Children with allergic and nonallergic rhinitis have a similar risk of asthma

Pediatric allergic rhinitis and asthma: can the march be halted?

The strong epidemiologic and pathophysiologic link between allergic rhinitis (AR) and asthma has led to the concept of 'united airways disease' or 'respiratory allergy', implying that allergy, in its widest sense, underlies this clinical syndrome. Progression from AR to asthma is frequent and part of the 'atopic march'. Since pediatric immune responses are more adaptable and therefore may be more amenable to treatment, interventions at early childhood are characterized by a higher chance to affect the natural history of respiratory allergy. Although current treatments are quite effective in alleviating respiratory allergy symptoms, it has proven much more difficult to confirm any influence on the progression of the disease. Much more promising is the field of specific allergen immunotherapy, where current evidence, although not yet of ideal robustness, points towards a disease-modifying effect. In addition, newer or emerging, possibly more effective or more targeted interventions are promising in the preventive sense.

Guidelines of care for the management of atopic dermatitis: section 1. Diagnosis and assessment of atopic dermatitis

Atopic dermatitis (AD) is a chronic, pruritic, inflammatory dermatosis that affects up to 25% of children and 2% to 3% of adults. This guideline addresses important clinical questions that arise in the management and care of AD, providing updated and expanded recommendations based on the available evidence. In this first of 4 sections, methods for the diagnosis and monitoring of disease, outcomes measures for assessment, and common clinical associations that affect patients with AD are discussed. Known risk factors for the development of disease are also reviewed.

Exhaled nitric oxide measures allergy not symptoms in children with allergic rhinitis in primary care: a prospective cross-sectional and longitudinal cohort study

Background:

Allergic rhinitis (AR) and asthma are both inflammatory diseases and are often associated. Relationships between fractional exhaled nitric oxide (FeNO) and asthma, atopy, and quality of life have been shown.

Aims:

This study aimed to determine whether FeNO in children with AR (n=158) or combined AR and asthma (n=93) was associated with clinical symptoms, house dust mite (HDM)-specific IgE, and rhinitis-specific quality of life, both cross-sectionally and longitudinally.

Methods:

Children with AR aged 6–18 years (n=251) in primary care were assessed for FeNO, nasal symptom scores, asthma symptom scores, quality of life, and HDM-specific IgE at baseline and 2 years later.

Results:

We found similarly elevated FeNO in children with only AR and in those with combined AR and asthma. No correlations were found between FeNO and nasal or asthma symptoms and rhinitis-related quality of life. Longitudinal correlations were strongest for HDM-specific IgE (r=0.91, p<0.0001).

Conclusions:

FeNO was similar in a selected group of children with AR with and without asthma in primary care and was unrelated to symptoms or quality of life in both groups. FeNO is unlikely to be a useful biomarker of the clinical severity of upper or lower airway disease in primary care.

Paediatric rhinitis: position paper of the European Academy of Allergy and Clinical Immunology

Rhinitis is a common problem in childhood and adolescence and impacts negatively on physical, social and psychological well-being. This position paper, prepared by the European Academy of Allergy and Clinical Immunology Taskforce on Rhinitis in Children, aims to provide evidence-based recommendations for the diagnosis and therapy of paediatric rhinitis. Rhinitis is characterized by at least two nasal symptoms: rhinorrhoea, blockage, sneezing or itching. It is classified as allergic rhinitis, infectious rhinitis and nonallergic, noninfectious rhinitis. Similar symptoms may occur with other conditions such as adenoidal hypertrophy, septal deviation and nasal polyps. Examination by anterior rhinoscopy and allergy tests may help to substantiate a diagnosis of allergic rhinitis. Avoidance of relevant allergens may be helpful for allergic rhinitis (AR). Oral and intranasal antihistamines and nasal corticosteroids are both appropriate for first-line AR treatment although the latter are more effective. Once-daily forms of corticosteroids are preferred given their improved safety profile. Potentially useful add-on therapies for AR include oral leukotriene receptor antagonists, short bursts of a nasal decongestant, saline douches and nasal anticholinergics. Allergen-specific immunotherapy is helpful in IgE-mediated AR and may prevent the progression of allergic disease. There are still a number of areas that need to be clarified in the management of rhinitis in children and adolescents.

