This document outlines guidelines for the management of asthma in children. It discusses definitions of asthma, risk factors, pathogenesis, assessment and diagnosis, investigations including spirometry and peak expiratory flow rates, pharmacological and non-pharmacological management, management in primary care settings and when to refer to specialists. It also provides a step-by-step approach to asthma treatment and medication options based on symptom control.

1. MANAGEMENT OF ASTHMA IN
CHILDREN
BY
DR SANGEETHA VIJIAN
PEGAWAI PERUBATAN UD 52
HOSPITAL SULTAN ISMAIL
JOHOR BAHRU

2. OUTLINE
1. DEFINITION
2. RISK FACTOR & PATHOGENESIS
3. ASSESSMENT AND DIAGNOSIS
4. INVESTIGATIONS
5. MANAGEMENT ( PHARMACOLOGICAL/ NON PHARMACOLOGICAL)
6. MANAGEMENT IN PRIMARY CARE SETTING, WHEN TO REFER ?
7. HOW TO USE A MDI WITH A AEROCHAMBER? –STEP BY STEP
8. CASE DISCUSSION
9. REFERENCES

3. DEFINITION
Chronic lung heterogeneous disease characterised by
recurrent/episodic/paroxysmal breathing problems & symptoms such as;
 Breathlessness
 Wheezing
 Chest tightness
 Coughing

4. RISK FACTOR
ALLERGENS
POLLUTANTS
EXTREME WEATHER
MEDICATIONS
OBESITY
URTI
FAMILY HX OF
BA/ATOPY

5. Pathophysiology
• Chronic inflammatory disorder of the airways. (Host)
• Airways are hyperresponsive; become obstructed (bronchoconstriction,
mucus plugs, & increased inflammation) when exposed to various risk
factors. (Host)
• Common risk factors; allergens (house dust mites, animals with fur,
cockroaches, pollens, molds), occupational irritants, tobacco smoke,
respiratory (viral) infections, exercise, strong emotional expressions,
chemical irritants, & drugs (aspirin & beta blockers). (Environment)

8. Assessment & DIAGNOSIS
A diagnosis of asthma in young children is largely based on
symptoms patterns combined with a careful clinical history and
physical findings. A positive family history or positive history of
atopy may be predictive.
Probability of asthma: LOW MODERATE HIGH
Duration of symptoms
(cough,wheeze, heavy
breathing) during URTI
< 10 days > 10 days > 10 days
Number of exacerbations 2-3 per year >3 per year, or severe
episodes
>3 per year, or severe
episodes
Interval symptoms
(between episodes or
exacerbations
No symptoms occasional cough or
wheeze
cough and/or wheeze
during play/
laughing/exercise
Atopy or family history of
asthma
Nil Nil Present

9. EVALUATION OF NEWLY DIAGNOSED ASTHMA IN CHILDREN

10. features suggestive of asthma in children < 5 years old
• Cough: recurrent/persistent non-productive cough that worsens at
night
• Wheezing : Recurrent wheezing during sleep or with triggers with
activity,eg: laughing, crying or exposure to tobacco smoke or air
pollution
• Past/family history of allergic disease or asthma in first degree
relative
• Difficult or heavy breathing or shortness of breath occurring
withexercise, laughing or playing
• Reduced activity: not running, playing, or laughing at the same
intensityas other children.
• Therapeutic trial with moderate dose inhaled steroids: Clinical
improvement in 2-4 wks of controller treatment and worsening when
treatment is stopped

11. EVALUATION OF ASTHMA CONTROL
Characteristic Controlled Partly Controlled Uncontrolled
Daytime symptoms None (2 or less/ week) More than twice a week
Three or more features of
partly controlled asthma
present in any week
Limitations of activity None Any
Nocturnal symptoms/
awakening
None Any
Need for reliever/ rescue
treatment
None (twice or less/ week More than twice/ week
Lung function (PEF or FEV1) Normal < 80% predicted or personal
best (if known)
Exacerbations None One or more/year

12. ASSESSMENT OF SEVERITY OF ACUTE ASTHMA
EXCERBATION FOR CHILDREN

14. SPIROMETRY
-useful in children > 6 years old
An Objective measure of airflow limitation
-Low FEV1 ( relative to percentage of predicted)
-FEV1/FVC Ratio < 0.80
Bronchodilator response ( to inhaled ᵝ agonist)
-Improvement in FEV >12% and >200mL
Exercise challenge
-Worsening in FEV1>15%
Daily peak flow or FEV1monitoring
-day to day and /or am-pm variation >20%

15. PEFR
Simple and inexpensive home use tools to meaure airflow and can be
helpful in a number of circumstances
-Significant diurnal variability (>20%).
Peak flow rate (PEFR) measurement
Based on the patient’s height and gender, identify the
predicted PEFR value i.e. x
(Refer to PEFR for Malaysian children).
Take the best patient’s PEFR measurement i.e. y
Calculation PEFR percentage:
• (y/x) x 100% = z%

16. • In Atypical cases ;
Chest x-ray
Sinus x-rays
High Resolution Computer Tomography (HRCT) thorax scan
Lung function tests
Bronchoscopy
Mantoux testing.

