World Health Organization · 1st edition, 2026 · 107 pages
Evidence-based recommendations for acute and long-term asthma management and bronchiolitis care in children aged 0–19 years
- Issuer
- World Health Organization
- Edition
- 1st edition, 2026
- Audience
- Clinicians, nurses, and public-health professionals working in primary, secondary and tertiary care settings, particularly in LMICs; policy-makers responsible for essential medicines lists and paediatric care protocols
- Evidence
- GRADE-rated systematic reviews for all recommendations; good practice statements where evidence review not feasible but clinical practice standard
- Reviewed
- 14 Oct 2026 · GMJ
What this guideline says
GMJ summary
This 2026 guideline consolidates WHO recommendations for two common paediatric respiratory conditions: asthma in children and adolescents, and bronchiolitis in infants and young children. For asthma, it addresses both acute exacerbation management in health facilities and long-term control strategies. For bronchiolitis, it covers clinical diagnosis, admission criteria, imaging use, oxygen delivery methods and nebulized saline therapy.
Key asthma recommendations include adding nebulized ipratropium bromide to standard first-line therapy (inhaled SABA and systemic corticosteroids) for severe or non-responsive moderate exacerbations; using IV magnesium sulfate (50 mg/kg, max 2 g over 20 minutes) as preferred second-line therapy; and considering combination inhaler maintenance and reliever therapy (MART) with budesonide/formoterol for children aged 6–11 years with persistent symptoms. IV aminophylline is not recommended if alternatives are available due to increased adverse effects without clear benefit.
For bronchiolitis, the guideline emphasizes clinical diagnosis based on upper respiratory prodrome followed by respiratory distress with wheeze or crackles. Admission criteria include IMCI danger signs, temperature ≥38°C, SpO₂ <90%, severe respiratory distress, apnoea, age <3 months, prematurity or comorbidities. Routine chest X-ray is not recommended. Humidified high-flow nasal cannula oxygen is suggested over standard flow for persistent hypoxaemia, and a trial of nebulized hypertonic (3%) saline is suggested for hospitalized infants.
Key points
For clinicians — doses and thresholds as stated in the guideline
- For moderate asthma exacerbations not responding to initial inhaled SABA and systemic corticosteroids, add nebulized ipratropium bromide; use immediately for severe exacerbations (strong recommendation).
- For severe asthma exacerbations or moderate exacerbations not responding to first-line therapy, use IV magnesium sulfate 50 mg/kg (max 2 g) diluted in 100 mL normal saline over 20–30 minutes as second-line therapy (strong recommendation).
- IV SABA should be used as potential third-line therapy after magnesium sulfate; IV aminophylline should not be used if alternative second-line options are available due to increased nausea and vomiting without clear benefit.
- For children aged 6–11 years with persistent asthma requiring regular ICS, consider combination inhaler (ICS plus fast-onset LABA) MART to reduce exacerbations (conditional recommendation).
- Diagnose bronchiolitis clinically in infants aged <2 years with upper respiratory prodrome, cough, respiratory distress, low-grade fever, and tachypnoea, chest indrawing and/or diffuse wheeze or crackles on auscultation.
- Admit infants with bronchiolitis if: IMCI danger signs present, temperature ≥38°C, SpO₂ <90%, severe respiratory distress, apnoea or history of apnoea, age <3 months, prematurity, or comorbidities (congenital heart disease, chronic lung disease, cerebral palsy, immunocompromised).
- Do not routinely use chest X-ray for initial diagnosis and management of bronchiolitis; reserve for suspected complications, alternate diagnosis, persistent symptoms >2 weeks, or severe disease requiring ICU (conditional recommendation).
- In hospitalized infants with bronchiolitis and persisting hypoxaemia (SpO₂ <90%) or severe respiratory distress despite standard low-flow oxygen, use humidified high-flow nasal cannula oxygen (conditional recommendation); consider a trial of nebulized hypertonic saline (3%) to reduce length of stay (conditional recommendation).
Classifications of asthma exacerbation severity
Table extracted from the guideline
| Severity | Speech/activity | Oxygen saturation | Peak expiratory flow | Heart rate (age ≥6 y) | Respiratory rate (age ≥6 y) | Other signs |
|---|---|---|---|---|---|---|
| Moderate | Able to talk in whole sentences; dyspnoea interferes with activity | ≥90–95% | >50% best or predicted | 100–120 bpm | Increased | Obvious respiratory distress |
| Severe | Unable to complete sentences in one breath; too breathless to talk or feed | <90% | ≤50% best or predicted | >120 bpm | >30/min | Dyspnoea at rest; obvious respiratory distress |
| Life-threatening | Too dyspnoeic to speak; reduced consciousness | — | <33% best or predicted (BTS/SIGN) or <25% (NHLBI) | — | — | Exhaustion, confusion, cyanosis, silent chest, poor respiratory effort |
Source: World Health Organization, Consolidated guidelines for the management of common childhood illness: management of asthma in children and adolescents and bronchiolitis in infants and young children. Reproduced in summary form.
What changed in this edition
Versus the previous edition
- First WHO consolidated guideline specifically addressing asthma management in children and adolescents and bronchiolitis in infants and young children.
- Updates and expands previous WHO Pocket book of hospital care for children recommendations with systematic GRADE-rated evidence reviews.
