Child Health · Respiratory
Childhood Asthma — Attack Severity & Action Plan
When your child is wheezing or coughing badly — how to assess severity, give salbutamol via spacer properly, know when to call 999, and use brown (preventer) vs blue (reliever) inhalers. Plus PRAM clinical severity scoring for hospital teams. NICE NG80 / BTS-SIGN 2024.
Last reviewed 1 June 2026
PRAM — paediatric asthma severity
5-item respiratory assessment
Suprasternal retractions
Scalene muscle contraction
Air entry
Wheezing
SpO2 (room air)
PRAM total · Mild (0–3)
0 / 12
SABA 4–10 puffs via spacer (or 2.5–5 mg salbutamol neb), oral prednisolone 1–2 mg/kg (max 40 mg). Observe ≥ 1 h post-bronchodilator. Discharge if sustained improvement, normal SpO2, parents confident with action plan.
Red flags
- Silent chest — no wheeze because no air moving; impending respiratory failure.
- Exhausted / drowsy — CO2 retention.
- Cyanosis — severe hypoxaemia.
- Reduced consciousness — pre-arrest.
- SpO2 < 90 % on O2 — near-fatal.
Educational tool only — not medical advice. Chalut 2000 J Pediatr; GINA 2024; NICE NG80; BTS-SIGN. Validated for ages 2–17. PASS (Paediatric Asthma Severity Score) is an alternative. Decisions by paediatric / emergency team.
What does this mean?
The PRAM is the most-used paediatric acute asthma severity score in EDs in Canada, the US, and increasingly the UK and Australia. It correlates well with PaO2/FEV1 outcomes, length of stay, and admission rate in multiple validations. Two big practical points: (1) Severity assessment is dynamic — PRAM should be re-measured 15–30 min after each bronchodilator dose. A static initial score is less useful than a trajectory: improving on treatment vs static vs worsening. (2) Steroids early: oral prednisolone 1–2 mg/kg (max 40 mg) reduces admission rates if given within the first hour (Cochrane 2003); IV methylprednisolone is reserved for vomiting or severe presentations. Salbutamol via spacer is equivalent to nebuliser for mild and moderate severity (Cochrane 2013) and has fewer side effects (less tachycardia, tremor). IV magnesium sulphate 25–75 mg/kg (max 2 g) is the rescue for severe cases not responding to bronchodilators (Griffiths 2016 Cochrane). The dreaded silent chest = no air moving = pre-arrest. PICU NOW.
Is my child having an asthma attack?
Signs of an attack:
- Wheezing — high-pitched whistling on breathing OUT.
- Coughing — persistent, worse at night or with activity.
- Shortness of breath — working hard to breathe.
- Chest tightness.
- Fast breathing.
- Retractions — sucking in around ribs / neck.
- Blue lips or fingernails (severe).
When to call 999
- Lips, tongue, fingernails BLUE or grey.
- Can’t speak in full sentences.
- Severe sucking-in of chest.
- Becoming drowsy or confused.
- Ventolin / inhaler NOT helping after 10 puffs.
- Getting worse despite treatment.
- Oxygen saturation <92% (if home pulse oximeter).
While waiting for ambulance: keep child upright, calm, give salbutamol 10 puffs via spacer every 30 sec.
Salbutamol via spacer (10-puff technique)
- Shake inhaler, attach to spacer.
- Mask covers mouth + nose (under 4) OR mouthpiece in mouth (over 4).
- Press once for one puff.
- Take 5-6 NORMAL breaths through spacer OR hold breath 10 sec.
- Wait 30-60 seconds.
- Repeat for total of 10 puffs in acute attack.
SPACER is essential. Without it, only ~10% of medication reaches lungs (vs ~40% with spacer). NHS provides spacers free for children.
Blue vs brown inhaler
- Blue (SABA — salbutamol / Ventolin): FOR ATTACKS / quick relief / before exercise. Works in 5-15 min. As needed.
- Brown (ICS — beclomethasone, fluticasone, budesonide): FOR PREVENTION / daily use. Reduces inflammation. Works over weeks. NOT for sudden attacks. Twice daily usually.
Rinse mouth after brown inhaler to prevent thrush.
Using blue >2x/week = asthma not controlled. See GP.
Common triggers
- Viral infections (60-80% of attacks in young children).
- Allergens (pollen, grass, pets, dust mites, mould).
- Exercise.
- Cold air / weather changes.
- Smoke (cigarette, wood-burning stove).
