International Journal for Doctor of Medicine and  Medical Students (IJDMMS)

Abstract

Background

Bronchial asthma is the most prevalent chronic respiratory disorder in children and a major contributor to global pediatric morbidity. The disease is characterized by chronic airway inflammation, bronchial hyperresponsiveness, and variable airflow limitation. Despite advances in therapeutic strategies, diagnostic uncertainty and inadequate disease control remain common in pediatric populations.

Objective

This study aims to critically review the diagnostic challenges, differential diagnosis, pathophysiological mechanisms, and contemporary management strategies of pediatric asthma with emphasis on precision medicine and global health perspectives.

Methods

A structured narrative review was conducted using databases including PubMed, Scopus, and Web of Science. Studies published between 2015 and 2025 were prioritized. Evidence from clinical trials, systematic reviews, and international guidelines was synthesized.

Results

Asthma in children is heterogeneous, with multiple phenotypes and endotypes. Advances in biomarker-based diagnosis and biologic therapies have improved outcomes. However, environmental exposures, poor adherence, and disparities in healthcare access continue to affect disease control.

Conclusion

Pediatric asthma management requires individualized treatment, early diagnosis, and comprehensive preventive strategies. Further research should focus on early life interventions, biomarker development, and global accessibility to advanced therapies.

Bronchial asthma is a chronic inflammatory disorder of the airways that manifests with recurrent wheezing, breathlessness, and cough. It remains one of the most common chronic diseases in childhood, significantly affecting quality of life, school performance, and long-term lung health. According to the Global Initiative for Asthma, asthma affects more than 300 million individuals worldwide, with a substantial proportion being children.

The global burden of childhood asthma continues to rise, particularly in low- and middle-income countries. Urbanization, environmental pollution, changes in lifestyle, and early life exposures have been implicated in this increasing prevalence. Epidemiological studies have demonstrated significant regional variation, with higher prevalence in urban compared to rural populations. Underdiagnosis and misdiagnosis remain common in resource-limited settings, leading to delayed treatment and increased complications.

The pathophysiology of pediatric asthma is complex and involves genetic predisposition, immune dysregulation, and environmental interactions. Recent advances in molecular immunology have highlighted the role of type-2 inflammation, airway remodeling, and epithelial barrier dysfunction.

This review aims to provide an updated and comprehensive overview of pediatric asthma, focusing on diagnostic challenges, differential diagnosis, pathophysiology, and modern therapeutic approaches.

A structured narrative review methodology was adopted. Literature searches were conducted in PubMed, Scopus, and Web of Science databases using keywords such as “pediatric asthma,” “childhood asthma,” “airway inflammation,” and “biologic therapy.” Studies published between 2015 and 2025 were prioritized, including randomized controlled trials, meta-analyses, and international guidelines.

Articles focusing on adult asthma were excluded unless relevant to pathophysiology. The data were synthesized to provide an evidence-based discussion of current knowledge.

Heterogeneity and Epidemiology of Pediatric Asthma

Asthma in children is a heterogeneous disease with variable clinical phenotypes. Recent large cohort studies have demonstrated that childhood asthma includes multiple phenotypes such as allergic, non-allergic, viral-induced, and severe therapy-resistant asthma. These phenotypes differ in pathogenesis, prognosis, and response to therapy.

The prevalence of asthma among children globally ranges between 5% and 10%, although this varies widely depending on environmental and socioeconomic factors. Rapid urbanization, air pollution, and exposure to indoor allergens are major contributors in developing regions. Early life factors such as maternal smoking, prematurity, and viral infections also play significant roles.

Pathophysiology and Molecular Mechanisms

The hallmark of asthma is chronic airway inflammation. In children, allergic or type-2 inflammation predominates, characterized by eosinophilic infiltration and activation of T-helper-2 lymphocytes. Cytokines such as interleukin-4, interleukin-5, and interleukin-13 contribute to immunoglobulin E production, eosinophil survival, and mucus hypersecretion.

Epithelial barrier dysfunction is increasingly recognized as a critical factor in asthma pathogenesis. Environmental pollutants and allergens disrupt epithelial integrity, facilitating immune activation and chronic inflammation. Repeated inflammatory injury leads to structural changes, including subepithelial fibrosis, smooth muscle hypertrophy, and angiogenesis, collectively termed airway remodeling.

Emerging research highlights the role of innate immunity, microbiome alterations, and early viral infections in disease development. Respiratory viral infections, particularly respiratory syncytial virus and rhinovirus, are associated with increased risk of asthma in genetically susceptible children.

