NICE vs RCPCH: Management of Childhood Asthma (2025)

Introduction

Childhood asthma is one of the most common chronic conditions managed by clinicians in the UK. Two major bodies provide authoritative guidance: the National Institute for Health and Care Excellence (NICE) and the Royal College of Paediatrics and Child Health (RCPCH). While both aim to improve care, their approaches have distinct philosophical and practical differences. The NICE guideline (NG80, updated February 2025) is a comprehensive, evidence-synthesised protocol for the NHS in England and Wales. In contrast, the RCPCH care pathway is a practical, consensus-based tool designed for everyday use by paediatricians across the UK. This comparison elucidates these differences to help clinicians navigate and apply the most appropriate guidance for their patients.

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Diagnosis and Initial Assessment

NICE (NG80, 2025 Update)

NICE advocates for a structured, objective diagnosis where possible. The guideline emphasises the use of objective tests, even in young children, to reduce misdiagnosis.

• Key Tests: Recommends FeNO (Fractional exhaled Nitric Oxide) and spirometry with bronchodilator reversibility as first-line tests for children aged 5 and over. For children under 5, diagnosis remains primarily clinical, based on symptom patterns.
• Documentation: Stresses the importance of documenting the basis for diagnosis before starting long-term treatment.
• Risk Assessment: Includes a formal assessment of future risk (e.g., exacerbations, accelerated decline in lung function) as part of the initial workup.

RCPCH Care Pathway

The RCPCH pathway takes a more pragmatic, symptom-focused approach, recognising the challenges of performing complex lung function tests in primary care and younger children.

• Key Focus: Diagnosis is based on a detailed clinical history identifying symptom patterns (wheeze, cough, breathlessness), triggers, and response to treatment. Objective tests are encouraged but not always deemed essential for a working diagnosis.
• Practical Tool: Heavily promotes the use of the "Asthma Diagnosis Tool" for school-aged children, which is a structured questionnaire.
• Risk Assessment: Focuses on identifying current uncontrolled asthma and triggers rather than a formal future risk prediction.

Key Difference: NICE is more rigorous in demanding objective evidence for diagnosis in children over 5, while RCPCH provides a more accessible, history-based framework that can be implemented quickly in a busy clinic.

Pharmacological Treatment: A Stepwise Approach

Both guidelines recommend a stepwise approach to treatment, but the sequence of medication escalation differs significantly, representing the most notable divergence for clinicians.

NICE (NG80, 2025 Update)

NICE's approach is influenced by evidence reviews on efficacy and cost-effectiveness.

• Step 1: Inhaled Short-Acting Beta2-Agonist (SABA) as reliever.
• Step 2: Offer a choice of either Low-Dose Inhaled Corticosteroid (ICS) or a Leukotriene Receptor Antagonist (LTRA). This patient-choice element is a key feature.
Step 3: Low-Dose ICS + LTRA.
• Step 4: Consider switching to a MART (Maintenance and Reliever Therapy) regimen with a Low-Dose ICS/Formoterol combination inhaler. Alternatively, continue ICS+LTRA and add a Long-Acting Beta2-Agonist (LABA).
• Step 5: Refer to a specialist paediatrician for consideration of higher-dose therapies or add-on treatments (e.g., theophylline).

RCPCH Care Pathway

The RCPCH pathway follows a more traditional sequence, aligning closely with international guidelines (GINA).

• Step 1: SABA as reliever.
Step 2: Regular Low-Dose ICS as the first-line preventer. LTRAs are positioned as an alternative only if ICS is not tolerated or is ineffective.
• Step 3: Low-Dose ICS + LABA (usually via a MART regimen if formoterol is used).
• Step 4: Increase ICS to a Medium Dose, or add a fourth drug (LTRA or Theophylline).
• Step 5: Refer to specialist care for high-dose ICS and consideration of biologic therapies.

