Asthma is common and most of it is managed well in primary care and general pediatrics. Referral is not a judgement on anyone's care. It becomes useful at specific points: when control is poor despite correct treatment, when the diagnosis itself is uncertain, or when something in the picture does not fit asthma at all.
The clearest reasons to refer
1. Control is poor despite regular preventer treatment
Before escalating treatment, three things need excluding: inhaler technique, adherence, and ongoing trigger exposure. Most apparently difficult asthma turns out to be one of those. But where a child is taking a reasonable preventer dose correctly and is still symptomatic, that is difficult-to-treat asthma and warrants specialist assessment.
Practical markers of poor control:
- Reliever needed more than twice a week, outside exercise
- Waking at night with cough or wheeze
- Symptoms limiting sport, play or school attendance
- More than one course of oral steroids in a year
2. Any hospital admission, or an emergency attendance
A child who has been admitted for asthma, or attended an emergency department, should have a specialist review afterwards. Attack history is one of the strongest predictors of future attacks, and the period after one is when a management plan actually gets changed.
3. The diagnosis has never been objectively confirmed
A surprising number of children carry an asthma label applied years earlier on symptoms alone. In a child old enough to perform the tests, asthma should be supported by spirometry with reversibility and FeNO. Children are also treated for asthma when they have allergic rhinitis, reflux, a habit cough, or a dysfunctional breathing pattern. Continuing inhaled steroids for years in a child who does not have asthma is not a neutral decision.
4. Features that do not fit asthma
- A wet, productive cough between attacks — asthma does not usually do this. See wet versus dry cough
- Poor growth or weight gain
- Finger clubbing — never a feature of asthma
- Symptoms present from the first weeks of life
- Stridor — noise on breathing in rather than out
- Signs always in the same part of the chest
- No response at all to bronchodilators
- A sudden onset in a previously well child — consider an inhaled foreign body
5. High-dose treatment, or frequent steroid courses
A child on high-dose inhaled corticosteroids, requiring add-on therapy, or needing repeated oral steroid courses should be reviewed by someone who can reassess the diagnosis and consider whether add-on or biologic treatment is appropriate.
6. Complex comorbidity
Significant allergic disease, obesity, obstructive sleep apnea, or vocal cord dysfunction all interact with asthma and often explain why it appears refractory. A child with asthma who also snores heavily may be two problems, not one — see pediatric sleep assessment.
7. Parental anxiety that has not been resolved
This is a legitimate reason and I would rather families came. A parent who is frightened every time their child coughs is not going to give treatment consistently, and that anxiety is often itself a marker that something has not been adequately explained.
Difficult asthma versus severe asthma
The distinction matters because it decides what happens next.
- Difficult-to-treat asthma is poorly controlled asthma where a modifiable factor is present: technique, adherence, ongoing allergen or smoke exposure, untreated rhinitis, or the wrong diagnosis. Most children referred fall here, and most improve once the factor is addressed.
- Severe asthma is the much smaller group who remain poorly controlled after all of that has been properly excluded. These children may need add-on therapy or biologic treatment, and need ongoing specialist care.
Separating the two takes a structured assessment, not a single appointment judgement.
What a specialist assessment adds
- Objective confirmation of the diagnosis — spirometry with reversibility, FeNO, and where needed bronchial challenge testing
- Observed inhaler technique, which frequently explains the whole problem
- Adherence assessment done without blame — prescription records often tell a different story from the consultation
- Allergy testing to identify what is actually driving symptoms
- Assessment of the nose and upper airway, since untreated rhinitis undermines asthma control
- Exclusion of alternatives — chest imaging, sweat test, immune bloods or bronchoscopy where the picture warrants it
- A written action plan that the family and school understand
What to bring
A specialist appointment is far more productive with: every inhaler and spacer your child uses, a list of what has been tried and whether it helped, dates of any emergency attendances or steroid courses, previous test results and chest X-rays, and a note of when symptoms are worst. If your child has been on a preventer for a long time, it is worth knowing roughly how many inhalers are actually collected in a year.
A note on the UAE
Two local factors change referral thresholds here. Year-round house dust mite exposure in year-round mite exposure in this coastal climate removes the seasonal remission that often makes asthma look better managed than it is. And a mobile population means many children arrive with an asthma diagnosis made elsewhere, on unclear grounds, with no records. Where a diagnosis cannot be verified and the child is old enough to test, it is worth confirming rather than inheriting.
Clinical references
- Brand PLP, et al. Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach. ERS Task Force. Eur Respir J 2008;32:1096–1110. View source →
- Morice AH, et al. ERS guidelines on the diagnosis and treatment of chronic cough in adults and children. Eur Respir J 2020;55:1901136. View source →
Frequently asked questions
When should a child with asthma be referred to a specialist?
What is difficult-to-treat asthma?
How do I know if my child's asthma is not well controlled?
Can a child be wrongly diagnosed with asthma?
What should I take to an asthma specialist appointment?
