This section will help you to manage asthma in children aged 5-11 years of age.
For younger children, please see our children aged under 5 page.
For older children, please see our asthma in people over the age of 12 page.
Please see the Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN) guideline and the PCRS First Steps for additional information.
Key facts for effective asthma management
No child should be on short acting bronchodilator (SABA) only treatment without an inhaled corticosteroid (ICS) containing inhaler. Multiple studies have shown using only a SABA to treat asthma is associated with a greater risk of fatal asthma attacks. It is essential to treat the underlying inflammation with ICS (inhaled corticosteroid) to achieve good asthma control.
Controlled asthma means children can participate in normal activities without symptoms, night-time disturbances, or using their reliever medication more than 3 times a week.
Uncontrolled asthma is defined as any exacerbation (flare up) needing requiring oral corticosteroids (prednisolone) or frequent, regular symptoms (such as using reliever inhaler 3 or more days a week or night-time waking 1 or more times a week
Starting treatment
It is helpful to record the child’s symptoms using an validated tool such as the child asthma control test.
Start the newly diagnosed child on twice daily paediatric low dose ICS with a SABA for symptom relief.
You can show or send this video to the child and their family.
Choosing an inhaler device
You can use a dry powder inhaler (DPI) or a pressurised metered dose inhaler (pMDI). Remember to always provide a a spacer with a pMDI.
It is good practice to consider the environmental impact and cost of inhaler devices but you need to prescribe an inhaler which the child can, and will, use and this decision needs to be made together with the patient and their family.
Check out our guide to choosing the right inhaler and spacer.
You should document why you have chosen the inhaler, so that other HCPs will understand your decision. Remember that no changes should be made to inhaler devices without consultation with the child and their family, as this is unsafe practice. This PCRS guide explains why, and offers advice on how to align environmental considerations with best practice.
Many primary school-aged children have the ability to use a DPI with effective training, support and practice . You can contact pharmaceutical companies for training aids to help with this. However, you should consider providing an additional pMDI SABA inhaler plus spacer for emergency use for children under 12 years who might not be able to to activate a dry powder inhaler during an acute asthma attack
RightBreathe can also help you choose the correct inhaler for your patient.
Demonstrate how to use the inhaler and remember to give an additional SABA and spacer for the child to take to school. If the child lives between two homes, you may want to prescribe an additional ICS, SABA and spacer.
Supported self management
Give the child an asthma action plan and upload a copy to their notes. Make sure that their parent or carer knows to share the action plan with school and any clubs that the child attends. Discuss triggers, and how to minimise contact with them, including exposure to cigarette smoke, vaping and air pollution.
For extra support, signpost the family to the A+LUK Helpline and Parent and Carer Network. Laura King and Bart’s Charity have produced a comprehensive information pack for parents and carers, with animations, all of which are available in a range of languages.
Arrange a review appointment and encourage the family to keep a symptom diary or video symptoms on their phone so that you can work out how well their treatment is working for them.
When you review them, repeat the asthma control test and ask both the child and their parent/carer about the child’s symptoms.
If asthma is not controlled
If the child’s asthma is not controlled, first of all check:
- adherence
- inhaler technique and
- any other factors that might be affecting their asthma control.
It is useful to check FeNO at this point, to see if the dose of medication is working. A low or normal reading suggests that there is no untreated inflammation present. Consider other causes for the symptoms. A high reading suggests untreated inflammation.
Check adherence, technique and then consider stepping up treatment if appropriate. You can consider starting the child on a paediatric low dose maintenance and reliever therapy regime (MART). Explain how MART works to both the child and their family and if you are sure that they understand, then you can prescribe an ICS and Formoterol combination inhaler.
Currently no inhalers are licensed for MART under the age of 12 years, so their use is off label. If you prescribe off label, you must ensure that the child’s parent/carer is aware of this and that you document why you have decided to use the medication off label.
NICE (2024) states: In November 2024, no asthma inhalers were licensed for MART in children under 12, so this use would be off-label. The current evidence supporting the use of MART in children aged 5 to 11 is based on the use of a dry powder inhaler. Learn more about prescribing off label.
Make sure that the child has a MART asthma action plan and that a copy of this goes to school and any clubs or childcare settings the child attends. This is because schools and other childcare settings may not understand that the MART inhaler can be used as a reliever inhaler and may think that this means the child cannot use the school’s own SABA emergency inhaler – or that they must use it instead of their MART one.
If you do not think the child can manage a MART regime, then you can keep them on their ICS and SABA regime and add an 8-12 week trial of a leukotriene receptor agonist (LTRA, also known as Montelukast) instead.
Montelukast
Montelukast is taken at night time in tablet form.
Ask the child’s parent/carer to keep a symptom diary during their trial of treatment.
Make sure they know to return if they have any side effects that are worrying them and ensure that you inform the family of the potential for mental health side effects. Report all suspected adverse drug reactions associated with montelukast to the Yellow Card scheme
If it is not helping or there are side effects then stop the LTRA after (or during) the trial.
If asthma is still not controlled
Check adherence, technique, FeNO (if available) and identify any triggers, such as parental smoking/vaping and mould arising from poor housing that can be addressed. Here is a template letter that can be sent to landlords where mould or damp is an issue. If all of these factors have been considered and the child is uncontrolled:
For children on MART,
- increase their dose to paediatric moderate dose MART.
For a child who is on ICS+SABA, with or without an LTRA ,
- start them on a twice daily paediatric low dose ICS and long acting bronchodilator (LABA) combination inhaler.
Check your local formulary to find out which inhalers are licensed for children.
Update action plan accordingly.
If asthma is still not controlled
If control is not achieved for the child on moderate dose paediatric MART, they need to be referred to a specialist, usually in secondary care. Explain to the parent/carer, and the child that they must continue with their medication whilst waiting.
Children with uncontrolled asthma who are on a twice daily paediatric low dose ICS and long acting bronchodilator (LABA) combination inhaler with or without a LTRA can be increased to a twice daily paediatric moderate dose ICS/LABA.
If this does not achieve asthma control then they must be referred to an asthma specialist, and should continue their medication while they wait.
These steps are shown in the diagram below.
Stepping down
When a child's asthma has been well controlled for at least three months, it’s important to consider stepping down their therapy.
Much like inhaler choices, reducing medication must always be a shared decision, weighing the potential benefits—such as fewer side effects and a lower treatment burden—against the risk of symptoms returning.
Before stepping down, take into account how effective the treatment was when first introduced, any side effects experienced, and the child's and family’s preference.
If the child has been using a low-dose inhaled corticosteroid (ICS) alone or a low-dose maintenance and reliever therapy (MART), the next step may be to transition to a low-dose ICS/formoterol as needed.
It’s essential to agree on how this step-down process will be monitored, whether by self-assessment or clinical review, and to arrange follow-ups to ensure symptoms remain controlled. Lastly, update the child’s asthma action plan to reflect any changes in treatment and ensure caregivers know what to do if symptoms return.
