Asthma in children: inhalers, spacers and school

What this article covers

What is asthma and what happens during an attack?
What triggers asthma and which ones are most important at home?
Understanding inhalers: reliever and preventer
How to use a spacer correctly: the most important practical skill
How many puffs during an attack and when to escalate?
A school asthma action plan: why it matters and what to put in it
Preventer inhalers and long-term control: the daily discipline
Exercise, sport, and school physical education
When asthma is difficult to control: reviewing the plan

What is asthma and what happens during an attack?

Asthma is a chronic condition of the airways, the tubes that carry air in and out of the lungs. In a child with asthma, these airways are persistently inflamed, meaning they are sensitive and prone to swelling. When exposed to a trigger such as dust, cold air, or a respiratory infection, the muscles around the airways tighten, the lining swells, and extra mucus is produced. The result is the familiar picture: a tight chest, a persistent cough, wheezing (a whistling sound when breathing out), and shortness of breath.

Between episodes, many children with asthma feel and look completely normal. This is one of the reasons asthma is sometimes diagnosed late: a child who coughs every night or gets wheezy with exercise may be accepted as normal by a family who has not seen what adequate treatment looks like.

A 2023 study of children and adolescents in western Saudi Arabia found asthma present in a significant proportion of those assessed, consistent with global patterns that show higher rates in arid, dusty environments. A national cross-sectional survey of Saudi children published in 2022 confirmed asthma is a leading cause of school absences and unplanned hospital visits in the region, underscoring that this is not a mild or occasional problem for many families.

Asthma is a chronic condition that cannot be cured, but it can be controlled very well with the right treatment and the right understanding of triggers. A child whose asthma is well controlled should be able to sleep through the night without symptoms, exercise normally, and miss no or very little school.

What triggers asthma and which ones are most important at home?

Triggers are things that provoke the airways of a child with asthma into reacting. Common triggers include respiratory infections such as colds and flu, which are the most common trigger of all. House dust mites, which live in mattresses, pillows, carpets, and upholstered furniture, are one of the most studied and modifiable indoor triggers. A 2003 study showed a clear relationship between dust mite allergen levels in the home and the development of asthma in children.

In Arab households, tobacco smoke and shisha smoke are particularly important regional triggers. Shisha smoke is not safer than cigarette smoke. A single shisha session produces smoke volumes many times greater than a single cigarette, and the chemicals are similar. A child who lives in a home where shisha is smoked regularly is being exposed to a sustained airway irritant that undermines the best medication. This is worth raising directly with families, because the impact can be very large.

Other common triggers include pollen from plants and trees, mould spores particularly in damp conditions, pet fur and dander, cold air, exercise (which can be managed with a reliever inhaler before activity, not avoided), strong smells from cleaning products, perfumes, and incense, and emotional stress or upset. A child does not have to react to all of these. Most children with asthma have a smaller number of personal triggers, and identifying them is one of the most practical steps a family can take.

Air pollution from traffic and construction dust is an important outdoor trigger in many Arab cities. On high-pollution days, keeping windows closed and reducing outdoor play during midday hours reduces exposure. Sand and dust storms, common in parts of the Gulf and Iraq, can provoke severe asthma attacks and should prompt families to ensure preventer medicine has been taken and a reliever is immediately accessible.

Common asthma triggers and what you can do about them

Trigger	What helps at home
Dust mites	Encase mattress and pillow in dust-mite covers, wash bedding at 60C weekly
Tobacco or shisha smoke	No smoking indoors, especially near the child
Mould	Fix damp, ventilate bathrooms, use extractor fans
Pet fur and dander	Keep pets out of the child's bedroom
Cold air	Use reliever inhaler before going outside in cold weather
Exercise	Use reliever inhaler 10 minutes before activity, do not avoid exercise

Understanding inhalers: reliever and preventer

The two main types of inhaler for asthma are the reliever and the preventer, and they work in completely different ways. Understanding this difference is one of the most important things a family can do.

The reliever inhaler, most commonly salbutamol (also sold as Ventolin or Salamol), is usually blue. It acts quickly, within 3 to 5 minutes, by relaxing the muscles around the airways. It is taken when symptoms appear, or before exercise to prevent exercise-induced symptoms. It is not a long-term fix. Using a reliever more than twice a week for symptoms (not including pre-exercise doses) suggests that asthma is not well controlled and that a preventer inhaler is needed.

The preventer inhaler contains a low-dose inhaled corticosteroid, most commonly budesonide or fluticasone. It is usually brown, orange, or maroon. It works by reducing the underlying inflammation in the airways and must be taken every day, even when the child feels fine, for it to work. It takes 1 to 2 weeks of daily use to build full effectiveness. Families often stop the preventer when the child seems well, which allows inflammation to return and the next infection or trigger to cause a more severe attack. The preventer does not open the airways; it reduces the tendency for them to close.

Some children are prescribed a combination inhaler that contains both a preventer steroid and a long-acting bronchodilator in the same device. This simplifies the regimen. A specialist, not a pharmacist or general practitioner alone, should guide this choice.

