Asthma is the most common long-term condition among children and young people and is one of the top 10 reasons for emergency hospital admission in the UK (Royal College of Paediatrics and Child Health, 2020). Asthma and Lung UK (2022) reported that the UK has the worst mortality rate for lung conditions such as asthma and chronic obstructive pulmonary disease compared to all other countries in western Europe. In England, 54 children died from asthma between 1 April 2019 and 31 March 2023 (National Child Mortality Database, 2024).
Given how common asthma is, and how poorly the UK compares, it is crucial that nurses in primary and community services understand what has been described as a ‘sea change’ in the National Institute for Health and Care Excellence (NICE) guidelines (Primary Care Respiratory Society, 2024).
What has changed?
The following text refers to the NICE (2024) guidelines (NG245), developed in collaboration with the British Thoracic Society and the Scottish Intercollegiate Guidelines Network.
Health professionals have described the new guidelines as an opportunity to ‘upgrade’ people's inhalers (Primary Care Respiratory Society, 2025). In the 5–11 years age group, the guidelines include the option of offering newly diagnosed children a maintenance and reliever therapy (MART) regimen if asthma is not controlled with twice-daily paediatric low-dose inhaled corticosteroids (ICS). This enables them to receive controller medication (ICS) alongside a long-acting reliever (fast-acting formoterol) with every dose, reducing the reliance on short-acting bronchodilators (SABA), which can be associated with poor control and increased exacerbations (Global Initiative for Asthma, 2024).
The new guidelines also stress the importance of objective testing. They acknowledge the difficulties in accessing fractional exhaled nitric oxide (FeNO) and spirometry equipment in some parts of the country. This requires more investment in primary care to avoid inequalities in asthma care.
‘Off-label’ prescribing of MART
At the time of writing, the prescription of MART regimens to those under the age of 12 years would need to be ‘off label’. This means prescribing outside the product licence for clinical situations judged by the prescriber to be in the person's best interest. Therefore, an independent nurse prescriber would have an increased responsibility to assess the risks and explain to the child and their carers why they are prescribing to someone below the recommended age (Medicines and Healthcare products Regulatory Agency (MHRA), 2014). There are studies being conducted to look at the safety and efficacy of MART dosing for children under 12 years. Once complete, these will influence the license of MART in the UK.
In addition, a switch to MART for children established on treatment with separate ICS and SABA metered dose inhalers (MDI) with a valve holding chamber or spacer may be considered if the child's asthma is poorly controlled or they prefer a single inhaler. Moving to a single MART inhaler is also better for the environment, as some people can rely on, and thus overuse, SABAs.
The carbon dioxide emissions created with inhaler use and disposal contributes significantly to the total inhaler carbon footprint in the UK (Wilkinson et al, 2021). However, the most important factor in prescribing inhaler devices is whether the child and parent feel happy to use them and can do so correctly.
Particular challenges in children and young people aged 5–11 years
Care of a child with breathing problems can be an emotional situation. A full explanation of reasons why a child may need regular inhaled steroids, especially as they may not appear to parents or carers to ‘work’ immediately (compared to beta agonists), and concerns about the effect on the child's growth, is needed.
At 11 years old, the young person is preparing for transition from primary to secondary school, so it is important to ensure that an up-to-date personalised asthma action plan is available to give to the new school, alongside a discussion with the relevant school nurse if the child has had multiple admissions (Henry, 2023).
Initial clinical assessment (paragraph 1.1.1)
The history of symptoms is the initial step to making a diagnosis, including:
Be aware that even if a clinical examination is normal, the child may still have asthma. Equally, there may be many reasons why children in particular might wheeze, so alternative diagnoses must be borne in mind.
Objective testing (paragraph 1.2.5)
The new asthma guidelines refer to a stepwise testing process, starting with FeNO testing and, if this is inconclusive or unavailable, moving on to the next test. Unlike previous guidelines, only one positive objective test is needed to confirm a diagnosis.
Treatment (paragraph 1.2.5)
Switching existing patients to the new regimen
Previous national asthma guidelines suggested that people with very mild or seasonal asthma should be offered a SABA alone. Some children, young people and parents/carers may normalise asthma symptoms and modify their activities to cope with asthma, so use probing questions to look for cough, wheeze and dyspnoea that the patient may be tolerating. Look for over-use of SABA, defined as needing three or more puffs per week, indicating poor control.
A search of the clinical system will identify those on SABA alone. They can be invited in for review. Objective testing at this point might mean that these patients can be removed from the asthma register. The 2024 NICE guidelines do not recommend SABA-only management; symptomatic patients aged 5–11 years need ICS/SABA or a MART regimen.
This switch will require the nurse to explain the important role of ICS in controlling inflammation as the root cause of asthma and how it must be used regularly, even if the patient is asymptomatic. Use of the phrase ‘I'm offering you an upgrade in your asthma treatment’ might help to sell the idea. Those already on ICS/SABA and whose asthma is well-controlled can remain in existing treatment, but symptomatic patients can be offered a MART regimen without reducing the dose of ICS.
Self-management (paragraph 1.14)
Annual review
At annual review, check for (Asthma and Lung UK, 2024):
Shared decision making
Decisions about treatment and care are best when they are made alongside children and their parents or carers. Health professionals should involve children and young people in decisions about their healthcare in ways that are appropriate to their maturity and understanding (NICE, 2021). Some children and young people will be able to give informed consent themselves, some will be able to contribute to the discussion and others may not be able to be involved at all. Nurses should give clear information, discuss options and listen carefully to the family's views and concerns. Ask about: