Table 2.

Guideline recommendations for referral of pediatric asthma patients to a specialist

	Situations indicated for specialist referral
Guideline	Diagnostic uncertainty	High-risk patients	Corticosteroid treatment (high dose, long-term use and side effects)	Add-on specialist treatment
GINA: Diagnosis and management of asthma in children 5 years or younger (2016)5	• Failure to thrive • Neonatal or very early onset of symptoms (especially if associated with failure to thrive) • Vomiting associated with respiratory symptoms • Continuous wheezing • Failure to respond to asthma controller medications • No association of symptoms with typical triggers, such as viral upper respiratory tract infection • Focal lung or cardiovascular signs, or finger clubbing • Hypoxemia outside the context of viral illness • Additional reasons for referral in children 6–11 years:  • Doubts about diagnosis of asthma	• If symptom control remains poor and/or flare-ups persist at step 4 treatment • Additional reasons for referral in children aged 6–11 years:  • Symptoms or exacerbations still remain uncontrolled despite moderate dose of ICS (step 4) with correct inhaler technique and good adherence	• If side effects of treatment are observed or suspected at step 4 of treatment • Additional reasons for referral in children aged 6–11 years:  • Suspected side effects of treatment	• NR
ICON on pediatric asthma (2012)14	• NR	• Where control cannot be achieved with the maximum dose of ICS and additional medication, with the final resort being the use of OCS	• NR	• NR
Diagnosis and treatment of asthma in childhood: PRACTALL consensus report (2008)13	• NR	• If insufficient control after:  • an increase in ICS dose (800 μg BDP equivalent)  • The addition of LTRA to ICS or  • The addition of LABA after checking compliance	• Patients requiring high doses of ICS or doses which are not licensed	• NR
National Asthma Council Australia (2015)88	• Diagnostic tests (FEV 1 pre-/post-bronchodilator, reversible airflow limitation, bronchial provocation test and cardiopulmonary test) do not support asthma diagnosis • Severe upper respiratory tract infection (severe rhinitis, nasal polyps) • Wheezing disorder where asthma is not confirmed • Multiple trigger wheeze • Child is unable to undergo spirometry (<6 months old)	• Uncontrolled on ICS high dose OR low-dose ICS plus montelukast OR ICS/LABA (low dose) seek referral	• NR
British Thoracic Society (2016)8	• Diagnosis unclear	• Symptoms present from birth or perinatal lung problem • Excessive vomiting or posseting, severe upper respiratory tract infection; persistent wet or productive cough, family history of unusual chest disease, failure to thrive, nasal polyps • 5–12 years of age, failure to respond to conventional treatment, particularly at step 5 (ICS up to 800 μg/day) • <5 years of age, uncontrolled at step 3 (200–400 mg of ICS with LTRA) • <2 years of age, uncontrolled at step 2 (200–400 mg ICS)	• Receiving high-dose ICS should be under specialist care • Continuous or frequent use of oral steroids
Canadian Thoracic Society Guideline Update: Diagnosis and management of asthma in preschoolers, children and adults (2012)50	• NR	• Children (6–12 years of age) who fail to achieve control on a medium dose of ICS • Uncontrolled asthma in individuals >12 years of age who are on an ICS/LABA combination	• In children, the use of high doses of ICS due to possible significant side effects • In all age groups, frequent courses of OCS should prompt referral to a specialist	• Omalizumab considered for patients >12 years of age with asthma poorly controlled despite high doses of ICS and appropriate add-on therapy, with or without OCS
Japanese guideline for childhood asthma (2014)11	• NR	• Uncontrolled patients with step 3 (medium ICS dose) or step 4 (high-dose ICS) management strategy	• NR	• NR
South African guidelines for the management of chronic asthma in children (2009)12	• Diagnosis is in doubt	• Uncontrolled asthma requiring level three treatment (<5 medium dose ICS with LTRA or >5 medium to high-dose ICS/LABA) • Life-threatening episode • Frequent hospitalizations or emergency room visits	• High dose of ICS (>400 μg/day) • OCS required regularly	• Omalizumab being considered an option
Singapore Ministry of Health clinical practice guidelines on asthma management (2008)7		• High-risk asthma with poor asthma control • <3 years and requires moderate to high doses of inhaled steroids and not responding as expected	• Requires high-dose steroids, BDP/BUD ≥400 μg/day or fluticasone ≥200 μg/day or is on prolonged inhaled steroid therapy for >6 months and remains symptomatic • A severe acute asthma attack and requires prolonged or repeated OCS for control

Abbreviations: BDP, beclomethasone dipropionate; BUD, budesonide; FEV₁, forced expiratory volume in 1 second; GINA, Global Initiative for Asthma; ICON, International Consensus; ICS, inhaled corticosteroid; LABA, long-acting beta agonist; LTRA, leukotriene receptor antagonist; NR, not reported; OCS, oral corticosteroid; PRACTALL, practical allergy.