Pre-referral guidelines for primary care providers

Asthma is a common condition seen in children over the age of 12 months characterized by reversible bronchoconstriction and inflammation with excess mucous production. In children it is commonly triggered by viral respiratory tract infections and aeroallergens.

Asthma is commonly familial and is seen in children with atopy, which includes asthma, eczema, rhinitis (hay fever) and food allergies.

For the management of acute asthma, please refer to the Royal Children’s Hospital clinical practice guidelines.


Asthma is a clinical diagnosis based on reversible bronchoconstriction (i.e. response to a bronchodilator such as salbutamol). Typical symptoms include wheeze, cough, shortness of breath and chest tightness. Interval symptoms (i.e. experienced between acute flares) such as nocturnal cough, exercise induced wheeze or morning shortness of breath are also typically seen in asthma, and distinguish asthma from viral induced wheeze (below).


Viral induced wheeze is typically seen in children up to five years of age and is characterized by wheeze only during acute illnesses that is often responsive to salbutamol. The child is well between episodes. There is no role for steroid preventers.

Bronchiolitis (see bronchiolitis pre-referral guideline) is seen in children up to 18 months of age and is characterized by bilateral wheeze and/or crepitations. There is no role for salbutamol or steroids.

Pneumonitis is typically seen in children two years of age and older. It is characterized by bilateral creptitations with hypoxia. There is minimal role for salbutamol and no role for steroids.

Practice points

  • Asthma is generally not diagnosed prior to 12 months of age
  • Viral induced wheeze is distinct from asthma and is seen in children up to five years of age with no interval symptoms
  • There is no role for liquid salbutamol or antibiotics in the management of asthma
  • First line preventer therapy for asthma is a single agent steroid (e.g. fluticasone), not combination steroid and long-acting beta-agonist, for which there is little evidence in the under 12 year old age group.
  • Use a step down approach to management, including preventers, once symptom relief is obtained, thus minimising steroid use.


For acute asthma management, please refer to the Royal Children’s Hospital clinical practice guidelines.

For chronic asthma control please consider the following points:

  • Ensure all children have an asthma management plan (see Useful Resources below) that the family understand, with a copy provided for the school/kinder.
  • Use salbutamol via metered dose inhaler (MDI) and spacer (plus mask for smaller children less then 3-4 years old) for acute symptoms.
  • There is no role for nebulized salbutamol in the home environment, given studies show equal efficacy to MDI with increased side effect profile.
  • There is no role for oral salbutamol liquid in any circumstances for the management of asthma in Australia.
  • Consider salbutamol prior to sport when there are frequent exercise induced symptoms.
  • Preventer therapy should be considered in children in whom salbutamol use is required more than 3 times per week (and response is observed):
    • First line preventer therapy is a single agent steroid (e.g. fluticasone).
    • Leukotriene inhibitors (e.g. montelukast or Singulair) can be considered as a single agent or add on therapy to steroids, particularly when there are significant exercise induced symptoms or co-morbid rhinitis. Be aware of behaviour and sleep problems as a side effect in a small number of patients.
    • Combination preventers using steroids plus long-acting beta-agonists (e.g. Seretide) should only be considered if single agent steroids fail to adequately contain symptoms
  • Consider the concurrent management of other atopic conditions (e.g. rhinitis, eczema)
  • Consider education around spacer technique, medication adherance and minimisation of triggers (e.g. smoking).
  • Further information can be found through the Royal Children’s Hospital clinical practice guidelines.

Referral pathways