Cough in Children Algorithm

Safety

Red Flags — Exclude emergency respiratory causes first

Done

Cough is rarely life-threatening but these presentations demand immediate action.

Stridor at rest Croup, epiglottitis, bacterial tracheitis or foreign body. Stridor at rest → Urgent same-day; with significant recession, cyanosis, exhaustion or altered consciousness → 999 — do not examine throat

Respiratory failure Apnoea, cyanosis or respiratory arrest; severe distress with exhaustion, reduced consciousness or inability to speak/feed; persistent hypoxia; rapidly progressive respiratory failure → 999

Choking episode / sudden onset Inhaled foreign body — especially age 6mo–3yr, during meal/play. Ongoing airway compromise → 999; no current complete obstruction → Same-day ED; back blows if conscious + choking

Whooping cough — young infant Particularly <6 months, or any infant with apnoea/cyanosis. Paroxysmal cough + whoop / cyanosis / apnoea → Same-day hospital (apnoea risk)

Haemoptysis Blood in sputum in child → urgent investigation. Consider bronchiectasis, TB, CF, foreign body → Same-day assessment

Severe wheeze / acute asthma Too breathless to talk/feed, silent chest, poor respiratory effort, exhaustion or altered consciousness, persistent hypoxia → 999

Suspected epiglottitis / bacterial tracheitis Toxic appearance, high fever, drooling, muffled voice, tripod posture, stridor, rapid deterioration = rare but rapidly fatal → 999 — do NOT examine the throat or attempt swabs; keep the child calm

Chronic wet cough + clubbing / faltering growth Or haemoptysis, hypoxia, recurrent pneumonia (≥2 in 1yr) or suspected bronchiectasis — consider CF, bronchiectasis, malignancy → Same-day paeds assessment

Foreign body inhalation kills rapidly from complete obstruction. Peak age is 6 months to 3 years. The classic history is sudden onset cough/choking during eating or play. CXR may show hyperinflation unilaterally (ball-valve effect) but a normal CXR does NOT exclude foreign body — rigid bronchoscopy is required if clinical suspicion is high.

Epiglottitis is rare since Hib vaccination but Hib uptake has declined. It is rapidly fatal — do NOT attempt to examine the throat or lay the child down. Call 999 and keep child upright with parent. Anaesthetic/ENT team are needed for airway management. Keep the child calm, avoid unnecessary procedures and transfer with appropriately trained personnel.

Diagnose

Characterise the cough — duration, quality, timing, triggers

Done

The character of the cough is your most important diagnostic tool — it narrows differentials before examination.

Acute (usually improves within 3–4 weeks)

Viral URTI (most common), croup, bronchiolitis, pneumonia, pertussis, foreign body, asthma exacerbation.

Prolonged (3–4 weeks)

Post-infectious cough (most common), pertussis, mycoplasma, early asthma. Consider COVID-related cough.

Chronic (daily >4 weeks)

Warrants chronic-cough assessment. Asthma, allergic rhinitis (post-nasal drip), recurrent viral infections, GORD, CF, tracheomalacia, habit cough, protracted bacterial bronchitis (PBB), bronchiectasis, primary ciliary dyskinesia, aspiration, retained foreign body, immunodeficiency, TB where relevant.

Barking / brassy

Croup (laryngotracheitis), tracheomalacia, subglottic stenosis, habit cough. Associated stridor in croup.

Paroxysmal + whoop

Pertussis (whooping cough) — regardless of vaccination status. Post-tussive vomiting. Cyanosis in infants.

Wet / productive

Bacterial infection, PBB, bronchiectasis, CF. Wet cough >4 weeks → assess for PBB, bronchiectasis, CF, primary ciliary dyskinesia, aspiration/swallowing dysfunction, retained foreign body, immunodeficiency and chronic infection (including TB where relevant). Chronic wet cough = red flag for structural disease.

Dry / non-productive

Asthma, viral, allergic, habit/tic cough, ACE inhibitor (adolescents on medication).

Nocturnal predominance

Asthma (classic — wakes child), GORD, post-nasal drip. Ask specifically: does it wake the child?

Exercise / laughing / cold air

Exercise-induced bronchoconstriction / asthma. Laughing- and cold-air-related symptoms also suggest asthma.

Other history

Duration and progression; choking episode or sudden onset; paroxysms, whoop, post-tussive vomiting or apnoea; fever, lethargy, chest pain or haemoptysis; feeding, fluid intake and wet nappies; birth history, prematurity and neonatal respiratory problems; recurrent infections, otitis, sinusitis or pneumonia; eczema, allergic rhinitis, food allergy, family history of asthma; faltering growth, steatorrhoea or bulky stools.

