Treatment of chronic asthma in children: the changing role of inhaled corticosteroids.

T he current increase in the incidence of asthma and in the number of deaths from asthma among young patients is of extreme concern.' Inflammation of the airways is the main pathophysiologic process in asthma, and it can be found even in patients with newly diagnosed, mild or asymptomatic asthma.2'3 Inhaled corticosteroid therapy is the best anti-inflammatory treatment available for asthma. It decreases airway inflammation and nonspecific bronchial hyperresponsiveness, improves pulmonary function and decreases the frequency and severity of asthma symptoms. Although not required by children with mild or intermittent asthma such therapy is currently underused in the treatment of moderate or severe asthma and is still viewed by many physicians as a last resort. This position paper aims to help physicians select the children with chronic asthma who are most likely to benefit from inhaled corticosteroid therapy. The objectives of treatment are that all children with asthma be free from symptoms of wheeze, cough and shortness of breath, attend school regularly, have normal exercise tolerance, sleep uninterruptedly at night and have the best pulmonary function possible, without adverse effects from medications.4-6 Of all children with asthma 75% have mild or intermittent symptoms and require minimal (no more than twice daily) use of a f2-adrenergic agonist (e.g., salbutamol) to treat intermittent cough or wheezing or to prevent exercise-induced symptoms.6 Preferably, the p32-agonist is given by inhalation. The device used should be the one best suited to the patient's age and dexterity, as determined in a demonstration session with the physician or his or her designate. Mild, infrequent asthma episodes in very young children can be managed with a #2-agonist given orally. Another 20% of children with asthma have frequent symptoms, defined as more than six episodes of asthma per year or as necessitating a 32-agonist more than twice daily. For these children we recommend a trial of cromolyn sodium, inhaled regularly four times daily, to reduce the need for a p32-agonist and to keep them free from symptoms. Cromolyn is effective in many young patients and has virtually no adverse effects, even if used regularly for years. Among school-aged children, if it has not prevented symptoms or the excessive use of an inhaled f32-agonist (more than two or three times daily) after 4 to 6 weeks and has not improved the peak expiratory flow rates, preventive treatment with an inhaled corticosteroid such as beclomethasone or budesonide should be considered.7-'3 Among younger children a much longer trial of cromolyn is warranted, and its efficacy should be assessed by means of a symptom diary. The newer antiallergic medications nedocromil and ketotifen seem to be no more effective than cromolyn and are more likely to produce adverse effects. There is little rationale for adding theophylline to treatment regimens with cromolyn, because this increases the risk of adverse effects and the expense of treatment without increasing cromolyn's efficacy.