Symposium: respiratory disordersManagement of problematic severe asthma in children

The majority of children with asthma are classified as mild or moderate and can be successfully managed with regular inhaled corticosteroids and bronchodilators. However, 5-10% of asthmatic children continue to have sub-optimal control despite apparent appropriate therapy. These children suffer significant morbidity including poor school attendance, adverse effects on family life and consume disproportionate healthcare resources. True therapy-resistant asthma is rare in children and paediatricians should focus on ensuring the correct diagnosis, identifying and managing modifiable risk factors for difficult to control asthma before using the label severe asthma. Management of problematic severe asthma requires a multidisciplinary approach and should be undertaken by professionals with appropriate skills. Symptomatic children on high dose therapy, those who require continuous or frequent use of oral steroids or in whom diagnostic uncertainty persists should be referred to the local severe asthma services which have a range of enhanced diagnostic tools and can access newer biologic therapies and funding for alternative treatments. This article outlines the scale of the problem and offers guidance on initial diagnostic work-up and criteria for referral.