Exposures & context

Smoke, vaping, mould, pets and environmental exposures; medications (including ACE inhibitors in older adolescents); immunisation history including pertussis; TB exposure, travel and household contacts; safeguarding concerns or possible aspiration.

Carer-reported “wheeze”

May represent nasal congestion, stridor, rattling secretions or true expiratory wheeze — clarify, or obtain a recording where useful.

Duration is the most powerful differentiator. Most acute coughs are viral and self-limiting, usually improving within 3–4 weeks (NICE NG120). Daily cough lasting >4 weeks has a different differential and warrants chronic-cough assessment. The BTS guideline (2008) recommends classifying cough by duration as the first step.

Protracted bacterial bronchitis (PBB) is under-recognised. It is a clinical diagnosis that should not be “confirmed” solely by a response to repeated antibiotics — other chronic wet-cough conditions (bronchiectasis, CF, primary ciliary dyskinesia, aspiration, retained foreign body, immunodeficiency) need appropriate exclusion. Recurrent or non-responsive wet cough needs paediatric respiratory assessment.

Diagnose

Age-based differential diagnosis framework

Done

Age shapes the differential — many diagnoses are age-specific.

<1 year

Bronchiolitis (RSV, Oct–March), pertussis, viral URTI, GORD, tracheomalacia, CF (if faltering growth). Do not diagnose asthma under 1 year solely because of wheeze — bronchiolitis and viral-induced wheeze are more common.

1–5 years

Viral URTI (most common), viral-induced wheeze, croup (6mo–6yr peak), foreign body, asthma (if recurrent wheeze), PBB.

5–12 years

Asthma (new or undiagnosed), allergic rhinitis + PND, mycoplasma pneumonia (school-age dry cough), pertussis, habit cough.

Bronchiolitis criteria

Usually under 2 years; most common in the first year, peak 3–6 months. 1–3 days of coryza → persistent cough + tachypnoea or chest recession + wheeze or crackles. Symptoms peak at days 3–5; cough resolves within 3 weeks in about 90% (NICE NG9). Think viral-induced wheeze / early asthma if recurrent episodic wheeze, persistent wheeze without crackles, strong atopic history, or repeated episodes in an older infant/child. Referral criteria: see Step 6.

Croup severity

Mild: barking cough / hoarse voice, no stridor at rest → single dose of oral dexamethasone per current local paediatric prescribing guidance. Moderate: stridor at rest → urgent same-day assessment. Severe: stridor with marked recession, exhaustion, cyanosis or altered consciousness → 999. Use a calm approach and avoid distressing examination. Nebulised adrenaline is hospital/emergency-led.

Pneumonia — consider if

Fever, persistent focal crackles, tachypnoea, hypoxia, increased work of breathing, systemic illness or focal chest signs. Outpatient childhood pneumonia is often a clinical diagnosis (NICE NG250).

Pertussis — suspect if

Paroxysmal cough, whoop, post-tussive vomiting, apnoea or cyanosis in infants, prolonged cough despite vaccination.

Asthma likelihood

Do not diagnose asthma from cough alone. Age 5–16: suggestive clinical history plus objective testing where possible (NG245) — FeNO first where available, then spirometry with bronchodilator reversibility, peak-flow variability when appropriate, and bronchial hyper-responsiveness testing if uncertainty remains. Under 5: asthma cannot always be confirmed objectively — consider a time-limited (8–12 week) trial of paediatric low-dose ICS when there are recurrent wheeze episodes or interval asthma-like symptoms, then review response and ongoing need. Reassess alternative diagnoses if no response, poor growth, persistent wet cough, focal chest signs or recurrent severe infection.

Asthma cannot be reliably diagnosed under 5 years because spirometry is not feasible and wheeze is common with viral infections ("viral-induced wheeze"). NG245 (2024) advises treating young children as having suspected asthma and reviewing regularly, rather than making a reflexive diagnosis.

Bronchiolitis is a common cause of infant hospital admission. Under NICE NG9, referral decisions depend on age, oxygen saturation, work of breathing, feeding, apnoea and risk factors. NICE’s admission oxygen thresholds differ from referral thresholds and depend on age and comorbidity — avoid using a single universal saturation threshold for every setting.

