Primary Care Liaison

Asthma pre-referral guideline

  • The following pre-referral guideline gives suggested management and investigations before referral to RCH Department of Allergy and Immunology.

    Initial work-up


    • History of allergic disease (e.g. atopic eczema/allergic rhinitis).
    • Family history of allergic disease.
    • History of asthma symptoms:
      • Severity and pattern - infrequent episodic, frequent episodic, persistent.
      • Worsening symptoms in pollen season (e.g. October to February).
      • Symptoms at night or early morning (e.g. house dust mite).
    • Physical examination.
    • Concurrent allergic rhinitis?


    • RAST test to assess for specific allergy, if the history indicates (e.g. cat dander, dust mite, grass pollen).

    Notes - asthma and food allergy

    • Food allergens are uncommon triggers for asthma.
    • As few as 2-5% of people with asthma react to foods.
    • Acute food allergen-induced respiratory symptoms may be due to anaphylaxis, not asthma - particularly if associated with urticaria or angioedema.
    • Any child with suspected anaphylaxis should be referred to the RCH Department of Allergy and Immunology immediately.

    Recommended pre-referral treatment

    Asthma treatment and management:

    • Use standard treatment (preventer and reliever).
    • Emphasize correct MDI or dry power inhaler technique.
    • Asthma Action Plan.
    • First Aid education

    Allergen avoidance

    • Only do dust mite avoidance if RAST and history strongly indicate perennial rhinitis and dust mite.
    • No evidence exists that dust mite avoidance works and it is expensive. Sprays do not work. Err on the side of under-recommending.

    Treat allergic rhinitis

    • Allergic rhinitis can exacerbate asthma symptoms.

    Medications to avoid

    • Aspirin.
    • Non-steroidal anti-inflammatory medicines.
    • Beta blockers.
    • 'Natural' remedies (e.g. echinacea or royal jelly) that may cause allergic reaction.

    When to refer

    Refer to the RCH Department of Allergy and Immunology when

    • History indicates allergy is a causative factor for asthma.


    • Positive RAST test result.

    AND one of the following

    • Persistent, unstable asthma despite regular preventer therapy.
    • Food allergy also present.

    Note: Unstable asthma is a risk factor for fatal food-induced anaphylaxis and patients with both conditions should be assessed by a specialist at the RCH.

    Information needed

    • Symptoms (including onset, duration and pattern).
    • Treatment given and patient response.
    • RAST test result.
    • Presence or absence of allergic rhinitis.
    • Presence or absence of food allergy.
    • Presence or absence of any other allergic disease.

    Contact information

    Department of Allergy and Immunology:(03) 9345 5701
    RCH Emergency Department:(03) 9345 6477




    Paediatric Handbook Ninth Edition (2015) , Blackwell Publishing. By the staff of the Royal Children's Hospital, Melbourne, Australia.

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