Question 1: Is exercise safe for children with asthma?

Recommendation: Exercise should be incorporated into the daily routine of children with asthma, with restrictions considered only in cases of severe EIB.

Evidence summary: Although concerns about EIB have historically led many parents to limit physical activity for children with asthma, accumulating evidence indicates that, for the majority of children, moderate exercise is both safe and beneficial [14,15,16,17,18]. Research indicates that many children with asthma tolerate physical activity well when supported by effective pharmacological management and individualized exercise plans [19, 20]. Optimal asthma control and appropriate medication use are essential to prevent exercise-induced airway constriction. Clinical guidelines emphasize the need for thorough assessment and monitoring of symptoms and lung function before, during and after exercise to ensure safety [21]. Before exercise, healthcare providers should evaluate symptoms and pulmonary status, confirm the use of preventive medications (e.g., ICS and SABA) and assess exercise suitability [22]. Hengeveld et al. [23] proposed incorporating exercise challenge tests (ECT) into the evaluation of respiratory symptoms, as this method helps assess both exercise capabilities and respiratory symptoms, ensuring the child can safely engage in exercise. During exercise, especially in children prone to EIB, monitoring respiratory rate, heart rate and airway symptoms (e.g., coughing, wheezing) is critical [24, 25]. Post-exercise, symptom monitoring and pulmonary function tests [e.g., forced expiratory volume in one second (FEV1)] may be required to assess airway response. In conclusion, most children with asthma can safely engage in physical activity with proper asthma management. Personalized exercise programs and regular health assessments are critical for optimizing safety and maximizing exercise benefits.

Question 2: What are the health benefits of exercise for children with asthma?

Recommendations: (1) Asthma management: exercise improves asthma control, reduces the frequency of acute exacerbations, decreases the need for medication, alleviates nocturnal symptoms and enhances sleep quality. (2) Cardiopulmonary function: aerobic exercise enhances cardiopulmonary function and reduces the risk of EIB. (3) Mental and social well-being: regular exercise positively affects mental health, quality of life and social skills, contributing to improved emotional regulation, reduced anxiety and depression and better social interactions.

Evidence summary: Growing evidence supports the beneficial role of exercise in asthma management. Regular exercise has been shown to improve symptom control [26,27,28], reduce medication use [29] and decrease the frequency of emergency visits and hospitalizations in children with asthma [14, 30]. A systematic review examining the impact of exercise on nocturnal asthma symptoms reveals that regular physical activity can substantially alleviate night-time symptoms, thus improving sleep quality [31]. However, while the positive effects of exercise on symptom control are well-established, its role in modulating airway inflammation and enhancing immune function remains unclear [32]. Some studies suggest that exercise may reduce airway inflammation, as indicated by lower fractional exhaled nitric oxide (FeNO) levels [33]; more research is needed to clarify the mechanisms involved.

Aerobic exercise improves cardiorespiratory function and exercise capacity in children with asthma, including an increase in maximal oxygen uptake [26, 30, 33,34,35,36]. Although current evidence does not provide strong support for the notion that general exercise interventions directly improve lung function, studies have indicated that specific types of exercise, such as swimming, may help improve lung function and reduce EIB symptoms [37, 38]. The rhythmic nature of swimming and the exposure to moist air may further reduce respiratory tract irritation, providing additional benefits for children with asthma.

Exercise has been shown to positively impact the psychological health and overall quality of life of children with asthma. A significant body of evidence consistently indicates that regular physical activity improves the quality of life of children with asthma [10, 18, 26, 39, 40]. Specifically, children who participate in regular exercise experience reductions in the symptoms of anxiety and depression that are associated with asthma [36]. Psychological benefits of exercise are most evident as improvements in emotional regulation and social interaction skills; these are vital for overall health and well-being [41].

Question 3: What key factors should be considered when formulating an exercise plan for asthmatic children?Question 3a: How does asthma control influence the formulation of an exercise plan?

Recommendations: For children with well-controlled asthma, exercise should align with the general guidelines for healthy children. For children with partially controlled asthma, initiation of low-intensity, short-duration exercise, with gradual increases in intensity and duration as tolerated is recommended. For children with poorly controlled asthma, only tolerable physical activity should be undertaken until asthma control improves.

