The National Child Mortality Database report on child deaths related to asthma and allergies was released in December 2024, providing sobering insights. Ravijyot Saggu offers an expert summary, emphasising key points from the thematic report and discussing necessary future actions.
One in 11 children and young people in the UK has asthma and it is the most common long-term medical condition in children in the UK.1 Additionally, the UK has one of the highest rates of prevalence, emergency admission and death for childhood disease in Europe, and children and young people living in the most deprived areas are the most severely affected.2
The National Review of Asthma Deaths (NRAD) ‘Why asthma still kills’ report from 2014 was a landmark publication.3 Among the nearly 200 deaths reviewed, 28 involved children and young people under 20 years of age. Key findings in this review emphasised that most of these children and young people died before reaching the hospital, with 46% receiving inadequate asthma care. Exposure to second-hand smoke and allergies – especially seasonal allergies – were also contributing factors.
As a result, several recommendations were made to improve asthma care and prevent future deaths for adults, children and young people. Since then, there has been some progress and key changes, including implementation of personal asthma action plans (PAAPs), creation of the National Bundle of Care for Children and Young People with Asthma4, and the publication of the National Capability Framework for Professionals who care for Children and Young People with Asthma and associated training.5
Child asthma and anaphylaxis: up-to-date analysis and insight
Despite being a decade on from the NRAD report, a high proportion of modifiable factors in asthma deaths continue to be identified by child death overview panels (CDOPs).
The recent National Child Mortality Database (NCMD) thematic report6 analysed deaths over a four-year period from April 2019 to March 2023 in children with confirmed or suspected asthma as the cause of death. The 54 deaths recorded during this period represent approximately one child death from asthma every four weeks.
A range of observations were outlined in the report, covering details such as demographics, risk factors and healthcare contact and medications in the lead up to their deaths.
Demographics
Mortality was higher in the 15-17-year-old group, followed by the 10-14-year-old group, with the death rates for boys double those of girls.
When it came to geography and deprivation, mortality rates were higher in urban areas than in rural ones, but child death rates in the most deprived areas of England were four-times greater than those in the least deprived areas.
This echoes previous data which have shown that children living in the poorest 10% of areas are up to four times more likely to have an emergency hospital admission compared to those in the least deprived 10%.7
Risk factors: child asthma deaths
Premature birth and low birth weight are recognised risk factors for asthma. Of the recorded asthma deaths in the NCMD report, 27% of children were born before 37 weeks of gestation or had a lower birth weight.
Seasonality was also observed. Deaths occurred throughout the year in descending order from winter to spring, autumn and then summer, and outdoor air pollution at the home or school was also highlighted as an issue in the deaths.
Risk factors resulting from the home environment were noted as contributory factors, such as overcrowding, excessive mould and dust, pets and dirty, tobacco smoke-filled houses. Indeed, parental or caregiver smoking was reported in 32 reviews and parental drug misuse, including cannabis smoking, was also noted in some cases. Substance misuse by the child was recorded in four reviews, with others identifying child smoking or vaping as contributing factors.
Safeguarding issues (34%), abuse and neglect (13%), and domestic violence (28%) were also recorded.
Healthcare contact and treatment
In total, 65% of the children visited the emergency department or experienced an emergency hospital admission at least once in the year before their death. Some deaths occurred due to cardiac arrest, predominantly outside of hospitals, with 29 children (58%) having unsuccessful cardiopulmonary resuscitation.
When it came to treatment history, 87% of children had three or more dispensed short-acting beta agonist (SABA) inhalers, such as salbutamol, or relievers in the year before their death, with 50% using 12 or more.
It is well known that having more than two SABA inhalers within 12 months is a red flag. As with adults, overuse of SABA is linked to an increased risk of asthma attacks and deaths, suggesting poorly controlled asthma.
Similar to the NRAD report, a lack of adequate inhaled corticosteroid prescriptions was identified as a factor, with 65% of children receiving fewer than nine inhalers dispensed in the year before their death. What’s more, the lack of dose counters on salbutamol metered dose inhalers (MDIs) was implicated as a contributory factor for fatal outcomes.
Service provision includes adherence to guidelines, pathways, and policies. However, issues arose due to a lack of PAAP, insufficient communication between or within services and families, failure to recognise child deterioration, and treatment delays. In five cases, no formal asthma diagnosis was made, yet relievers were prescribed.
Anaphylaxis-related deaths
The NCMD report also analysed the 19 child deaths due to anaphylaxis during the same period from April 2019 to March 2023.
In five of the deaths, the causes were attributed to both asthma and anaphylaxis. The highest death rate occurred among children aged 15-17 years, followed by those aged 10-14 years, with similar numbers of deaths reported for both females and males.
There were 21 completed reviews of deaths due to anaphylaxis, including cases of children who died before 1 April 2019. Some 76% of the reviews identified at least one modifiable factor. Most children (95%) had known allergies, with the most common food allergies recorded as being nuts – including tree nuts and peanuts – followed by cows’ milk, eggs and seafood. The most prevalent allergens for non-food allergies were house dust, pollen (including tree pollen), grass and animals.
What healthcare professionals can do
Although the nature of the allergen may not be obvious, it is important to always consider anaphylaxis in someone with a known food allergy who has sudden breathing difficulties, particularly in children with asthma. People with both asthma and allergies are at a higher risk of having a more severe allergic reaction.
