ABSTRACT
Good asthma control can be achieved in most children with a short-acting
beta-agonist and with low doses of inhaled steroid given alone or in combination with a long-acting beta-agonist or a leukotriene recepter antagonist.
Inhaled steroids have a flat dose-response curve for efficacy, the top of the
dose-response curve being reached at approximately 400-800mcg beclo-
methasone equivalent in children (1). Children who have asthma that is
difficult to control, despite being prescribed high doses (800mcg or more
of beclomethasone equivalent) of inhaled steroids combined with other
asthma medication, should be reviewed by a pediatrician specializing in
respiratory disease. The first consideration will be whether the diagnosis of asthma is correct. There may be environmental or psychosocial factors
affecting the asthma that have not been recognized or the prescribed treat-
ment may not be being taken. A small proportion of children with severe
asthma remain symptomatic despite appropriate environmental measures
and treatment that includes high doses of an inhaled steroid and beta-
agonists. The care of these children requires considerable skill and sometimes
a therapeutic approach that may involve a delicate balance of risk against benefit. They comprise no more than 5% of the childhood asthma population but, because asthma is so common, there will be 5000 to 10,000 such
children in the United Kingom. They are a heterogeneous group in whom
the pathophysiology is poorly understood. They require frequent consulta-
tions, complex treatment regimes, and are often admitted to the hospital.
As a result, they consume the bulk of the D250 million spent on childhood asthma care in the United Kingdom.