How to use a spacer correctly: the most important practical skill

A spacer is a plastic chamber that attaches to the inhaler and holds the puff of medicine briefly so that the child has time to breathe it in slowly and deeply. Without a spacer, much of the medicine hits the back of the throat and is swallowed rather than reaching the lungs. A 2020 study confirmed that poor inhaler technique is directly associated with worse asthma outcomes in children hospitalised with attacks. With a spacer and correct technique, the lungs receive several times more medicine than without one.

Children under about 8 years cannot coordinate pressing the inhaler and breathing in at the same time, which makes a spacer not optional but essential. Older children can sometimes manage without one, but using a spacer is almost always more effective. Every child who uses a pressurised metered-dose inhaler (pMDI, the standard pump-type inhaler) should have a spacer.

A spacer needs to be cleaned correctly or it builds up a static charge that attracts the medicine particles to the walls of the chamber rather than letting them reach the child's lungs. Wash the spacer in warm soapy water, do not rinse it, and let it air dry. This leaves a thin film that reduces static. Replace the spacer every 6 to 12 months or when it is cracked or dirty.

How to use a spacer correctly

1Shake the inhaler well for 5 seconds before use
2Attach the inhaler firmly to the back of the spacer
3Ask the child to breathe out gently, then seal their lips around the spacer mouthpiece
4Press the inhaler once to release one puff into the spacer
5The child breathes in slowly and deeply, then holds the breath for 5 to 10 seconds if they can
6Wait 30 to 60 seconds before repeating for a second puff
7If the child is too young for a mouthpiece, use the mask attachment and hold it firmly but gently over nose and mouth

How many puffs during an attack and when to escalate?

Knowing what to do in the first 20 minutes of an asthma attack can prevent a moderate episode from becoming a severe one. When a child starts wheezing, coughing severely, or complaining of chest tightness, the immediate step is to give the reliever inhaler with a spacer. Give 2 to 4 puffs, one at a time, and wait. If there is no improvement after 15 to 20 minutes, give another 2 to 4 puffs.

If the child is not improving after this second round, or if they are getting worse at any point, go to hospital. Do not wait. In severe attacks, up to 10 puffs of salbutamol may be given using a spacer before reaching hospital, one puff at a time, but this does not replace emergency care: it buys time while you travel.

A 2017 article in the BMJ emphasised that one of the most consistent findings in audit of paediatric asthma deaths was delay in seeking emergency help. The family tried repeated reliever doses at home while the child deteriorated. The lesson is clear: if the first round of reliever does not produce clear improvement within 20 minutes, the child needs to be seen by a medical team. A written asthma action plan, discussed in the next section, makes this clearer and removes the guesswork.

Children who are having an asthma attack should sit upright, leaning slightly forward. Do not lay them down. Staying calm as the adult matters: a child who sees a parent panicking will breathe faster and feel worse. Reassure them while you give the inhaler and prepare to go to hospital if needed.

A school asthma action plan: why it matters and what to put in it

A school asthma action plan is a simple written document that tells teachers and school nurses exactly what to do when a child develops symptoms at school. Studies including a 2022 report in NASN School Nurse confirm that children whose schools have a copy of their action plan are managed more consistently and recover faster from school-day attacks than those without one.

The action plan should state clearly: the child's name and photograph, their specific triggers if known, the name and dose of their reliever inhaler, how many puffs to give when symptoms appear, when to call the parents, and when to call an ambulance without waiting for the parents. It should also state that the child must be allowed to carry their reliever inhaler on their person, not locked in a bag at reception.

In many schools in the region, inhalers are taken from children and stored by the teacher or the school nurse, which means the child cannot access them immediately during an attack. This delay is dangerous. The prevailing standard of care worldwide is that children who can self-administer their inhaler should carry it with them and be allowed to use it without having to request permission. Advocate for this with the school directly, and put the instruction in the action plan.

The action plan should be updated every year or when the treatment changes. The specialist or paediatrician managing the child's asthma can help write it or sign it, which gives it more authority with school administration.

Preventer inhalers and long-term control: the daily discipline

The most common reason asthma is poorly controlled in children is not that the medication does not work, but that it is not taken consistently. The preventer inhaler must be taken every day, morning and evening, even when the child is completely well. Families who stop it once the child stops wheezing set the stage for the next flare.

Building the preventer into an existing daily routine makes it much easier to sustain. Many families find that attaching it to tooth-brushing morning and night, or to the routine before leaving for school and before going to bed, removes the need to remember it separately. A visible reminder, such as keeping the inhaler on the bathroom shelf, helps.

There is often worry about long-dose steroid inhalers in children, particularly around growth. The inhaled steroids in preventer inhalers are at very low doses compared to oral steroids and the evidence shows that the impact on growth is minimal, typically less than 1 centimetre over long periods, and far outweighed by the benefit of controlled asthma. A child with poorly controlled asthma may also have reduced growth from chronic inflammation and frequent missed school days. Discuss specific concerns with the specialist.

Rinsing the mouth and spitting after using a preventer inhaler reduces the risk of oral thrush, a fungal infection in the mouth that can occasionally occur with inhaled steroids. Teach children this from the beginning so it becomes automatic.

