Asthma in children — what parents need to know

In brief

• Asthma affects about 1 in 5 children in Singapore and often shows as repeated wheezy colds or a night cough.
• A daily preventer treats the airway inflammation, while a reliever such as salbutamol only eases symptoms.
• Every child using a puffer needs a spacer, with a face mask for children under about 4 or 5.
• Low-dose inhaled steroids have at most a small effect on growth, and poorly controlled asthma affects growth more.
• Salbutamol helps wheeze and breathlessness but not most coughs.
• Call 995 if your child is struggling to breathe, can’t speak in full sentences, is blue around the lips, or the reliever isn’t helping.

We care for children with asthma at our Punggol clinic, with written action plans for home and school. Book a children’s appointment.

How asthma looks in children at different ages

Asthma is the most common long-term condition of childhood in Singapore, affecting roughly 1 in 5 children at some point. Most cases are mild and managed well in primary care. For general principles, see Asthma — what it is, and how we treat it today.

The pattern changes with age:

• Under 2 years: the main sign is recurrent wheeze (a high-pitched whistle when breathing out), usually with colds. Many children outgrow viral wheeze, so we confirm asthma over time, once the pattern recurs and responds clearly to treatment.
• 2 to 5 years: wheezy episodes continue, sometimes with cough at night or with exertion. A family history of asthma, eczema or allergic rhinitis supports the diagnosis. Lung function tests aren’t reliable yet, so the diagnosis is clinical.
• 6 to 11 years: spirometry becomes possible and the picture resembles adult asthma, with clearer night cough, exercise symptoms and triggers such as dust or pets.
• Adolescence: control often worsens as adherence drops, smoking starts and parents monitor less. The diagnosis may be re-evaluated.

Tell us if your child gets one “chesty cold” after another, especially with a whistle or slow recovery. That is often how asthma shows in young children.

How we diagnose it

Before children can do reliable spirometry, we look for a pattern:

• Recurrent wheeze over time, not just with one cold
• Cough worse at night or with exercise
• A clear response to a trial of reliever or, sometimes, inhaled corticosteroid
• An atopic background: eczema, food allergy or allergic rhinitis in the child; asthma or allergies in the family
• No other cause: inhaled foreign body, bronchiolitis, pneumonia, cystic fibrosis (rare but important) or a heart cause of wheeze

From around age 6, spirometry and peak flow become useful. A blood eosinophil count can also help: a count above the laboratory reference range points to allergic (“type 2”) asthma, which usually responds well to inhaled steroid. It is not a test for asthma on its own: eczema, other allergies and worm infections also raise it, and a normal count does not rule asthma out.

The treatment approach

As for adults, treat the airway inflammation with a preventer, not just the symptoms with a reliever.

Under 6 years

• Daily low-dose inhaled corticosteroid (ICS) is the usual first-line preventer, given by metered-dose inhaler (pMDI) with a spacer and face mask.
• Montelukast (Singulair) is an alternative or add-on (see the HSA safety note below).
• As-needed salbutamol (Ventolin) by pMDI and spacer is the reliever.
• Maintenance-and-reliever therapy (MART), used in older children and adults, is not routinely used under age 6.

Under-2s: we are more cautious, because many children who wheeze early do not develop ongoing asthma. We often try treatment and reassess, rather than start long-term therapy straight away.

6 to 11 years

• Daily low-dose ICS remains first-line.
• ICS-formoterol can be used as both daily and as-needed treatment (Maintenance And Reliever Therapy, MART) from around this age, as in adults. Budesonide-formoterol has been studied from about age 6.
• As-needed salbutamol remains the reliever for children not on MART.

12 and older

Management follows the adult approach. See the main asthma guide for details.

Inhalers for children — spacers and technique

A pMDI used without a spacer, or with poor technique, can deliver less than a third of the dose.

• A spacer is essential for every child using a pMDI. It makes coordination matter less.
• A face mask is needed for young children who can’t seal their lips around the mouthpiece, typically under 4 or 5.
• Technique: shake the inhaler and attach the spacer. For each puff, your child takes 4 to 6 slow breaths through the spacer, or 1 deep breath with a 10-second hold if older. Wait about 30 seconds between puffs.
• Rinse the mouth, or wipe around it, after ICS doses to reduce the small risk of oral thrush.
• Clean the spacer once a week with mild detergent and let it air-dry. Rubbing it dry builds static that reduces drug delivery.
• Replace the spacer at least once a year, or sooner if the manufacturer advises or it shows cracks, a stuck valve or wear. Bring it to reviews so we can check it.
• Show us the technique at every visit. Children’s technique drifts over time.

