Wheeze in Children
Red Flags — the wheezy child who needs more than reassurance
| Red flag | Why dangerous | Action |
|---|---|---|
| Life-threatening features — silent chest, cyanosis, poor respiratory effort, exhaustion, altered consciousness (with SpO2 <92%) | Imminent respiratory failure. A "quiet" chest in a tiring child is more dangerous than a loud wheeze. | 999; high-flow oxygen; back-to-back salbutamol; steroids; blue-light transfer |
| Acute severe — too breathless to feed/talk, marked recession, RR/HR very high, SpO2 <92% | Needs urgent treatment and assessment; can progress to life-threatening. | Salbutamol burst via spacer; oral steroid; oxygen; urgent paediatric assessment/admission |
| Sudden onset ± choking, unilateral/monophonic wheeze | Inhaled foreign body — may be missed as "viral wheeze"; risks complete obstruction and distal collapse/infection. | Urgent ENT/paediatric assessment ± rigid bronchoscopy |
| Infant <1 yr — first wheeze with poor feeding / apnoea / oxygen needs | Bronchiolitis can deteriorate; young infants and those with risk factors (prematurity, cardiac/lung disease) are vulnerable to apnoea and feeding failure. | 999: apnoea, grunting/marked recession/RR >70, central cyanosis, looks seriously unwell Consider referral: RR >60, intake 50–75% of usual, dehydration, persistent SpO2 <92% in air (NICE NG9) |
| Atypical chronic features — faltering growth, wet productive cough, clubbing, persistent focal signs, wheeze from early infancy | Suggests cystic fibrosis, bronchiectasis, congenital/cardiac disease, recurrent aspiration — not simple viral wheeze. | Paediatric referral and investigation; do not keep escalating inhalers |
| Systemic features — unexplained lymphadenopathy/hepatosplenomegaly, pallor, persistent fever, weight loss | Raises a mediastinal mass / haematological malignancy; NICE NG12: unexplained hepatosplenomegaly or petechiae in a child → immediate specialist assessment for leukaemia; generalised lymphadenopathy, pallor, persistent fatigue or unexplained fever → very urgent FBC (within 48 hours). | Very urgent FBC + paediatric referral (NICE NG12 children & young people) |
😴 Exhaustion & helplessness
Broken nights and the helplessness of watching a child struggle drive anxiety. Acknowledge it and give concrete control: what to do, what to watch, when to seek help.
"It's exhausting and frightening watching him like this — let's make sure you leave today knowing exactly what to do at home and exactly what would mean he needs to be seen urgently."🏷️ The wish for a label
A diagnosis feels like certainty. Explain that under five, the honest answer is often "wait and watch the pattern," and that this is good medicine, not indecision.
"I know a clear name would feel reassuring. At three it's genuinely hard to be certain it's asthma — many children wheeze with colds and grow out of it. Watching how the pattern develops is the most honest way to get it right for him."🚬 Smoke exposure
If anyone smokes at home, this is a major modifiable factor — raise it supportively, tied to the child's breathing, not as blame.
"One of the biggest things that helps a wheezy child's chest is keeping the home and car completely smoke-free — I can help anyone in the house who'd like support to cut down or stop."👍 Empowerment through a plan
A written action plan and confident spacer technique turn a frightening situation into a managed one — often more reassuring than any prescription.
