Childhood asthma: breakthroughs and challenges

As we move forward, our goal is to control and eliminate asthma and other allergic disorders. This may come through broadly applied manipulation of environmental, dietary, and infectious risk factors, possibly during the perinatal period. Or we may learn to identify genetically susceptible children and to intervene with individualized genotype-specific treatment before the onset of disease. Maybe we'll learn how to block the mechanisms that give rise to chronic inflammation, or how to subdue Th2 activation. However, as the Swedish proverb says--Don't throw away the old bucket until you know whether the new one holds water. To continue using the old bucket, we have to fix the leaks. One approach to reducing asthma disparities is through traditional disease prevention stages. Primary prevention targets asthma incidence; secondary prevention mitigates established disease and involves disease detection, management, and control; and tertiary prevention is the reduction of complications caused by severe disease. Once causative factors at each level of disease prevention are understood, this knowledge can be translated into clinical practice and public health policy. We need reliable diagnostic criteria to provide correct treatment for infants and toddlers. This will require longitudinal cohort studies supported by assessment of pulmonary function and inflammatory markers. We must find ways to convince more physicians to embrace controller therapy for more severe disease, and to identify the patients with less severe disease who also require ongoing controller therapy. We need to close the gap between what we know and what we do in practice. We need to link basic research to healthcare delivery, and to gain acceptance and support from the intended recipients of new interventions. We need better strategies for improving adherence. We need accountability, foresight, and imagination.