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A growing body of literature has investigated optimizing asthma management by identifying phenotypes and biomarkers to guide the treatment. In particular, management of asthma in preschool children remains challenging due to different phenotype presentation in early life. The focus of this review is to summarize the recent data on personalized medicine in management of preschool children with wheezing.

This is a “proof of concept” study to determine whether inhalation of 13C-urea can be safely used to detect the presence of urease producing bacteria in the airways of patients with cystic fibrosis (CF) by detecting 13CO2 in breath. This was a prospective, 2-part, open label, single-center, single-arm, single-administration, dose-escalation investigational device exemption trial. First, the safety of 20 and 50 mg inhaled 13C-urea was evaluated in 6 healthy adult participants. Then, 3 adult CF participants colonized with Pseudomonas aeruginosa were enrolled for each dose of inhaled 13C-urea. The safety of inhaled 13C-urea was assessed by spirometry and physical examination. 13C-urea was administered using a jet nebulizer, followed by serial spirometry (10 min and 30 min post inhalation) and collection of exhaled breath at 5, 10, and 15 min post inhalation. There was no clinical significant change in any of the spirometry values compared to baseline in healthy participants and CF patients. Mean of 13CO2/12C...

Recently, the United States Food and Drug Administration (FDA) elected not to approve a once-daily inhaled corticosteroid/long-acting β2 agonist combination product in 12-17-year-old patients due to lack of sufficient data, despite approval of previous combination products with similar levels of supporting evidence. As the FDA's stance toward adolescent data is changing, the opportunity to learn about their response to asthma medication has now arisen. A review of the relevant issues pertinent to pharmacotherapy of asthma in the 12-17-year-old population is discussed in this review.

Many observational studies have investigated the potential association between vitamin D and asthma. However, it is difficult to find a temporal causal relationship in cross-sectional or observational studies. This review presents recent clinical trials and the evidence of association between vitamin D and asthma in different patient populations and asthma status. Well-designed clinical trials are warranted in order to define the optimal level of vitamin D, as well as dosing and duration of vitamin D supplementation, in pediatric patients.

Empiric use of proton pump inhibitors (PPI) for the treatment of poorly controlled asthma has increased substantially in the past decade under the presumption that gastroesophageal reflux is precipitating symptoms. No PPI has a Food and Drug Administration (FDA) approved indication for the treatment of asthma symptoms. Use has been driven by data indicating that up to 80% of children and adults with asthma have reflux by pH probe monitoring and that nearly half of patients lack typical reflux symptoms. Data from controlled studies of adults have shown only a minimal improvement in peak expiratory flow with PPI use in the overall population, with only a slightly larger improvement in patients with diagnosed gastroesophageal reflux disease, and no effect on asthma exacerbation rate in one study. The single largest placebo-controlled study in children with poorly controlled asthma without gastroesophageal reflux symptoms found no improvement in any indices of asthma control, even in children with gastroesoph...

Inhaled corticosteroids (ICS) are recommended by The National Asthma Education and Prevention Program's Expert Panel Report 3 for all levels of persistent asthma in the pediatric population. The recommended ICS doses are based on assessment of severity and control of asthma. The pharmacodynamics and pharmacokinetics of the current ICSs are reviewed. While comparable efficacy can be achieved with equipotent dosing, some of the newer ICSs, fluticasone propionate, mometasone furoate, and ciclesonide, have pharmacokinetic profiles that produce less risk of systemic effects. However, at high doses systemic activity increases with all ICSs. The clinicians need to weigh the benefits and risks of these different products and dosing schemes in their patients for optimal use.

The objective of the study was to measure peak inspiratory flow (PIF) generated through Turbuhaler, Aerolizer, and Diskus inhalers in children 2 to 12 years old. An open-labeled, stratified, random...

Urinary free cortisol (UFC) concentration is one of the most sensitive indicators of systemic effect of glucocorticoids. The purpose of this study was to determine normal UFC values in healthy chil...

Our aim was to directly compare anti-inflammatory activity, as measured by fraction of exhaled nitric oxide (FeNO), relative efficacy, and safety of a low-dose inhaled corticosteroid and a leukotri...

The purpose of this review is to discuss the effect of daily inhaled corticosteroids (ICSs) on the height of children with asthma. The effect of ICSs on growth and height is dependent on the dose and the therapeutic index of the ICS; however, the effect on final adult height was not clear until recently. New data suggest that if growth suppression occurs with the use of ICSs in children, it is sustained, but not cumulative over the years. The observed reduction in the final adult height is small and does not outweigh the benefits of ICSs, and the growth effect may be minimized by use of newer ICSs and other approaches for management of asthma in children with mild to moderate asthma.

Equal efficacious doses of the inhaled corticosteroids can result in significant differences in systemic effects due to differences in their pharmacokinetic profile. The purpose of this study was to evaluate a model to compare systemic activity of inhaled corticosteroids given in topically equipotent doses in children. Systemic effects were measured by 24-hour urinary free cortisol (UFC) and a.m. and p.m. serum osteocalcin. Efficacy was monitored by a.m. and p.m. exhaled nitric oxide (eNO) and a.m. peak expiratory flow (PEF). Twenty-one children, 6-16 years old on inhaled corticosteroids at ≥400 μg/day beclomethasone dipropionate (BDP) equivalent were placed on BDP for a 2-week, open-label, run-in, baseline period. Patients were then randomized into a double-blind, double-dummy, crossover trial for two 3-week periods of equipotent doses of fluticasone propionate (FP) or triamcinolone acetonide (TAA) as defined by the NHLBI Expert Panel Report 2. At the end of baseline and each treatment phase patients wer...

The National Asthma Education and Prevention Program's Expert Panel Report 3 (EPR3), Guidelines for the Diagnosis and Management of Asthma, provides recommendations for initial assessment of asthma severity based on both impairment and risk domains. Subsequently, the follow-up visits are designed to assess asthma control and to adjust the therapy to the lowest effective dose of inhaled corticosteroids (ICSs) or various combinations for optimal control. EPR3 recommends considering step down in therapy if patient is well controlled for 3 consecutive months, which may lead to discontinuation of daily medications for patients receiving low dose ICSs or other controller monotherapy. In addition, patients and parents have a tendency to stop the daily medications after having a period of controlled asthma. In these situations, the challenge is to find the best way to discontinue daily medications in patients with mild or intermittent asthma whose daily or weekly impairment is under good control but may still be at risk for asthma exacerbations. The question is, “May another regimen other than daily use of ICSs be used in these patients who become asymptomatic with appropriate treatment to decrease the risk of asthma exacerbation?”

Diagnosis and management of asthma in preschool children are challenging. The Expert Panel Report 3 has recommendations for specific illness phenotypes to start long-term controller medication to reduce risk and impairment in children ages 0–4-year old. The use of daily-inhaled corticosteroids has shown to be effective in preschool children with persistent asthma, but there are also reports of growth retardation. For children with recurrent or intermittent wheezing without symptoms in between episodes, the intermittent use of controller medications may be an option for certain phenotypes. This review will discuss the available data on use of intermittent controller medications in preschool children with wheezing.