Asthma in children — what parents need to know

About this guide

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 can be managed well in primary care — but it’s a condition where parents carry a lot of the day-to-day responsibility, and clear information on what to watch for and what to do makes a real difference.

This guide is a parent-facing companion to our main asthma guide. If you haven’t yet read the adult guide, it’s worth a skim first for the general background:

• Asthma — what it is, and how we treat it today — the principles that apply at every age

The paediatric-specific differences are covered below.

How asthma looks in children at different ages

The pattern changes with age:

• Under 2 years — the main sign is recurrent wheeze (a high-pitched whistling sound when breathing out), usually triggered by viral colds. Not every wheezy child has asthma — many episodes of viral wheeze resolve as the child grows. We confirm the diagnosis over time, usually only when the pattern becomes recurrent and a clear response to asthma treatment is seen.
• 2 to 5 years — wheezy episodes continue, sometimes with cough (especially at night or with exertion). A family history of asthma, eczema, or allergic rhinitis supports the diagnosis. Formal lung function testing isn’t usually reliable at this age, so diagnosis is clinical.
• 6 to 11 years — spirometry becomes possible; the picture starts to resemble adult asthma. Nighttime cough, exercise-induced symptoms, and triggers like dust or pets become clearer.
• Adolescence — a common time for asthma control to worsen (adherence drops, smoking starts, independence makes parental monitoring harder) or for the diagnosis to be re-evaluated.

If your child seems to get one “chesty cold” after another, especially with an audible whistle or prolonged recovery, please mention it — that’s often how asthma shows up in young children.

How we diagnose it

In children too young for reliable spirometry, we look for the pattern:

• Recurrent wheeze (not every wheeze in every cold, but a pattern over time)
• Cough worse at night or with exercise
• Clear response to a trial of an inhaled reliever or, sometimes, to inhaled corticosteroid
• Atopic background — eczema, food allergy, allergic rhinitis in the child; family history of asthma or allergies
• Exclusion of other conditions — foreign body aspiration, bronchiolitis, pneumonia, cystic fibrosis (rare but important), cardiac causes of wheeze

From around age 6, spirometry and peak flow become useful. A blood eosinophil count can also help — higher eosinophils support the diagnosis of allergic (eosinophilic) asthma and predict response to inhaled steroid.

The treatment approach

The core principle is the same as for adults: treat the underlying 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 via a metered-dose inhaler (pMDI) with a spacer and face mask.
• Montelukast (Singulair) is an alternative or add-on. Please see the important safety note below on the HSA advisory about montelukast.
• As-needed salbutamol (Ventolin) via pMDI + spacer is the reliever.
• The maintenance-and-reliever (MART) approach used in older children and adults is not routinely used under age 6.

A note specific to under-2s: treatment decisions in very young children are more cautious because the natural history is uncertain — many children with early wheezing episodes will not turn out to have ongoing asthma. We’ll often use a trial of treatment and then reassess rather than commit to long-term therapy straightaway.

6 to 11 years

• Daily low-dose ICS remains first-line.
• ICS-formoterol combinations can be used as both daily and as-needed treatment (Maintenance And Reliever Therapy / MART) from around this age — the same approach as 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 full details.

Inhalers for children — spacers and technique

This is where a lot of treatment fails. A pMDI used without a spacer, or with poor technique, can deliver less than a third of the prescribed dose.

• A spacer is essential for every child using a pMDI. The spacer separates the puff from the breathing-in, so coordination matters less.
• A face mask is needed for young children who can’t reliably form a seal with their lips around the mouthpiece — typically children under 4 or 5.
• Technique: shake the inhaler, attach to spacer, have the child take 4 to 6 slow breaths in and out through the spacer per puff (or 1 deep breath with a 10-second hold for older children who can manage it). Wait about 30 seconds between puffs.
• Rinse mouth (or wipe face around the mouth) after ICS doses to reduce the small risk of oral thrush.
• Clean the spacer once a week with mild detergent, air-dry (don’t rub dry — static in the plastic reduces drug delivery).
• Replace the spacer at least once a year (or earlier if the manufacturer advises, or if there are cracks, a stuck valve, or visible wear). Plastic ages with use — valves can become sticky and delivery drops off. We’ll inspect the spacer at your review visits; bring it along.
• Show us the technique at every visit — we’ll watch and fine-tune. Children’s technique drifts, and what was fine last year may not be now.

If your child is using a dry powder inhaler (DPI) like Turbohaler — these need a fast, deep inhale, which younger children often can’t generate reliably. A pMDI plus spacer is usually more reliable under age 10.

Common parental concerns we hear

Two questions come up in almost every clinic visit for children with asthma. Both deserve honest, evidence-based answers.

