• Adjust treatment using the step-wise approach outlined below.
• Before starting a new drug or stepping up treatment, confirm with the parents their understanding of the role of treatment, adherence to treatment, inhaler technique, and appropriate elimination of trigger factors.
• Choose an effective delivery system on the basis of convenience, cost, and suitability:
• Step 1: Prescribe a short-acting beta2-agonist to all children with asthma, for rapid symptom relief.
• Step 2: Consider starting an inhaled corticosteroid (ICS) at a dose most appropriate to the severity of symptoms; for beclometasone CFC-free as Clenil Modulite^® this is 200 to 400 micrograms/day. Indications include:
• Having symptoms three times weekly or more, or
• Awakening with symptoms one night a week or more, or
• Having an exacerbation in the past 2 years, or
• Using their inhaled beta₂-agonist three times weekly or more.
• If ICS therapy is not tolerated, consider starting a leukotriene receptor antagonist or cromones. Long-acting beta₂-agonists (LABA) should only be prescribed with an ICS and therefore should not be considered an alternative to ICS.
• Step 3: Consider starting Long-acting beta2-agonists (LABA) if symptoms are still uncontrolled when using an ICS at 400 micrograms/day:
• If the child has a good response to the LABA with adequate symptom control, continue the LABA and current dose of the ICS.
• If the child has a good response to the LABA but symptom control is still inadequate, and the child is receiving 400 micrograms/day of an ICS, continue the LABA and go to step 4.
• If the child does not respond to LABA, stop the LABA. If the symptom control is inadequate and the child is receiving 400 micrograms/day of an ICS, then consider an alternative add-on treatment, such as a leukotriene receptor antagonist or modified-release theophylline, before moving to step 4.
• Step 4: Consider increasing the ICS to the maximum recommended daily dose. For beclometasone CFC-free as Clenil Modulite^® this is 800 micrograms/day.
• Step 5: Refer to a paediatrician with knowledge of respiratory medicine.
• Offer self-management education, including written action plans focusing on the individual's needs.

In depth

• Review a child with stable asthma at least once a year. More frequent follow up may be needed after the initial diagnosis, when there is a change to medication, or in children with severe asthma or recurrent exacerbations.
• Review asthma control:
• Ask about symptoms, during the day; difficulty sleeping; and the impact of asthma on such activities as exercise and schooling in the past week or month.
• Ask about past exacerbations and their frequency, and whether oral corticosteroids or hospital admission was needed.
• Ask about possible trigger factors such as exercise and allergens.
• Ask about other conditions, that are known to co-exist with asthma and aggravate symptoms: for example, allergic rhinitis.
• Look for signs of complications which may necessitate referral to a specialist.
• Review asthma medication:
• Ask about the use of reliever medication, any benefits seen with changes in medication, and compliance with treatment.
• Assess the child's inhaler technique and check peak expiratory flow rate to compare with the previously recorded value.
• Review smoking habit. Encourage parents of children with asthma to stop smoking.
• Review self-management education and make any necessary changes to written action plans.