Recommendations against first line use of combination asthma inhalers and prescribing antibiotics for asthma exacerbations top a paediatric-focused “Choosing Wisely” list released by the Thoracic Society of Australia and New Zealand.

The five recommendations are the latest updates to the lists of recommendations from professional groups on low value tests, treatments and procedures that consumers and clinicians should question.

Also published under the auspices of the RACP’s Evolve initiative the five recommendations are:

1. Do not prescribe combination therapy (inhaled corticosteroids with long-acting beta-2 agonist) as initial therapy in mild to moderate asthma before a trial of inhaled corticosteroids alone.
2. Do not prescribe antibiotics for exacerbation of asthma.
3. Do not use oral beta-2 agonists as bronchodilators in asthma, wheeze or bronchiolitis.
4. For children with bronchiolitis without other co-morbidities, do not delay discharge from an inpatient admission based on oxygen saturations alone if saturations are ≥90%.
5. Do not delay immunisation/s based on presence of mild respiratory symptoms in the absence of fever.

Commenting on the antibiotic recommendation, Associate Professor Nitin Kapur, a paediatric respiratory specialist and RACP Fellow, said there was currently no evidence that antibiotics reduce the severity of symptoms associated with exacerbations of asthma in children.

The recommendations note that a potential role for azithromycin in reducing the duration of an episode of asthma-like symptoms in children less than three years of age requires further investigation.

“We recommend against prescribing antibiotics for children with severe symptoms of asthma unless there is strong evidence of fever or pneumonia,” said Dr Kapur

The list was developed from a shortlist of 12 recommendations on low-value care in paediatric thoracic medicine, discussed by members of the Paediatric Special Interest Group (SIG) of TSANZ.