Watching her daughter struggle for breath had become an all-too-common, yet harrowing experience for Sophie Hafford.

Since Amelia-Rose was just three months old, she has suffered from severe asthma attacks, leading to frequent emergency calls and hospital stays. Now six, she has been admitted to the hospital on average every two weeks, sometimes for extended periods.

During each severe episode, Amelia-Rose was administered high-dose steroid tablets to manage the airway inflammation. While these were necessary, they also resulted in weight gain and concerns about potential impacts on her growth, as oral steroids are known to carry such risks due to their higher dosage compared to inhalers.

“There were moments when I feared losing her because her condition would worsen so quickly,” shares Sophie, a 31-year-old stay-at-home mom of four from Manchester.

Amelia-Rose is among two million children in the UK living with asthma, a condition that inflames and narrows the airways when exposed to triggers like pollen, pet fur, or dust mites.

Asthma and Lung UK estimates that as many as 100,000 children, or 5 percent of those with asthma, have a severe form of the condition like Amelia-Rose. This makes managing their symptoms particularly challenging, even with high doses of medication.

But, remarkably, Amelia-Rose hasn’t had an asthma attack or hospital admission for more than a year – simply thanks to changing her inhalers.

Following her asthma diagnosis at the age of three, she had been using a traditional blue reliever (containing salbutamol, which quickly relaxes narrowed airways) and a brown preventer inhaler (used morning and night, this contains a low dose of steroids to minimise inflammation). But in 2024 she was switched to a combination inhaler, which her mother says transformed her life.

Six-year-old Amelia-Rose, who suffers from sever asthma, with her mother Sophie

Combination inhalers contain steroids and fast- and long-acting bronchodilators (drugs which open up the airways) such as formoterol.

They are usually taken morning and night – this is known as maintenance and reliever therapy (MART) – as well as when needed to treat a flare-up, and mean that people only have one inhaler to remember to use.

There is a ‘significant issue’ with patients who have separate preventer and reliever inhalers not taking their preventers enough – which treats the underlying inflammation causing the symptoms, says Dr Andy Whittamore, a GP based in Portsmouth and clinical lead at Asthma and Lung UK.

‘We know that reliever inhalers work very quickly so people get a good response and trust them,’ he explains. ‘But it doesn’t treat the background inflammation that causes the symptoms.’

Another advantage of a combination inhaler is it prevents an over-reliance on reliever inhalers, which contain drugs such as salbutamol. Overuse can be harmful, as the medication becomes less effective; it can also cause a racing heart, shakiness and anxiety, says Professor Louise Fleming, a consultant respiratory physician at Imperial College Healthcare NHS Trust in London.

Combination inhalers don’t contain short-acting relievers such as salbutamol, but rely on longer-acting drugs such as formoterol.

‘Formoterol works as quickly and for longer than salbutamol, and using it with steroids within a combined inhaler also treats the underlying inflammation,’ says Dr Whittamore.

Research shows people using combined inhalers twice a day are less likely to need additional puffs to treat symptoms as their overall asthma has improved.

They also need fewer steroid tablets (which usually contain 20mg, 200 times as much as the 100mcg in inhalers) in emergencies, as combined inhalers make flare-ups less likely, explains Dr Whittamore.

Combination inhalers are now commonplace for adults and children over 12 years – but until recently were not routinely offered to the under-12s due to a lack of research about their safety and effectiveness (although some respiratory consultants may prescribe them to severe cases and, last September, a licence was granted for one combined inhaler to provide a low dose of MART in children aged six to 11 with moderate asthma in the UK).

However, the combination inhalers are not offered widely to children, and with more than 16,000 aged 15 and under admitted to hospital in England due to asthma in 2024-2025, it’s clear that many children would benefit from better asthma management – and experts are now calling for this change.

Indeed, research published in The Lancet in September suggests combination inhalers almost halved the risk of potentially life-threatening asthma attacks in children.

The trial in New Zealand involved 360 children, aged five to 15, with mild asthma who were randomly assigned either a combination inhaler (containing low-dose steroid, budesonide plus formoterol) or a salbutamol inhaler.

The researchers found that the combination inhaler reduced asthma attacks by 45 per cent. It’s thought the difference was due to the addition of the steroid in the combined inhaler. Importantly, there was no significant difference in the children’s growth or lung function.

Amelia-Rose’s mother say that ‘her asthma is very well managed now’ and she can lead a normal childhood

There’s research showing that for adults, adopting a combined approach is ‘safer, leads to fewer asthma attacks and hospital admissions and less need for steroid tablets’, says Dr Whittamore.

It’s hoped that the New Zealand study may now help change the approach for children, particularly those with mild asthma ‘who might be going back and forth to their GP or to hospital because they’re struggling to manage the condition’, he adds.

It’s important to recognise that even mild asthma can be serious – ‘any asthma attack can be life-threatening’, adds Andrew Bush, a professor of paediatric respirology at Imperial College London and a co-author of the New Zealand study.

‘If your asthma treatment is right, you should not be having attacks or getting symptoms that prevent you going to school or work,’ he says.

Now, a new UK study, led by Imperial College London, will examine the safety and efficacy of using different doses of combination inhalers for children with varying severities of asthma, whether as part of MART treatment or just when needed.

The study, the first of its kind in the UK to examine combination inhalers as relievers in children aged six to 11, aims to recruit around 1,350 children – half will use a combination inhaler for a year, while the control group will remain on their current treatment.

Although some children are currently prescribed the new combination inhalers, the prescriptions are not always used appropriately – for instance, there may not be clear instructions about the maximum number of puffs taken at one time or in a day, according to Professor Fleming, chief investigator of the UK trial.

It’s hoped the study’s findings will form the basis for more consistent clinical guidance as well as new combination inhaler licences.

Yet there are challenges in making combination inhalers a mainstream treatment for all children with asthma.

Correct use is key but combination inhalers can be harder to suck in and are best used with spacers (a plastic tube attached to the mouthpiece enabling the medicine to be more effectively inhaled), says Professor Bush, who adds: ‘I would encourage parents of children aged five and over to ask their GP about using a combined inhaler.’

Before Amelia-Rose was prescribed a combination inhaler, she was taking a cocktail of different medicines – including her preventer and reliever inhalers, frequent steroid tablets and antibiotics, as well as montelukast (a drug which blocks chemicals that cause inflammation in the airways) and antihistamines (one of her asthma triggers is dog hair).

The situation was ‘hugely stressful’ for Sophie, who’d get up early every day to ensure Amelia-Rose’s medication was ready.

She says: ‘She missed a lot of school due to poor health and being in hospital. I also have three other children to look after so my mum had to go with Amelia-Rose to hospital. It was a nightmare.’

All of this changed once Amelia-Rose was offered the combination inhaler through her specialist respiratory consultant once she was five.

‘As soon as she gets wheezy or starts coughing, she uses it and then she’s like a different child,’ says Sophie. ‘She no longer needs steroid tablets and was taken off all her other medications a few months later.’

Amelia-Rose now has excellent school attendance and can run around with other children at parties without getting breathless, says Sophie. ‘Her asthma is very well managed now. It’s given Amelia-Rose the freedom to lead a normal childhood.’

asthmaandlung.org.uk