Dry powder inhalers (DPIs) such as Turbohaler need a fast, deep breath that younger children often can’t manage. Under age 10, a pMDI with spacer is usually more reliable.

Common parental concerns we hear

“Will inhaled steroids stunt my child’s growth?”

The evidence:

• In the first year or two of inhaled corticosteroids, some children grow about 0.5 cm less per year on average.
• The effect is non-progressive: it doesn’t accumulate, and growth usually returns to normal after that.
• It is dose-dependent. Low-dose ICS with a spacer and mouth-rinsing often has no measurable effect. Higher doses may have a slightly larger effect.
• Long-term studies, notably the CAMP study that followed children into adulthood, show most children catch up substantially. Around 1 cm of adult height, on average, can be lost with long-term treatment started young.
• Untreated asthma is worse for growth than appropriate ICS. Frequent oral steroid courses (often needed in poorly controlled asthma), broken sleep and chronic inflammation all affect growth more.

We use the lowest effective ICS dose, review regularly, step down once asthma has been well controlled for 3 to 6 months, and measure height at every visit. A spacer and mouth-rinsing minimise any effect on the body.

Inhaled corticosteroids for well-indicated asthma are safe in children. The benefits of good control outweigh the small growth effect, which we monitor.

“My child has a cough — should I give salbutamol?”

Salbutamol (Ventolin) is a bronchodilator: it relaxes the muscle around the airways. It helps wheeze, chest tightness and the breathlessness of an asthma flare.

It does not treat cough in general. Most childhood coughs (viral illness, post-viral cough, post-nasal drip, reflux) don’t come from airway tightening, so salbutamol doesn’t help.

Giving it for every cough has downsides:

• No benefit if the cough isn’t from bronchoconstriction. Cochrane and other reviews found it no better than placebo for non-asthma coughs.
• Side effects: tremor, fast heart rate, nervousness, hyperactivity, and occasionally nausea and vomiting, especially at higher doses in small children.
• A “puff-for-anything” habit, linked with worse control. It hides whether asthma is really controlled, and habitual SABA overuse marks poor outcomes in adults and older children.

Salbutamol is right for clear wheeze, chest tightness, breathlessness at rest or with exertion, or a flare of known asthma. Follow the dose on your child’s action plan.

If a cough lasts more than a week or two, disturbs sleep or is getting worse, bring your child in rather than reaching for the inhaler. It may be asthma, or something needing a different approach: post-infectious cough, post-nasal drip, reflux or whooping cough.

Asthma action plan — and your child’s school

Every child with asthma needs a written action plan, with a copy for childcare or school. It has three zones:

1. Green (well controlled): usual daily treatment and which activities are fine.
2. Yellow (worsening): the reliever dose, how often, and when to step up the preventer. Use the dose we set for your child, as doses vary with age and weight.
3. Red (emergency): the rescue reliever dose. Call 995 or go to A&E at the same time if your child is struggling to breathe, can’t speak in full sentences, is blue around the lips or is very distressed. Don’t delay the call to give puffs.

Bring the plan to every review so we can update doses as your child grows.

At school:

• Give the school the written plan. Most keep a spare reliever and spacer at the office.
• Pre-exercise salbutamol, shortly before sport or PE, works well if exercise is a reliable trigger. We set the dose and timing on the plan.
• Watch for worsening in the haze season, after a viral illness in the family, and at stressful times such as exams or moving house.

Recognising a flare in a child

Act early on these warning signs:

• Coughing or wheezing more than usual, especially at night
• Needing the reliever more often than usual
• Reluctance to play, or getting breathless easily with normal activity
• Waking from sleep with a cough or tight chest

Urgent — call 995 or go to the emergency department:

• Struggling to breathe: chest pulling in at the ribs or neck, or breathing very fast
• Can’t speak in full sentences, or only short phrases between breaths
• Blue or grey around the lips, fingernails or earlobes
• The reliever isn’t giving the usual relief, or wears off very quickly
• Drowsy, confused or unusually quiet. A wheezy child who becomes calm can be more worrying, not less.
• Your instinct tells you something is seriously wrong. Trust it.

If it is bad, call an ambulance rather than driving. While waiting, sit your child upright (never lying flat), keep them calm, and give reliever puffs through the spacer every few minutes.

Oral corticosteroids in children — when and when not

Short courses of oral prednisolone can be life-saving in a severe flare. Repeated use affects growth and has other side effects, so we reserve them for:

• Moderate-to-severe flares that don’t settle with high-dose inhaled reliever
• Bridging while a new maintenance plan takes effect

If your child has needed oral steroids more than once or twice in the past year, come back for review: the preventer plan needs stepping up rather than more oral courses. Oral steroids are not for everyday asthma control.

