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

The paediatric asthma guidelines have been successful in providing a uniform approach to the management of asthma for the medical profession as a whole. Unfortunately, the guidelines were generated without input from patients themselves and consequently do not consider issues that are important to patients 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 tendency to assume that all wheezing in infancy is asthma and this had led to gross overtreatment in certain patients. In contrast, severe asthma often remains underdiagnosed and undertreated. The most recent revision of the guidelines has classified asthma in terms of the patterns of disease; infrequent episodic, frequent episodic and chronic persistent. The treatment required for each of these groups is clearly defined and there is no need for stepwise therapy. Other changes to the guidelines will occur and are needed. None of the treatments available can modify the natural history of asthma; they control the symptoms not the disease process. Evidence from bronchial biopsies suggests that both inflammation and remodelling occur early, even before the first symptoms appear. We need to look for the factors in early life that predict which children will go on to develop asthma and intervene at that stage. Anti-histamines and leukotriene receptor antagonists may be interesting as interventions in that respect. Two important unresolved issues are to understand what drives remodelling and inflammation, and to look at early life origins of asthma. These approaches may provide effective therapeutic targets and, ultimately, a means of prevention.