GINA 2025
Asthma in Children
What You Need to Know
A concise summary of GINA 2025 guidelines focused on pediatric asthma — diagnosis, challenges, and stepwise treatment for children under 5 and aged 6–11 years.
Criteria for Initial Diagnosis of Asthma
GINA 2025 requires two things: a compatible symptom history AND evidence of variable expiratory airflow limitation.
A. History
Symptoms: wheeze, shortness of breath, chest tightness, and/or cough. These should vary in frequency and intensity, and classically:
Timing
Worse at night or after exertion
Triggers
Exercise, allergens, laughter, cold air
Pattern
Worsens after viral infections
Variation
Symptoms vary — not fixed obstruction
B. Evidence of Variable Expiratory Airflow
Any ONE of the following criteria satisfies this:
① Bronchodilator reversibility (BDR)
FEV₁ ≥12% of predicted or PEF ≥15% of predicted
Adults: PEF ≥20%
② Average daily PEF variability
Children ≥13%
③ Significant ICS response
FEV₁ ↑ ≥12% or PEF ≥15% — after 4 weeks of ICS
④ Positive bronchial challenge test
⑤ Excessive variation in lung function between visits
Practical Challenges in Diagnosis — Children
A. BDR Testing — Spirometry is Impractical in Kids
Spirometry is the gold standard — but in children it has real limitations: limited availability, and interpretation is not always accessible. Risk of over- or under-diagnosis is real.
So GINA 2025 prefers PEF in children: PEF ≥15% after bronchodilator (vs ≥20% in adults, FEV₁ ≥12%).
If spirometry or PEF is unavailable or uninterpretable:
B. FEV₁/FVC Ratio — Omitted in Children
GINA 2025 has deliberately dropped FEV₁/FVC ratio testing in children because:
False positives
Poor testing methods in children
Laryngospasm risk
Can induce laryngospasms during forced maneuvers
Clinical mismatch
Children can wheeze and cough with a normal FEV₁/FVC ratio
C. Bronchial Provocation Testing
Hyperventilation and methacholine challenge — excluded from routine pediatric use. Risk of provoking severe bronchospasm.
D. Cough Variant Asthma
Classical wheeze absent. Spirometry may be normal. Diagnosis of exclusion in chronic non-specific cough.
Clues: Family history of asthma, history of atopy.
Rule out: GERD, post-nasal drip, sinusitis, ACE inhibitor use.
Management: Trial of ICS — if cough improves, supports diagnosis.
How to Investigate Uncontrolled Asthma
If already on ICS and uncontrolled: increase dose and re-measure lung function in 3 months.
Treatment — Children 6–11 Years
| Step | Clinical Picture | Treatment |
|---|---|---|
| Step 1 | Symptoms <2 days/week | SABA PRN + ICS PRN SABA alone → ↑ mortality. Always add ICS. |
| Step 2 | Symptoms 2–5 days/week | Daily low-dose ICS + SABA PRN e.g. Budesonide 100–200 mcg/day |
| Step 3 | Most days, waking ≥1×/week. No low lung function. | MART: Low dose ICS + formoterol or medium dose ICS or low dose ICS-LABA + SABA |
| Step 4 | Most days, waking ≥1×/week + low lung function | MART: Medium dose ICS + formoterol Short course OCS may be needed |
| Step 5 | Poor control despite Step 4 | Individualised. Phenotypic assessment. Biologics or expert referral. |
Step 5 — Severe / Refractory Asthma
Individualised treatment. Do phenotypic assessment first.
Type 2 Inflammation
Raised eosinophils → Steroid-responsive
Non-Type 2
Raised neutrophils → Steroid non-responsive
Assess comorbidities: obesity, GERD, allergic rhinitis.
Biologic Add-On Options
Treatment — Age ≥12 Years
| Step | Preferred Treatment |
|---|---|
| Steps 1–2 | ICS + formoterol PRN (MART). LABA combination reduces future exacerbations. |
| Step 3 | MART: Low dose ICS + formoterol |
| Step 4 | MART: Medium dose ICS + formoterol |
| Step 5 | Expert referral + phenotypic assessment. Add-on: biologics or LAMA (tiotropium) |
Montelukast: Less effective than ICS. Associated with serious mental health effects — counsel families.
Children Under 5 Years
Clinical diagnosis only. No spirometry. No formal BDR. Intermittent wheeze can be asthma or viral wheeze (RSV, bronchiolitis) — cannot always be distinguished early.
Clinical Diagnosis Requires All Three:
Initial Management:
Key Numbers
FEV₁ ≥12% BDR threshold — all ages
PEF ≥15% Children (vs ≥20% adults)
Daily variability ≥13% Children
FeNO ≥35 ppb Children — supports T2
ICS response Check at 4 weeks
Uncontrolled reassessment At 3 months
SABA >2×/week in 1 month Start regular ICS (<5yr)
No SABA 4h before testing Washout rule