Diagnostic Challenges and Differential Diagnosis

Accurate diagnosis of asthma in children remains challenging, particularly in infants and preschool children where objective testing is limited. Misdiagnosis is common, and many children are either overtreated or undertreated.

Viral bronchiolitis is a frequent cause of wheezing in infancy and may mimic asthma. However, bronchiolitis is typically characterized by acute infection and transient airway inflammation rather than chronic disease. Longitudinal studies have shown that only a subset of children with recurrent viral wheeze develop persistent asthma.

Foreign body aspiration must be considered in children with sudden onset wheezing or unilateral symptoms. Persistent localized wheeze unresponsive to bronchodilators should raise suspicion, and bronchoscopy remains the gold standard for diagnosis.

Congenital airway anomalies such as tracheomalacia and bronchomalacia may also present with recurrent respiratory symptoms. These conditions involve structural airway instability rather than inflammation and require different management approaches.

Chronic respiratory diseases such as cystic fibrosis and primary ciliary dyskinesia represent important differential diagnoses. Cystic fibrosis, caused by mutations in the CFTR gene, results in abnormal mucus and chronic infection. Primary ciliary dyskinesia involves impaired mucociliary clearance. Persistent productive cough, failure to thrive, and recurrent sinopulmonary infections suggest these conditions.

Contemporary Therapeutic Strategies

The management of pediatric asthma has shifted from episodic symptom control to long-term disease modification. Early intervention is crucial to prevent irreversible airway remodeling and decline in lung function.

Inhaled corticosteroids remain the cornerstone of treatment due to their ability to suppress inflammation and improve lung function. Multiple randomized trials have demonstrated that early and consistent use reduces exacerbations and hospitalization.

Short-acting beta-agonists are essential for acute symptom relief; however, overreliance is associated with poor outcomes. Current guidelines emphasize regular anti-inflammatory therapy rather than rescue medication.

Leukotriene receptor antagonists provide modest benefit in allergic and exercise-induced asthma. Their oral route may improve adherence in selected populations.

Combination therapy with inhaled corticosteroids and long-acting beta-agonists is recommended for persistent asthma not controlled with monotherapy.

Biologic therapies have revolutionized severe pediatric asthma management. Anti-IgE therapy and monoclonal antibodies targeting interleukin pathways reduce exacerbations and corticosteroid dependence. These therapies represent the transition toward precision medicine and personalized care.

Background

 Bronchial asthma is the most current chronic respiratory disorder in children and a major contributor to global pediatric morbidity. The complaint is characterized by chronic airway inflammation, bronchial hyperresponsiveness, and variable airflow limitation. Despite advances in remedial strategies, individual uncertainty and inadequate disease control remain common in pediatric populations. Prevalence of ever bronchial asthma was found to be 5.3%, of which 4.2% had current episode of asthma during the last 1-year period. About 72.7% of the current asthmatics had cold or rhinitis and 54.5% each had itching or rashes and nocturnal dry cough. Prevalence is more among the 12-13 years age group (6.5%) compared to the 14-16 years age group (3.6%). Boys (5.4%) and girls (5.2%) had comparable prevalence rates.

 Objective

 This study aims to critically review the individual challenges, differential diagnosis, pathophysiological mechanisms, and contemporary management strategies of pediatric asthma with emphasis on precision drug and global health perspectives.

 Methods

 A structured narrative review was conducted using databases including PubMed, Scopus, and Web of Science. Studies published between 2015 and 2025 were prioritized. Evidence from clinical trials, methodical reviews, and international guidelines was synthesized.

 Results

 Asthma in children is heterogeneous, with multiple phenotypes and endotypes. Advances in biomarker- based diagnosis and birth therapies have bettered issues. However, environmental exposures, poor adherence, and difference in healthcare access continue to affect complaint control.

 Conclusion

 Pediatric asthma management requires personalized treatment, early diagnosis, and comprehensive preventative strategies. farther research should concentrate on early life interventions, biomarker development, and global accessibility to advanced therapies.

 Introduction

 Bronchial asthma is a chronic inflammatory disorder of the airways that manifests with intermittent wheezing, breathlessness, and cough. It remains one of the most common habitual diseases in childhood, significantly affecting quality of life, school performance, and long- term lung health. According to the Global Initiative for Asthma, asthma affects further than 300 million individuals worldwide, with a substantial proportion being children.

