manage their condition. Both you and your child should be shown how to recognise when their symptoms are getting worse and the appropriate steps to take. You should also be given information about what to do if they have an asthma attack.

You and your child should review their personal asthma action plan with their GP or asthma nurse at least once a year, or more frequently if their symptoms are severe or not well controlled.

As part of their asthma management, your child may be given a diary card and sometimes a peak flow meter to monitor their symptoms and the effects of treatment.

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Taking asthma medicines

Inhalers

Asthma medicines are usually taken using inhalers. These are devices that deliver the drug directly into the airways through your child’s mouth when your child breathes in. Inhaling is an effective way of taking an asthma medicine as it goes straight to the lungs, with very little ending up elsewhere in the body. This means a smaller dose can be taken with fewer side effects.

Spacers

Most young children find using inhalers difficult, so a spacer may be used. Spacers are large plastic or metal containers that have a mouthpiece at one end and a hole for the inhaler at the other. The medicine is ‘puffed’ into the spacer by the inhaler and it is then breathed in through the spacer mouthpiece. Children under the age of three have the spacer attached to a facemask rather than a mouthpiece, this makes it easier for them to breathe in the medicine. Spacers are also good for reducing the risk of thrush in the mouth or throat, which is an occasional side effect of inhaled steroid medicines. Steroid inhalers should always be taken with a spacer.

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Reliever inhalers

Reliever inhalers are taken as soon as asthma symptoms develop. The inhaler, also known as a reliever, contains a medicine called a short-acting beta2-agonist. This will relieve the symptoms of asthma. Relievers work fast by relaxing muscles surrounding the narrowed airways. This allows the airways to open wider, making it easier to breathe. Examples of reliever medicines include salbutamol and terbutaline. They are generally safe medicines with few side effects.

If your child’s symptoms are mild and do not occur often, they will just be given a reliever inhaler. Reliever inhalers are usually blue.

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Preventer inhalers

Preventer inhalers work over time to reduce the amount of inflammation and ‘twitchiness’ in the airways and prevent asthma attacks occurring. Your child will normally be recommended to take their preventer inhaler every day to prevent symptoms. Your child will need to use their preventer inhaler daily for some time before they gain the full benefit. They should still use their reliever inhaler to relieve symptoms.

The preventer inhaler contains a medicine called an inhaled corticosteroid. Examples of preventer medicines include beclometasone, budesonide and fluticasone. Preventers are usually brown, red or orange.

Preventer treatment is normally recommended if your child:

  • has asthma symptoms more than twice a week
  • wakes at least once a week due to asthma symptoms
  • has to use a reliever inhaler more than twice a week

Inhaled corticosteroids (preventers) occasionally cause fungal infections (oral thrush) in the mouth and throat. Your child should rinse their mouth thoroughly after inhaling a dose. For more information on side effects, see below.

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Other treatments and ‘add-on’ therapy

Long-acting reliever inhaler

If your child’s asthma does not respond to treatment, the doses of their preventer inhaler can be increased if agreed with their healthcare team. If this does not control your child’s asthma symptoms, you may be given a different inhaler containing a medicine called a long-acting bronchodilator or long-acting beta2-agonist (LABA). Examples of LABAs include formoterol and salmeterol. LABAs are given in an inhaler that combines an inhaled steroid and a long-acting bronchodilator in a single device. It is known as a combination inhaler. LABAs work in a similar way to short-acting relievers, but their effects last up to 12 hours. Examples of combination inhalers include Seretide and Symbicort. These are usually purple or red and white.

If your child is under two years of age and has frequent symptoms, they should be referred to a specialist in children’s asthma.

Other preventer medicines

If treatment of your child’s asthma is still not successful, additional preventer medicines will be tried. Two possible alternatives are:

  • Leukotriene receptor antagonists – this medicine, in the form of a chewable tablet or granules, can be added to food and works by blocking a chemical reaction that can lead to inflammation of the airways.
  • Theophyllines – this medicine, in the form of a tablet, helps widen the airways by relaxing the muscles around them.

In rare cases, if your child’s asthma is still not under control, they may be prescribed regular oral steroids (steroid tablets). This treatment should be supervised by a specialist in children’s asthma (a respiratory paediatrician). Long-term use of oral steroids carries possible serious side effects, so is only used once other treatment options have been tried. See below for more information on the side effects of steroid tablets.

