Issues and unmet needs in pediatric asthma

Asthma is common and becoming more so in childhood. Although mild asthma ma y incur low average annual costs per child, these estimates need to be view ed in the context of the very large numbers of affected individuals. Wherea s asthma and wheezing illness in childhood had in the past been broadly sub divided into asthma (often associated with atopy) and wheezy bronchitis (wh eeze only, with associated upper respiratory tract infection), this distinc tion was lost during the 1970s in view of the demonstrated underdiagnosis a nd undertreatment of symptomatic school-age children. The acceptance of ast hma as a chronic inflammatory disease and evidence for airway remodeling an d progressive deterioration in airway function in association with symptoms and atopy have led to earlier use of topical steroids at higher starting d oses delivered by improved age-appropriate devices. Treating all children a s if they were destined to become atopic asthmatics and at risk of airway r emodeling may not be rational, particularly in those whose symptoms will su bsequently resolve. However, there are as yet no screening tests which can clearly identify individuals at risk of long-term chronic airway inflammati on and airway remodeling. The large number of infants and young children wi th current symptoms suggestive of asthma and in whom resolution is likely i n the majority poses problems for the clinician in deciding the best initia l therapy. There is an urgent need to develop simple and reliable measures that can identify the early manifestations of atopic airway sensitisation a nd to establish the place of early intervention with nonsteroidal drugs, in cluding leukotriene antigonists. (C) 2000 Wiley-Liss, Inc.