Office-based exhaled nitric oxide measurement in children 4 years of age and older

BACKGROUND

Fractional exhaled nitric oxide (FENO) is increasingly being used in the office-based management of asthma, but data in children are limited.

OBJECTIVES

To report FENO values in 4- to 7-year-old children with suspected asthma and characterize their relation to clinical variables and describe the relation among FENO levels, age, and sex in 4- to 18-year-old children with suspected asthma.

METHODS

Retrospective data in 4- to 18-year-old children (n = 825) who underwent FENO testing using the NIOX MINO device were collected and analyzed. Chart reviews were performed for the 4- to 7-year-old children (n = 75).

RESULTS

FENO values ranged from less than or equal to 5 to 89 ppb in 75 4- to 7-year-old children and less than or equal to 5 to 300 ppb in 750 > 7 to 18-year-old children. Approximately one tenth of 4- to 7-year-old children and one third of > 7 to 18-year-old children had FENO values indicative of eosinophilic/allergic inflammation (>35 ppb). In regression analysis of the 4- to 7-year-old children, increasing age (P = .03) and asthma severity (P = .01) were associated with higher FENO levels. Atopic dermatitis was significantly associated (P = .03), whereas allergic rhinitis was marginally associated (P = .06), with higher FENO levels. Inhaled corticosteroid use was associated with lower FENO levels (P = .02).

CONCLUSION

This study characterizes the largest cohort of 4- to 7-year-old children to undergo FENO testing in ambulatory asthma management. Correlations between FENO levels and clinical variables were consistent with established findings in older children. This preliminary real-world study suggests that FENO assessment may be feasible and useful in the office-based asthma management of children as young as 4 years.

Rhinitis has an association with asthma in school children

BACKGROUND

A relevant relationship exists between the upper and lower airway, indicating the concept of a unified airway. This study aimed to evaluate whether rhinitis has an association with asthma in children.

METHODS

A cross-sectional nationwide survey was performed among children 6-7, 13-14, and 16-17 years old, using the International Study of Asthma and Allergies in Children (ISAAC) questionnaire in Japan. According to the responses to the ISAAC core questions, a child who had experienced nasal symptoms in the past 12 months in the absence of a cold was defined as having current rhinitis.

RESULTS

After excluding 11,475 children because of incomplete data, 136,506 children were analyzed. Even after adjusting for demographics, sex, and obesity, children with current rhinitis were more likely to have asthma (adjusted odds ratio [OR], 3.10 [95% CI, 2.92-3.30] in children aged 6-7 years; OR, 3.76 [95% CI, 3.45-4.10] in children aged 13-14 years; and OR, 3.59 [95% CI, 3.33-3.88] in children aged 16-17 years). Children whose daily activities were more impaired by rhinitis symptoms had a significantly higher prevalence of severe asthma. The adjusted ORs for severe asthma among asthmatic children whose daily activities were severely impaired by rhinitis symptoms were 3.66 (95% CI, 2.29-5.85) in children aged 6-7 years, 2.55 (95% CI, 1.64-3.96) in children aged 13-14 years, and 1.87 (95% CI, 1.24-2.82) in children aged 16-17 years compared with asthmatic children whose daily activities were not impaired at all.

CONCLUSION

There was a close association between rhinitis and asthma in young children to adolescents. Asthma should be examined in children with rhinitis symptoms.

Fraction of exhaled nitric oxide and bronchial responsiveness are associated and continuous traits in young children independent of asthma

BACKGROUND

Elevated fraction of exhaled nitric oxide (FENO) and bronchial hyperresponsiveness are used as surrogate markers of asthma. These traits may be continuous in the population. The objective of this study was to investigate whether FENO and bronchial responsiveness are associated in both children with and children without a history of asthma symptoms.

