• 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, for rapid symptom relief.
• Step 2: Consider starting an inhaled corticosteroid (ICS) at a dose that is appropriate for the severity of symptoms (usually equivalent to beclometasone CFC-free as Clenil Modulite^® 200 to 400 micrograms/day). Indications for ICS include:
• Having symptoms three times weekly or more, or
• Awakening with symptoms one night weekly or more, or
• Having an exacerbation in the last 2 years, or
• Using inhaled short-acting beta₂-agonist three times weekly or more.
• If ICS are not tolerated or are contraindicated, consider starting a leukotriene receptor antagonist at step 2 (but do so only in children aged 2–5 years).
• Step 3: If the child still has symptoms while using regular ICS (equivalent to Clenil Modulite^® [beclometasone CFC-free] 400 micrograms/day), consider:
• For children younger than 2 years: move to step 4.
• For children aged 2–5 years: initiate a trial of a leukotriene receptor antagonist; if asthma remains inadequately controlled, move to step 4.
• Step 4: Refer to a paediatrician with knowledge about respiratory diseases.
• Offer self-management education, including written action plans focusing on the child's and the family'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.