Reasoning GP · Algorithm · 1-page summary
Wheeze in a child
For: infants, children and young people under 18 with acute or recurrent wheeze in primary care. Not for: adults (adult asthma pathways); long-term asthma stepping is in the full algorithm.
Core rule: a child with wheeze does not necessarily have asthma, and a quiet chest is not improvement. Grade severity in the first 60 seconds; SpO₂ <92% in suspected acute asthma means 999.
0Stop — call 999 now — any one feature
- Silent or very quiet chest with distress, exhaustion or poor effort, cyanosis, drowsiness, too breathless to speak, drink or feed, SpO₂ <92% in suspected acute asthma, or no response or worsening after initial bronchodilator → 999
- Anaphylaxis (wheeze with urticaria, angioedema or collapse after an allergen) → IM adrenaline 1 mg/mL, thigh (micrograms: 100–150 <6 months, 150 to <6 y, 300 6–12 y, 500 >12 y), repeat after 5 min if no better → 999. Sit up if breathless, lie flat if faint; never stand the child.
- Stridor with wheeze, drooling, tripod posture (upper airway obstruction), or choking / foreign body with respiratory compromise → 999. Position of comfort; do not examine the throat.
- While waiting: sit comfortably; oxygen if hypoxaemic (at least 92% during transfer); salbutamol by pMDI and spacer or nebuliser plus ipratropium; oral prednisolone if able to swallow. Never sedate.
1Triage by severity — suspected acute asthma (SIGN 158)
| Severity | Features → action |
|---|---|
| Moderate | SpO₂ ≥92%, PEF ≥50%, able to talk → treat (block 5), reassess each dose |
| Severe | Any one: SpO₂ <92%, PEF 33–50%, too breathless to talk or feed, HR >140 or RR >40 (2–5 y), HR >125 or RR >30 (>5 y) → 999 |
| Life-threatening | SpO₂ <92% plus silent chest, cyanosis, poor effort, exhaustion, altered consciousness, or PEF <33% → 999 |
| Under 5 | Feeding stopped or cannot cry normally = severe |
| After salbutamol | SpO₂ ≥94%, comfortable → may go home, review in 2 working days. Not improving → 999 |
2Screen — not asthma until shown
- Sudden onset, choking episode, age <4, focal or unilateral wheeze, no salbutamol response (inhaled foreign body) → stable: Same-day emergency assessment
- Infant <12 months, murmur, hepatomegaly, poor feeding (cardiac) → Same-day paediatrics
- Bronchiolitis with persistent low SpO₂ (NG9: <90% ≥6 weeks; <92% <6 weeks or comorbidity), poor feeding or rising work of breathing → Same-day hospital
- Any wheeze in an infant <12 months, known near-fatal asthma (PICU, intubation) with any attack, or home monitoring or review not possible → Same-day hospital, phone ahead
3Assess
☐ RR, HR, SpO₂ in air (may read high in darker skin) ☐ Recession, speech, feeding, air entry, stridor, focal signs ☐ PEF if 5+ ☐ Choking, allergen, rash; past admissions, PICU, oral steroids
No routine tests when acute. Asthma at 5+ needs an objective test: FeNO ≥35 ppb, reversibility or PEF variability (NG245).
4Classify — once blocks 0–2 are clear
- Viral-induced wheeze — preschool, only with colds, no interval symptoms → reliever as needed; preventer not always needed.
- Asthma — multiple triggers, interval or night symptoms, atopy → objective test at 5+; under 5, 8–12-week low-dose ICS trial; if resolved, consider stopping, review 3 months later.
- Bronchiolitis — infant, coryza, fine crackles, no bronchodilator response → supportive; no salbutamol, ipratropium, steroids, antibiotics or montelukast (NG9).
- Croup (barking cough, stridor) → dexamethasone 0.15 mg/kg oral once. Teen VCD (inspiratory, on exercise, normal SpO₂) → paediatric respiratory.
- Uncertain or atypical — fixed or focal wheeze, clubbing, wet cough, faltering growth → rethink and refer.
5Treat today — doses: NICE/SPC, BNFC, local formulary
- Salbutamol pMDI + spacer, 1 puff at a time: 2–10 puffs titrated to response, all ages, repeated every 20–30 min; 10 puffs if severe; ipratropium if poor response (BTS/SIGN 158).
- Prednisolone 20 mg (2–5 y), 30–40 mg (>5 y) once daily, usually up to 3 days; no taper.
- Oxygen if SpO₂ <92%, to the local paediatric target. Anaphylaxis: adrenaline first.
- Before home: spacer technique, written action plan matching the reliever regimen, review within 2 working days.
6Refer routinely — paediatric respiratory / allergy
- Uncontrolled on paediatric moderate-dose MART or moderate-dose ICS/LABA (± LTRA); under 5 after an 8–12-week LTRA trial on moderate-dose ICS (NG245).
- Preschool child after a hospital admission, or ≥2 ED admissions for wheeze in 12 months (NG245).
- Recurrent severe attacks, poor control despite good technique, diagnostic uncertainty.
7Never reassure by
- A quiet chest — silence means minimal airflow.
- A normal SpO₂ in an exhausted, tachypnoeic child.
- Response to salbutamol as proof of asthma.
- Repeated salbutamol for sudden, focal or one-sided wheeze.
- A normal chest X-ray when a foreign body is possible.
- An asthma label at 5+ without an objective test.
8Safety-net — say it, then document it
999 “Call 999 if your child is struggling to breathe, turns blue, goes quiet or exhausted, is too breathless to talk, drink or feed, or the reliever is not helping.” Same day “Contact us today if it gets worse despite the action plan, the reliever is needed more often than every 4 hours, wheeze wakes them at night, or you are worried.”
After every attack: review within 2 working days (NICE QS25): recovery, technique, adherence, triggers, action plan, preventer.
✓Safe to leave primary care only if — all five, documented
No block 0–2 row applies
SpO₂ ≥94% and comfortable after treatment
Cause named, or uncertainty stated
Prednisolone, spacer technique and action plan given
Review within 2 working days booked; safety-net given
Summary of the full Reasoning GP wheeze in a child algorithm, which holds the causes by age, diagnosis, drug ladder, prevention and evidence. Sources: NICE NG245 and NG244 (BTS/NICE/SIGN); BTS/SIGN 158 acute asthma; NICE NG9; NICE QS25; Resuscitation Council UK anaphylaxis 2021; MHRA. Clinical reference — follow the local paediatric acute-wheeze pathway and check doses in the SPC and your local formulary.