Asthma is the most common long-term condition amongst children and young people and is one of the top ten reasons for emergency hospital admission in the UK (Royal College of Paediatrics and Child Health, 2020). Asthma and Lung UK reported (2022) that the UK has the worst death rate for lung conditions such as asthma and chronic obstructive pulmonary disease (COPD) than anywhere else in western Europe. Given how common is, and how poorly the UK compares, it is critical that nurses in primary and community services understand what has been described as a ‘sea change’ in national guidelines (Hickman, 2024; BTS/SIGN/NICE, 2024).
What's changed?
These new guidelines resolve longstanding differences between the previous BTS and SIGN guidelines, and NICE guidelines. In addition, health professionals describe the new guidelines as an opportunity for an ‘upgrade’ people's inhalers (PCRS, 2025). For example, for older children and adults, this might mean a move (where clinically indicated) towards maintenance and reliever therapy (MART) regimes, enabling people to receive controller medication alongside a long acting reliever with every dose, thus reducing the reliance on short acting bronchodilators (SABA), which can be associated with poor control and increased exacerbations (GINA, 2024). Diagnostic testing has also changed in those aged 5 and over, with a move towards blood eosinophils or fractional exhaled nitric oxide (FeNO) as the first line. The following paragraph and algorithm references refer to the 2024 BTS/SIGN/NICE guidelines.
Particular challenges in children under 5 years
Asthma is characterized by airway inflammation, hyper-responsiveness, and variable airflow obstruction. Symptoms include wheezing, coughing, breathlessness, and chest tightness. Unfortunately, very young children commonly experience these symptoms for several reasons, often due to viral infections that can resolve themselves. In addition, the gold standard for asthma care is objective testing such as FeNO, which small children cannot do.
The committee that drew up the new guidelines explain that young children with recurrent wheeze and features suggesting asthma should be treated empirically with a low dose of inhaled corticosteroid (ICS) for 8 to 12 weeks and then stopped. If symptoms soon re-appear after stopping ICS, this suggests that the ICS was beneficial rather than the improvement being due to the natural remission of a viral episode (figure 1). The committee agreed that once the presence of asthma is established with reasonable certainty regular paediatric low-dose ICS should be restarted, with subsequent steps added if needed (paragraph 1.9.6; figure 1). This means that nurses need to be able to explain these trials of treatment, which can be stopped and restarted, to worried parents.
As diagnosis in this age group is so difficult, the committee agreed that thresholds for referral to an asthma specialist should be low (paragraph 1.9.6,).
Care of a small child with breathing problems can be an emotional situation. A full explanation of why a small child may need regular inhaled steroids, especially as they may not appear to carers to ‘work’ immediately (compared to beta agonists) and addresses concerns about the effect on the child's growth.
Initial clinical assessment (paragraph 1.1)
Be aware that even if a clinical examination is normal, the child may still have asthma.
Diagnosis (paragraphs 1.2 and 1.3)
Treatment (Figure 1)
Self-management (paragraph 1.1)
Annual review (Asthma and Lung UK, 2024)
At annual review check for:
Shared decision-making
Decisions about treatment and care are best when they are made alongside children and their parents or carers. Healthcare 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.
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