Summary of paediatric asthma national guidelines: focusing on management
| Guideline | Year | First-line management | Add-on therapies* | Treatment withdrawal |
| NICE Guidelines (UK)49 | 2017 | Aged 1–4 years: SABA monotherapy Aged 5–16 years: SABA monotherapy | Aged 1–4 years: second line: low-dose ICS, third line: low-dose ICS and LTRA, fourth line: referral for specialist management Aged 5–16 years: second line: low-dose ICS, third line: low-dose ICS and LTRA, fourth line: low-dose ICS and LABA; fifth line: high-dose ICS and LABA; sixth line: referral for specialist management | Consider withdrawing maintenance treatment after 3 months of stable asthma. Only consider stopping ICS on those who are on ICS monotherapy. |
| GINA (global)20 | 2021 | 5 years and under: SABA monotherapy 6–11 years: combined low-dose ICS+SABA (as needed) Adolescents: combined low-dose ICS+SABA | 5 years and under: second line: low-dose ICS, third line: medium-dose ICS or low-dose ICE and LTRA, fourth line: refer for expert advice Aged 6–11 years: second line: low-dose ICS; third line: low-dose ICS and LABA or medium-dose ICS or daily SMART combined ICS/LABA; refer for expert advice; fourth line: refer for phenotype assessment Adolescents: second line: low-dose ICS; third line: medium-dose ICS; fourth line: medium-dose/high-dose ICS±LAMA; refer for phenotype assessment | Stepping down treatment should be considered when both asthma symptoms and lung function have been stable for a period of 3 months or more. |
| Canadian Thoracic Society (Canada)32 | 2021 | Aged 1–5 years: SABA monotherapy Aged 6–11: SABA monotherapy Age 12+: SABA monotherapy | Aged 1–5 years: second line: ICS and LTRA, third line: high-dose ICS and LTRA, fourth line: referral for specialist management Aged 6–11: second line: ICS and LTRA; third line: high-dose ICS and LTRA; fourth line: high-dose ICS, LTRA and LABA; fifth line: high-dose ICS, LTRA, LABA and oral steroids Age 12+: second line: ICS and LTRA; third line: ICS, LTRA and LABA; fourth line: high-dose ICS, LTRA, LABA and tiotropium | After asthma has been well controlled for a period of 3–6 months |
| National Asthma Council Australia30 | 2021 | Age 1–5 years: SABA monotherapy Aged six and over: SABA monotherapy | Age 1–5 years: second line: low-dose ICS or LTRA; third line: low-dose ICS and LTRA; fourth line: referral for specialist management Age 6 and over: second line: low-dose ICS or LTRA; third line: low-dose ICS and LTRA or high-dose ICS or ICS/LABA combination; fourth line: referral for specialist management | Step-down of treatment should be considered when symptoms have been well controlled for a period of at least 6 months. |
| Asthma and Respiratory Foundation NZ (New Zealand)31 | 2020 | Aged 1–4 years: SABA and low-dose ICS Aged 5–11 years: SABA monotherapy | Age 1–4 years: second line: low-dose ICS and LTRA, third line: referral for specialist management Age 5–11 years: second line: SABA and low-dose ICS; third line: LABA and low-dose ICS; fourth line: LABA, high dose ICS, LTRA and referral for specialist management | If the child has been stable for 3 months or more on treatment, step-down with an incremental approach. |
| Irish College of General Practitioners (Ireland)50 | 2020 | Aged 6–11: ICS and SABA (ICS only to be taken when SABA is used as a reliever) Adolescents: ICS and SABA (ICS only to be taken when SABA is used as a reliever) | Aged 6–11: second line: low-dose ICS or LTRA (if ICS is not appropriate); third line: low-dose ICS and LABA or high dose ICS; fourth line: medium-dose ICS, LABA and referral to paediatrics for management advice; fifth line: refer to paediatrics for phenotype assessment Adolescents: second line: low-dose ICS; third line: low-dose ICS and LABA; fourth line: medium-dose ICS and LABA or low dose ICS, LABA and LAMA; fifth line: refer to paediatrics for phenotype assessment | |
| The Japanese Society of Allergology (Japan)27 | 2020 | Age 1–5 years: SABA monotherapy Age 6–15 years: SABA monotherapy | Age 1–5 years: second line: low-dose ICS or LTRA or disodium cromoglycate, third line: medium-dose ICS, fourth line: high dose ICS and LTRA Age 6–15 years: second line: low-dose ICS or LTRA, third line: medium-dose ICS or combined low-dose ICS/LABA, fourth line: high-dose ICS or combined medium dose ICS/LABA | – |
| International Consensus on Paediatric Asthma (global)25 | 2015 | Quotes GINA and NICE guidelines | Quotes GINA and NICE guidelines | |
| GEMA (Spain)24 | 2009 | Age 3 and under: SABA monotherapy Age 3 and over: SABA monotherapy | Age 3 and under: second line: low-dose ICS or LTRA; third line: moderate-dose ICS or low-dose ICS and LTRA; fourth line: moderate-dose ICS and LTRA; fifth line: high-dose ICS and LTRA; consider adding LABA; sixth line: oral steroids Age 3 and under: second line: low-dose ICS or LTRA; third line: moderate-dose ICS or low dose ICS and LTRA or low dose ICS and LABA; fourth line: moderate-dose ICS and LTRA or moderate-dose ICS and LABA; fifth line: high-dose ICS and LABA; consider adding LTRA and theophyllines; sixth line: consider oral steroids and omalizumab | |
| Ministry of Health (Singapore)26 | 2008 | No stepwise approach outlined | No stepwise approach outlined | Consider stepping down treatment when symptoms are stable for 3–6 months considering the child’s risk of poor outcomes. Do not stop ICS. |
| South African Thoracic Society (South Africa)67 | 2007 | Adolescents: SABA +low-dose ICS | Adolescents : second line: LABA and ICS; third line: LABA, low-dose ICS and LTRA/LABA or high dose ICS or LABA, low dose ICS and theophyllines. Consider oral corticosteroids; fourth line: referral to specialist | - |
*SABA reliever therapy as required at any stage.
GINA, Global Initiative for Asthma; ICS, inhaled corticosteroid; LABA, long-acting beta agonist; LAMA, long-acting muscarinic antagonist; LTRA, leucotriene receptor antagonist; NICE, National Institute for Health and Care Excellence; SABA, short-acting beta agonist; SMART, single maintenance and reliever therapy.