METHODS

One hundred ninety-six 6-year-old children with no asthma symptoms, intermittent asthma symptoms, and persistent asthma were randomly included from the Copenhagen Prospective Study on Asthma in Childhood prospective clinical birth cohort of mothers with asthma. Bronchial responsiveness was assessed as the relative change in specific airway resistance after cold dry air hyperventilation. FENO measurements were performed prior to the hyperventilation test. The association between FENO and bronchial responsiveness was assessed by generalized linear models.

RESULTS

Bronchial responsiveness and FENO exhibited a significant and linear association in the population. A doubling of FENO corresponded to an 8.4% (95% CI, 3.7%-13.1%; P = .0006) increase in airway resistance after challenge testing and remained significant after adjustment for sex, allergic rhinitis, current asthma, inhaled corticosteroid treatment, and upper respiratory tract infections prior to testing. Stratified analyses showed similar associations in children with and without asthma.

CONCLUSIONS

FENO and bronchial responsiveness are associated and continuous traits in young children regardless of asthma symptoms, suggesting a continuous subclinical to clinical process underlying asthma. The findings also suggest caution against the use of these surrogate markers for a dichotomized approach to asthma diagnosis.

Cell-mediated non-allergic rhinitis in children

OBJECTIVE

Non-allergic rhinitis is a heterogeneous disease whose etiology is largely unknown. Nasal cytology only allows us to recognize different non-allergic rhinitis forms on the basis of the prevalent inflammatory cell infiltrate: non-allergic rhinitis with eosinophils, with neutrophils, with mast-cells and with both eosinophils and mast-cells. The aim of this study is to define the incidence, clinical features and comorbidity of the different types of cell-mediated non-allergic rhinitis in a pediatric age group.

METHODS

One hundred and fourteen non-allergic children with chronic nasal obstruction and associated symptoms (rhinorrhea, sneezing and nasal itchiness) were retrospectively selected. All patients had been submitted to a clinical history, pediatric evaluation, anterior rhinoscopy and fiberendoscopy, rhinomanometry and nasal cytology.

RESULTS

Non-allergic rhinitis with neutrophils was present in 46 (40.4%) children, non-allergic rhinitis with eosinophils in 53 (46.5%), non-allergic rhinitis with mast-cells in 12 (10.5%) and non-allergic rhinitis with both eosinophils and mast-cells in 3 (2.6%). Nasal obstruction was prevalent in non-allergic rhinitis with eosinophils and in non-allergic rhinitis with mast-cells patients (P<0.001) whereas rhinorrea and sneezing only in the form with eosinophils (P<0.0001). Nasal itching on the other hand was prevalent in the form with mast-cells (P<0.0003). Non-allergic rhinitis with eosinophils group showed a higher probability of asthma (P<0.02) and respiratory sleep disorders (P<0.04).

CONCLUSIONS

In the pediatric age group the most frequent forms of non-allergic rhinitis are those with eosinophils or with neutrophils. A diagnosis of non-allergic rhinitis with eosinophils in children presumes more severe symptoms and a higher incidence of pulmonary disease and roncopathy.

Comparison of orally exhaled nitric oxide in allergic versus nonallergic rhinitis

BACKGROUND

Fractional exhaled nitric oxide (FeNO), a well-known marker of airway inflammation, is rarely evaluated in rhinitis of different etiology. We aimed to compare the eNO levels in allergic rhinitis (AR) and nonallergic rhinitis (NAR) with/without asthma, as well as the contributing factors that interfere with elevated FeNO.

METHODS

Patients were enrolled based on chronic nasal symptoms. Orally exhaled NO was measured with the single exhalation method at 50 mL/s. All subjects underwent a panel of tests: skin-prick tests, asthma control test, blood sampling, spirometry, and health-related quality-of-life questionnaires.