Evidence summary: Asthma control is essential to determine exercise safety. This is usually assessed using pulmonary function tests and validated questionnaires, such as the childhood asthma control test (C-ACT), asthma control test (ACT) and test for respiratory and asthma control in kids (TRACK), which are commonly used in clinical practice and research [42]. Peak expiratory flow (PEF) monitoring is another useful tool for home-based assessment, tracking asthma control via PEF values and their variability [43]. However, questionnaires may be unreliable in children and PEF measurements are prone to manipulation, which may not provide sufficient insight into expiratory flow limitation. Advances in technology have introduced portable spirometers and smartphone apps, allowing children to perform spirometry tests at home. Although not directly comparable to laboratory results, these tools provide better insights into expiratory flow limitation and allow professionals to assess measurement quality through flow-volume loops. Healthcare providers must identify children at risk of asthma deterioration and tailor exercise plans accordingly. For high-risk children, exercise should be restricted, while others, particularly those with partially controlled asthma, can engage in exercise if symptoms are controlled, with SABA available as needed. Several studies have shown that children with well-controlled asthma can safely exercise, while those with poorly controlled asthma are at higher risk for exacerbations or EIB [40, 44]. Clinical guidelines recommend that exercise be postponed for children with acute asthma exacerbations or poor control until their condition stabilizes [21, 45,46,47]. Exercise intervention studies typically exclude children with recent flare-ups or medication changes to avoid worsening symptoms. Most randomized controlled trials (RCTs) focus on children with mild-to-moderate asthma, with limited data available on those with severe asthma. Studies, including that of Fanelli [40], show that while children with severe asthma are more likely to experience EIB, appropriate exercise interventions can still positively impact asthma management. Even with the potential for EIB, exercise can reduce the incidence of EIB and alleviate exercise-induced dyspnea, suggesting long-term benefits for asthma control.

Question 3b: How should exercise habits be considered when designing an exercise plan?

Recommendations: Children without a regular exercise habit should start with low- to moderate-intensity exercise, gradually increasing in intensity. For children who already have a regular exercise routine, moderate to high-intensity exercise should be maintained.

Evidence summary: Assessing exercise habits is essential for developing a personalized exercise plan for children with asthma. The American College of Sports Medicine (ACSM) recommends conducting an exercise history screening to assess an individual’s physical activity regularity, tolerance and potential risks [48]. According to ACSM, individuals who engage in moderate-intensity exercise at least three times a week for at least 30 minutes per session, sustained for more than three months, can be considered “regular exercisers” [48]. This screening helps identify children who have not yet adapted to regular exercise, as they may be at higher risk of overexertion and injury. It is crucial to tailor exercise intensity based on the exercise history and cardiopulmonary function of the child to ensure safety and effectiveness.

Question 3c: How should cardiopulmonary function be assessed to ensure safe participation in exercise?

Recommendations: Cardiopulmonary function can be assessed using maximal or submaximal exercise testing. Key parameters to monitor during testing include heart rate, blood pressure, respiratory rate, perceived breathlessness, oxygen saturation and perceived exertion.

Evidence summary: Cardiopulmonary exercise testing (CPET) is considered the “gold standard” for assessing cardiorespiratory fitness. It measures maximum oxygen uptake (VO2max) and provides detailed physiological data on metabolic parameters and exercise capacity [49, 50]. However, due to its complexity, high cost and the requirement for maximal exertion, CPET may not be necessary in most cases. An alternative approach, the ECT as recommended by the European Respiratory Society (ERS) and American Thoracic Society (ATS), provides a viable alternative. This test, typically performed using a treadmill or cycle ergometer, effectively evaluates exercise tolerance and cardiorespiratory function without necessitating maximal intensity or expensive equipment. The six-minute walk test (6MWT) is another commonly used submaximal test, especially for children with low fitness levels or chronic respiratory conditions [51, 52]. Standardized by the ATS, the 6MWT protocol makes a reliable and clinically valuable tool for assessing exercise tolerance and guiding exercise prescriptions [53].