Occasional use of oral steroids

Most children only need to take a course of oral steroids for three to five days to treat an asthma attack.

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Side effects of treatments

Your doctor or nurse will discuss with you the need to balance control of your child’s asthma with the risk of side effects, and how to keep side effects to a minimum.

Side effects of relievers

Relievers (short-acting beta2 agonists) are safe and effective and have few side effects. The main ones include a mild shaking of the hands, headache and muscle cramps. These usually only happen with high doses of reliever inhalers and do not last very long.

Side effects of preventers

Preventers (corticosteroids), which may be given for asthma as tablets, by injection or through inhalers, can cause a range of side effects. However, when a low-dose corticosteroid is given as a preventer using an appropriate inhaler device, side effects are rare. One side effect of an inhaled steroid given regularly as a preventer is a fungal infection (oral candidiasis or thrush) of the mouth or throat. Very occasionally, children also develop a hoarse voice. Using a spacer can help prevent these side effects. Your child should also rinse their mouth or clean their teeth after taking their preventer inhaler.

During the first year of treatment with an inhaled steroid reliever, there is often a slight slowing of growth. However, with standard doses, children achieve their expected normal adult height. Similarly, regular use of standard doses of a steroid inhaler for several years does not increase the risk of thinning of the bones or of bone fractures.

If your child uses a preventer inhaler for a long time at high doses, there is a small risk of the more serious side effects associated with long-term oral steroid use (see side effects of steroid tablets, below). Children receiving long-term treatment with high doses of an inhaled steroid should be reviewed in a hospital clinic by a specialist respiratory paediatrician.

Side effects of add-on therapy

Some regular treatments for asthma are added when preventer treatment with an inhaled corticosteroid alone does not fully control your child’s symptoms.

Long-acting relievers (long-acting beta2 agonists or LABAs) may cause similar side effects to short-acting relievers: a mild shaking of the hands, headache and muscle cramps. Your GP can discuss the risks and benefits of this medication with you. As with all asthma treatment, your child should be monitored and reviewed regularly. If you feel your child is not benefiting from the use of the long-acting reliever, it should be stopped.

Leukotriene receptor agonists seldom cause side effects but have been known to cause stomach upsets, thirst, headache and occasionally nightmares.

Theophylline tablets are an effective add-on treatment for asthma but commonly cause side effects in children, including nausea, vomiting and stomach upset, headaches, irritability and sleep disturbance.

Side effects of steroid tablets

Children taking oral steroids for more than three months, or who take frequent courses of oral steroids (three to four times a year), are at risk of side effects, these can include:

It is rare for children to need long-term treatment with steroid tablets. Such children should be reviewed at a hospital clinic by a paediatric respiratory specialist. They will require regular examinations to check for the development of these side effects and careful monitoring of their growth in height and weight. 

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Asthma attacks

Your child’s personal asthma action plan will help you and them to recognise the symptoms of an asthma attack, what to do and when to seek medical attention.

Treatment of asthma attacks usually involves taking several extra doses of the reliever inhaler (which is most often blue). If the symptoms of your child’s asthma attack worsen, they may need hospital treatment.

If your child is admitted to hospital with an asthma attack, they will be given high doses of reliever treatment by inhalation and a course of steroid tablets (or occasionally injections). They may also need oxygen to bring their asthma under control.

After an asthma attack, your child’s personal asthma action plan will need to be reviewed and reasons for the asthma attack identified so that, if possible, a future one can be avoided.

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Complementary therapies

A number of complementary therapies have been suggested for the treatment of asthma, including:

  • breathing exercises 
  • traditional Chinese medicine 
  • acupuncture 
  • ionisers (a device that uses an electric current to charge or ionise molecules of air) 
  • the Alexander technique (a training programme designed to change the way you move your body) 
  • homoeopathy 
  • dietary supplements

There is little evidence that any of these treatments, other than certain breathing exercises, are of benefit to children with asthma.

There is good evidence that breathing exercises taught by a physiotherapist, yoga, and the Buteyko method (a technique involving shallow breathing) can improve symptoms and reduce the need for reliever medicines in some people, although most of the work in this area has been done in adults and not children.

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