RESULTS

The study group consisted of mainly women (130 women/41 men), with a mean age of 32.6 ± 13.2 years. AR was diagnosed in 122 (78.2%), NAR in 34 (21.8%), and 15 subjects were healthy controls. FeNO was insignificantly higher in patients with AR compared with patients with NAR and controls (32.2 parts per billion [ppb] versus 27 and 19.4 ppb), with no difference between genders. NAR + asthma had higher FeNO than those without asthma (40.5 ppb versus 14.9 ppb; p < 0.03), whereas accompanying asthma did not affect FeNO levels in the AR group. AR ± asthma had significantly higher FeNO levels than the NAR-only group (p < 0.01). Among AR + asthma, perennial sensitization caused higher FeNO levels than did seasonal allergens (48.5 ± 33.9 and 19.5 ± 13.6' p = 0.003), whereas FeNO was significantly higher during the allergen season. Nasally inhaled corticosteroids insignificantly reduced FeNO levels in all groups. Severity and seasonality of rhinitis, asthma, and ocular symptoms, but not gender, age, body mass index, Total IgE, forced expiratory volume in 1 second, and smoking, were associated with FeNO.

CONCLUSION

Rhinitis and comorbid asthma are responsible for increased FeNO, irrespective of atopy. However, NAR without asthma may not be considered as a strong risk factor for airway inflammation.

Epigenetics and childhood asthma: current evidence and future research directions

Asthma is the most common chronic disease of childhood, affecting one in eight children in the USA and worldwide. It is a complex disease, influenced by both environmental exposures and genetic factors. Although epigenetic modifications (DNA methylation, histone modification and miRNA) can affect transcriptional activity in multiple genetic pathways relevant for asthma development, very limited work has been carried out so far to examine the role of epigenetic variations on asthma development and management. This review provides a brief overview of epigenetic modifications, summarizes recent findings, and discusses some of the major methodological concerns that are relevant for asthma epigenetics.

A population-based 5-year follow-up of allergic rhinitis in Chinese children

BACKGROUND

There have been few longitudinal investigations of allergic rhinitis (AR) in Chinese children. We previously conducted an investigation of the prevalence of AR in 3- to 6-year old children for the year of 2005-2006. The aim of this study was to observe the natural course of AR in children in the previously investigated population during a cohort study for 5 years.

METHODS

A total of 1211 children in the previously investigated population were included in this study. Telephone interviews were conducted three times during the 1st, 3rd, and 5th year from the previous study.(14) Questions including duration, severity of nasal symptoms, asthma, and related problems of allergy were examined. Skin-prick tests (SPTs) were performed again on those children who had done SPTs in the previous study(14) after the last follow-up (i.e., after 5 years).

RESULTS

Of the 1211 children, 870 (71.8%) completed the 5-year observation period. In the 5th year, the prevalence of positive nasal symptoms was 29.4% (256 of the 870 children), including 64/70 (91.4%) of those who were formerly symptom positive and SPT(+), 45/104 (43.3%) of those who were formerly symptom positive and SPT(-), 40/66 (60.6%) of those who were formerly symptom positive with SPTs not performed (SPTs[x]), and 107/630 (17.0%) of those who were formerly symptom negative. SPT results showed that 96.1% (73/76) of previous SPT(+) children remained SPT(+); only 3.9% (6/154) became SPT(+) in previous SPT(-) children.

CONCLUSION

We concluded that the natural course of AR (symptom positive and SPT(+)) and non-AR (symptom positive and SPT(-)) children were quite different.

Development and comorbidity of eczema, asthma and rhinitis to age 12: data from the BAMSE birth cohort

BACKGROUND

Allergy-related diseases are a public health issue, but knowledge on development and comorbidity among children is scarce. The aim was to study the development of eczema, asthma and rhinitis in relation to sex and parental allergy, in a population-based cohort, during childhood.

