Definition and epidemiology
Asthma is a heterogeneous, chronic inflammatory airway disease defined by a history of respiratory symptoms — wheeze, breathlessness, chest tightness and cough — that vary over time and in intensity, together with variable expiratory airflow. It is the most common chronic disease of childhood. In India the burden is substantial and likely under-diagnosed, with under-treatment and reliance on oral bronchodilators and short courses of oral steroids rather than inhaled controller therapy a persistent care gap. Prevalence estimates vary widely by region, urbanisation and diagnostic method.
Clinical features
Suspect asthma when a child has recurrent episodic symptoms, particularly more than one of wheeze, cough, difficulty breathing and chest tightness. Features increasing the probability of asthma include symptoms that are worse at night or early morning; triggered by exercise, viral infection, allergen exposure, cold air, laughter or smoke; a personal or family history of atopy (eczema, allergic rhinitis); and widespread expiratory wheeze on auscultation. Isolated cough without wheeze, symptoms only with colds in a child under 5, and a normal examination during symptomatic periods should prompt consideration of alternatives.
Diagnosis
GINA 2025 anchors diagnosis on two pillars: a history of variable respiratory symptoms and documented variable expiratory airflow. In children able to perform spirometry (typically ≥5–6 years), confirm airflow variability with bronchodilator reversibility — an increase in FEV1 of >12% predicted after a bronchodilator — or excessive peak expiratory flow (PEF) variability, with mean daily diurnal PEF variability of more than 13% over two weeks supporting the diagnosis in children. GINA 2025 deliberately speaks of “variable expiratory airflow,” underscoring that airflow limitation need not be present at the moment of assessment. In preschoolers, diagnosis is clinical and often provisional, supported by a therapeutic trial of controller therapy with review.
See the full criteria: Asthma
Red flags
- Silent chest, cyanosis, exhaustion, altered consciousness or SpO2 <92% — life-threatening exacerbation
- Inability to speak in sentences, marked accessory muscle use or paradoxical thoracoabdominal movement
- Poor response to repeated bronchodilator in the acute setting
- Atypical features suggesting an alternative: failure to thrive, focal signs, clubbing, persistent productive cough, or onset in early infancy (consider cystic fibrosis, aspiration, tracheomalacia, structural disease)
Management overview
Treatment follows a stepwise approach aimed at symptom control and risk reduction. GINA no longer endorses short-acting beta-agonist (SABA)-only treatment; even mild asthma should receive inhaled corticosteroid (ICS)-containing therapy. Controller options escalate from low-dose ICS to ICS plus long-acting beta-agonist, with the as-needed ICS-formoterol approach increasingly used in older children and adolescents. Inhaler technique and a spacer (with face mask in the young) are essential, and adherence and trigger control reviewed at every visit. Acute exacerbations are managed with repeated inhaled SABA via spacer, early systemic corticosteroids, controlled oxygen to target saturation, and escalation to nebulised ipratropium, magnesium sulphate and critical care for severe cases. Provide a written action plan and arrange follow-up to step therapy up or down.
References
- Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2025 update.
- IAP Respiratory Chapter pediatric asthma guidelines.
- Nelson Textbook of Pediatrics, 21st ed.
Decision support for qualified clinicians only — verify against current primary guidelines and your clinical judgement.