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If it’s ‘only’ asthma, why are children still dying?
  1. Will Carroll1,2,
  2. Sadie Clayton3,
  3. Susan Frost4,
  4. Atul Gupta5,
  5. Steve Holmes6,
  6. Prasad Nagakumar4,
  7. Mark Levy7,8
  1. 1 Children's Respiratory Services, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, Staffordshire, UK
  2. 2 Institute of Applied Clinical Sciences, Keele University, Keele, Staffordshire, UK
  3. 3 Child health, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
  4. 4 Paediatric Respiratory Medicine and Cystic Fibrosis, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
  5. 5 Paediatric Respiratory Medicine, King's College London, London, UK
  6. 6 Primary Care Respiratory Society UK, Park Medical Practice, Shepton Mallet, Somerset, UK
  7. 7 Clinical Lead for the UK National Review of Asthma Deaths (2011-4), London, UK
  8. 8 Global Initiative on Asthma (GINA), Fontana, California, USA
  1. Correspondence to Dr Will Carroll, Children's Respiratory Services, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent ST4 6QG, UK; will.carroll{at}

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What is already known?

  • The UK has the highest rate of asthma deaths for children and young people (CYP) aged 10–24 years in Europe.

  • A confidential review of asthma deaths in 2014 identified avoidable factors in almost all cases involving CYP.

  • Asthma outcomes are better in adults and children who have specialist care.

What this study adds?

  • This commentary summarises the advice from available national and international asthma guidelines highlighting where evidence exists.

  • It presents new data on how self-reported thresholds for referral in primary and secondary care deviate from existing guidelines.

  • It describes the potential benefits of referring high risk children for specialist care.


Outcomes for children with asthma in the UK continue to lag behind other European countries. Mortality remains unacceptably high and in contrast to adults with asthma, most deaths occur in the 1 in 20 children with asthma who have severe asthma. Despite evidence that children with asthma have better outcomes with subspecialist care, many children with severe asthma are not referred onwards and barriers exist at every level of the UK healthcare system. The National Review of Asthma Deaths (NRAD) recommended that specialist review should be requested if there had been three or more courses of oral steroids, two or more visits to accident and emergency or an admission to hospital. This review reports the results of a recent interview study of 126 healthcare professionals. More than half of general practitioners (n=49) reported adopting a higher threshold than this. General paediatricians (n=47) set a higher bar still. Their median thresholds for referral to a subspecialist asthma clinic were 4 courses of oral steroids, 3 hospital admissions and 30 days off school in the previous year. This review offers a simple working definition of severe asthma based on current national and international guidelines and provides an example of the recently adopted referral criteria to …

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  • Contributors The original outline plan for the manuscript was developed by all authors. The initial draft manuscript was prepared by WC and this was circulated to all authors who provided references and additional content. Editorial assistance and manuscript preparation was then undertaken by a medical writer before a final draft was circulated for further comment of all authors. The raw data concerning referral thresholds for healthcare professionals in primary and secondary care was provided by Novartis Pharmaceuticals, who also paid for the services of the medical writer. The paper was reviewed by Dr Adam Strong of Novartis prior to submission to ensure that it was compliant with ABPI regulations.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests WC reports personal fees for lecturing and advisory board work from: GlaxoSmithKline, Trudell Medical International, Orion Medical and Novartis Pharmaceuticals. SC has received funding from Astra Zeneca, GlaxoSmithKline, Napp, Novartis, Teva and Circassia. SF has received funding from Novartis and is co-treasurer of the Severe Asthma Nurses Network which organises conferences for professional development. AG reports fees for lecturing/advisory board work from: GlaxoSmithKline, Novartis Pharmaceuticals, Boehringer Ingelheim and Astra Zeneca. He has been CI/PI of the the clinical trials with GlaxoSmithKline, Novartis Pharmaceuticals, Boehringer Ingelheim, & Airosnett for which his institution has been paid. He is also a director of the non-profit organisation Paediatric Respiratory Academy which organises educational meetings. SH works as a GP, he is funded for 1/2 session per week as a clinical commissioner, has received funding from Astra Zeneca, Beximco, Boehringer Ingelheim, Chiesi, Glaxo Smith Kline, Johnson and Johnson, Mylan, Napp, Novartis, Nutricia, Orion, Pfizer, Sandoz, Teva and Trudell Medical International. PN has received funding from Novartis. ML reports personal fees from: Clement Clarke International, Teva, Astra Zeneca, Chiesi, Orion Pharmaceuticals, Napp Pharmaceuticals, Soar Beyond, Trudell Pharmaceuticals, National Services for Health Improvement, a company providing services for practices (Nurse asthma Reviews), Novartis Pharmaceuticals, GlaxoSmithKline, reimbursement of travel and accommodation support from GINA, grants from Conzorcio Futuro In Ricerca, personal fees from, non-financial support from Asthma and COPD (Joint) Lead for Whole Systems Integrated Care (WSIC) NorthWest London.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.