Dr Vivek’s Blog — Clinical Notes

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.

GINA 2025 Pediatrics Dr. Vivek

Asthma is one of the most common chronic diseases in children. GINA 2025 brings updates that are clinically important — especially for the way we diagnose asthma in kids, where spirometry limitations change the game, and how treatment is now structured around MART and phenotypic assessment at higher steps.

01 / Diagnosis

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

Type 2 Biomarkers: FeNO ≥50 ppb (adults) / ≥35 ppb (children); eosinophilia — these support Type 2 asthma but do not confirm diagnosis alone.

02 / Diagnostic Challenges

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:

→Start a trial of ICS

→Re-assess lung function later

→Look for: FEV₁ ≥12% or PEF ≥15% after 4 weeks of ICS

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.

Only acceptable provocation method in children: Standardized Exercise Challenge Test.

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.

03 / Uncontrolled Asthma

How to Investigate Uncontrolled Asthma

①Correct inhaler technique

②Confirm diagnosis of asthma

③Reduce risk factors (NSAIDs, smoking, beta blockers, allergens)

④Assess and manage comorbidities (obesity, GERD, allergic rhinitis)

⑤Consider short-term treatment step-up

⑥Refer for expert advice

Before testing: No SABA for 4 hours. No ICS-LABA ×24 hrs (formoterol) or ×36 hrs (vilanterol). No LAMA ×36 hours.

If already on ICS and uncontrolled: increase dose and re-measure lung function in 3 months.

04 / Treatment

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.

MART = single inhaler (ICS + formoterol) used as both daily maintenance and reliever. Only formoterol qualifies — fast-onset LABA.

05 / Step 5

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

Omalizumab

Anti-IgE

Mepolizumab

Anti-IL-5

Dupilumab

Anti-IL-4Rα

06 / ≥12 Years

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)

Not recommended: Oral salbutamol, oral theophylline, inhaled fenoterol.
Montelukast: Less effective than ICS. Associated with serious mental health effects — counsel families.

07 / Under 5

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:

①Recurrent acute wheeze or at least 1 wheezing episode + asthma-like symptoms in between

+No likely alternative cause

+Clinical response to SABA and/or ICS

Acute wheezing episode: Expiratory wheeze + SOB + accessory muscle use — lasting more than 24 hours, or confirmed by a healthcare worker.

Initial Management:

→Give SABA for 1–7 days

→If SABA needed >2×/week in one month → start low-dose ICS for 3 months

Quick Reference

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

GINA 2025Asthma in ChildrenWhat You Need to Know