"I'll give you a simple written plan — how much reliever to give through the spacer, how often, and the signs that mean call 999 or come straight in. You'll know exactly what to do next time."- Labelling asthma and starting a regular preventer in a pre-schooler with episodic viral wheeze
- Not assessing acute severity (feeding, speech, effort, colour)
- Not distinguishing true wheeze from stridor/stertor; missing foreign body
- Dismissing the parent's worry without a plan
999 / blue light
Life-threatening- Silent chest, cyanosis, exhaustion, poor effortAltered consciousness, usually with SpO2 <92% → oxygen, back-to-back salbutamol, steroids, 999
- Apnoea (infant)Observed or reported apnoea → 999 (NICE NG9); highest risk under 3 months, premature or with heart/lung disease
- Complete airway obstruction (foreign body)Unable to cry/cough/breathe → paediatric basic life support; 999
Same day / soon
Hours- Acute severe — can't feed/talk, marked recession, SpO2 <92%Treat + urgent paediatric assessment/admission
- Suspected inhaled foreign bodyUrgent ENT/paediatric assessment ± bronchoscopy
- Infant bronchiolitis with feeding/oxygen concernConsider referral: RR >60, intake 50–75% of usual, dehydration, SpO2 <92% in air (NICE NG9)
Community
Primary care- Episodic viral wheeze — well childReliever via spacer; written plan; safety-net; review
- Suspected asthma — interval symptomsTreatment trial + structured review; objective tests in school-age
- Atypical features (non-acute)Paediatric referral for investigation
- Not recognising a silent chest/exhaustion as life-threatening
- Missing foreign body or an unwell infant who needs admission
- Reassured by a "quiet chest" in a tiring child
- Not checking SpO2 / work of breathing / growth
- Ordering spirometry in a 3-year-old (unreliable)
- Starting long-term treatment with no review or documented pattern
- Reflex chest X-ray with no indication
🚩 Don't anchor — the patterns that should stop you escalating inhalers
Two disciplines protect the wheezy child: don't over-diagnose asthma in a pre-schooler with simple viral wheeze (avoiding unnecessary long-term treatment and a sticky label), and don't under-investigate the child whose course is atypical — sudden onset (foreign body), faltering growth or wet cough (CF/bronchiectasis), or systemic features (mediastinal/haematological). For Theo, the pattern is reassuringly typical episodic viral wheeze; the formulation is "viral-induced wheeze, no features of asthma or sinister disease today, safe for community management with review."
- Committing to "asthma" without the supporting pattern
- Missing an atypical course that needs investigation
- Failing to admit an unwell infant / severe episode
- Persisting with inhalers in an atypical child who needs investigation
Validate — name the expectation and the fear behind it
Theo's mother wants two things: a regular preventer and a definite label of asthma. Behind both sits a fear shaped by her sister's child, who has been admitted with asthma, and the exhaustion of three wheezy winters. Naming the request out loud, and naming the fear, stops the conversation feeling like a refusal before it has begun. The preventer is a reasonable thing to ask about — it is the right treatment for some wheezy children, just not for Theo's pattern today.
"You came in hoping for a preventer inhaler and a clear answer about asthma — and after watching your nephew go through it, and three bouts this winter, I completely understand why. Let me explain what I think is going on, and then we'll decide together."Explain — share the reasoning in plain language
Wheeze only with colds, and completely well in between, is the pattern of episodic viral wheeze — the commonest cause of wheeze at this age; many children improve as their airways mature, though some go on to have symptoms later, so the pattern is reviewed over time. Under 5, asthma cannot be confirmed with breathing tests (NICE NG245, joint with BTS and SIGN), so any label now would be a guess that tends to stay in the record. A daily preventer treats the airway between colds, and Theo's airway is fine between colds. What changes the decision is clear: symptoms between colds (night cough, wheeze on running or laughing), frequent or severe attacks needing steroids or hospital, or signs of allergy.
"His airways are small, and when he catches a cold they narrow and whistle. Because he's completely fine in between, a daily preventer wouldn't have anything to work on most of the time. If he starts coughing at night, wheezing when he runs about, or needs steroid medicine or hospital for an attack, that changes things — and I'd then suggest a trial of a preventer with a set date to review it."Negotiate — offer concrete control today
The mother must leave with more than a "no". A salbutamol inhaler with a spacer and mask, the technique taught and watched in the room, a written plan saying how many puffs and when to call 999, a smoke-free home conversation with an offer of help for Theo's father, and a booked review. Record the working description as "episodic viral wheeze" (or "pre-school wheeze") with a review date, not "asthma".
"Here's what I'll do today: a blue reliever and a spacer, and I'll show you how to use them now; a written plan with exactly what to do and when to call 999; help for his dad if he'd like to stop smoking; and a review so we can watch the pattern together. If things change, we change the plan."A pMDI fired directly into a young child's mouth deposits most of the drug in the mouth and throat. A spacer holds the aerosol so it can be inhaled with normal breathing; a face mask gives a seal in children too young to close their lips around a mouthpiece. Delivered this way, salbutamol is as effective as a nebuliser in most acute attacks (BTS/SIGN 158), with less tachycardia and tremor.
Shake the inhaler, fit it to the spacer, mask sealed over nose and mouth, one puff at a time followed by about five normal breaths, then repeat. Never put several puffs into the spacer at once. Clean it according to the manufacturer's instructions and let it drip-dry (rubbing causes static that holds the drug on the wall). Move to a mouthpiece once the child can reliably seal their lips around it. A calm child on a parent's lap breathes the drug in; a screaming child mostly does not.