- Strong smells, perfumes, cleaning products.
- Emotions (laughing, crying).
- Aspirin (older children); beta-blockers.
Asthma action plan
Written plan from GP / asthma nurse with usual meds, when to use blue, when to start oral steroid, when to call 999. Three colour zones:
- Green — well, normal meds.
- Amber — getting worse, increase blue, ± oral steroid.
- Red — severe, 999.
Every child with asthma should have one. Asthma UK templates free. Share with school, grandparents, anyone caring for child. Update annually.
PRAM severity score (clinical tool)
Used in hospitals / EDs for acute asthma in children age 2-17. Five items, 0-3 each, total 0-12:
- Suprasternal retractions.
- Scalene contraction.
- Air entry on listening.
- Wheezing.
- Oxygen saturation.
Bands: 0-3 mild; 4-7 moderate; 8-12 severe.
Different scenarios — childhood asthma
Scenario 1: 5-year-old with cold + wheeze starting
Blue inhaler 4-10 puffs via spacer; recheck in 30 min. If known asthma action plan, follow amber zone. If repeated viral wheeze, consider preventer review with GP.
Scenario 2: Toddler, 3rd episode this winter, atopic family
Pattern emerging. See GP for asthma assessment. May start trial of brown preventer. Smoke-free environment.
Scenario 3: Severe attack, blue lips, can’t speak
999 NOW. Salbutamol 10 puffs via spacer every 30 sec while waiting. Keep upright. Stay calm.
Scenario 4: Asthma stable for years, just had attack needing A&E
Review with GP within a week. Check inhaler technique. Update action plan. Identify trigger if possible. May need step-up treatment.
Scenario 5: Teenager, asthma, won’t take brown inhaler
Common. Adherence drops in adolescence. Open conversation about why. Combination inhalers may help (one device). Asthma nurse adolescent clinic if available. Stress: brown inhaler is what keeps attacks away.
Care guidance — childhood asthma
- Daily brown inhaler if prescribed (even when well).
- Rinse mouth after brown inhaler.
- Always use spacer.
- Blue inhaler in school bag / nursery.
- Asthma action plan — written, updated annually.
- Annual flu vaccine (NHS free for children).
- Smoke-free home.
- Know triggers — minimise exposure.
- Recognise worsening early — don’t wait until severe.
- Regular review at GP / asthma nurse.
- Call 999 for blue lips, no improvement after 10 puffs, severe sucking-in.
Sources
- NICE NG80. Asthma: diagnosis, monitoring and chronic asthma management.
- BTS / SIGN. British guideline on the management of asthma (158, 2019; 2024 update).
- Asthma + Lung UK. Children’s asthma action plan.
- Chalut DS, Ducharme FM, et al. The Preschool Respiratory Assessment Measure (PRAM): a responsive index of acute asthma severity. J Pediatr 2000.
- RCPCH. Acute asthma in children clinical guideline.
Frequently asked questions
Is my child having an asthma attack?
Signs of an asthma attack: WHEEZING (high-pitched whistling sound, especially on breathing OUT); COUGHING (often dry, persistent, worse at night or with activity); SHORTNESS OF BREATH (working hard to breathe, may not be able to complete sentences); CHEST TIGHTNESS (older children may describe); FAST BREATHING; SUCKING IN around ribs / neck (retractions); BLUE-TINGED lips or fingernails (severe). MILD ATTACK: still active, talking normally, wheezing but ventolin helps. SEVERE: can't speak in full sentences, sucking in chest, lips blue, ventolin not helping — 999 / A&E NOW.
When should I call 999 for asthma?
EMERGENCY (999) IF: (1) Lips, tongue, or fingernails BLUE or grey; (2) Can't speak in full sentences; (3) SEVERE chest sucking-in (intercostal / subcostal recession); (4) Becoming DROWSY or confused; (5) Ventolin / inhaler NOT helping after 10 puffs; (6) GETTING WORSE despite treatment; (7) RESPIRATORY rate >40-60/min in child; (8) Heart rate very fast >140-180/min (age-dependent); (9) OXYGEN saturation <92% if home pulse oximeter. WHILE waiting for ambulance: keep child upright, calm, give salbutamol 10 puffs via spacer every 30 sec; check breathing.
How do I give salbutamol (Ventolin) properly?