Key Difference: The critical divergence is at Step 2. NICE places ICS and LTRA as equal choices, while RCPCH firmly positions ICS as the primary and superior option. Furthermore, RCPCH introduces the MART regimen earlier (Step 3) than NICE's consideration at Step 4.

Special Situations and Non-Pharmacological Management

Viral-Induced Wheeze

• NICE: Distinguishes between episodic viral wheeze and persistent asthma, suggesting intermittent preventer therapy (e.g., high-dose ICS at the onset of a cold) may be an option for children with episodic symptoms but no interval symptoms.
• RCPCH: Takes a more unified "asthma" view. It advises that if symptoms are frequent or severe, regular low-dose ICS should be used, blurring the distinction between the phenotypes.

Non-Pharmacological Advice

Both guidelines strongly emphasise self-management. However:

• NICE: Provides detailed recommendations on written asthma action plans, including specific criteria for escalating treatment and when to seek emergency help.
• RCPCH: Strongly promotes the use of its specific "Asthma Attack Plan" for children, which is a visual and simple tool for families.

Practical Clinical Flow: A Hybrid Approach

For a UK clinician, a pragmatic hybrid approach can be effective:

1. Diagnosis: Use the RCPCH clinical history tools for a rapid initial assessment. Where possible and practical (especially in children over 5), incorporate NICE's objective tests (FeNO/spirometry) to confirm the diagnosis firmly.
2. Treatment Initiation (Step 2): This is the key decision point. Many paediatricians lean towards the RCPCH/GINA approach of starting low-dose ICS first due to its proven efficacy. However, the NICE approach of offering a choice can be valuable for engaging older children/teenagers or if there is strong parental reluctance about steroids.
3. Escalation (Step 3+): Adopt the RCPCH MART strategy early for adherent patients, as it is a highly effective regimen for many.
4. Management: Use the RCPCH "Asthma Attack Plan" for its simplicity, but ensure the detail within a full written action plan meets the standards suggested by NICE.

Frequently Asked Questions (FAQs) for Clinicians

1. Which guideline should I follow in my NHS practice?

NICE guidelines formally constitute evidence-based advice for the NHS in England and Wales. However, the RCPCH pathway is written by and for paediatric specialists and is highly respected across the UK. The best practice is to be aware of both, understand their differences, and apply clinical judgement. Local NHS trust formularies may also influence choice.

2. A child is uncontrolled on SABA alone. Do I start an ICS or an LTRA?

This is the core conflict. The weight of evidence supports ICS as the most effective preventer. Most paediatric specialists would follow RCPCH and start ICS. You could use the NICE "choice" conversation to improve adherence, but the default clinical recommendation should favour ICS.

3. How do I diagnose asthma in a 6-year-old who can't perform spirometry?

Use the RCPCH Asthma Diagnosis Tool to structure your history. If FeNO is available, it can provide valuable objective support (per NICE). A diagnosed trial of treatment (e.g., 8 weeks of low-dose ICS) with clear symptom monitoring can also be a pragmatic diagnostic tool.

4. When should I refer to a paediatric respiratory specialist?

Both guidelines agree on referral at Step 5 (severe, uncontrolled asthma despite medium/high-dose therapy). Refer earlier if the diagnosis is uncertain, if there are atypical features, or if the child has had a life-threatening attack.

5. Are biologic therapies mentioned?

Yes, both guidelines reference them for severe asthma. NICE has separate Technology Appraisals (e.g., TA879 for dupilumab) detailing specific eligibility criteria for NHS use. The RCPCH pathway signposts their use in a tertiary setting.

Source Links

• NICE Guideline NG80 (2025 Update): [https://www.nice.org.uk/guidance/ng80]
• RCPCH Childhood Asthma Care Pathway: [https://www.rcpch.ac.uk/resources/childhood-asthma-care-pathway]
• RCPCH Asthma Attack Plan: [https://www.rcpch.ac.uk/resources/asthma-attack-plan]
• NICE Asthma Diagnosis Tool: [https://www.nice.org.uk/guidance/ng80/resources] (Associated resources page)