Tobacco smoke irritates and inflames the small airways, increases the frequency and severity of viral wheezy episodes and reduces the response to treatment. Smoking outside still leaves smoke residue on clothes, hair and skin that the child is exposed to when held. Smoking in a car carrying anyone under 18 has been illegal in England and Wales since 2015.
Ask every time, including about vaping and smoking "only outside". Offer Theo's father a referral to the local stop-smoking service and pharmacotherapy — very brief advice (ask, advise, act) is more effective than advice alone. Frame it around Theo's breathing, not blame. Record smoke exposure in the child's notes.
A written plan converts the parent's fear into a sequence of actions: when to start the reliever, how many puffs, what "not working" looks like, and when to call 999. The National Review of Asthma Deaths (RCP, 2014) found that only 23% of those who died had a personal asthma action plan, and that 45% did not seek or receive medical help during the fatal attack.
Use a standard children's plan (for example the Asthma + Lung UK child action plan, adapted for a pre-schooler with viral wheeze). Fill it in with the parent in the room. Include the danger signs in plain words: too breathless to feed, talk or play; sucking in under the ribs; blue or grey lips; drowsy or floppy; reliever not lasting 4 hours. Give a copy for the nursery.
Damp and mould release spores and irritants that worsen respiratory symptoms, and children with respiratory conditions are particularly vulnerable. The UK government's 2023 guidance for the housing sector on the health risks of damp and mould followed the death of two-year-old Awaab Ishak. In a child with multiple-trigger wheeze, house-dust mite, pets and cold air may also play a part.
Ask about damp, visible mould and condensation. Where present, a GP letter documenting the child's respiratory condition can support a repair request to a landlord. Avoid expensive allergen-avoidance products without evidence of sensitisation. Treat coexisting eczema and allergic rhinitis properly.
Viral infections are the trigger for almost every episode of pre-school wheeze. Influenza can cause severe attacks in children with asthma. Children from age 2 are offered the nasal influenza vaccine (LAIV) through the national programme — but not while acutely wheezy: a child with increased wheeze or extra bronchodilator use in the previous 72 hours should be offered an inactivated vaccine instead to avoid delay (Green Book, chapter 19) — and children with asthma needing continuous or repeated inhaled or oral steroids, or with a previous admission, are in a clinical risk group (UKHSA Green Book, chapter 19).
Check the immunisation record at the review. Offer influenza vaccine each autumn. The practice protocol for childhood asthma also asks that immunisations be kept up to date.
Episodes often start during the day at nursery. Staff who hold the child's own reliever and spacer, and know the danger signs, can start treatment early. Schools in England have been permitted since 2014 to keep an emergency salbutamol inhaler for children diagnosed with asthma and prescribed a reliever, with written parental consent (Department of Health guidance on emergency salbutamol inhalers in schools).
Give the parent a second inhaler and spacer for the setting if needed, and a copy of the plan. Correct the "the nursery says he's asthmatic" message gently: the plan says "wheeze with colds — give reliever via spacer as below". Revisit when the child starts school.
Episodic viral wheeze (Theo): SABA via spacer and mask for episodes only
- No routine preventer for infrequent, mild episodes with no symptoms between colds (practice protocol)
- Suspected asthma with symptoms needing maintenance therapy, or severe acute episodes: consider an 8–12 week trial of twice-daily paediatric low-dose ICS plus SABA as needed (NG245)
- If symptoms have resolved on the trial: consider stopping ICS and SABA treatment and review symptoms after a further 3 months. If symptoms recur by that review, or there is an attack needing systemic steroids or hospital, restart regular ICS at paediatric low dose (titrating to moderate dose if needed) with SABA (NG245). If symptoms did not resolve on the trial, reconsider the diagnosis
- If uncontrolled on a paediatric moderate-dose ICS: consider an LTRA for an 8–12 week trial; if unsuccessful, stop it and refer to a specialist in asthma care (NG245)
Twice-daily paediatric low-dose ICS + SABA as needed
- Diagnose first: FeNO ≥35 ppb; if not raised or unavailable, spirometry with BDR (FEV₁ ↑ ≥12%, or ≥10% of predicted); if unavailable or delayed, PEF variability ≥20% over 2 weeks; then HDM skin-prick or total IgE plus eosinophils; refer if doubt remains