A note on montelukast (Singulair)

Montelukast is a leukotriene receptor antagonist, a once-daily tablet used as an alternative or add-on to ICS. It can help children with significant allergic rhinitis or exercise-induced asthma, or who won’t reliably use an inhaler.

Singapore’s Health Sciences Authority has an advisory on possible neuropsychiatric effects: mood changes, agitation, sleep disturbance and, rarely, suicidal thoughts. Most children have none of these, but watch for:

• Unusual irritability, aggression or agitation
• New nightmares or sleep disturbance
• Mood change: flatness, sadness, withdrawal
• Any talk of self-harm, even casual

If you notice any of these, stop the medicine and contact us the same day. We will discuss alternatives.

Food allergy, eczema, and the “atopic march”

Many children with asthma also have eczema or allergic rhinitis, and some have food allergies. These sometimes appear in sequence (the atopic march), but many children have only one.

Two practical points:

• Treating allergic rhinitis (a nasal corticosteroid spray, saline rinses, sometimes an oral antihistamine) often improves asthma control. Mention a persistently blocked or runny nose.
• Food-allergy testing is useful only with a clear pattern: a specific food repeatedly causing an obvious reaction within minutes to a couple of hours. Broad panels without a pattern tend to give false positives, needless food avoidance and nutritional risk.

For more on eczema, see Children with eczema — and when to call us.

Growing out of it — what to expect

Many children improve significantly through the primary school years, and some seem to “grow out of it” by adolescence. What seems to matter most:

• Consistent preventer use in the early years. Well-controlled children often have smoother long-term courses.
• Severity at onset. Mild viral wheeze often resolves; persistent allergic asthma with several atopic features is more likely to continue.
• Smoke exposure. Second-hand smoke, and later teenage smoking, is one of the strongest modifiable factors that worsen asthma.
• Adherence in adolescence, when treatment often drifts.

Keep a record of your child’s asthma history. It can return in adulthood, and knowing the childhood pattern helps us manage it faster.

Vaccinations

Children with asthma should be up to date with:

• Annual influenza (flu) vaccine: strongly recommended, as respiratory viruses trigger most childhood flares
• The National Childhood Immunisation Schedule (NCIS); see Childhood vaccinations (NCIS)
• COVID-19 boosters in line with current MOH recommendations for children with chronic conditions

Regular follow-up

Children with asthma should be reviewed:

• Within 1 to 2 weeks after an exacerbation managed at home, and within a few days after an A&E visit or hospital stay
• Within 1 to 3 months after starting or adjusting treatment
• Every 3 to 6 months once stable, at minimum

At each visit we check inhaler technique, symptom control (the adult 4-question check), growth, triggers and adherence. Short visits count.

Who we manage at KTMC — and when we’ll refer your child to a specialist

Most children do well with primary care. We usually suggest a paediatric respiratory specialist when:

• The diagnosis is uncertain or atypical: wheeze from early infancy, poor response to standard treatment, or a possible other cause (inhaled foreign body, cystic fibrosis, primary ciliary dyskinesia, a structural airway problem or a heart cause)
• Asthma is severe or hard to control: needing medium-to-high dose ICS to stay stable, or poorly controlled despite combination preventer therapy
• Flares are frequent despite an optimised plan and addressed triggers
• There has been an ICU admission or severe attack, a marker of ongoing risk
• A child aged 0 to 5 has recurrent wheeze, where specialist assessment can help tell viral wheeze from early asthma
• Triggers are unusual (mould, occupational allergens) or the atopic background is complicated
• Biologic therapy is being considered for severe eosinophilic or allergic asthma (omalizumab, mepolizumab, benralizumab, dupilumab)

What a specialist adds

A respiratory paediatrician can offer:

• More detailed lung tests: spirometry with bronchodilator response, fractional exhaled nitric oxide (FeNO), bronchial challenge (older children) and impulse oscillometry (younger children)
• Biologic injections, which specialists start; they are not usually prescribed in primary care
• A wider team: specialist nurses, respiratory physiotherapists, paediatric allergists and, where relevant, psychologists
• Hospital facilities for complex tests, admission for severe flares, and the move to adult services

Referral doesn’t mean anything was wrong with your child’s care; some patterns are best handled by clinicians who see them weekly. Usually we continue day-to-day care alongside the specialist, sharing notes to keep one plan.