18. Add-on anti-IL5
or, as last resort,
consider add-on
low dose OCS, but
consider side-effects
*Very low dose: BUD-FORM 100/6 mcg
†Low dose: BUD-FORM 200/6 mcg (metered doses).
PREFERRED
CONTROLLER
to prevent exacerbations
and control symptoms
Other controller options
(limited indications, or
less evidence for efficacy
or safety)
RELIEVER
STEP 1
Low dose ICS
taken whenever
SABA taken
Consider daily
low dose ICS
Children 6-11 years
Personalized asthma management:
Assess, Adjust, Review
Asthma medication options:
Adjust treatment up and down for
individual child’s needs
STEP 2
Daily low dose inhaled corticosteroid (ICS)
(see table of ICS dose ranges for children)
Daily leukotriene receptor antagonist (LTRA), or
low dose ICS taken whenever SABA taken
STEP 3
Low dose ICS-
LABA, OR medium
dose ICS, OR
very low dose*
ICS-formoterol
maintenance and
reliever (MART)
STEP 4
Medium dose
ICS-LABA,
OR low dose†
ICS-formoterol
maintenance
and reliever
therapy (MART).
Refer for expert
advice
STEP 5
Refer for
phenotypic
assessment
± higher dose
ICS-LABA or
add-on therapy,
e.g. anti-IgE,
anti-IL4R
Add tiotropium
or add LTRA
Low dose
ICS + LTRA
As-needed short-acting beta2-agonist (or ICS-formoterol reliever in MART in Steps 3 and 4)
Symptoms
Exacerbations
Side-effects
Lung function
Child and parent
satisfaction
Confirmation of diagnosis if necessary
Symptom control & modifiable
risk factors (see Box 2-2B)
Comorbidities
Inhaler technique & adherence
Child and parent preferences and goals
Treatment of modifiable risk factors
& comorbidities
Non-pharmacological strategies
Asthma medications (adjust down or up)
Education & skills training
Box 3-5B © Global Initiative for Asthma 2022, www.ginasthma.org

19. Add-on anti-IL5
or, as last resort,
consider add-on
low dose OCS, but
consider side-effects
*Very low dose: BUD-FORM 100/6 mcg
†Low dose: BUD-FORM 200/6 mcg (metered doses).
PREFERRED
CONTROLLER
to prevent exacerbations
and control symptoms
Other controller options
(limited indications, or
less evidence for efficacy
or safety)
RELIEVER
STEP 1
Low dose ICS
taken whenever
SABA taken
Consider daily
low dose ICS
Asthma medication options:
Adjust treatment up and down for
individual child’s needs
STEP 2
Daily low dose inhaled corticosteroid (ICS)
(see table of ICS dose ranges for children)
Daily leukotriene receptor antagonist (LTRA), or
low dose ICS taken whenever SABA taken
STEP 3
Low dose ICS-
LABA, OR medium
dose ICS, OR
very low dose*
ICS-formoterol
maintenance and
reliever (MART)
STEP 4
Medium dose
ICS-LABA,
OR low dose†
ICS-formoterol
maintenance
and reliever
therapy (MART).
Refer for expert
advice
STEP 5
Refer for
phenotypic
assessment
± higher dose
ICS-LABA or
add-on therapy,
e.g. anti-IgE,
anti-IL4R
Add tiotropium
or add LTRA
Low dose
ICS + LTRA
As-needed short-acting beta2-agonist (or ICS-formoterol reliever in MART in Steps 3 and 4)
Symptoms
Exacerbations
Side-effects
Lung function
Child and parent
satisfaction
Confirmation of diagnosis if necessary
Symptom control & modifiable
risk factors (see Box 2-2B)
Comorbidities
Inhaler technique & adherence
Child and parent preferences and goals
Treatment of modifiable risk factors
& comorbidities
Non-pharmacological strategies
Asthma medications (adjust down or up)
Education & skills training
Children 6-11 years
Personalized asthma management:
Assess, Adjust, Review
Symptoms
Exacerbations
Side-effects
Lung function
Child and parent
satisfaction
Confirmation of diagnosis if necessary
Symptom control & modifiable
risk factors (see Box 2-2B)
Comorbidities
Inhaler technique & adherence
Child and parent preferences and goals
Treatment of modifiable risk factors
& comorbidities
Non-pharmacological strategies
Asthma medications (adjust down or up)
Education & skills training
Box 3-5B, 1/6 © Global Initiative for Asthma 2022, www.ginasthma.org

