Your child has been nebulised three times this year. Should they be on a preventer?

The pattern I see most often

A child coughs at night for a fortnight. The chest gets tight, a wheeze appears, and at some point the family ends up at a clinic or a casualty at nine in the evening. A nebuliser is given, the child improves within twenty minutes, everyone goes home relieved, and often a short course of oral steroids goes with them. Three months later the same thing happens.

Each of those episodes was managed correctly in itself. The problem is the pattern. Three or more courses of rescue treatment in a year is the definition of asthma that is not controlled — and the answer to uncontrolled asthma is not faster rescue, it is treatment of the inflammation between the attacks.

Why the nebuliser feels safer than the inhaler

This is worth saying out loud, because almost every parent feels it. The nebuliser is large, it is in a clinic, a professional operates it, it makes a noise and produces visible mist, and it takes fifteen minutes. The inhaler is small, plastic, used at home, over in seconds, and invisible. One looks like serious medicine and the other looks like nothing.

The pharmacology does not agree. A metered-dose inhaler used with a spacer — and a mask for a small child — delivers the same drug to the lungs as effectively as a nebuliser for the great majority of childhood wheeze, with fewer side effects and much less fuss. This is one of the better-established findings in paediatric respiratory medicine. The spacer is the equipment, not a compromise.

Two things do need to be right: the technique, and the spacer itself. A great deal of apparent treatment failure is a child breathing through the mouth around a badly fitted mask, or a spacer that has never been washed. We check technique at every visit, and we will ask you to demonstrate it rather than describe it.

The steroid question, answered directly

Parents are not being irrational when they worry about steroids. They are thinking of the oral and injected steroids that cause weight gain, mood change, raised sugar and bone loss with prolonged use. Those concerns are legitimate — for those drugs.

An inhaled preventer is a different proposition. The daily dose is measured in micrograms, delivered to the airway surface, and a large proportion of what is swallowed is broken down before it reaches the circulation. The effect on growth that has been demonstrated in trials is a small reduction in growth rate in the first year of treatment, with a modest effect on final adult height — of the order of a centimetre, and not cumulative year on year.

Set that against the alternative. Repeated courses of oral prednisolone, several times a year, deliver far more systemic steroid than a low-dose preventer does. And untreated asthma has its own effect on growth, on sleep, on appetite, on school attendance, and on how much a child can do with other children. The honest comparison is not steroid against no steroid; it is a small controlled dose against a larger uncontrolled one.

Simple habits reduce even that small risk: a spacer always, rinsing the mouth and spitting after each dose, and reviewing the dose at least yearly with the aim of stepping down to the lowest that keeps the child well. Preventer treatment is not a life sentence — it is reviewed.

Ask for a test before a long-term prescription

This is the part I would most like parents to take away. Asthma should not be diagnosed and lifelong treatment begun on symptoms alone — the AAAAI's guidance is explicit that asthma should not be diagnosed or managed without spirometry.

From about five or six, most children can do spirometry, often with game software that turns the blow into candles going out. Reversibility testing — measuring again after a reliever — is what distinguishes asthma from other causes of cough and wheeze. Below that age we rely on history, examination, FeNO where available, and a carefully monitored trial of treatment with a defined review date rather than an open-ended prescription.

Allergy testing matters here too. A large share of children with difficult asthma have untreated allergic rhinitis driving it, and treating the nose properly sometimes does more for the chest than increasing the inhaler.

What you should leave a consultation with

• A written asthma action plan — what to give daily, what to give when symptoms start, and the specific signs that mean go to hospital now.
• A demonstration of inhaler and spacer technique, done by your child in front of us, not explained to you.
• A named review date, so the treatment is re-examined rather than repeated indefinitely.
• An objective measurement where age allows, and a clear reason if it was not possible.

Next step

Bring the inhalers and the nebulisation records

Every device, including ones you stopped, plus the dates of any emergency visits and steroid courses. That history is what tells us whether this is controlled or not.