During exercise testing, key physiological parameters, such as heart rate (HR), blood pressure (BP), respiratory rate, perceived breathlessness, oxygen saturation and subjective fatigue, should be monitored to ensure safety and a reliable assessment [48]. HR should be measured at the 2nd and 3rd minutes of the test to assess cardiac load and recovery trends. BP should be recorded one minute before the test ends to assess hemodynamic responses. Respiratory rate and oxygen saturation should be monitored continuously throughout the test. Perceived exertion can be assessed using the Borg rating of perceived exertion (RPE) scale, and perceived breathlessness can be evaluated using a visual analog scale or similar method, both during the final minute of exercise to assess the participant’s perception of exercise intensity and comfort. These parameters help in making necessary adjustments to exercise intensity and in evaluating potential risks during exercise.

Question 3d: How should body composition be assessed when creating an exercise plan?

Recommendations: Children’s height and weight should be measured to calculate their body mass index (BMI)-Z score for assessment of nutritional and developmental status. For children with suboptimal nutritional status or low muscle mass, exercises requiring high intensity or explosive power should be avoided to minimize the risk of injury.

Evidence summary: Nutritional status and body composition directly affect exercise capacity and risks. Obese children may have more severe asthma symptoms and lower exercise tolerance due to increased fat mass, reduced lung function and chronic airway inflammation [6]. Malnourished children or those with low muscle mass are at greater risk for falls and injuries during exercise [54]. Measuring height, weight, and calculating BMI-Z scores is recommended before intervention to assess nutritional status and identify malnutrition or growth deviations [55].

Obese children often have poor motor coordination and insufficient core strength, requiring caution during high-intensity exercises [56, 57]. Children with low muscle mass should avoid explosive strength exercises to minimize injury risk [58]. In addition, obese children may experience discomfort during high-intensity activities, leading to lower exercise compliance [59, 60]. Personalized interventions, such as gamified exercises, have been shown to improve long-term adherence [61, 62]. For malnourished children, assessing motor control and stability is crucial before starting exercise. A gradual, low-intensity approach, combined with nutritional support, enhances physical development and tolerance to exercise. While BMI-Z is a valuable tool, it does not distinguish between muscle and fat mass, and combining it with other measurements like skinfold thickness or handgrip strength can improve accuracy.

Question 3e: How do age-related factors influence exercise plan?

Recommendations: For preschool children, the focus should be on developing basic motor skills primarily through play. For school-aged children, it is recommended that excessive high-intensity exercise and weight-bearing resistance training is avoided to ensure safe physical development.

Evidence summary: Children at different ages have distinct physical, motor, and psychological characteristics, which influence their exercise needs and adaptability. For preschool-aged children, the focus should be on developing basic motor skills such as walking, running, jumping, throwing and balancing [63]. The primary goal at this stage is to enhance these abilities through playful, unstructured activities, with guidelines emphasizing free play and parent–child interactions rather than structured or competitive training [64,65,66].

In school-aged children, physical abilities are improving, but bones, tendons and joints are still developing, limiting their tolerance for impact and load. Excessive high-intensity exercise or heavy resistance training should be avoided to reduce the risk of musculoskeletal injuries, especially exercises involving large, uncontrolled movements or explosive force [67]. Safer alternatives include bodyweight resistance training, basic coordination exercises and fun group activities. While structured exercise plans can be beneficial for children with specific needs or conditions, for most healthy children, it is essential to prioritize unstructured, natural play for physical and motor skill development. Encouraging free play, physical exploration and non-competitive activities fosters better engagement and supports overall development.

Current research on exercise interventions for those with asthma primarily focuses on adolescents and adults, with limited studies on preschool and prepubertal children. These studies often have small sample sizes with short follow-up periods, which limits their long-term applicability. In addition, cultural differences and variations in educational systems may influence exercise patterns and affect the generalizability of intervention outcomes.

Question 3f: What environmental factors should be considered when planning exercise?

Recommendations: The ideal exercise environment for children with asthma should be at a temperature of 20–24 °C, with either a relative Humidity above 40% or an absolute Humidity above 10 g/m3. Concentrations of fine particulate matter less than 2.5 μm in diameter (PM2.5) should be below 10 μg/m3, and allergen exposure should be avoided.