20. Add-on anti-IL5
or, as last resort,
consider add-on
low dose OCS, but
consider side-effects
*Very low dose: BUD-FORM 100/6 mcg
†Low dose: BUD-FORM 200/6 mcg (metered doses).
PREFERRED
CONTROLLER
to prevent exacerbations
and control symptoms
Other controller options
(limited indications, or
less evidence for efficacy
or safety)
RELIEVER
STEP 1
Low dose ICS
taken whenever
SABA taken
Consider daily
low dose ICS
Asthma medication options:
Adjust treatment up and down for
individual child’s needs
STEP 2
Daily low dose inhaled corticosteroid (ICS)
(see table of ICS dose ranges for children)
Daily leukotriene receptor antagonist (LTRA), or
low dose ICS taken whenever SABA taken
STEP 3
Low dose ICS-
LABA, OR medium
dose ICS, OR
very low dose*
ICS-formoterol
maintenance and
reliever (MART)
STEP 4
Medium dose
ICS-LABA,
OR low dose†
ICS-formoterol
maintenance
and reliever
therapy (MART).
Refer for expert
advice
STEP 5
Refer for
phenotypic
assessment
± higher dose
ICS-LABA or
add-on therapy,
e.g. anti-IgE,
anti-IL4R
Add tiotropium
or add LTRA
Low dose
ICS + LTRA
As-needed short-acting beta2-agonist (or ICS-formoterol reliever in MART in Steps 3 and 4)
Symptoms
Exacerbations
Side-effects
Lung function
Child and parent
satisfaction
Confirmation of diagnosis if necessary
Symptom control & modifiable
risk factors (see Box 2-2B)
Comorbidities
Inhaler technique & adherence
Child and parent preferences and goals
Treatment of modifiable risk factors
& comorbidities
Non-pharmacological strategies
Asthma medications (adjust down or up)
Education & skills training
Children 6-11 years
Personalized asthma management:
Assess, Adjust, Review
RELIEVER As-needed short-acting beta2-agonist (or ICS-formoterol reliever in MART in Steps 3 and 4)
PREFERRED
CONTROLLER
to prevent exacerbations
and control symptoms
Other controller options
(limited indications, or
less evidence for efficacy
or safety)
STEP 1
Low dose ICS
taken whenever
SABA taken
Consider daily
low dose ICS
Asthma medication options:
Adjust treatment up and down for
individual child’s needs
STEP 2
STEP 3
STEP 4
STEP 5
Box 3-5B, 2/6 © Global Initiative for Asthma 2022, www.ginasthma.org

21. Add-on anti-IL5
or, as last resort,
consider add-on
low dose OCS, but
consider side-effects
*Very low dose: BUD-FORM 100/6 mcg
†Low dose: BUD-FORM 200/6 mcg (metered doses).
PREFERRED
CONTROLLER
to prevent exacerbations
and control symptoms
Other controller options
(limited indications, or
less evidence for efficacy
or safety)
RELIEVER
STEP 1
Low dose ICS
taken whenever
SABA taken
Consider daily
low dose ICS
Asthma medication options:
Adjust treatment up and down for
individual child’s needs
STEP 2
Daily low dose inhaled corticosteroid (ICS)
(see table of ICS dose ranges for children)
Daily leukotriene receptor antagonist (LTRA), or
low dose ICS taken whenever SABA taken
STEP 3
Low dose ICS-
LABA, OR medium
dose ICS, OR
very low dose*
ICS-formoterol
maintenance and
reliever (MART)
STEP 4
Medium dose
ICS-LABA,
OR low dose†
ICS-formoterol
maintenance
and reliever
therapy (MART).
Refer for expert
advice
STEP 5
Refer for
phenotypic
assessment
± higher dose
ICS-LABA or
add-on therapy,
e.g. anti-IgE,
anti-IL4R
Add tiotropium
or add LTRA
Low dose
ICS + LTRA
As-needed short-acting beta2-agonist (or ICS-formoterol reliever in MART in Steps 3 and 4)
Symptoms
Exacerbations
Side-effects
Lung function
Child and parent
satisfaction
Confirmation of diagnosis if necessary
Symptom control & modifiable
risk factors (see Box 2-2B)
Comorbidities
Inhaler technique & adherence
Child and parent preferences and goals
Treatment of modifiable risk factors
& comorbidities
Non-pharmacological strategies
Asthma medications (adjust down or up)
Education & skills training
Children 6-11 years
Personalized asthma management:
Assess, Adjust, Review
PREFERRED
CONTROLLER
to prevent exacerbations
and control symptoms
Other controller options
(limited indications, or
less evidence for efficacy
or safety)
STEP 1
Asthma medication options:
Adjust treatment up and down for
individual child’s needs
STEP 4
STEP 5
STEP 2
STEP 3
Low dose ICS-
LABA, OR medium
dose ICS, OR
very low dose*
ICS-formoterol
maintenance and
reliever (MART)
Low dose
ICS + LTRA
RELIEVER As-needed short-acting beta2-agonist (or ICS-formoterol reliever in MART in Steps 3 and 4)
Box 3-5B, 4/6 © Global Initiative for Asthma 2022, www.ginasthma.org

