Background: Intravenous magnesium sulfate (MgSO? )is an effective second-line therapy for acute severe asthma used in many international guidelines, improving lung function, reducing hospital admissions, and enhancing severity scores in children. In contrast, aminophylline is less favored due to a narrow therapeutic index, frequent side effects, and limited evidence, yet both are still used in pediatric practice. Objective: To evaluate clinicians’ preferences and practices regarding the use of intravenous aminophylline versus magnesium sulfate as second-line therapy for acute severe asthma in pediatric wards in Sri Lanka. Methods: A prospective clinical audit was conducted among 50 clinicians, including pediatricconsultants, senior registrars, registrars, and medical officers working in paediatric wards whose patietns transfered to Paediatric Intensive Care Unit,Lady Ridgeway hospital for Children. An interviewer-administered questionnaire assessed their preferences, concerns on use of intravenous MgSO? andaminophylline. Results: Eighty percent (40/50) of clinicians preferred intravenous aminophylline over MgSO? .Hesitationto use MgSO? was due to concerns about potential adverse effects, including hypotension (100%), arrhythmias (100%), bradycardia/heart block (60%), muscle weakness andreduced reflexes (100%), respiratory depression (44%), and flaccid paralysis (10%); however, none had encountered these in practice. Meanwhile, 60% (30/50) were aware of aminophyllineassociatedarrhythmias and its narrow therapeutic index, and some had observed aminophylline toxicity in the pediatric intensive care setting. Conclusion: Greater awareness is needed regarding the safety and proven benefits of intravenous MgSO? in pediatric acute severe asthma. Magnesium sulfate is relatively safe, requires less complex monitoring than aminophylline, and offers clear clinical advantages.