New approaches in childhood asthma treatment

Management of severe asthma in children: current insights and future directions

INTRODUCTION

Severe pediatric asthma represents a critical challenge in respiratory medicine, affecting a small but significant subset of children with disproportionate morbidity and healthcare burden. Its complexity arises from diverse phenotypes, endotypes, and inflammatory pathways that complicate diagnosis and management. Recent advances in precision medicine, particularly biologic therapies targeting Type 2 inflammation, offer new opportunities for improved outcomes.

AREAS COVERED

This review synthesizes current knowledge on severe pediatric asthma, emphasizing the pathophysiology, clinical phenotypes, and therapeutic advancements. It explores the role of biomarkers and endotypes in guiding personalized therapy and critically examines challenges such as non-Type 2 inflammation, barriers to biologic access, and variability in treatment response. A comprehensive literature search was conducted, focusing on biologic therapies, diagnostic innovations, and emerging care models.

EXPERT OPINION

Despite progress, challenges remain in achieving standardized treatment response definitions, validating biomarkers, and addressing cost barriers. Early biologic initiation in high-risk children and multidisciplinary care are critical to advancing outcomes. Future efforts should prioritize predictive algorithms, innovative therapies, and equitable access to shift from symptom control to disease prevention, potentially redefining the pediatric asthma care paradigm.

Unveiling the Complexities of Pediatric Asthma Treatment: Evidence, Controversies, and Emerging Approaches

Pediatric asthma remains a prevalent and challenging chronic condition globally, affecting quality of life and imposing significant burdens on families and healthcare systems. Despite advancements in understanding asthma pathophysiology and treatment, key controversies persist in optimizing management strategies. Inhaled corticosteroids (ICS) are the cornerstone of treatment, reducing inflammation and preventing exacerbations. While concerns about growth suppression exist, evidence suggests that this effect is primarily associated with high doses and prolonged use, rather than standard maintenance therapy. Nonetheless, adherence to ICS remains suboptimal, necessitating strategies to ensure effective and sustained treatment. The introduction of maintenance and reliever therapy (MART) with ICS-formoterol has offered improved outcomes by simplifying regimens and reducing reliance on short-acting beta-agonists (SABA). However, evidence supporting MART and ICS-SABA regimens in younger children is limited, highlighting gaps in pediatric-focused research. Biologics targeting inflammatory pathways, such as omalizumab, mepolizumab, and dupilumab, represent a personalized approach for severe asthma but face challenges including high costs, limited long-term safety data, and uncertainty regarding their ability to modify disease progression. In addition, the complexity of treatment decisions is compounded by insufficient biomarkers and age-specific evidence to guide therapy. Addressing these gaps requires robust clinical studies and improved adherence strategies tailored to pediatric populations. This review critically examines current pharmacological strategies, unresolved issues, and evolving approaches in asthma management, emphasizing the need for personalized and evidence-based care. Enhancing treatment outcomes for pediatric asthma necessitates balancing therapeutic benefits with minimal adverse effects and leveraging ongoing research to inform future practice.

Severe Asthma in School-Age Children: An Updated Appraisal on Biological Options and Challenges in This Age Group

This review examines the growing role of biological therapies in managing severe asthma in children aged 6-11 years. Severe asthma, characterized by persistent symptoms and frequent exacerbations, presents significant challenges in pediatric care. Biologic treatments, including mepolizumab, omalizumab, and dupilumab, provide targeted interventions for patients with high eosinophilic inflammation or allergic asthma (T2-high asthma). Alongside their therapeutic benefits, the review evaluates the safety profiles of these biologics, highlighting potential side effects and the necessity for monitoring during long-term use. Cost considerations and treatment adherence also emerge as important challenges that need to be addressed in clinical practice. Additionally, the review emphasizes the need for identifying patients who would derive the most benefit from biologic therapies, advocating for the development of biomarkers to aid in treatment decisions. Emerging biologics, such as tezepelumab, are introduced as promising alternatives with the potential to target upstream inflammatory pathways, offering hope for treating T2-low asthma forms, which currently lack effective treatment options in children.

Synbiotics, a promising approach for alleviating exacerbated allergic airway immune responses in offspring of a preclinical murine pollution model

Exposure to pollutants like environmental cigarette smoke (CS) poses a major global health risk, affecting individuals from an early age. Therefore, this study explores how postnatal synbiotic supplementation affects allergic asthma symptoms in house-dust-mite (HDM)- challenged offspring maternally exposed to CS. In HDM-allergic offspring of CS-exposed dams, lung resistance was elevated, but synbiotic supplementation effectively reduced this resistance. Elevated eosinophil BALF counts following HDM challenge were intensified in pups maternally exposed to CS. Similarly, Th2 cell activation and serum IgE and IgG1 levels were more pronounced in HDM-allergic offspring of CS-exposed mothers. Synbiotics reduced eosinophil numbers and serum IgE and IgG1, and tended to decrease Th2 cell infiltration and activation. Synbiotics promoted beneficial gut bacteria like Bifidobacterium and Akkermansia. In conclusion, early-life synbiotic intervention mitigated allergic asthma associated with maternal air pollution exposure, highlighting the potential of synbiotics for clinical evaluation as a strategy to prevent allergy development in offspring.

The Role of Regulatory B Lymphocytes in Allergic Diseases

PURPOSE OF REVIEW

Regulatory B cells (Bregs) are a key component in the regulation of the immune system. Their immunosuppressive function, which includes limiting the inflammatory cascade, occurs through interactions with other immune cells and the secretion of cytokines, primarily IL-10. As knowledge about B cells continues to expand, their diversity is becoming more recognized, with many subpopulations identified in both human and animal models. However, identifying specific transcription factors or markers that could definitively distinguish regulatory B cells remains a challenge. This review summarizes recent findings on the role of B regulatory cells in allergic diseases.

RECENT FINDINGS

In patients with bronchial asthma, atopic dermatitis, and food allergies, the number of regulatory B cells is reduced, and disease severity is inversely proportional to the quantity of these cells. Furthermore, in patients with atopic dermatitis, the ability of regulatory B cells to produce IL-10 in response to IL-6 stimulation is diminished. However, allergen immunotherapy has been shown to induce the formation of regulatory T cells as well as regulatory B cells.

SUMMARY

The success of future therapies based on B cells may depend on deepening our current understanding of their phenotypes, induction, differentiation, and function. Research in these areas is essential for understanding the mechanisms regulating Breg activity and for developing potential targeted therapies in the treatment of allergic diseases.

The role of regulatory B cells in immune regulation and childhood allergic asthma

BACKGROUND

As the most common chronic disease in childhood, asthma displays a major public health problem worldwide with the incidence of those affected rising. As there is currently no cure for allergic asthma, it is mandatory to get a better understanding of the underlying molecular mechanism.

MAIN BODY

By producing IgE antibodies upon allergen contact, B cells play a pivotal role in allergic asthma. Besides that, IL-10-secreting B cell subsets, namely regulatory B cells (Bregs), are reported in mice and humans to play a role in allergic asthma. In humans, several Breg subsets with distinct phenotypic and functional properties are identified among B cells at different maturational and differentiation stages that exert anti-inflammatory functions by expressing several suppressor molecules. Emerging research has focused on the role of Bregs in allergic asthma as well as their role for future diagnostic and preventive strategies.

CONCLUSION

Knowledge about the exact function of human Bregs in allergic asthma is still very limited. This review aims to summarize the current knowledge on Bregs. We discuss different human Breg subsets, several ways of Breg induction as well as the mechanisms through which they exert immunoregulatory functions, and their role in (childhood) allergic asthma.