 The global burden of childhood asthma continues to rise, particularly in low- and middle- income countries. Urbanization, environmental pollution, changes in life, and early life exposures have been intertwined in this adding   frequence. Epidemiological studies have demonstrated significant indigenous variation, with advanced frequence in urban compared to rural populations. Underdiagnosis and misdiagnosis remain common in resource- limited settings, leading to delayed treatment and increased complications.

 The pathophysiology of pediatric asthma is complex and involves genetic predisposition, immune dysregulation, and environmental interactions. Recent advances in molecular immunology have highlighted the role of type- 2 inflammation, airway remodeling, and epithelial barrier dysfunction.

 This review aims to give a streamlined and comprehensive overview of pediatric asthma, focusing on individual challenges, differential diagnosis, pathophysiology, and modern remedial approaches.

 Methods

 A structured narrative review methodology was adopted. Literature searches were conducted in PubMed, Scopus, and Web of Science databases using keywords similar as “pediatric asthma,” “childhood asthma,” “airway inflammation,” and “biologic therapy.” Studies published between 2015 and 2025 were prioritized, including randomized controlled trials, meta- analyses, and international guidelines.

 Articles focusing on adult asthma were barred unless applicable to pathophysiology. The data were synthesized to provide an evidence- grounded discussion of current knowledge.

 Results

 Heterogeneity and Epidemiology of Pediatric Asthma

 Asthma in children is a heterogeneous complaint with variable clinical phenotypes. Recent large cohort studies have demonstrated that childhood asthma includes multiple phenotypes similar as allergic, on-allergic, viral- induced, and severe therapy- resistant asthma. These phenotypes differ in pathogenesis, prognostic, and response to remedy.

 The frequence of asthma among children encyclopedically ranges between 5 and 10, although this varies extensively depending on environmental and socioeconomic factors. Rapid urbanization, air pollution, and exposure to inner allergens are major contributors in developing regions. Early life factors similar as motherly smoking, prematurity, and viral infections also play significant roles.

 Pathophysiology and Molecular Mechanisms

 The hallmark of asthma is chronic airway inflammation. In children, allergic or type- 2 inflammation predominates, characterized by eosinophilic infiltration and activation of T- helper- 2 lymphocytes. Cytokines such as interleukin- 4, interleukin- 5, and interleukin- 13 contribute to immunoglobulin E production, eosinophil survival, and mucus hypersecretion.

 Epithelial barrier dysfunction is increasingly recognized as a critical factor in asthma pathogenesis. Environmental adulterants and allergens disrupt epithelial integrity, easing vulnerable activation and chronic inflammation. Repeated seditious injury leads to structural changes, including subepithelial fibrosis, smooth muscle hypertrophy, and angiogenesis, collectively termed airway remodeling.

 Emerging research highlights the role of innate immunity, microbiome alterations, and early viral infections in disease development. Respiratory viral infections, particularly respiratory syncytial virus and rhinovirus, are associated with increased risk of asthma in genetically susceptible children.

 Diagnostic Challenges and Differential Diagnosis

 Accurate diagnosis of asthma in children remains challenging, particularly in infants and preschool children where objective testing is limited. Misdiagnosis is common, and numerous children are either overtreated or undertreated.

 Viral bronchiolitis is a frequent cause of wheezing in infancy and may mimic asthma. still, bronchiolitis is typically characterized by acute infection and transient airway inflammation rather than chronic disease. Longitudinal studies have shown that only a subset of children with intermittent viral wheeze develop patient asthma.

 Foreign body aspiration must be considered in children with unforeseen onset wheezing or unilateral symptoms. patient localized wheeze unresponsive to bronchodilators should raise suspicion, and bronchoscopy remains the gold standard for diagnosis.

 Congenital airway anomalies similar as tracheomalacia and bronchomalacia may also present with intermittent respiratory symptoms. These conditions involve structural airway instability rather than inflammation and require different management approaches.

 Chronic respiratory diseases similar as cystic fibrosis and primary ciliary dyskinesia represent important differential diagnoses. Cystic fibrosis, caused by mutations in the CFTR gene, results in abnormal mucus and habitual infection. Primary ciliary dyskinesia involves impaired mucociliary clearance. Persistent productive cough, failure to thrive, and intermittent sinopulmonary infections suggest these conditions.

 Contemporary Therapeutic Strategies

 The management of pediatric asthma has shifted from episodic symptom control to long- term complaint modification. Beforehand intervention is pivotal to help unrecoverable airway redoing and decline in lung function.

 Inhaled corticosteroids remain the foundation of treatment due to their capability to suppress inflammation and improve lung function. Multiple randomized trials have demonstrated that early and harmonious use reduces exacerbations and hospitalization.