Learnings from the CDOPs showed that allergy symptoms were not always communicated to healthcare professionals. However, they should be inquired about during asthma reviews, and food allergy-specific questions should be included in these reviews.
In instances of anaphylactic reactions, only half of the children received an adrenaline autoinjector, and in other cases, the injection was either expired or of suboptimal strength – even in school settings – or not administered.
CDOPs recorded factors related to public safety in a third of the anaphylaxis reviews. Of those, the most common factor was unclear, misleading, or inaccurate food labelling (either packaged or cooked, bought from supermarkets or takeaways).
While NCMD analyses may have limitations and review small numbers of deaths, they highlight significant themes of concern.
Key areas for improvement: child asthma and anaphylaxis
Recommendations for key areas of improvement centre around seven domains:
- Policy: improved implementation of guidance and recommendations and mandated asthma training for professionals who care for children, as well as education for children and young people to raise awareness of asthma and allergies
- Air pollution: relevant agencies urged to adopt the Asthma Friendly Homes initiative and consider adding targets on reducing smoking in households in the Joint Strategic Needs Assessments and joint forward plans
- Commissioning: service specifications to include that asthma nurses offer home visits to high-risk children post-intensive care discharge. Ensuring pharmacists are aware of the dangers of inhalers with no dosage counters and can contextualise this in terms of mitigation strategies when counselling about inhalers with children and their carers. Explore technological solutions to identify both under- and over-prescribing of inhaled medications and to ensure proper checks and direct observation of inhaler techniques
- Education: to fund nursing provision in schools and raise awareness among children and young people about all aspects of asthma and its management
- Medicines: all inhalers to include dose counters and this has been recognised as a safety concern by the Medicines and Healthcare products Regulatory Agency (MHRA)
- Healthcare practice: recognising asthma attacks as significant events and providing timely follow-up 48 hours after the attack
- Research: look into the use and effectiveness of peak flow monitors before they can be used more widely.
What needs to be done?
Child deaths from asthma and allergies are preventable. At the time of writing, the National Bundle of Care for Children and Young People with Asthma is currently under review and set to be updated. It serves as a valuable tool for facilitating change, yet more still needs to be done.
Timeliness, knowledge and communication are key areas for improvement. All staff responsible for children with asthma should complete training according to the National Capability Framework for Professionals who care for Children and Young People with Asthma.5
Encouraging smoking cessation, including use of vapes, in parents – and children where this is occurring – to reduce child exposures and improve air quality is important, as is raising concerns sensitively if there are any suspected safeguarding factors.
The British National Formulary and the British National Formulary for Children have recently been updated to include information alerting healthcare professionals to the dangers of inhalers without dose counters and the advice they should provide. The MHRA is working to ensure an integral dose counter is included for future pressurised metered dose inhalers (pMDIs).
All healthcare staff, especially prescribers and pharmacy staff, should review prescribing records to identify patterns of overuse of SABA and underuse of inhaled corticosteroid prescriptions for patients with asthma.
They should also include questions about food allergies in asthma reviews. Additionally, they are well positioned to counsel patients and caregivers of children and young people on the appropriate use of inhalers and approximately how long they should last, using the dose counter (where available) as a guide for usage and when to reorder prescriptions. This is important as without a dose counter there is no reliable way to check how much medicine is left within the inhaler. Methods such as shaking or attempting to float the inhaler cannister are not reliable or recommended.
If the MDI does not have a dose counter, it is important to emphasise that the inhaler may feel and sound like it contains medicine, even appearing to emit upon actuation. However, this is only propellant gas, not medicine, and therefore they should not use the effectively ‘empty’ inhaler.
Adhering to therapy and regularly checking the expiry dates to ensure medications are current is essential. This is also applicable to adrenaline autoinjectors which have an expiry date of roughly one year from dispensing and are unlikely to be used regularly. Expiry checks are additionally important if inhalers or adrenaline autoinjectors are stored in different locations for example, at home, school or other family locations.
Any expired or unwanted inhalers should be returned to pharmacies for correct disposal and/or recycling, where applicable. Having a PAAP, understanding how to use it, and recognising the symptoms of early deterioration, such as asthma or anaphylaxis, is crucial for timely intervention.
The recent joint national UK asthma guidelines8 are expected to reduce reliance on SABA and promote better asthma care by encouraging the use of inhalers with integral dose counters.
Author
Ravijyot Saggu
Respiratory pharmacist, London, UK, chair of the UK Clinical Pharmacy Association Respiratory Committee and NICE medicines and prescribing associate
References
- NHS England. Childhood asthma. [Accessed March 2025].
- Royal College of Paediatrics and Child Health. State of Child Health – Insight into the state of child health in the UK. 2020 [Accessed March 2025].
- Royal College of Physicians. Why asthma still kills. The National Review of Asthma Deaths (NRAD) report. 2014. [Accessed March 2025].
- NHS. National Bundle of Care for Children and Young People with Asthma: Phase one. 2021. [Accessed March 2025].
- NHS Health Education England. The National Capabilities Framework for Professionals who care for Children and Young People with Asthma. 2022. [Accessed March 2025].
- National Child Mortality Database. Child deaths due to Asthma or Anaphylaxis. 2024. [Accessed March 2025].
- Asthma + Lung UK. Youngsters experiencing deprivation more likely to have asthma attacks when they return to school. 2023. [Accessed March 2025].
- National Institute for Health and Care Excellence. Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN). NICE guideline NG245. 2024. [Accessed March 2025].