If you feel your child’s asthma isn’t well managed, tell us. We would rather refer a little early than watch a pattern drift.

The Singapore context

• Healthier SG Chronic Tier: family members aged 40+ who are enrolled with a Healthier SG clinic and hold a CHAS, Pioneer Generation or Merdeka Generation card can get selected chronic medicines at prices similar to polyclinics.
• Community Health Assist Scheme (CHAS): means-tested subsidies for consultations and selected medicines, including for children in eligible households.
• NCIS-subsidised vaccinations, including the flu vaccine for children with chronic conditions.
• Class Primary Care Network: KTMC is part of Class PCN, which supports nurse counselling and other services.

Get in touch

Punggol — 658 Punggol East, #01-04, Singapore 820658 · Tel 6312 4589

Joo Chiat — 172 Joo Chiat Road, #01-01, Singapore 427443 · Tel 6920 1952

Email — admin@ktmc.sg

References

Guidelines and national programmes

• Agency for Care Effectiveness (ACE). Asthma — optimising long-term management with inhaled corticosteroid. ACE Clinical Guidance, Ministry of Health, Singapore. October 2020. ace-hta.gov.sg
• Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention — 2026 update. ginasthma.org
• Health Sciences Authority Singapore. Drug Safety Information — advisory on montelukast and neuropsychiatric effects.
• Ministry of Health Singapore. National Childhood Immunisation Schedule (NCIS). healthhub.sg
• Ministry of Health Singapore. Healthier SG Chronic Tier subsidy framework to start from 1 February 2024 — for CHAS, Pioneer Generation and Merdeka Generation cardholders enrolled at a Healthier SG GP clinic. 25 January 2024. moh.gov.sg
• Healthier SG. Healthier SG Chronic Tier and How to enrol (Singapore Citizens and Permanent Residents aged 40 and above). Updated September 2026. healthiersg.gov.sg

Inhaled corticosteroids and growth

• Kelly HW, Sternberg AL, Lescher R, et al. Effect of inhaled glucocorticoids in childhood on adult height. N Engl J Med. 2012;367(10):904–912 — the CAMP long-term follow-up study, showing ~1.2 cm residual reduction in adult height with long-term budesonide started in prepubertal childhood. nejm.org
• Axelsson I, Naumburg E, Prietsch SO, Zhang L. Inhaled corticosteroids in children with persistent asthma: effects of different drugs and delivery devices on growth. Cochrane Database Syst Rev. 2019;6:CD010126. cochranelibrary.com
• Zhang L, Prietsch SO, Ducharme FM. Inhaled corticosteroids in children with persistent asthma: effects on growth. Cochrane Database Syst Rev. 2014;7:CD009471.
• Pruteanu AI, Chauhan BF, Zhang L, Prietsch SO, Ducharme FM. Inhaled corticosteroids in children with persistent asthma: dose-response effects on growth. Cochrane Database Syst Rev. 2014;(7):CD009878.

Spacer use, cleaning, and replacement

• National Asthma Council Australia. Spacer use and care — information sheet for patients and carers. 2023 update. Annual replacement recommended (or per manufacturer), plus inspection of valve integrity every 6–12 months. nationalasthma.org.au

Salbutamol (SABA) and non-asthma cough

• Chang AB, Oppenheimer JJ, Weinberger MM, et al. Managing Chronic Cough as a Symptom in Children and Management Algorithms: CHEST Guideline and Expert Panel Report. Chest. 2020;158(1):303–329 — ACCP-endorsed guidance; no routine role for β2-agonists in children with cough without evidence of airflow obstruction.
• Tomerak AA, Vyas H, Lakenpaul M, McGlashan JJ, McKean M. Inhaled beta(2)-agonists for treating non-specific chronic cough in children. Cochrane Database Syst Rev. 2005;(3):CD005373 — no significant difference between salbutamol and placebo in non-specific chronic cough in children.
• Nwaru BI, Ekström M, Hasvold P, Wiklund F, Telg G, Janson C. Overuse of short-acting β2-agonists in asthma is associated with increased risk of exacerbation and mortality: a nationwide cohort study of the global SABINA programme. Eur Respir J. 2020;55(4):1901872. ersjournals.com
• MHRA (UK). Short-acting beta-2 agonists (SABA): reminder of the risks from overuse in asthma. Drug Safety Update, 2024. gov.uk

This information is for general education only and is not a substitute for medical advice. Paediatric asthma management must be individualised to your child’s age, severity, and triggers — please speak with our team. v1.1 · October 2026 (v1.0 April 2026) · Review due April 2028.