Diagnose

Targeted Examination

Done

Respiratory rate

Count for a full minute, with the child calm where possible, and interpret against age-appropriate ranges. Rate varies with age, fever, distress and crying — do not use a single respiratory-rate threshold in isolation; interpret with the overall clinical picture.

Oxygen saturation

Use a reliable paediatric probe. Interpret with age, device reliability, baseline disease and clinical condition. Persistent SaO₂ <92% on a reliable reading (e.g., suspected bronchiolitis) → consider hospital referral (NICE NG9); same-day hospital if persistently <90% aged 6 weeks and over, or <92% under 6 weeks or with underlying health conditions (NG9 admission thresholds); 999 if seriously unwell; lower readings require confirmation and clinical assessment. Normal SaO₂ does not rule out significant respiratory illness.

General / circulation

General appearance, alertness and interaction. Ability to feed, speak or cry. Heart rate, temperature, capillary refill and hydration.

Respiratory signs

Intercostal / subcostal recession (increased WOB). Nasal flaring. Grunting = severe respiratory distress → emergency referral (NICE NG9). Tracheal tug. Hyperexpanded chest (asthma/FB).

Auscultation

Wheeze: expiratory predominant (asthma, bronchiolitis). Inspiratory stridor: upper airway (croup, FB). Focal crackles or bronchial breathing: pneumonia, bronchiectasis. Bilateral fine crackles: bronchiolitis. Check air entry; asymmetry of breath sounds or unilateral hyperinflation suggests foreign body.

Cardiac

Cardiac murmurs and signs of heart failure.

ENT

Nasal polyps (CF). Cobblestoning of posterior pharynx (post-nasal drip). Ear drums (AOM + cough in young child). Tonsillar hypertrophy.

Growth / nutrition

Plot on centile chart. Faltering growth + chronic wet cough → CF until proven otherwise. Finger clubbing = CF, bronchiectasis, malignancy. Chest deformity and other signs of chronic respiratory disease.

Skin / allergy

Eczema, urticaria → atopic — raises asthma probability significantly. Allergic shiners, transverse nasal crease (allergic salute).

Respiratory rate is a useful sign for pneumonia in children, but interpret it with age, fever, distress and the overall clinical picture rather than a single threshold. A child with cough + tachypnoea should be assessed for pneumonia even without focal auscultatory findings (early lobar pneumonia may be "silent" to the stethoscope).

Faltering growth with chronic wet cough should prompt CF testing through paediatrics (sweat chloride or genetics) — CF can be diagnosed late if it is not considered, and early diagnosis improves outcomes.

Diagnose

Investigations — when, what, and what to avoid

Done

Acute viral cough

No investigations needed. Usually improves within 3–4 weeks. Do not routinely request CXR, blood tests or antibiotics for a well child with uncomplicated viral cough. Green/coloured sputum or nasal discharge does not by itself indicate bacterial infection. Reassess if rapidly worsening, systemically unwell, feeding deteriorates or cough persists beyond the expected course.

FeNO

Asthma diagnosis 5–16yr Offer first where available (NICE NG245).

Spirometry

Asthma diagnosis ≥5yr Do not use a fixed FEV₁/FVC threshold of 0.7 in children — interpret using paediatric reference ranges and the laboratory report. Significant bronchodilator reversibility in ages 5–16 = FEV₁ improvement of 12% or more (NICE NG245, joint with BTS and SIGN; the additional ≥200 ml criterion applies to adults); interpret with clinical context and test quality. Perform when child is symptomatic if possible. Consider bronchial hyper-responsiveness testing (via specialist) if uncertainty remains.

Peak flow diary

Asthma monitoring Morning + evening readings at home. Use peak-flow variability when appropriate within the current NG245 test sequence — not a standalone diagnosis; interpret according to the quality of measurements.

Pertussis PCR / serology

Testing depends on cough duration and age — follow current UKHSA laboratory guidance and the local health-protection pathway (PCR earlier in the illness; oral fluid anti-pertussis toxin IgG later in children aged 2–16). Notify the UKHSA health protection team when suspected or confirmed and follow contact-prophylaxis advice.

CXR

Targeted: Suspected pneumonia with focal signs, suspected FB (unilateral hyperinflation), persistent wet cough ≥4 weeks, haemoptysis, clubbing, recurrent pneumonia, unexplained recurrent wheeze. Outpatient childhood pneumonia is often a clinical diagnosis — imaging is not routine in uncomplicated cases. Not routine in bronchiolitis (changes can mimic pneumonia).