22. Add-on anti-IL5
or, as last resort,
consider add-on
low dose OCS, but
consider side-effects
*Very low dose: BUD-FORM 100/6 mcg
†Low dose: BUD-FORM 200/6 mcg (metered doses).
PREFERRED
CONTROLLER
to prevent exacerbations
and control symptoms
Other controller options
(limited indications, or
less evidence for efficacy
or safety)
RELIEVER
STEP 1
Low dose ICS
taken whenever
SABA taken
Consider daily
low dose ICS
Asthma medication options:
Adjust treatment up and down for
individual child’s needs
STEP 2
Daily low dose inhaled corticosteroid (ICS)
(see table of ICS dose ranges for children)
Daily leukotriene receptor antagonist (LTRA), or
low dose ICS taken whenever SABA taken
STEP 3
Low dose ICS-
LABA, OR medium
dose ICS, OR
very low dose*
ICS-formoterol
maintenance and
reliever (MART)
STEP 4
Medium dose
ICS-LABA,
OR low dose†
ICS-formoterol
maintenance
and reliever
therapy (MART).
Refer for expert
advice
STEP 5
Refer for
phenotypic
assessment
± higher dose
ICS-LABA or
add-on therapy,
e.g. anti-IgE,
anti-IL4R
Add tiotropium
or add LTRA
Low dose
ICS + LTRA
As-needed short-acting beta2-agonist (or ICS-formoterol reliever in MART in Steps 3 and 4)
Symptoms
Exacerbations
Side-effects
Lung function
Child and parent
satisfaction
Confirmation of diagnosis if necessary
Symptom control & modifiable
risk factors (see Box 2-2B)
Comorbidities
Inhaler technique & adherence
Child and parent preferences and goals
Treatment of modifiable risk factors
& comorbidities
Non-pharmacological strategies
Asthma medications (adjust down or up)
Education & skills training
Children 6-11 years
Personalized asthma management:
Assess, Adjust, Review
PREFERRED
CONTROLLER
to prevent exacerbations
and control symptoms
Other controller options
(limited indications, or
less evidence for efficacy
or safety)
STEP 1
Asthma medication options:
Adjust treatment up and down for
individual child’s needs
STEP 5
STEP 2
STEP 4
Medium dose
ICS-LABA,
OR low dose†
ICS-formoterol
maintenance
and reliever
therapy (MART).
Refer for expert
advice
Add tiotropium
or add LTRA
STEP 3
RELIEVER As-needed short-acting beta2-agonist (or ICS-formoterol reliever in MART in Steps 3 and 4)
Box 3-5B, 5/6 © Global Initiative for Asthma 2022, www.ginasthma.org

