Unmet needs in the treatment of asthmatic children and adolescents: 1

The paediatric asthma guidelines have been successful in providing a unifor m approach to the management of asthma for the medical profession as a whol e. Unfortunately, the guidelines were generated without input from patients themselves and consequently do not consider issues that are important to p atients such as a preference for oral treatment. Asthma is a heterogeneous group of conditions and the guidelines do not sufficiently define subgroups of patients and their particular needs. As a result, there has been a tend ency to assume that all wheezing in infancy is asthma and this had led to g ross overtreatment in certain patients. In contrast, severe asthma often re mains underdiagnosed and undertreated. The most recent revision of the guid elines has classified asthma in terms of the patterns of disease; infrequen t episodic, frequent episodic and chronic persistent. The treatment require d for each of these groups is clearly defined and there is no need for step wise therapy. Other changes to the guidelines will occur and are needed. No ne of the treatments available can modify the natural history of asthma; th ey control the symptoms not the disease process. Evidence from bronchial bi opsies suggests that both inflammation and remodelling occur early, even be fore the first symptoms appear. We need to look for the factors in early li fe that predict which children will go on to develop asthma and intervene a t that stage. Anti-histamines and leukotriene receptor antagonists may be i nteresting as interventions in that respect. Two important unresolved issue s are to understand what drives remodelling and inflammation, and to look a t early life origins of asthma. These approaches may provide effective ther apeutic targets and, ultimately, a means of prevention.