ALWAYS via SPACER (not directly from inhaler) in children under 12. TECHNIQUE: (1) Shake inhaler, attach to spacer. (2) Mask covers mouth + nose (under 4) OR mouthpiece in mouth (over 4). (3) Press once for one puff. (4) Take 5-6 NORMAL breaths through spacer OR hold breath 10 sec. (5) WAIT 30-60 seconds. (6) Repeat for total of 10 puffs in acute attack. NOT: rapid back-to-back puffs without breathing. SPACER essential — without it, only ~10% of medication reaches lungs (vs ~40% with spacer). Different brands work; NHS provides free for children.
What does the PRAM score measure?
PRAM (PAEDIATRIC RESPIRATORY ASSESSMENT MEASURE) — 5-item severity score for acute asthma in children, age 2-17. Used by hospitals / urgent care to grade severity + guide treatment. ITEMS: (1) SUPRASTERNAL RETRACTIONS (sucking in at neck base); (2) SCALENE CONTRACTION (neck muscles working); (3) AIR ENTRY (how much air moves in lungs on listening); (4) WHEEZING; (5) OXYGEN SATURATION. EACH 0-3 points → total 0-12. BANDS: 0-3 mild; 4-7 moderate; 8-12 severe. NOT for home use — clinical tool. PARENT version of 'how worried should I be' = symptom severity + medication response + general worsening trend.
What triggers asthma attacks?
(1) VIRAL INFECTIONS — most common trigger in young children; 60-80% of attacks. (2) ALLERGENS — pollen (spring/summer), grass, pets, dust mites, mould. (3) EXERCISE — running, especially in cold air. (4) COLD AIR / weather changes. (5) IRRITANTS — smoke (cigarette, fire, wood-burning stove), strong smells, perfumes, cleaning products. (6) EMOTIONS — laughing, crying, stress. (7) FOOD ALLERGENS for some. (8) MEDICATIONS — aspirin (in older children); beta-blockers. (9) THUNDERSTORMS (rare 'thunderstorm asthma'). KNOW YOUR child's triggers to reduce exposure.
How do I know if my child has asthma?
DIAGNOSIS difficult in young children — they wheeze for many reasons (viral, bronchiolitis). ASTHMA suggested by: (1) RECURRENT wheezing episodes (≥3 episodes); (2) WHEEZE responsive to bronchodilators (salbutamol); (3) SYMPTOMS WORSE at night / early morning / with triggers; (4) FAMILY HISTORY asthma / eczema / allergic rhinitis (atopy); (5) PERSONAL history eczema / hay fever; (6) NO infection at the time. UNDER 5: 'preschool wheeze' — may or may not become asthma. OVER 5: spirometry / peak flow testing possible. DIAGNOSIS often clinical + response to inhaler trial.
What's the difference between blue and brown inhalers?
BLUE inhaler (SHORT-ACTING BETA AGONIST, SABA) — usually salbutamol (Ventolin). FOR ATTACKS / quick relief / before exercise. Works in 5-15 minutes. Used 'as needed'. If using >2x/week, asthma not controlled. BROWN inhaler (INHALED CORTICOSTEROID, ICS) — usually beclomethasone, fluticasone, or budesonide. FOR PREVENTION / daily use. Reduces inflammation. Works over weeks. NOT for sudden attacks. Used DAILY (twice/day usually). MUST RINSE MOUTH after to prevent thrush. PURPLE / OTHER inhalers: combinations or long-acting + steroid. NOT INTERCHANGEABLE — blue treats attacks, brown prevents them.
Why does my child need a brown inhaler daily?
PREVENTS attacks. If your child uses BLUE inhaler >2x/week or has had ATTACK requiring oral steroids in past year, NICE / BTS recommend DAILY brown (ICS) inhaler. REDUCES INFLAMMATION in airways over weeks; not immediate relief. CONSISTENT use = fewer attacks, less wheezing, less missed school, better growth. NOT addictive. SAFE long-term at correct dose. CONCERNS: small effect on growth (~1 cm reduced height in lifetime — outweighed by asthma control benefit). MUST USE EVERY DAY even when well — protective effect builds up.
Will my child grow out of asthma?
MAYBE. ~50% of children with preschool wheeze grow out of it by age 6. ~30% of childhood asthma persists into adulthood. PROGNOSIS BETTER if: episodic / viral-trigger only; no atopy (eczema, hay fever, food allergies); no family history. PROGNOSIS WORSE if: atopic (eczema + asthma + hay fever); persistent symptoms; severe early attacks; smoking in household. EVEN if symptoms resolve, airways may remain sensitive — relapse possible in adulthood. CONTROL DURING childhood reduces airway damage long-term. NEVER 'just let it go untreated' to 'grow out of it'.