23. Add-on anti-IL5
or, as last resort,
consider add-on
low dose OCS, but
consider side-effects
*Very low dose: BUD-FORM 100/6 mcg
†Low dose: BUD-FORM 200/6 mcg (metered doses).
PREFERRED
CONTROLLER
to prevent exacerbations
and control symptoms
Other controller options
(limited indications, or
less evidence for efficacy
or safety)
RELIEVER
STEP 1
Low dose ICS
taken whenever
SABA taken
Consider daily
low dose ICS
Asthma medication options:
Adjust treatment up and down for
individual child’s needs
STEP 2
Daily low dose inhaled corticosteroid (ICS)
(see table of ICS dose ranges for children)
Daily leukotriene receptor antagonist (LTRA), or
low dose ICS taken whenever SABA taken
STEP 3
Low dose ICS-
LABA, OR medium
dose ICS, OR
very low dose*
ICS-formoterol
maintenance and
reliever (MART)
STEP 4
Medium dose
ICS-LABA,
OR low dose†
ICS-formoterol
maintenance
and reliever
therapy (MART).
Refer for expert
advice
STEP 5
Refer for
phenotypic
assessment
± higher dose
ICS-LABA or
add-on therapy,
e.g. anti-IgE,
anti-IL4R
Add tiotropium
or add LTRA
Low dose
ICS + LTRA
As-needed short-acting beta2-agonist (or ICS-formoterol reliever in MART in Steps 3 and 4)
Symptoms
Exacerbations
Side-effects
Lung function
Child and parent
satisfaction
Confirmation of diagnosis if necessary
Symptom control & modifiable
risk factors (see Box 2-2B)
Comorbidities
Inhaler technique & adherence
Child and parent preferences and goals
Treatment of modifiable risk factors
& comorbidities
Non-pharmacological strategies
Asthma medications (adjust down or up)
Education & skills training
Children 6-11 years
Personalized asthma management:
Assess, Adjust, Review
PREFERRED
CONTROLLER
to prevent exacerbations
and control symptoms
Other controller options
(limited indications, or
less evidence for efficacy
or safety)
STEP 1
Asthma medication options:
Adjust treatment up and down for
individual child’s needs
STEP 2
STEP 3
Add-on anti-IL5
or, as last resort,
consider add-on
low dose OCS, but
consider side-effects
STEP 5
Refer for
phenotypic
assessment
± higher dose
ICS-LABA or
add-on therapy,
e.g. anti-IgE,
anti-IL4R
STEP 4
RELIEVER As-needed short-acting beta2-agonist (or ICS-formoterol reliever in MART in Steps 3 and 4)
Box 3-5B, 6/6 © Global Initiative for Asthma 2022, www.ginasthma.org

24. PREFERRED
CONTROLLER
CHOICE
Other controller options
(limited indications, or
less evidence for efficacy
or safety)
RELIEVER
CONSIDER
THIS STEP FOR
CHILDREN WITH:
STEP 1
Children 5 years and younger
Personalized asthma management:
Assess,Adjust, Review response
Asthma medication options:
Adjust treatment up and down for
individual child’s needs
Infrequent viral
wheezing and no
or few interval
symptoms
Asthma diagnosis, and
asthma not well-controlled
on low dose ICS
Asthma not
well-controlled
on double ICS
Before stepping up, check for alternative diagnosis,
check inhaler skills, review adherence and exposures
As-needed short-acting beta2-agonist
Symptom pattern not consistent with asthma but wheezing
episodes requiring SABA occur frequently, e.g. ≥3 per year.
Give diagnostic trial for 3 months. Consider specialist referral.
Symptom pattern consistent with asthma, and asthma
symptoms not well-controlled or ≥3 exacerbations per year.
STEP 2
Daily low dose inhaled corticosteroid (ICS)
(see table of ICS dose ranges for pre-school children)
STEP 3
Double ‘low
dose’ ICS
Low dose ICS + LTRA
Consider specialist
referral
STEP 4
Continue
controller & refer
for specialist
assessment
Add LTRA, or increase
ICS frequency, or add
intermittent ICS
Daily leukotriene receptor antagonist (LTRA), or
intermittent short course of ICS at onset of
respiratory illness
Symptoms
Exacerbations
Side-effects
Parent satisfaction
Exclude alternative diagnoses
Symptom control & modifiable
risk factors
Comorbidities
Inhaler technique & adherence
Parent preferences and goals
Treat modifiable risk factors
and comorbidities
Non-pharmacological strategies
Asthma medications
Education & skills training
Consider intermittent
short course ICS at
onset of viral illness
Box 6-5 © Global Initiative for Asthma 2022, www.ginasthma.org

25. PREFERRED
CONTROLLER
CHOICE
Other controller options
(limited indications, or
less evidence for efficacy
or safety)
RELIEVER
CONSIDER
THIS STEP FOR
CHILDREN WITH:
STEP 1
Asthma medication options:
Adjust treatment up and down for
individual child’s needs
Infrequent viral
wheezing and no
or few interval
symptoms
Asthma diagnosis, and
asthma not well-controlled
on low dose ICS
Asthma not
well-controlled
on double ICS
Before stepping up, check for alternative diagnosis,
check inhaler skills, review adherence and exposures
As-needed short-acting beta2-agonist
Symptom pattern not consistent with asthma but wheezing
episodes requiring SABA occur frequently, e.g. ≥3 per year.
Give diagnostic trial for 3 months. Consider specialist referral.
Symptom pattern consistent with asthma, and asthma
symptoms not well-controlled or ≥3 exacerbations per year.
STEP 2
Daily low dose inhaled corticosteroid (ICS)
(see table of ICS dose ranges for pre-school children)
STEP 3
Double ‘low
dose’ ICS
Low dose ICS + LTRA
Consider specialist
referral
STEP 4
Continue
controller & refer
for specialist
assessment
Add LTRA, or increase
ICS frequency, or add
intermittent ICS
Daily leukotriene receptor antagonist (LTRA), or
intermittent short course of ICS at onset of
respiratory illness
Symptoms
Exacerbations
Side-effects
Parent satisfaction
Exclude alternative diagnoses
Symptom control & modifiable
risk factors
Comorbidities
Inhaler technique & adherence
Parent preferences and goals
Treat modifiable risk factors
and comorbidities
Non-pharmacological strategies
Asthma medications
Education & skills training
Consider intermittent
short course ICS at
onset of viral illness
Children 5 years and younger
Personalized asthma management:
Assess,Adjust, Review response
Symptoms
Exacerbations
Side-effects
Parent satisfaction
Exclude alternative diagnoses
Symptom control & modifiable
risk factors
Comorbidities
Inhaler technique & adherence
Parent preferences and goals
Treat modifiable risk factors
and comorbidities
Non-pharmacological strategies
Asthma medications
Education & skills training
Box 6-5, 1/5 © Global Initiative for Asthma 2022, www.ginasthma.org