Sweat chloride / CF genetics

Wet cough with faltering growth, recurrent chest infection or malabsorption/steatorrhoea. Refer to paeds for sweat test — not requested without paediatric referral; do not delay.

Allergy testing

Skin prick test or specific IgE (RAST) if multiple atopic features and asthma likely. Refer to paeds allergy. Not needed for routine asthma diagnosis.

Chest CT / bronchoscopy

Hospital-initiated only. For persistent bronchiectasis, recurrent aspiration, persistent atelectasis, or suspected structural anomaly.

CXR for acute cough in children without danger signs adds radiation exposure without changing management in the majority of cases. A 2012 Cochrane review found no benefit of CXR in non-severe community-acquired LRTI. Reserve for cases where the result will genuinely change management.

Spirometry is the gold standard for asthma diagnosis but is only reliable over age 5. Under 5, consider an 8–12 week trial of twice-daily paediatric low-dose ICS (NICE NG245, joint with BTS and SIGN). If the cough/wheeze resolves on ICS and returns on stopping, the diagnosis is supported. Document this clearly to avoid inappropriate long-term prescribing.

Refer

Referral Criteria

Done

999

Apnoea, cyanosis or respiratory arrest. Severe respiratory distress with exhaustion, reduced consciousness or inability to speak/feed. Severe asthma (silent chest, poor respiratory effort or persistent hypoxia). Stridor at rest with significant recession, cyanosis, exhaustion or altered consciousness. Suspected epiglottitis. Inhaled FB with ongoing airway compromise. Bacterial tracheitis with toxicity and airway obstruction. Rapidly progressive respiratory failure.

Same-day ED

Moderate asthma not responding adequately to initial bronchodilator treatment. Bronchiolitis with dehydration, inadequate intake (around 50–75% of usual), persistent SaO₂ <90% (aged 6 weeks and over) or <92% (under 6 weeks or underlying health conditions), or increasing work of breathing (apnoea → 999). Pertussis in a young infant (particularly <6 months) or any infant with apnoea/cyanosis. Stridor at rest (moderate croup). Suspected pneumonia with hypoxia, significant respiratory distress or systemic illness. Haemoptysis. Suspected FB without current complete airway obstruction. Chronic wet cough with clubbing, faltering growth, haemoptysis or hypoxia. Recurrent pneumonia (≥2 in 1yr) or suspected bronchiectasis.

Bronchiolitis (NICE NG9)

Emergency referral (999): apnoea; central cyanosis; severe respiratory distress (grunting, marked recession or respiratory rate >70/min); exhaustion or reduced responsiveness; seriously unwell. Consider referral: persistent SaO₂ <92% on air when the reading is reliable (same-day hospital if <90% aged 6 weeks and over, or <92% under 6 weeks or with underlying health conditions); respiratory rate >60/min; intake around 50–75% of usual or worsening feeding; dehydration; significant prematurity, chronic lung disease, haemodynamically important congenital heart disease, neuromuscular disease, immunodeficiency or age <3 months. Use clinical judgement.

Urgent paeds (1–2wk)

Suspected CF or aspiration in a well child. Chronic wet cough recurrent or persistent despite an appropriate initial treatment course, or more than one course required without a clear diagnosis. (Clubbing, faltering growth, haemoptysis, hypoxia, recurrent pneumonia or suspected bronchiectasis → same-day, above.)

Paeds outpatient

Uncontrolled asthma on step 3+. Diagnostic uncertainty for asthma in child <5yr. Chronic cough (daily >4 weeks) without diagnosis. Suspected primary ciliary dyskinesia (recurrent otitis + bronchiectasis).

Primary care manage

Viral acute cough — coloured sputum or nasal discharge does not by itself indicate bacterial infection. Mild asthma well-controlled on step 1–2. Croup — mild, responds to oral dexamethasone. Post-infectious cough resolving.

Habit cough

Honking cough disappearing during sleep, school-age child, no nocturnal symptoms → refer CAMHS / specialist respiratory. Suggestion therapy / reassurance can be effective.

CF diagnosis can be delayed in children not detected by newborn screening (NBS), and NBS false negatives exist. Any child with chronic wet cough + faltering growth + recurrent chest infections deserves CF investigation regardless of NBS result.

Recurrent pneumonia (≥2 episodes in 12 months) should always be referred for investigation — underlying structural lesion (sequestration, congenital airway malformation), immunodeficiency, or aspiration should be excluded. These are missed in primary care.