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

This is the single most common worry. The honest picture:

• In the first year or two of taking inhaled corticosteroids, some children grow very slightly slower than they would without ICS — on average about 0.5 cm less per year.
• This effect is non-progressive — it doesn’t accumulate, and the rate of growth usually returns to normal after the first year or two on treatment.
• It is dose-dependent — modern low-dose ICS, delivered with a spacer and with appropriate mouth-rinsing, often has no measurable effect on growth at all. Higher doses carry a small risk of a slightly larger effect.
• Long-term follow-up studies (notably the CAMP study, which followed children into adulthood) show that most children catch up substantially, though a small residual reduction in adult height — around 1 cm on average — can persist with long-term treatment starting at a young age.
• Crucially, untreated asthma is worse for growth than appropriate ICS. Frequent oral steroid courses (which poorly-controlled asthma often requires), broken sleep from night-time symptoms, and chronic airway inflammation all affect growth more than a well-chosen preventer.

Our approach:

• Use the lowest effective ICS dose and review regularly
• Step down once asthma has been well controlled for 3 to 6 months
• Measure height at every visit and track the trajectory
• Use spacer technique and mouth-rinsing to minimise any systemic effect

The bottom line: inhaled corticosteroids for well-indicated asthma are safe in children. The small growth effect is outweighed by the benefits of good control, and we monitor it actively.

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

Salbutamol (Ventolin) is a bronchodilator — it works by relaxing the muscle around the airway. It’s effective for symptoms caused by airway tightening (wheeze, chest tightness, 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 — are not caused by bronchoconstriction, and salbutamol doesn’t help them.

Giving salbutamol for every cough, as a reflex, has real downsides:

• No benefit if the cough isn’t from bronchoconstriction — reviews and Cochrane analyses have found no difference versus placebo for non-asthma coughs
• Side effects — tremor, fast heart rate, nervousness, hyperactivity, occasionally nausea and vomiting, especially at higher doses in small children
• Reinforces a “puff-for-anything” pattern which, over time, is associated with worse asthma control — both because it obscures whether your child’s asthma is really controlled, and because habitual SABA overuse has been shown in adults and older children to be an independent marker of poor outcomes

When IS salbutamol right? When there’s clear wheeze, chest tightness, breathlessness at rest or with exertion, or a flare of known asthma. In those cases, follow the dose on your child’s action plan.

If your child has a cough you’re unsure about — especially if it’s going on longer than a week or two, disturbing sleep, or getting worse rather than better — please bring them in rather than reaching for the inhaler. We may find asthma, but we may equally find something else (viral post-infectious cough, post-nasal drip, reflux, whooping cough) that needs a different approach.

Asthma action plan — and your child’s school

Every child with asthma should have a written action plan, and a copy should go to the childcare centre or school.

The plan covers three zones:

1. Green (well-controlled) — usual daily treatment, what activities are fine
2. Yellow (worsening) — the specific reliever dose, frequency, and when to step up the preventer will be written on your child’s personalised plan. Children vary substantially by age and weight, so the right dose is the one we’ve set for your child, not a generic figure.
3. Red (emergency) — your plan will set out the rescue reliever dose. In parallel, call 995 or go to A&E 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 while giving puffs.

Because children grow and respond differently at different ages, please bring your child’s action plan to every review so we can update the doses as your child changes.

Practical school points:

• Speak to the school and provide the written plan; most schools are willing to keep a spare reliever and spacer at the office.
• Pre-exercise salbutamol, taken shortly before sports or PE, works well if exercise is a reliable trigger — we’ll set the exact dose and timing on your child’s plan.
• Watch for deterioration during haze season, after a viral illness in the family, or during stress points (exams, moves).

Recognising a flare in a child

Warning signs worth acting on early:

• 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 cough or tight chest

Urgent (call 995 / go to emergency department):

• Struggling to breathe — chest pulling in at the ribs or neck, breathing very fast
• Can’t speak in full sentences, or only short phrases between breaths
• Blue or grey around the lips, fingernails, or earlobes
• Reliever not giving the usual relief, or wearing off very quickly
• Drowsy, confused, or unusually quiet — a calm child who was wheezing is sometimes more worrying, not less
• Your parental instinct tells you something is seriously wrong — trust it

Don’t drive yourself if the situation is bad — call an ambulance. In the meantime, sit the child upright (never lying flat), keep them calm, and keep giving puffs of reliever via spacer every few minutes while waiting.

Oral corticosteroids in children — when and when not

Short courses of oral prednisolone can be life-saving during a severe flare. But we use them carefully in children because of the effect on growth and other side effects with repeated use. They’re reserved for:

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

If your child has needed oral steroids more than once or twice in the past year, that’s a signal that the preventer plan needs stepping up, rather than using more oral courses. Please come back for review.

Oral steroids should not be used for the routine management of everyday asthma control.

A note on montelukast (Singulair)

Montelukast is a leukotriene receptor antagonist — an oral tablet taken once a day, used as an alternative or add-on to ICS. It can be helpful, particularly in children with significant allergic rhinitis, exercise-induced asthma, or those who won’t reliably use an inhaler.