Exercise, sport, and school physical education

Exercise-induced asthma, where symptoms appear during or shortly after physical activity, is very common and leads many families and teachers to restrict a child's sport or PE participation unnecessarily. Exercise is important for all children, including those with asthma, and with the right approach most children can participate fully.

The key practical step is to use the reliever inhaler 10 to 15 minutes before exercise. This pre-medicates the airways and prevents the exercise-triggered tightening for most children. The child should also have their reliever inhaler available on the sideline during sport, not locked away.

Some sports are better tolerated than others in asthma. Swimming is generally well tolerated because the air near water is humid and warm. Long-distance running in cold, dry air tends to be a stronger trigger. Indoor sports in dusty environments, such as gymnastics on old mats or football on dusty outdoor pitches, can provoke symptoms. Identifying which activities trigger symptoms allows a more targeted management plan rather than blanket restriction.

A teacher who understands that a child's need to use their inhaler before PE is a medical requirement, not an attempt to avoid exercise, makes an enormous practical difference. Including this point in the school action plan, and discussing it with the PE teacher directly, is worth the effort.

When asthma is difficult to control: reviewing the plan

If a child is using their reliever inhaler more than twice a week for symptoms, waking at night with coughing or wheezing more than once a week, or missing school regularly because of asthma, the treatment plan needs reviewing. This is not a failure of the child or the parents. It usually means that the preventer dose needs adjusting, that there is an unidentified trigger, that the inhaler technique is not correct, or that a different type of preventer or a combination inhaler is needed.

Annual reviews with a specialist or a trained paediatric nurse are the best way to stay on top of asthma control. In these reviews, the clinician will check inhaler technique, ask about the frequency of symptoms and reliever use, assess growth, and consider whether the current treatment step is still appropriate.

Some children outgrow asthma as the airways mature during adolescence. Others continue to have asthma into adulthood. It is not possible to predict this reliably in an individual child, so continuing treatment and monitoring is important even if symptoms seem to have disappeared for a period.

Use Sihtak to log your child's asthma symptoms, reliever use, and nights disturbed each week. This data, over a month or two, is the most useful thing you can bring to a review appointment. A pattern that shows symptoms worsening at weekends or after visiting a particular house can point directly to a trigger that has not been identified.

Frequently asked questions

Does my child need to use the inhaler every day even when they feel fine?

If they have a preventer inhaler, yes. The preventer works by reducing inflammation every day. It is not taken for symptoms; it is taken to prevent symptoms. Stopping it when the child is well is the most common reason asthma flares up again. The reliever inhaler is only used when symptoms appear or before exercise.

Is asthma hereditary?

There is a strong genetic component to asthma. If one parent has asthma, a child has a roughly 25 percent higher chance of developing it. If both parents have asthma or allergies, the risk is higher still. But genes are not the whole story: many children with no family history develop asthma, and many children from affected families do not. Environmental exposures also play a major role.

Can we use one spacer for the whole family to save money?

No. Spacers should not be shared between people. Each child needs their own spacer to prevent cross-infection. Spacers are not expensive and are usually available at pharmacies. In many countries they are dispensed with the initial inhaler prescription.

My child had asthma as a young child. Now at age 10 they seem fine. Do they still have it?

Some children do appear to grow out of asthma symptoms during primary school years, but the underlying tendency of the airways to be sensitive often remains. Many of these children see their asthma return in adolescence or early adulthood, particularly when they start smoking or are exposed to new triggers. A follow-up review with a specialist, even if the child seems symptom-free, is worthwhile.

Is it safe to fly with an asthmatic child?

Yes, with preparation. Carry all inhalers in hand luggage, not in the hold. Bring a letter from the doctor describing the condition and the medication. Keep the reliever inhaler accessible throughout the flight. The cabin air is dry, which can be a trigger for some children, so staying hydrated helps. Check the airline's policy on nebulisers if the child uses one.

Why does my child cough at night but not during the day?

Asthma symptoms, especially coughing, are typically worse in the early hours of the morning because of natural changes in the level of cortisol in the body, cooler bedroom temperatures, and lying flat, which affects how the airways drain. Night coughing that disturbs sleep more than once a week is a sign that asthma is not well controlled and the treatment plan should be reviewed.

Can a child have asthma even if the peak flow or spirometry test is normal?

Yes. Lung function tests are often normal between episodes in children with mild to moderate asthma. The diagnosis is usually made on the pattern of symptoms (wheeze, cough, chest tightness that comes and goes) and the response to a trial of reliever treatment, not on a single test result. A specialist can arrange a provocation test or a trial of treatment to clarify the picture.

My child has been prescribed a nebuliser for home use. Is that better than an inhaler with a spacer?

Not for routine use. Studies consistently show that a reliever inhaler with a well-used spacer delivers as much medicine as a nebuliser for most children, is faster, and requires no electricity. Nebulisers have a role in hospital management of severe attacks and for some children who cannot use a spacer at all. For home management of mild to moderate episodes, an inhaler with a spacer is the recommended approach.

Sources

This content is for health education only and is not a substitute for medical advice. If you have symptoms that worry you, see your doctor.