26. PREFERRED
CONTROLLER
CHOICE
Other controller options
(limited indications, or
less evidence for efficacy
or safety)
RELIEVER
CONSIDER
THIS STEP FOR
CHILDREN WITH:
STEP 1
Asthma medication options:
Adjust treatment up and down for
individual child’s needs
Infrequent viral
wheezing and no
or few interval
symptoms
Asthma diagnosis, and
asthma not well-controlled
on low dose ICS
Asthma not
well-controlled
on double ICS
Before stepping up, check for alternative diagnosis,
check inhaler skills, review adherence and exposures
As-needed short-acting beta2-agonist
Symptom pattern not consistent with asthma but wheezing
episodes requiring SABA occur frequently, e.g. ≥3 per year.
Give diagnostic trial for 3 months. Consider specialist referral.
Symptom pattern consistent with asthma, and asthma
symptoms not well-controlled or ≥3 exacerbations per year.
STEP 2
Daily low dose inhaled corticosteroid (ICS)
(see table of ICS dose ranges for pre-school children)
STEP 3
Double ‘low
dose’ ICS
Low dose ICS + LTRA
Consider specialist
referral
STEP 4
Continue
controller & refer
for specialist
assessment
Add LTRA, or increase
ICS frequency, or add
intermittent ICS
Daily leukotriene receptor antagonist (LTRA), or
intermittent short course of ICS at onset of
respiratory illness
Symptoms
Exacerbations
Side-effects
Parent satisfaction
Exclude alternative diagnoses
Symptom control & modifiable
risk factors
Comorbidities
Inhaler technique & adherence
Parent preferences and goals
Treat modifiable risk factors
and comorbidities
Non-pharmacological strategies
Asthma medications
Education & skills training
Consider intermittent
short course ICS at
onset of viral illness
Children 5 years and younger
Personalized asthma management:
Assess,Adjust, Review response
PREFERRED
CONTROLLER
CHOICE
Other controller options
(limited indications, or
less evidence for efficacy
or safety)
RELIEVER
CONSIDER
THIS STEP FOR
CHILDREN WITH:
Asthma medication options:
Adjust treatment up and down for
individual child’s needs
Infrequent viral
wheezing and no
or few interval
symptoms
As-needed short-acting beta2-agonist
STEP 2
STEP 3
STEP 4
Consider intermittent
short course ICS at
onset of viral illness
STEP 1
Box 6-5, 2/5 © Global Initiative for Asthma 2022, www.ginasthma.org