Treat

Treatment — condition-specific drug ladder

Done

Mild croup

Oral dexamethasone Single dose

Single oral dose — use the current local paediatric dose and maximum (BNFC). Can send home if mild. Stridor at rest → urgent assessment; severe croup with distress → emergency care — do not delay transfer to give oral medication. Avoid in varicella.

Acute wheeze / asthma

Salbutamol MDI + spacer First-line

Assess speech/feeding, respiratory effort, SaO₂, air entry, response to salbutamol, exhaustion or altered consciousness. Follow the current local acute-asthma pathway for salbutamol, ipratropium and oral corticosteroid dosing (age/weight maximums), tailored to age, weight, device, clinical severity and prior action plan. Oral corticosteroids are not automatic for every moderate wheeze episode.

Pertussis (suspected/confirmed)

Azithromycin or clarithromycin Within 14 days

Azithromycin or clarithromycin (clarithromycin under 1 month; dose per NICE/SPC (children: BNFC)/UKHSA pertussis guidance) if within 14 days of cough onset, or within 21 days if there is a priority group 1 contact (for example a young infant not fully vaccinated) (UKHSA). Given early, may reduce transmission; usually does not shorten an established cough. Notify the UKHSA health protection team when suspected or confirmed (notifiable disease). Chemoprophylaxis for household contacts is advised by the UKHSA health protection team when a priority contact is present (for example an infant not fully vaccinated or a pregnant woman).

Asthma ladder below is a summary — reconcile with the current NG245/BTS/SIGN pathway and local formulary. Check diagnosis or suspected-asthma status, age and licensed device, MART eligibility, adherence, spacer and inhaler technique, smoke exposure, personalised asthma action plan, reliever use and exacerbation history.

Asthma Step 1Paediatric low-dose ICS BD + SABA PRN (NG245 first-line, age 5–11) — SABA without ICS is no longer recommended. Under 5 with suspected asthma: 8–12 week trial of twice-daily paediatric low-dose ICS, then review. Age 12+: as-needed low-dose ICS/formoterol (AIR).

Asthma Step 2Paediatric low-dose MART (5–11, if uncontrolled on low-dose ICS and able to manage MART) — check adherence and technique first. Refer if <5yr and uncontrolled.

Asthma Step 3Paediatric moderate-dose MART (or moderate-dose ICS/LABA + SABA) ± LTRA (montelukast 4mg <6yr / 5mg 6–14yr OD at night) — counsel about neuropsychiatric adverse effects, including mood and behavioural change.

Asthma Step 4Refer to paediatric asthma specialist if not controlled on paediatric moderate-dose MART or moderate-dose ICS/LABA (± LTRA).

PBB (wet cough >4wk)

If suspected, follow local paediatric antimicrobial guidance — a prolonged antibiotic course may be appropriate. Response does not by itself confirm the diagnosis. Recurrent or non-responsive disease → paediatric respiratory referral and consideration of alternative diagnoses, rather than repeated empirical prescribing.

Viral cough

No antibiotic. Honey in children >1yr at night (not infants — botulism risk). OTC cough and cold medicines should not be used under 6 years; 6–12 years only on pharmacist advice (MHRA, 2009). Fluids and age-appropriate analgesia. Coloured sputum or nasal discharge alone does not indicate bacterial infection. Reassure and give clear safety-netting.

Bronchiolitis

Supportive care; small frequent feeds; nasal saline and gentle nasal clearance where needed. Avoid routine antibiotics, bronchodilators, corticosteroids, nebulised adrenaline and chest physiotherapy. No routine CXR or blood tests. Provide written safety-netting.

Next steps: see Asthma in children · Pre-school wheeze · Whooping cough · Acute cough and chest infections · Bronchiectasis

Salbutamol via MDI + spacer is as effective as nebulisation in mild-moderate asthma (Cochrane 2013) and avoids hospitalisation delays. Every asthmatic child should have a spacer (e.g., AeroChamber Plus) — technique must be checked at every visit.

Honey at night reduces cough frequency in children over 1 year — a Cochrane review (2018) found a small but statistically significant benefit over no treatment. It should not be given to infants under 1 year due to infant botulism risk. OTC cough medicines have little evidence of benefit; the MHRA (2009) advises they should not be used in children under 6, and only on pharmacist advice at ages 6–12.

Montelukast for asthma: MHRA Drug Safety Updates (September 2019, reinforced April 2024) highlighted neuropsychiatric side effects (sleep disturbances, nightmares, aggression, suicidal ideation). Counsel parents and document. Consider risk vs benefit especially in children with pre-existing behavioural issues.