- Uncontrolled: paediatric low-dose MART if the child can manage the regimen; if not, consider adding an LTRA (8–12 week trial, stop if ineffective), then paediatric low-dose ICS/LABA + SABA
- Still uncontrolled: paediatric moderate-dose MART (or moderate-dose ICS/LABA)
- Refer to a specialist if uncontrolled on moderate-dose MART or moderate-dose ICS/LABA (± LTRA)
Grade severity first; SABA via spacer ± mask; steroid; reassess
- Moderate (SpO₂ ≥92%, able to talk/feed): salbutamol 2–10 puffs via spacer, one puff at a time, titrated to response; consider oral prednisolone
- Severe (SpO₂ <92%, too breathless to talk/feed, HR/RR over age thresholds): oxygen to SpO₂ 94–98%, 10 puffs via spacer or nebulised salbutamol, prednisolone; emergency treatment and hospital assessment (999 if life-threatening)
- Life-threatening: 999, oxygen, nebulised salbutamol with ipratropium, prednisolone, repeat bronchodilator while awaiting transfer
- Prednisolone: 20 mg age 2–5, 30–40 mg over 5, usually up to 3 days (BTS/SIGN 158); children’s SPC 1–2 mg/kg (max 40 mg) under 12
- First wheezy illness in an infant (most under 1; NG9 covers under 2s) with coryza, cough, tachypnoea, crackles and/or wheeze, poor feeding
- Management is supportive: feeding, fluids, oxygen if needed. NG9 recommends not using salbutamol, ipratropium, adrenaline, montelukast, antibiotics or corticosteroids
- 999: apnoea, looks seriously unwell, severe respiratory distress (grunting, marked recession, RR >70), central cyanosis
- Consider referral: RR >60, difficulty breastfeeding or intake 50–75% of usual, clinical dehydration, persistent SpO₂ <92% in air — with a lower threshold for prematurity, age under 3 months, chronic lung disease, congenital heart disease, neuromuscular disorders or immunodeficiency
- Tell parents the illness peaks around days 3–5 and the cough resolves in 90% of infants within 3 weeks
- Regular ICS: not indicated for infrequent episodic viral wheeze with no interval symptoms; would expose him to a daily steroid with little to treat between colds
- Routine oral prednisolone for mild viral wheeze in a well pre-school child: the evidence of benefit is weak; reserve for a severe episode or a significant attack in a child already on a preventer (practice protocol)
- Antibiotics: not indicated for wheeze; only for genuine bacterial infection (focal signs, high fever, unwell child)
- Montelukast as a default: evidence in episodic viral wheeze is inconsistent; if used, it should be a specialist decision or a time-limited trial, with MHRA neuropsychiatric counselling
- Nebuliser at home: a spacer is as effective for most attacks and avoids delaying help by treating a severe attack at home
"Shake it, put it in the spacer, mask on snugly, one puff, then let him take five normal breaths. Then the next puff. If he needs it more than every four hours, or it isn't helping, he needs to be seen — and if he's struggling to breathe, talk or feed, call 999."
SCA: teaching spacer technique in the room — not just prescribing an inhaler — is a Tasks and Relating to Others marker. Say "one puff at a time".
"This is a preventer — it works slowly by calming the airways, so it has to be given every day, morning and evening, even when he's well. It won't help in an attack; that's what the blue one is for. We'll review it in 8 to 12 weeks and stop it if it hasn't made a clear difference."
SCA: the words "trial" and "review date" are what distinguish appropriate use from premature labelling.
"This one inhaler is both the preventer and the reliever. Use it every day as agreed, and use it for symptoms too. If you find you need lots of extra doses, contact us — and follow the plan for when to call 999."
Off-label use: NICE NG245 notes that only Symbicort Turbohaler 100/6 is licensed for MART at 6–11, so MART with other ICS/formoterol inhalers under 12 (or at age 5) is off-label — explain and document if used.
"This is a trial for about two to three months. A small number of children get bad dreams, trouble sleeping, or changes in mood or behaviour — if you notice that, stop it and let us know."
SCA: naming the MHRA neuropsychiatric warning and building in a stop date shows safe prescribing.
"Give this once a day in the morning, dissolved in water, for the days on the label — it settles the swelling in the airways over a day or so. Keep using the blue inhaler through the spacer as the plan says."
SCA: state the dose by age and the duration; a 3-day course usually needs no taper.
"This is croup — a virus that swells the voice box, not the lower airways. One dose of this medicine helps settle it. Keep him calm on your lap; if the noisy breathing is there even when he's resting, or he's struggling, call 999."
SCA: distinguishing stridor (inspiratory, upper airway) from wheeze (expiratory, lower airway) is the first reasoning step in this case.