27. PREFERRED
CONTROLLER
CHOICE
Other controller options
(limited indications, or
less evidence for efficacy
or safety)
RELIEVER
CONSIDER
THIS STEP FOR
CHILDREN WITH:
STEP 1
Asthma medication options:
Adjust treatment up and down for
individual child’s needs
Infrequent viral
wheezing and no
or few interval
symptoms
Asthma diagnosis, and
asthma not well-controlled
on low dose ICS
Asthma not
well-controlled
on double ICS
Before stepping up, check for alternative diagnosis,
check inhaler skills, review adherence and exposures
As-needed short-acting beta2-agonist
Symptom pattern not consistent with asthma but wheezing
episodes requiring SABA occur frequently, e.g. ≥3 per year.
Give diagnostic trial for 3 months. Consider specialist referral.
Symptom pattern consistent with asthma, and asthma
symptoms not well-controlled or ≥3 exacerbations per year.
STEP 2
Daily low dose inhaled corticosteroid (ICS)
(see table of ICS dose ranges for pre-school children)
STEP 3
Double ‘low
dose’ ICS
Low dose ICS + LTRA
Consider specialist
referral
STEP 4
Continue
controller & refer
for specialist
assessment
Add LTRA, or increase
ICS frequency, or add
intermittent ICS
Daily leukotriene receptor antagonist (LTRA), or
intermittent short course of ICS at onset of
respiratory illness
Symptoms
Exacerbations
Side-effects
Parent satisfaction
Exclude alternative diagnoses
Symptom control & modifiable
risk factors
Comorbidities
Inhaler technique & adherence
Parent preferences and goals
Treat modifiable risk factors
and comorbidities
Non-pharmacological strategies
Asthma medications
Education & skills training
Consider intermittent
short course ICS at
onset of viral illness
Children 5 years and younger
Personalized asthma management:
Assess,Adjust, Review response
PREFERRED
CONTROLLER
CHOICE
Other controller options
(limited indications, or
less evidence for efficacy
or safety)
RELIEVER
CONSIDER
THIS STEP FOR
CHILDREN WITH:
Asthma medication options:
Adjust treatment up and down for
individual child’s needs STEP 3
STEP 4
Symptom pattern not consistent with asthma but wheezing
episodes requiring SABA occur frequently, e.g. ≥3 per year.
Give diagnostic trial for 3 months. Consider specialist referral.
Symptom pattern consistent with asthma, and asthma
symptoms not well-controlled or ≥3 exacerbations per year.
STEP 2
Daily low dose inhaled corticosteroid (ICS)
(see table of ICS dose ranges for pre-school children)
Daily leukotriene receptor antagonist (LTRA), or
intermittent short course of ICS at onset of
respiratory illness
STEP 1
As-needed short-acting beta2-agonist
Box 6-5, 3/5 © Global Initiative for Asthma 2022, www.ginasthma.org

28. PREFERRED
CONTROLLER
CHOICE
Other controller options
(limited indications, or
less evidence for efficacy
or safety)
RELIEVER
CONSIDER
THIS STEP FOR
CHILDREN WITH:
STEP 1
Asthma medication options:
Adjust treatment up and down for
individual child’s needs
Infrequent viral
wheezing and no
or few interval
symptoms
Asthma diagnosis, and
asthma not well-controlled
on low dose ICS
Asthma not
well-controlled
on double ICS
Before stepping up, check for alternative diagnosis,
check inhaler skills, review adherence and exposures
As-needed short-acting beta2-agonist
Symptom pattern not consistent with asthma but wheezing
episodes requiring SABA occur frequently, e.g. ≥3 per year.
Give diagnostic trial for 3 months. Consider specialist referral.
Symptom pattern consistent with asthma, and asthma
symptoms not well-controlled or ≥3 exacerbations per year.
STEP 2
Daily low dose inhaled corticosteroid (ICS)
(see table of ICS dose ranges for pre-school children)
STEP 3
Double ‘low
dose’ ICS
Low dose ICS + LTRA
Consider specialist
referral
STEP 4
Continue
controller & refer
for specialist
assessment
Add LTRA, or increase
ICS frequency, or add
intermittent ICS
Daily leukotriene receptor antagonist (LTRA), or
intermittent short course of ICS at onset of
respiratory illness
Symptoms
Exacerbations
Side-effects
Parent satisfaction
Exclude alternative diagnoses
Symptom control & modifiable
risk factors
Comorbidities
Inhaler technique & adherence
Parent preferences and goals
Treat modifiable risk factors
and comorbidities
Non-pharmacological strategies
Asthma medications
Education & skills training
Consider intermittent
short course ICS at
onset of viral illness
Children 5 years and younger
Personalized asthma management:
Assess,Adjust, Review response
Before stepping up, check for alternative diagnosis,
check inhaler skills, review adherence and exposures
PREFERRED
CONTROLLER
CHOICE
Other controller options
(limited indications, or
less evidence for efficacy
or safety)
RELIEVER
CONSIDER
THIS STEP FOR
CHILDREN WITH:
Asthma medication options:
Adjust treatment up and down for
individual child’s needs
As-needed short-acting beta2-agonist
STEP 2
STEP 4
STEP 1
Asthma diagnosis, and
asthma not well-controlled
on low dose ICS
STEP 3
Double ‘low
dose’ ICS
Low dose ICS + LTRA
Consider specialist
referral
Box 6-5, 4/5 © Global Initiative for Asthma 2022, www.ginasthma.org

