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Corticosteroid-sparing options in the treatment of childhood asthma
1Department of Child Health, University of Aberdeen Medical School,Foresterhill, Aberdeen, Scotland.
Insights
Wheezing illness in children is rising, with no clear definition. Early inhaled corticosteroid (ICS) treatment may benefit persistent disease, but symptomatic therapy is best for mild or viral cases.
Area of Science:
- Pediatric respiratory medicine
- Clinical immunology
- Epidemiology of childhood illnesses
Background:
- Wheezing illness in children has increased significantly over 30 years.
- The condition is heterogeneous, lacking a clear definition and encompassing various syndromes.
- Chronic airway inflammation is recognized in persistent disease, particularly in adults.
Purpose of the Study:
- To clarify subtypes of childhood wheezing illness using molecular and epidemiological data.
- To inform therapeutic options for different wheezing phenotypes.
- To evaluate the role of early anti-inflammatory treatment versus symptomatic therapy.
Main Methods:
- Review of current literature on childhood wheezing and asthma management.
- Analysis of epidemiological trends and molecular advances.
- Assessment of the efficacy and safety of various treatment modalities, including inhaled corticosteroids (ICS).
Main Results:
- Early introduction of ICS is beneficial for persistent disease with chronic airway inflammation.
- Symptomatic therapy alone is recommended for newly presenting or viral-induced wheezing in young children.
- The efficacy of ICS in young or mildly affected children is questionable, raising concerns about long-term use and adverse effects.
Conclusions:
- Identifying children with developing chronic airway inflammation is crucial for optimal ICS use.
- Alternative treatments like leukotriene modifiers and cromones may be suitable for certain groups.
- Leukotriene modifying drugs show promise for managing symptoms in children with various wheezing illnesses and asthma.
Abstract:
During the last 30 years, a significant rise in wheezing illness has occurred in the child population. Despite its high prevalence there is no clear definition of the disease, which includes a heterogeneous group of syndromes ranging from transient wheezing in infancy to atopic asthma with persistence into adult life. Molecular advances and further epidemiological information from well characterised individuals and their families are likely to clarify the different subtypes of wheezing illness and inform therapeutic options. With the recognition that chronic airway inflammation is a feature of persistent disease, at least in adults, there has been a trend towards the early introduction of anti-inflammatory treatment and particularly inhaled corticosteroids (ICS). However, the natural resolution of much wheezing illness, particularly in young children and in children with viral-induced episodes, suggests that newly presenting children should remain on symptomatic therapy alone while the severity of the disease is being assessed. Although ICS have become a cornerstone of management of chronic persistent disease, their ability to protect against exacerbations in young and mildly affected 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 for doubling the doses of ICS and long-acting beta2-agonists, may be unsound. Other approaches include the early introduction of inhaled cromones, use of second generation antihistamines, low dose theophyllines and, more recently, leukotriene modifiers. As the majority of preschool children will become asymptomatic by mid-childhood, there is an urgent need to identify those in whom chronic airway inflammation is developing, as it is in this group that early introduction of ICS may be of maximum benefit. In the remainder, other approaches, including use of corticosteroid-sparing longacting P2-agonists and leukotriene modifying drugs, may be more appropriate. Safe and effective oral preparations such as leukotriene modifying drugs are likely to establish a significant role in the management of symptoms in children of all ages and with all types of asthma and wheezing illness.