Should I worry about asthma deaths?
ASTHMA can be fatal. UK: ~1,200 asthma deaths/year, ~25 children. RARE but preventable. RISK FACTORS for fatal attack: poor adherence to brown inhaler; over-reliance on blue inhaler; previous hospital admission especially ICU; current oral steroid course; smoking; allergic asthma (multiple allergens); psychological factors (denial, anxiety). PREVENTION: USE brown inhaler daily; HAVE asthma action plan from GP; KNOW when to seek emergency help; REGULAR review at GP / asthma nurse. ASTHMA UK has free action plan templates. RTI (respiratory illness) is the most common trigger — get blue inhaler before colds get bad.
What is an asthma action plan?
WRITTEN PLAN from GP / asthma nurse, summarising your child's: (1) USUAL MEDICATIONS + doses; (2) WHEN to use blue inhaler (worsening symptoms); (3) WHEN to start oral steroid (if prescribed); (4) WHEN to call 999 / go to A&E. THREE COLOURS / ZONES typically: GREEN (well, normal meds); AMBER (getting worse, increase blue inhaler, ± oral steroid); RED (severe — 999). EVERY child with asthma should have one. ASTHMA UK has free templates. SHOW to school, grandparents, anyone caring for child. UPDATE annually with GP.
What about steroid side effects?
INHALED STEROIDS (brown / preventer inhaler): minimal systemic absorption when used correctly. SMALL EFFECT on lifetime height (~1 cm shorter) — outweighed by asthma control benefit. ORAL STEROIDS (prednisolone tablets) for severe attacks: short courses (3-5 days) generally well-tolerated; longer / repeated courses can affect growth, bone density, mood, weight. WHY USE: severe asthma without oral steroid carries much higher risk than steroid itself. RINSE MOUTH after inhaled to prevent thrush + hoarse voice. USE SPACER to reduce mouth deposit. AVOID smoking around children.
How does asthma differ from bronchiolitis or viral wheeze?
AGE: BRONCHIOLITIS typically under 2 (especially under 6 months) — RSV is main cause. VIRAL-INDUCED WHEEZE: 1-5 years often, with cold. ASTHMA: usually clearer pattern from 3-5+. BRONCHIOLITIS: cold-like illness + wheeze + struggling to feed + fast breathing; SUPPORTIVE care only (no bronchodilator works); NICE NG9 admission criteria. VIRAL WHEEZE: similar to asthma attack but only with viruses; bronchodilator often helps. ASTHMA: recurrent wheeze, multiple triggers (not just colds), responsive to bronchodilator. OVERLAP: viral wheeze in toddler can progress to asthma diagnosis.
What helps in an asthma attack at home?
(1) SIT child UPRIGHT (don't lie down). (2) GIVE SALBUTAMOL via spacer — 10 puffs, one at a time, with breaths between. (3) WAIT 5-10 minutes. (4) ASSESS: better? continue monitor. NOT improved? REPEAT 10 puffs. (5) CALL 999 if: no improvement after 10-20 puffs; getting worse; blue lips; can't speak; severe sucking-in; drowsy. (6) KEEP CALM — your calm helps child. (7) DON'T give cough medicine, antihistamines, or 'remedies' instead of inhaler. (8) DON'T give nebulised treatment unless prescribed. STEROIDS by mouth (if you have at home) per action plan.
What about COVID / RSV / flu in asthmatic children?
RESPIRATORY infections trigger asthma. PREVENTION: ANNUAL flu vaccine (nasal spray for children, NHS free); RSV protection (nirsevimab) for high-risk infants; STANDARD vaccines on schedule. MASK in high-risk situations (medical visits). HAND HYGIENE. PERSISTENT cough after virus common (post-viral hypersensitivity) — different from asthma worsening. WHEN INFECTION HITS: increase blue inhaler use; consider asthma action plan amber zone; oral steroid if per plan; seek help if not improving in 24-48h.
How does this relate to other calculators on BumpBites?
Companion: /calculators/baby-cough for cough differential; /calculators/croup-westley for croup; /calculators/croup-home-hospital; /calculators/baby-fever for febrile illness; /calculators/bronchiolitis (if added); /calculators/hand-foot-mouth; /calculators/vaccine-scheduler for flu vaccine; /calculators/oral-thrush (steroid inhaler side effect).