However, Singapore’s Health Sciences Authority has issued an advisory about possible neuropsychiatric effects — changes in mood, agitation, sleep disturbance, and in rare cases suicidal thoughts. Most children who take montelukast do not experience these — but caregivers should be aware and 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, please stop the medication and contact us the same day — we’ll discuss alternatives.

Food allergy, eczema, and the “atopic march”

Many children with asthma also have eczema or allergic rhinitis, and some have food allergies. The pattern of these conditions appearing in sequence is sometimes called the atopic march — but not every child follows it, and many don’t progress beyond one of these conditions.

Two practical points:

• Treating allergic rhinitis (a nasal corticosteroid spray, saline rinse, sometimes oral antihistamine) often improves lower-airway asthma control. If your child has a persistently blocked or runny nose, it’s worth mentioning.
• Food-allergy testing is useful only when there’s a clear clinical pattern — specific food causing obvious reaction within minutes to a couple of hours, repeatedly. Broad allergy panels in the absence of a pattern tend to produce false-positive results, unnecessary food avoidance, and nutritional risk.

For more on the atopic background of eczema, see our guide Children with eczema — and when to call us.

Growing out of it — what to expect

Many children with asthma improve significantly through the primary school years, and some appear to “grow out of it” by adolescence. The factors that most seem to affect this trajectory:

• Consistency of preventer use in the early years — children on well-controlled ICS regimens often have smoother long-term courses
• Severity at onset — mild viral wheeze often resolves; persistent allergic asthma with multiple atopic features is more likely to continue
• Smoking exposure — secondhand smoke (and later, active smoking in teens) is one of the strongest modifiable worsening factors
• Adherence during adolescence — a common time for treatment to drift

A child’s asthma history is worth keeping track of over the years — even if it seems to resolve, recurrence in adulthood is possible, and knowing the childhood pattern helps us manage it faster.

Vaccinations

Children with asthma should be up to date on:

• Annual influenza (flu) vaccine — strongly recommended; respiratory viruses trigger most paediatric exacerbations
• National Childhood Immunisation Programme (NCIP) — the standard SG childhood schedule. See our guide on Childhood vaccinations (NCIP).
• COVID-19 boosters per current MOH recommendations for children with chronic conditions

Regular follow-up

Children with asthma should be reviewed:

• Every 1 to 2 weeks after an exacerbation
• Every 1 to 3 months after starting or adjusting treatment
• Every 3 to 6 months once stable, at minimum

At each visit we’ll check inhaler technique, symptom control (using the same 4-question check as for adults), growth, triggers, and medication adherence. Quick visits count — we don’t need to cover everything every time.

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

Most children with asthma can be managed very well in primary care. However, certain patterns benefit from a paediatric respiratory specialist’s involvement, and we’ll usually suggest a referral when:

• The diagnosis is uncertain or atypical — wheeze from very early infancy, poor response to standard treatment, suspicion of a non-asthma cause (foreign body aspiration, cystic fibrosis, primary ciliary dyskinesia, a structural airway problem, or a cardiac cause of wheeze)
• Severe or difficult-to-control asthma — needing medium-to-high dose ICS to stay stable, or already on combination preventer therapy without good control
• Frequent exacerbations despite an optimised plan and addressed triggers
• A previous ICU admission or severe attack — an important marker of ongoing risk
• Children aged 0 to 5 with recurrent wheeze — a specialist assessment is often valuable at this age to distinguish viral-wheeze phenotypes from early asthma and to plan treatment accordingly
• Occupational or unusual environmental triggers — mould, occupational allergen exposure, complicated atopic backgrounds
• When 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-function testing — spirometry with bronchodilator response, fractional exhaled nitric oxide (FeNO), bronchial challenge testing (in older children), impulse oscillometry for younger children
• Access to biologic injections — these are specialist-initiated and not typically prescribed in primary care
• Multidisciplinary input — specialist nurses, respiratory physiotherapists, paediatric allergists, and (where relevant) psychologists
• Hospital-based infrastructure — for more complex investigations, admissions for severe flares, and transition planning into adult services

A referral is not a sign that something is wrong with the care you’ve been getting — it simply means certain patterns are best handled by clinicians who see a lot of those patterns each week. In most cases we continue day-to-day care while the specialist is involved periodically — sharing notes and keeping the plan coherent across teams.

If you have concerns that your child’s asthma isn’t being managed well, please raise them at a visit. We’d rather refer a little earlier than watch a pattern drift.

The Singapore context

• Healthier SG Chronic Tier — for family members aged 40+, enrolled patients can access subsidised chronic medications at prices similar to polyclinics.
• Community Health Assist Scheme (CHAS) — means-tested subsidies for consultations and selected medications, including for children in eligible households.
• NCIP-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

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

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

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 Programme (NCIP). healthhub.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. v1.0 · April 2026 · Review due April 2028.