Evidence summary: Both low and high temperatures can exacerbate the occurrence of EIB. Cold air cools the airways, leading to airway constriction and worsening symptoms, while hot air can dry out the airways, triggering similar respiratory reactions. Therefore, a temperature range of 20–24 °C is considered optimal from EIB-related experiments. This range helps avoid the negative impact of extreme temperatures on the airways, controls the cooling effect, and reduces the occurrence of EIB [68, 69]. In addition, humidity is another critical factor influencing EIB. The study of Tikkakoski indicates that when the absolute humidity (AH) is below 5 g/m3, the incidence of EIB significantly increases, whereas when the AH reaches or exceeds 10 g/m3, the risk of EIB is lower [70,71,72]. Furthermore, the study of Stensrud suggests that when relative humidity (RH) is Maintained above 40%, the incidence of EIB is reduced and further decreases when humidity exceeds this threshold [73]. However, current studies have not established a precise upper limit for humidity, with many simply confirming that higher humidity is generally associated with lower EIB incidence.

Air quality is a central factor in exercise safety [74]. According to guidelines, outdoor activities are generally considered safe when the air quality index (AQI) is between 0 and 100; this indicates good air quality, which is ideal for exercise [75, 76]. However, when the AQI is between 101 and 200 (moderate pollution), the intensity and duration of outdoor activities should be Limited, or less polluted times and areas should be chosen for low-intensity exercise. If the AQI exceeds 200 (severe pollution), outdoor exercise should be avoided to reduce exposure to harmful irritants. The negative impact of air pollution on asthma is well-established and outdoor exercise on polluted days can exacerbate symptoms. Asthmatic children should avoid outdoor activities during high-pollution days, pollen peaks, or when the weather is cold and dry. Notably, studies have shown that PM2.5 concentrations above 10 μg/m3 are associated with an increased incidence of EIB in children with asthma [70, 77]. If outdoor exercise is necessary, protective measures such as wearing masks to warm and humidify the air can help minimize exposure to harmful pollutants [45]. Although longer durations of outdoor activity have been shown to be protective against asthma, this benefit may be offset under poor air quality or in the presence of other environmental risk factors [78]. While allergen exposure, such as pollen, may be difficult to avoid entirely, it should not prevent children from exercising. In these cases, alternatives such as indoor exercise or choosing areas with lower pollen levels can help minimize exposure. In addition, using medications like antihistamines can effectively manage symptoms, allowing children with asthma to safely continue physical activity.

In addition to these outdoor and allergen-related considerations, indoor exercise environments also present potential risks. Poorly ventilated indoor spaces may contain asthma triggers such as volatile organic compounds (VOCs), mold and dust, which can exacerbate respiratory symptoms [79,80,81]. Swimming, often recommended for asthmatic children due to the warm and humid environment that helps reduce airway irritation, is generally considered safe. However, in indoor pools with inadequate ventilation, chloramine gases may accumulate and irritate the airways. Ensuring proper ventilation is, therefore, essential when engaging in indoor swimming activities.

Question 3g: What strategies can promote exercise participation and overcome barriers?

Recommendations: A thorough evaluation of family, school and social resources should be conducted to optimize the exercise plan for the child. Behavioral theories should be used to identify factors influencing exercise participation, helping professionals to develop strategies that promote and sustain regular physical activity.

Evidence summary: Children with asthma can reap significant health benefits from regular physical activity, but participation and adherence are often hindered by various factors. Identifying and addressing these barriers is essential for developing effective, sustainable exercise plans. Research highlights that family, school and societal resources are crucial external factors influencing exercise adherence in children with asthma [82, 83].

At the family level, studies indicate that parental exercise habits, attitudes and support play a significant role in a child’s physical activity levels. Activities such as parent–child exercise and encouragement are particularly effective [84, 85]. Parents also serve as key role models, with a positive correlation between parental and child activity levels, especially for moderate-to-vigorous-intensity exercise [86]. Creating a family-oriented exercise environment is essential, particularly for preschool-aged children.

At school, flexible physical education curricula, understanding of asthma by teachers, and their ability to manage emergencies are important to ensure children can participate safely [87, 88]. Social factors, including access to community exercise spaces, air quality and medical support, also affect opportunities for physical activity. High air pollution and limited exercise facilities significantly constrain exercise options [89].

Integrating exercise plans into asthma action plans is recommended to improve adherence, providing parents and children with a sense of safety and trust in managing asthma [21, 35]. Setting clear, measurable goals and tracking progress further motivates children. Motivational interviewing (MI) has also been shown to effectively improve exercise participation, especially for children at the preparation or hesitation stage [90, 91].

Theoretical models, such as self-determination theory (SDT) [