Corticosteroid-sparing options in the treatment of childhood asthma

During the last 30 years, a significant rise in wheezing illness has occurr ed in the child population. Despite its high prevalence there is no clear d efinition of the disease, which includes a heterogeneous group of syndromes ranging from transient wheezing in infancy to atopic asthma with persisten ce into adult life. Molecular advances and further epidemiological informat ion from well characterised individuals and their families are likely to cl arify the different subtypes of wheezing illness and inform therapeutic opt ions. With the recognition that chronic airway inflammation is a feature of persistent disease, at least in adults, then has been a trend towards the early introduction of anti-inflammatory treatment and particularly inhaled corticosteroids (ICS). However, the natural resolution of much wheezing ill ness, particularly in young children and in children with viral-induced epi sodes, suggests that newly presenting children should remain on symptomatic therapy alone while the severity of the disease is being assessed. Althoug h ICS have become a cornerstone of management of chronic persistent disease , their ability to protect against exacerbations in young and mildly affect ed children is questionable. Alongside concerns about long term use of ICS and possible systemic adverse effects, there remains a need for alternative approaches to the control of the disease in children. Extrapolation of the findings of large multicentre adult studies into childhood, particularly f or doubling the doses of ICS and long-acting beta(2)-agonists, may be unsou nd. Other approaches include the early introduction of inhaled cromones, us e of second generation antihistamines, low dose theophyllines and, more rec ently, leukotriene modifiers. As the majority of preschool children will be come asymptomatic by mid-childhood, there is an urgent need to identify tho se in whom chronic airway inflammation is developing, as it is in this grou p that early introduction of ICS may be of maximum benefit. In the remainde r, other approaches, including use of corticosteroid-sparing long-acting be ta(2)-agonists and leukotriene modifying drugs, may be more appropriate. Sa fe and effective oral preparations such as leukotriene modifying drugs are likely to establish a significant role in the management of symptoms in chi ldren of all ages and with all types of asthma and wheezing illness.