Lifestyle

Preventive measures & self-management

Done

Inhaler technique Check at every asthma review — poor technique is the commonest cause of uncontrolled asthma. MDI + spacer = standard for under 8yr. Use InCheck DIAL or demonstrate at appointment.

Smoke-free environment Avoid all household smoke exposure; it worsens respiratory symptoms and asthma control. Every smoking parent/carer should be offered smoking cessation referral. Carbon monoxide test for parents if appropriate.

Vaccinations Check annual influenza-vaccine eligibility (universal childhood programme, generally ages 2 to under 17 in England; clinical risk group from 6 months, including asthma needing regular or repeated corticosteroids or a previous asthma admission — Green Book chapter 19). Pertussis-containing pre-school booster from 3 years 4 months if not up to date. Check immunisation record at every consultation.

Allergen avoidance House dust mite physical or chemical measures (mattress covers, acaricides, air filters) are not routinely recommended — no consistent benefit (BTS/SIGN). Pet dander avoidance if sensitised. Pollen avoidance strategies in pollen season.

Asthma action plan All asthmatics should have a written personalised asthma action plan (PAAP). Available via Asthma + Lung UK (asthma.org.uk). Review at every appointment.

Breast-feeding / diet Breastfeeding reduces bronchiolitis and recurrent wheeze risk. No evidence for elimination diets unless confirmed allergy. Good nutrition supports immune function.

Inhaler technique is often poor in asthmatic children and their carers. The most common errors are lack of spacer use, failure to actuate during inhalation, and not holding breath after. Improving technique can reduce exacerbations without medication change.

Environmental tobacco smoke (ETS) exposure worsens respiratory symptoms and asthma control in children. Parental smoking cessation is an important intervention for childhood respiratory health but requires sensitive non-judgemental communication.

Safety

Follow-up, Safety-Netting & Monitoring

Done

Acute viral cough

No routine follow-up needed. Safety-net: same-day review if the cough worsens rapidly, the child becomes systemically unwell, breathes faster or harder, or develops fever, wheeze or poor feeding (999 signs below); routine review if it persists beyond 3–4 weeks.

Asthma — new diagnosis

Review at 4–8 weeks to assess response to ICS. Annual asthma review (NHS QOF). Check inhaler technique, PAAP, reliever use. Step down after 3 months of good control.

Bronchiolitis

Review at 24–48hrs if managed at home. Same-day reassessment or referral if worsening, SaO₂ persistently low, or feeding falls to about 50–75% of usual; apnoea, cyanosis or severe distress → 999. Cough usually resolves within 3 weeks. Give written safety-netting.

Pertussis

Notify UKHSA (pertussis is notifiable). Chemoprophylaxis for contacts is decided with the UKHSA health protection team (priority contacts include infants not fully vaccinated). School/nursery exclusion is a public-health instruction — follow current UKHSA exclusion guidance and health protection team advice. Infant <6 months, or with apnoea, cyanosis, poor feeding or respiratory distress → same-day hospital assessment.

Wet cough / PBB

Review after the treatment course — has cough resolved? If not, if it recurs, or if more than one course is needed without a clear diagnosis → paediatric respiratory referral. Do not repeat empirical antibiotics indefinitely in primary care.

Call 999 if:

Child stops breathing / turns blue. Struggling to breathe — grunting, sucking in under the ribs, or too breathless to talk or feed. Wheeze not responding to salbutamol. Child collapses, is floppy or cannot be roused. Stridor at rest getting worse.

Same-day if:

Low SaO₂ on a reliable reading — interpret with age, device, baseline disease and clinical condition (persistent <92% in suspected bronchiolitis = hospital-referral threshold; lower readings need confirmation and clinical assessment). Cough becomes suddenly much worse with distress. Noisy breathing in (stridor) at rest. Feeding much less than usual or a dry nappy for 12 hours or more. Parent very worried — parental concern is a reason to reassess urgently, combined with clinical assessment, not a substitute for triage.

Annual asthma review is a QOF target (QOF indicator AST) and has been shown to reduce asthma mortality. The UK has one of the highest rates of preventable asthma deaths in Europe — the majority related to inadequate monitoring, no PAAP, and failure to step up treatment.

The National Review of Asthma Deaths (NRAD 2014) identified potentially avoidable factors in about two-thirds of the deaths reviewed. Common failures: no written action plan, no escalation plan communicated to parents, excessive reliance on SABA, under-use of ICS. Follow-up and monitoring saves lives.