29. PREFERRED
CONTROLLER
CHOICE
Other controller options
(limited indications, or
less evidence for efficacy
or safety)
RELIEVER
CONSIDER
THIS STEP FOR
CHILDREN WITH:
STEP 1
Asthma medication options:
Adjust treatment up and down for
individual child’s needs
Infrequent viral
wheezing and no
or few interval
symptoms
Asthma diagnosis, and
asthma not well-controlled
on low dose ICS
Asthma not
well-controlled
on double ICS
Before stepping up, check for alternative diagnosis,
check inhaler skills, review adherence and exposures
As-needed short-acting beta2-agonist
Symptom pattern not consistent with asthma but wheezing
episodes requiring SABA occur frequently, e.g. ≥3 per year.
Give diagnostic trial for 3 months. Consider specialist referral.
Symptom pattern consistent with asthma, and asthma
symptoms not well-controlled or ≥3 exacerbations per year.
STEP 2
Daily low dose inhaled corticosteroid (ICS)
(see table of ICS dose ranges for pre-school children)
STEP 3
Double ‘low
dose’ ICS
Low dose ICS + LTRA
Consider specialist
referral
STEP 4
Continue
controller & refer
for specialist
assessment
Add LTRA, or increase
ICS frequency, or add
intermittent ICS
Daily leukotriene receptor antagonist (LTRA), or
intermittent short course of ICS at onset of
respiratory illness
Symptoms
Exacerbations
Side-effects
Parent satisfaction
Exclude alternative diagnoses
Symptom control & modifiable
risk factors
Comorbidities
Inhaler technique & adherence
Parent preferences and goals
Treat modifiable risk factors
and comorbidities
Non-pharmacological strategies
Asthma medications
Education & skills training
Consider intermittent
short course ICS at
onset of viral illness
Children 5 years and younger
Personalized asthma management:
Assess,Adjust, Review response
Before stepping up, check for alternative diagnosis,
check inhaler skills, review adherence and exposures
PREFERRED
CONTROLLER
CHOICE
Other controller options
(limited indications, or
less evidence for efficacy
or safety)
RELIEVER
CONSIDER
THIS STEP FOR
CHILDREN WITH:
Asthma medication options:
Adjust treatment up and down for
individual child’s needs
As-needed short-acting beta2-agonist
STEP 2
STEP 1
STEP 3
Asthma not
well-controlled
on double ICS
STEP 4
Continue
controller & refer
for specialist
assessment
Add LTRA, or increase
ICS frequency, or add
intermittent ICS
Box 6-5, 5/5 © Global Initiative for Asthma 2022, www.ginasthma.org

31. NON PHARMACOLOGICAL APPROACH
Identifying and avoiding the following common triggers:
Exercise
PREVENTION
Respiratory tract
infections
Cigarette smoke
Environmental
allergens
Food allergy

32. PRIMARY CARE MANAGEMENT
ASTHMA IN CHILDREN
(ACUTE/CHRONIC CASE)

33. Initial management of asthma exacerbations in children ≤5 years

34. Indicationsfor immediatetransferto hospital for children≤5 years

41. KEY INDICATION OF REFERRAL CHILDREN
< 5 YEARS OLD
Failure to thrive
 Neonatal or very early onset of symptoms especially associated
with failure to thrive
Vomiting with respiratory symptoms
Continuous wheezing
Failure to respond to controller medications
 No associations of symptoms with typical triggers such as URTI
 Focal or cardiovascular signs or finger clubbing
 Hypoxaemia outside context of viral illness

42. PATIENT EDUCATION
 Explanation of the nature of the disease and its
treatment. It is important to emphasise that it is likely
to be a prolonged process but the long term outcome is
encouraging. Children with well-managed asthma can enjoy a
normal active life.
 Recognition of signs and symptoms of asthma, avoiding
trigger factors and understanding the causal mechanisms
of the disease.
 Information about medications including the role of each
medication, dosages, timing and technique of using
delivery devices. There should be precise instructions
and demonstrations on their proper administration.
Potential side effects should be discussed.
 Instructions on self-management: written asthma action
plans/ Asthma diary

45. GOALS OF THERAPY in primary care
participation in normal activities
•minimal chronic symptoms, including nocturnal and exercise induced cough
minimal absences from school
minimal adverse effects from medications
minimal need for use of beta-agonists
elimination of the necessity for visits to emergency departments and hospitalization

46. HOW TO USE A MDI
WITH A AEROCHAMBER?
*video*

49. CASE SCENARIO
A 3-year-old boy, has been brought to the clinic by his
parents due to three episodes of coughing and wheezing,
with the first episode occurring approximately 6 months
previously. The child has a history of eczema and his
mother suffered from asthma. The father is a smoker.
I) What are the further history that you want to know?
II) What is the probable diagnosis in this Case?
III) What is the differential diagnosis?

50. IV) What are the investigations that you want to
do?
V) How do you manage this patient and how often
do you want to see him in your clinic ?

51. REFERENCES
1. Management of Asthma at Primary Care Level
2. Paediatric Proctocols for Malaysian Hospital
3. Clinical Practice Guidelines for the Management of Childhood
Asthma
4.GINA Guidelines 2022