• Consider an alternative diagnosis, or refer to secondary care for further investigations.

In depth

• Start a trial of asthma treatment for 2–3 months. The choice of treatment depends on the severity and frequency of symptoms.
• If response is good, continue treatment.
• If response is poor:
• Assess compliance and inhaler technique.
• Consider checking airway reversibility, or refer to secondary care for additional tests.

In depth

• The following options may be tried depending on the frequency and severity of symptoms:
• Watchful waiting — review the child after a time interval agreed with the parents or carers.
• Start a trial of asthma treatment for 2–3 months. The choice of treatment depends upon the severity and frequency of symptoms:
• If response is good, continue treatment.
• If response is poor, assess compliance and inhaler technique, and consider referral for additional tests to secondary care.
• If it is unclear whether a child has improved, careful observation during a trial of treatment withdrawal may clarify whether they have responded to asthma treatment.

In depth

• Check for airway obstruction using spirometry:
• Spirometry should be done by a trained healthcare professional; if this is not possible, seek advice.
• If there is no evidence of airway obstruction, consider referring to secondary care for additional tests.
• If there is evidence of airway obstruction, assess for reversibility to either bronchodilator therapy (e.g. salbutamol 400 micrograms via metered-dose inhaler and spacer) and/or to a trial of asthma treatment for 2–3 months:
• If there is significant reversibility (greater than 12% increase in forced expiratory volume in 1 second [FEV₁]) or clinical response to a trial of asthma treatment is good, a diagnosis of asthma is probable. Continue to treat as asthma.
• If there is no significant reversibility (less than 12% increase in FEV₁), and a trial of treatment is not beneficial, refer to secondary care for additional tests.
• If it is unclear whether a child has improved on a trial of asthma treatment, careful observation during a trial of treatment withdrawal may clarify whether they have responded to asthma treatment.

In depth

• Explain that lifestyle changes and medication are meant to control asthma symptoms and prevent an exacerbation.
• Explain the difference between reliever and preventive therapy, and demonstrate how to use inhalers and spacer devices.
• Prescribe an effective delivery system on the basis of convenience, cost, and suitability.
• Prescribe a short-acting beta2-agonist for use as required to treat daytime symptoms (twice weekly or less often) of short duration (lasting only a few hours).
• Prescribe a regular inhaled corticosteroid with the short-acting beta₂-agonist if symptoms are at least three times weekly, or waking the person one night weekly.
• Prescribe a peak flow meter; record the person's best peak expiratory flow rate reading; and advise regular monitoring, especially during an exacerbation, worsening symptoms, or a medication change.
• Provide education about asthma, such as how to monitor symptoms and recognize an exacerbation.

In depth