- Introduces recommendation for combination inhaler MART (budesonide/formoterol) for children aged 6–11 years with persistent asthma.
- Recommends against routine use of IV aminophylline for acute asthma if alternatives available; recommends against subcutaneous adrenaline except for anaphylaxis.
- Provides structured approach to second- and third-line therapy for severe asthma: IV magnesium sulfate preferred as second-line, IV SABA as third-line.
- Introduces specific temperature threshold (≥38°C) as admission criterion for bronchiolitis, recognizing it may indicate more severe disease.
- Addresses emerging oxygen delivery technologies (humidified high-flow nasal cannula) and nebulized hypertonic saline for bronchiolitis management.
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As Editor-in-Chief of the Georgian Medical Journal and Chair of the Public Health Institute of Georgia, I view this consolidated guideline as timely for our region, where bronchiolitis drives winter paediatric admissions and asthma control remains suboptimal in many districts. I would stress to Georgian clinicians the strong recommendation for early IV magnesium sulfate in severe asthma exacerbations—a safe, inexpensive intervention already stocked in our maternity units that can prevent ICU escalation. The main implementation challenge will be ensuring uninterrupted supply of nebulised ipratropium bromide and 3% hypertonic saline in rural rayons, where procurement chains are fragile and paediatric formulary updates lag behind national protocols.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 14 Oct 2026
Applicability
Georgia and the South Caucasus
These recommendations are highly relevant for Georgia and the South Caucasus region, where asthma prevalence in school-aged children varies widely and bronchiolitis remains a leading cause of infant hospitalization, particularly during winter RSV seasons. Georgia’s national essential medicines list and procurement systems should be reviewed to ensure availability of nebulized ipratropium bromide, IV magnesium sulfate (already available for obstetric use), and combination ICS/LABA inhalers for children aged ≥6 years. Implementation will require training primary and secondary care providers in asthma severity assessment, appropriate escalation of therapy, and clinical diagnosis of bronchiolitis to avoid over-use of chest X-rays and antibiotics. In rural and resource-limited settings, where oxygen-driven nebulizers may be unavailable, the guideline supports use of metered-dose inhalers with spacers (including low-cost bottle spacers) as effective alternatives. National adaptation should consider local RSV seasonality, availability of PICU beds and mechanical ventilation, and cost-effectiveness of humidified high-flow oxygen systems in regional hospitals.
Questions this guideline answers
Quick answers
When should I add ipratropium bromide to SABA and steroids for acute asthma?
Add ipratropium bromide immediately for severe paediatric asthma exacerbations, and for moderate exacerbations that do not respond to initial standard first-line therapy with inhaled SABA and systemic corticosteroids. The most common dosing is 500 μg nebulized (or via MDI with spacer if oxygen unavailable) repeated every 20 minutes for three doses, then as needed.
What is the preferred second-line therapy for severe asthma exacerbation in children?
IV magnesium sulfate is the preferred second-line therapy: 50 mg/kg (maximum 2 g) diluted in 100 mL normal saline given over 20–30 minutes as a single short infusion. Monitor blood pressure regularly. If magnesium sulfate is unavailable, IV SABA (salbutamol 15–20 μg/kg over 10–20 minutes) can be used as third-line therapy, but requires ECG monitoring for arrhythmias.
How do I diagnose bronchiolitis and decide which infants need hospital admission?
Diagnose bronchiolitis clinically in infants aged <2 years with upper respiratory prodrome (rhinitis, coryza, cough) followed by respiratory distress, low-grade fever, and tachypnoea, chest indrawing and/or diffuse wheeze or crackles. Admit if: IMCI danger signs, temperature ≥38°C, SpO₂ <90%, severe respiratory distress, apnoea or history of apnoea, age <3 months, prematurity, or comorbidities (congenital heart disease, chronic lung disease, cerebral palsy, immunocompromised). Do not routinely do chest X-ray unless suspecting complications or alternate diagnosis.
Can metered-dose inhalers replace oxygen-driven nebulisers for asthma exacerbations in settings without piped oxygen?
Yes, the guideline supports metered-dose inhalers with spacers—including improvised bottle spacers—as effective alternatives to nebulisers for delivering short-acting beta-agonists and ipratropium bromide in resource-limited settings.
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- Issuer
- World Health Organization
- Type
- Guideline
- Edition
- 1st edition, 2026
- Status
- Current
- Published
- 2026-05-12
- Languages
- English
- Scope
- Children and adolescents aged <19 years with asthma (acute exacerbations and long-term management); infants and young children aged <2 years with bronchiolitis
- Audience
- Clinicians, nurses, and public-health professionals working in primary, secondary and tertiary care settings, particularly in LMICs; policy-makers responsible for essential medicines lists and paediatric care protocols
- Pages
- 107
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 978-92-4-012268-0
- Evidence
- GRADE-rated systematic reviews for all recommendations; good practice statements where evidence review not feasible but clinical practice standard
- Record history
- Created 14 Oct 2026 · updated 14 Oct 2026 · next check Apr 2027
World Health Organization. WHO consolidated guidelines for the management of common childhood illness: management of asthma in children and adolescents and bronchiolitis in infants and young children. Geneva: World Health Organization; 2026. Licence: CC BY-NC-SA 3.0 IGO.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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