Parental fear and hypervigilance
Parents of wheezy children often lie awake listening to breathing, and a relative's severe asthma magnifies the fear. Fear without a plan leads either to repeated emergency attendances or, worse, to freezing when the child is truly unwell. Concrete danger signs and a practised response are the best treatment for parental anxiety.
"What would help you feel more confident at 2 o'clock in the morning? Let's go through exactly what you'd see and exactly what you'd do."Work and childcare
Each episode can mean days off work, nursery exclusion and financial strain, particularly for single parents or those in insecure work. Asking about it signals that you have seen the whole picture, and a note for the employer or nursery can help.
"How has work been with all these bouts? If a letter for your employer or the nursery would help, I'm happy to write one."Sleep and exhaustion
Night-time coughing and checking on the child disrupt the whole household. Exhaustion lowers the threshold for wanting "something stronger" and makes it harder to follow a plan. Acknowledge it; check the parent's own mood; involve the other parent in night-time care and in the plan.
"You sound exhausted — which is completely understandable. How are you doing yourself? Is there anyone who can share the nights when he's poorly?"Guilt, blame and the smoking parent
A parent who smokes may feel accused, and the other parent may feel angry. Framing smoke exposure as a shared, fixable risk — with practical help — protects the relationship with the family and makes change more likely.
"Lots of parents smoke, and it's really hard to stop. The good news is that making the home and car smoke-free, and getting support to quit, makes a real difference to children's chests. Would Theo's dad be open to some help?"The label and identity
An "asthma" code in a pre-schooler's record tends to persist, shapes how nursery and school treat the child, and commits the family to long-term treatment decisions. A provisional description ("pre-school viral wheeze") with a review date protects the child while keeping the possibility of asthma open.
"I'll write it down as wheeze with colds for now. That doesn't mean we're ignoring it — it means we're keeping an open mind until the pattern is clear."Driving and getting help
There is no DVLA issue for the child, but the practical question matters: families without a car, or a parent tempted to drive a struggling child to hospital, need clear advice. A child with severe or life-threatening features should travel by ambulance, not in the back of a car with one parent driving.
"If he's struggling to breathe, don't drive him yourself — call 999 so he can have oxygen and treatment on the way."Within 48 hours — after an episode treated at home
Review within 48 hours after an acute episode managed in the community, and after any emergency attendance (practice protocols). Is the reliever lasting 4 hours? Feeding and sleeping? Recheck severity and SpO₂. Watch the spacer technique again. Confirm the parent has the written plan and understands the danger signs. If prednisolone was given, check the course is completed.
1–2 weeks after an acute attack
For a child with asthma who has had an attack or a steroid course, the childhood asthma protocol asks for a further review at 1–2 weeks: why did the attack happen (virus, missed preventer, technique, smoke)? Update the action plan. Each attack is information about whether maintenance treatment is adequate.
8–12 weeks — end of any ICS trial
If a preventer trial was started (suspected asthma or multiple-trigger wheeze), review deliberately: has there been a clear reduction in episodes and interval symptoms? If the symptoms have resolved, NG245 says to consider stopping ICS and SABA treatment and review symptoms after a further 3 months. If symptoms have not resolved, check technique and adherence, environmental sources and the mimics, and refer to a specialist in asthma care if none explains it (NG245).
End of winter / after the next episode — the pattern review
For Theo: how many episodes, how severe, any symptoms between colds, any steroid courses or attendances? Is the smoke-free plan working? A shift to interval symptoms or frequent severe episodes justifies an ICS trial; an unchanged episodic pattern supports continuing the current plan. Plot growth.
Annually, and at school age
Any child on a preventer: review at least annually — control, reliever use, technique, adherence, growth, smoke exposure, influenza vaccine, and whether treatment is still needed (step down if control is sustained). At age 5 or over, revisit the diagnosis: NG245 objective tests (FeNO, spirometry with BDR, PEF variability) become possible. Many children will have stopped wheezing and any provisional label can be removed.
