Management of severe asthma in children

Lancet. 2010 Sep 4;376(9743):814-25. doi: 10.1016/S0140-6736(10)61054-9.


Children who are referred to specialist care with asthma that does not respond to treatment (problematic severe asthma) are a heterogeneous group, with substantial morbidity. The evidence base for management is sparse, and is mostly based on data from studies in children with mild and moderate asthma and on extrapolation of data from studies in adults with severe asthma. In many children with severe asthma, the diagnosis is wrong or adherence to treatment is poor. The first step is a detailed diagnostic assessment to exclude an alternative diagnosis ("not asthma at all"), followed by a multidisciplinary approach to exclude comorbidities ("asthma plus") and to assess whether the child has difficult asthma (improves when the basic management needs, such as adherence and inhaler technique, are corrected) or true, therapy-resistant asthma (still symptomatic even when the basic management needs are resolved). In particular, environmental causes of secondary steroid resistance should be identified. An individualised treatment plan should be devised depending on the clinical and pathophysiological characterisation. Licensed therapeutic approaches include high-dose inhaled steroids, the Symbicort maintenance and reliever (SMART) regimen (with budesonide and formoterol fumarate), and anti-IgE therapy. Unlicensed treatments include methotrexate, azathioprine, ciclosporin, and subcutaneous terbutaline infusions. Paediatric data are needed on cytokine-specific monoclonal antibody therapies and bronchial thermoplasty. However, despite the interest in innovative approaches, getting the basics right in children with apparently severe asthma will remain the foundation of management for the foreseeable future.

Publication types

  • Review

MeSH terms

  • Administration, Inhalation
  • Adrenal Cortex Hormones / therapeutic use
  • Allergens / adverse effects
  • Anti-Asthmatic Agents / administration & dosage
  • Anti-Asthmatic Agents / therapeutic use*
  • Asthma* / diagnosis
  • Asthma* / drug therapy
  • Asthma* / etiology
  • Asthma* / immunology
  • Asthma* / physiopathology
  • Azathioprine / therapeutic use
  • Bronchial Provocation Tests
  • Bronchodilator Agents / administration & dosage
  • Bronchodilator Agents / therapeutic use*
  • Budesonide / therapeutic use
  • Budesonide, Formoterol Fumarate Drug Combination
  • Child
  • Clinical Trials as Topic
  • Comorbidity
  • Cyclosporine / therapeutic use
  • Drug Combinations
  • Drug Resistance, Multiple
  • Drug Therapy, Combination
  • Eosinophils
  • Ethanolamines / therapeutic use
  • Formoterol Fumarate
  • House Calls
  • Humans
  • Immunoglobulin E
  • Interdisciplinary Communication
  • Methotrexate / therapeutic use
  • Off-Label Use
  • Risk Factors
  • Severity of Illness Index
  • Spirometry
  • Terbutaline / therapeutic use
  • Tobacco Smoke Pollution / adverse effects
  • Tomography, X-Ray Computed
  • Treatment Outcome


  • Adrenal Cortex Hormones
  • Allergens
  • Anti-Asthmatic Agents
  • Bronchodilator Agents
  • Budesonide, Formoterol Fumarate Drug Combination
  • Drug Combinations
  • Ethanolamines
  • Tobacco Smoke Pollution
  • Immunoglobulin E
  • Budesonide
  • Cyclosporine
  • Azathioprine
  • Terbutaline
  • Formoterol Fumarate
  • Methotrexate