 Short- acting beta- agonists are essential for acute symptom relief; still, overreliance is associated with poor issues. Current guidelines emphasize regularity-inflammatory remedy rather than rescue drug.

 Leukotriene receptor antagonists provide modest benefit in antipathetic and exercise- induced asthma. Their oral route may improve adherence in selected populations.

 Combination therapy with inhaled corticosteroids and long- acting beta- agonists is recommended for persistent asthma not controlled with monotherapy.

 Biologic therapies have revolutionized severe pediatric asthma management. Anti-IgE therapy and monoclonal antibodies targeting interleukin pathways reduce exacerbations and corticosteroid dependence. These therapies represent the transition toward precision drug and personalized care.

 preventative and on-Pharmacological Interventions

 Environmental and life interventions are critical factors of asthma management. Exposure to tobacco smoke, air pollution, and inner allergens contributes to disease continuity and exacerbations. Public health strategies targeting these exposures are essential.

 Education of caregivers and children significantly improves complaint issues. Structured asthma education programs enhance adherence, inhaler technique, and early recognition of exacerbations.

 Vaccination reduces infection- triggered exacerbations and healthcare application. Digital monitoring and telemedicine are arising tools that ameliorate access and complaint monitoring.

 Lifestyle factors similar as obesity and physical inactivity also impact asthma severity. Arising evidence suggests dietary patterns rich in antioxidants and omega- 3 adipose acids may reduce inflammation.

 Complications and Long- Term Outcomes

 Uncontrolled asthma leads to recurrent hospitalizations and increased healthcare costs. Chronic inflammation results in airway remodeling and reduced lung growth. Longitudinal studies suggest that poorly controlled childhood asthma increases the risk of chronic obstructive pulmonary disease in majority.

 Cerebral and social consequences are also significant. Anxiety, depression, and reduced quality of life are common among children with severe asthma. Growth impairment is primarily associated with complaint inflexibility and systemic corticosteroid exposure.

 Challenges in Pediatric Asthma Care

 Despite advancements, global disparities in diagnosis and treatment persist. Underdiagnosis in low- resource settings remain a major concern. Limited access to spirometry, inhaled medications, and specialist care contributes to poor outcomes.

 Adherence to remedy remains one of the most important determinants of control. Socioeconomic factors, artistic beliefs, and shy education contribute Tonon-adherence.

 Environmental pollution and climate change represent emerging threats. Increasing levels of particulate matter and allergens are linked to rising prevalence and exacerbations.

 Future directions include biomarker- guided remedy, early prevention strategies, and integration of artificial intelligence in complaint monitoring.

 Discussion

 Pediatric asthma is a multifactorial and miscellaneous complaint taking a personalized approach. Advances in molecular biology and immunology have improved understanding of disease mechanisms and enabled targeted therapies.

 Early opinion and regular treatment significantly improve outcomes. still, the burden remains high due to environmental factors, health difference, and poor adherence.

 Global collaboration, research in early life exposures, and availability of advanced curatives are essential to reduce complaint burden.

 Conclusion

 Bronchial asthma in children remains a global health challenge despite advances in understanding and treatment. Early opinion, personalized remedy, and preventative strategies are essential to improve long- term issues. unborn exploration should concentrate on precision drug, environmental interventions, and indifferent healthcare access.

References

1. Global Initiative for Asthma. Global strategy for asthma management and prevention. https://ginasthma.org/

2. Fitzpatrick AM. Severe childhood asthma. Journal of Allergy and Clinical Immunology. https://pubmed.ncbi.nlm.nih.gov/21195471/

3. Skloot GS. Asthma phenotypes and endotypes: a personalized approach to treatment. Curr Opin Pulm Med. 2016 Jan;22(1):3-9. doi: 10.1097/MCP.0000000000000225. PMID: 26574717.

4. Martinez F. D. (2002). Development of wheezing disorders and asthma in preschool children. Pediatrics, 109(2 Suppl), 362–367.