Memory rule — "TASTE" before any step-up
At every review check Technique (watch it), Adherence (prescription count), Smoke and trigger exposure, The diagnosis (is it really wheeze or asthma — or a mimic?), and Events (attacks, steroid courses, emergency attendances). NG245 and both practice protocols require these to be checked before treatment is increased — escalating against poor technique gives a higher dose and the same symptoms.
| Treatment / marker | Monitor | Timing | Action threshold |
|---|---|---|---|
| Reliever (SABA) use | Frequency of use; prescriptions issued | Every contact | Needed more than every 4 hours in an episode → same-day review. Frequent use between colds → reassess pattern (multiple-trigger / asthma). More than 12 reliever prescriptions a year → urgent review (NRAD 2014) |
| Inhaler and spacer technique | Observed technique; mask seal; spacer condition | Every contact | Any error → re-teach and re-check before changing medication |
| ICS (preventer) | Height and weight plotted; oral thrush; adherence | End of trial (8–12 weeks); at least annually | No clear benefit → stop. Controlled → step down to lowest effective dose. Falling growth centiles → review dose and refer |
| Montelukast | Sleep, mood, behaviour | End of 8–12 week trial; any contact | Neuropsychiatric effect → stop (MHRA April 2024). No benefit → stop |
| Oral steroid courses | Number of courses; attendances; admissions | Every review | Repeated courses → review maintenance therapy; frequent courses or escalation beyond low-dose ICS → paediatric referral (practice protocol) |
| Growth and atypical features | Weight/height centiles; wet cough; clubbing; focal signs | Each review | Any atypical feature → stop escalating inhalers; paediatric referral |
| Diagnostic label | Coded description in record | At review and at age 5 | "Suspected asthma" / "pre-school wheeze" revisited; objective tests from 5 (NG245); remove label if symptoms have resolved |
⚠ Three scenario-specific phrases — use these verbatim
Why safety-netting matters beyond clinical care — document it
- Starting a regular preventer for episodic viral wheeze
- Not teaching spacer technique
- No written safety-net / danger signs; no review
Who you are
You are Theo's mum. Theo is 3, normally a whirlwind. Three times this winter he's started with a runny nose and cough and gone wheezy for a few days, then been completely fine again — running around, eating well, sleeping well, no night cough, no problems when he's playing. Today he's at the tail end of a cold, a bit wheezy and coughing but chatting away, playing with the toys and not distressed. You're shattered from broken nights and worried. Your sister's son has severe asthma and it frightens you. You came in convinced Theo needs to be started on a regular preventer inhaler and given a clear diagnosis.
Hidden concerns (reveal if explored)
Fear (main): watching him struggle to breathe scares you and you feel helpless. If the doctor gives you a clear plan and shows you what to do, you feel much better.
Wanting certainty: "not knowing" is hard. If the doctor explains honestly why they'd wait before calling it asthma, and what they'd watch for, you can accept it.
Smoking: Theo's dad smokes (outside, mostly). You'll mention it if asked and are open to help.
Clinical details if asked
- Completely well between colds — no night cough, no wheeze when running about, no symptoms without a cold
- Each episode starts with coryza, lasts a few days, settles
- No eczema; no hay fever; parents not asthmatic (sister's child is)
- Born at term; growing well; eating and gaining normally
- Today: feeding, talking in full sentences, playing; mild wheeze/cough; not blue, not sucking in
- No sudden choking episode; no small-object incident; no weight loss, lumps or unusual tiredness
- Theo's dad smokes
Reactions at key moments
- On "not asthma yet": "But he clearly wheezes — why won't you call it asthma?" → reassured by an honest explanation of pattern and age.
- On no preventer: mild disappointment → satisfied if given a reliever + spacer + written plan instead.
- On the spacer: grateful to be shown how to use it properly.
- Challenge line: "So you're not going to do anything? I came here for a preventer."
Resolution: Theo's mum leaves satisfied if the GP: (1) takes her fear seriously and assesses the acute episode (safe for home); (2) explains the difference between viral wheeze and asthma, and why a firm label/preventer is deferred at 3 — without dismissing her; (3) provides a reliever via spacer with technique taught, and a clear written safety-net with danger signs; (4) addresses smoke exposure supportively; (5) arranges review to watch the pattern. She disengages if she feels fobbed off with "it's nothing," given no plan, or if her worry is brushed aside.
- Silent chest, cyanosis, exhaustion, poor effort
- Altered consciousness, apnoea (SpO2 <92% alone = severe: oxygen + admit)
- Can't feed/talk, marked recession
- Foreign body; unwell infant (bronchiolitis)
- Episodic viral wheeze (well child)
- Suspected asthma — trial
Well between colds; no interval symptoms. Reliever via spacer for episodes; technique; written safety-net; review. No routine preventer; no firm asthma label <5.
Interval symptoms, atopy, family history. Structured treatment trial + review; objective tests (spirometry/FeNO) in school-age. Investigate atypical features (CF, foreign body, cardiac, mediastinal mass).