5. Busse, W. W., Banks-Schlegel, S., & Wenzel, S. E. (2000). Pathophysiology of severe asthma. The Journal of allergy and clinical immunology, 106(6), 1033–1042. https://doi.org/10.1067/mai.2000.111307

6. Holgate ST. Mechanisms of asthma. Holgate S. T. (2013). Mechanisms of asthma and implications for its prevention and treatment: a personal journey. Allergy, asthma & immunology research, 5(6), 343–347. https://doi.org/10.4168/aair.2013.5.6.343

7. Papadopoulos NG. Pediatric asthma. Papadopoulos, N. G., Custovic, A., Deschildre, A., Gern, J. E., Nieto Garcia, A., Miligkos, M., Phipatanakul, W., Wong, G., Xepapadaki, P., Agache, I., Arasi, S., Awad El-Sayed, Z., Bacharier, L. B., Bonini, M., Braido, F., Caimmi, D., Castro-Rodriguez, J. A., Chen, Z., Clausen, M., Craig, T., … WAO Pediatric Asthma Committee (2024). Recommendations for asthma monitoring in children: A PeARL document endorsed by APAPARI, EAACI, INTERASMA, REG, and WAO. Pediatric allergy and immunology : official publication of the European Society of Pediatric Allergy and Immunology, 35(4), e14129. https://doi.org/10.1111/pai.14129

8. Castro-Rodriguez JA. Early wheezing and asthma. Rodríguez-Martínez, C. E., Sossa-Briceño, M. P., & Castro-Rodriguez, J. A. (2017). Factors predicting persistence of early wheezing through childhood and adolescence: a systematic review of the literature. Journal of asthma and allergy, 10, 83–98. https://doi.org/10.2147/JAA.S128319

9. Shefler SJ. Childhood asthma control. Anderson, W. C., 3rd, & Szefler, S. J. (2015). New and future strategies to improve asthma control in children. The Journal of allergy and clinical immunology, 136(4), 848–859. https://doi.org/10.1016/j.jaci.2015.07.007

10. Song P. Global epidemiology of asthma. Song, P., Adeloye, D., Salim, H., Dos Santos, J. P., Campbell, H., Sheikh, A., & Rudan, I. (2022). Global, regional, and national prevalence of asthma in 2019: a systematic analysis and modelling study. Journal of global health, 12, 04052. https://doi.org/10.7189/jogh.12.04052

11. Bousquet J. Allergy and asthma. Bousquet, J., Hellings, P. W., Agache, I., Amat, F., Annesi-Maesano, I., Ansotegui, I. J., Anto, J. M., Bachert, C., Bateman, E. D., Bedbrook, A., Bennoor, K., Bewick, M., Bindslev-Jensen, C., Bosnic-Anticevich, S., Bosse, I., Brozek, J., Brussino, L., Canonica, G. W., Cardona, V., Casale, T., … Mobile Airways Sentinel Network (MASK) Study Group (2019). Allergic Rhinitis and its Impact on Asthma (ARIA) Phase 4 (2018): Change management in allergic rhinitis and asthma multimorbidity using mobile technology. The Journal of allergy and clinical immunology, 143(3), 864–879. https://doi.org/10.1016/j.jaci.2018.08.049

12. Wenzel SE. Severe asthma. Wenzel S. (2005). Severe asthma in adults. American journal of respiratory and critical care medicine, 172(2), 149–160. https://doi.org/10.1164/rccm.200409-1181PP

13. Custovic A. Environmental factors in asthma. Custovic, A., de Moira, A. P., Murray, C. S., & Simpson, A. (2023). Environmental influences on childhood asthma: Allergens. Pediatric allergy and immunology : official publication of the European Society of Pediatric Allergy and Immunology, 34(2), e13915. https://doi.org/10.1111/pai.13915

14. Ober C. Genetics of asthma. Ober, C., & Yao, T. C. (2011). The genetics of asthma and allergic disease: a 21st century perspective. Immunological reviews, 242(1), 10–30. https://doi.org/10.1111/j.1600-065X.2011.01029.x

15. Gern JE. Viral infections and asthma. Radermecker M. (1996). Infections virales et asthme [Viral infections and asthma]. Revue francaise d'allergologie et d'immunologie clinique, 36(8), 950–954. https://doi.org/10.1016/S0335-7457(96)80118-3

16. Global burden of disease asthma. https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(24)00630-8/fulltext

17. Bateman ED. Asthma control strategies. 

18. National Asthma Education Program.

19. British Thoracic Society asthma guidelines.

20. WHO Global Asthma Report.

21. Wood LG. Diet and asthma.

22. Papadopoulos NG. Pediatric airway inflammation.

23. Fitzpatrick AM. Biomarkers in asthma.

24. Schatz M. Pediatric asthma management.

25. Szefler SJ. Inhaled corticosteroids in children.

26. Olin JT. Pediatric airway disorders.

27. Castro-Rodriguez JA. Viral wheeze and asthma.

28. Busse PJ. Immunology of asthma.

29. Wenzel SE. Precision medicine in asthma.

30. Holgate ST. Future directions in asthma research.