METHODS

At 1, 2, 4, 8 and 12 years, parental questionnaires were used to obtain data on allergy-related diseases. Complete data for all five follow-up occasions were available from 2916 children. Odds ratios for the risk of any allergy-related disease in relation to heredity and sex were calculated using generalized estimating equations.

RESULTS

At 12 years, 58% of the children had had eczema, asthma and/or rhinitis at some time. Disease turnover was high for all three diseases throughout the study. Comorbidity increased with age, and at 12 years, 7.5% of all the children were affected by at least two allergy-related diseases. Parental allergy was associated with increased comorbidity and more persistent disease and increased the risk of having any allergy-related disease (adjusted OR 1.76; 95% CI 1.57-1.97) up to 12 years. Male sex was associated with an increased risk throughout childhood. Boys and girls did not differ in disease persistence, and for comorbidity, the differences were minor.

CONCLUSIONS

Allergy-related diseases may affect a majority of children. Eczema, asthma and rhinitis develop dynamically throughout childhood, and allergic comorbidity is common. These findings indicate that allergy-related diseases should be neither seen nor studied as isolated entities.

Interaction between asthma and lung function growth in early life

RATIONALE

The causal direction between asthma and lung function deficit is unknown, but important for the focus of preventive measures and research into the origins of asthma.

OBJECTIVES

To analyze the interaction between lung function development and asthma from birth to 7 years of age.

METHODS

The Copenhagen Prospective Studies on Asthma in Childhood is a prospective clinical study of a birth cohort of 411 at-risk children. Spirometry was completed in 403 (98%) neonates and again by age 7 in 317 children (77%).

MEASUREMENTS AND MAIN RESULTS

Neonatal spirometry and bronchial responsiveness to methacholine was measured during sedation by forced flow-volume measurements. Asthma was diagnosed prospectively from daily diary cards and clinic visits every 6 months. Children with asthma by age 7 (14%) already had a significant airflow deficit as neonates (forced expiratory flow at 50% of vital capacity second in neonates reduced by 0.34 z score by 1 mo; P = 0.03). This deficit progressed significantly during early childhood (forced expiratory flow at 0.5 seconds in neonates at age 7 reduced by 0.82 z score by age 7; P < 0.0001), suggesting that approximately 40% of the airflow deficit associated with asthma is present at birth, whereas 60% develops with clinical disease. Environmental tobacco exposure, but not allergic sensitization, also hampered airflow growth. Bronchial responsiveness to methacholine in the neonates was associated with the development of asthma (P = 0.01).

CONCLUSIONS

Children developing asthma by age 7 had a lung function deficit and increased bronchial responsiveness as neonates. This lung function deficit progressed to age 7. Therefore, research into the origins and prevention of asthma should consider early life before and after birth.

Elevated eosinophil protein X in urine from healthy neonates precedes development of atopy in the first 6 years of life

RATIONALE

Biomarkers predicting development of atopic disease are needed for targeted preventive measures and to study if disease pathology may be active before onset of symptoms.

OBJECTIVES

To investigate whether eosinophil protein X, leukotriene-C4/D4/E4, and 11β-prostaglandin (PG) F2α (PGD2 metabolite) assessed in urine from healthy at-risk neonates precede development of atopic disease during the first 6 years of life.

METHODS

We measured eosinophil protein X (n = 369), leukotriene-C4/D4/E4 (n = 367), and 11β-PGF2α (n = 366) in urine from 1-month-old children participating in the Copenhagen Prospective Studies on Asthma in Childhood birth cohort. Clinical data on development of allergic sensitization, allergic rhinitis, nasal eosinophilia, blood eosinophilia, eczema, troublesome lung symptoms (significant cough or wheeze or dyspnea), and asthma were collected prospectively until age 6 years. Associations between urinary biomarkers and development of atopic traits were investigated using general estimating equations, logistic regression, and Cox regression.

MEASUREMENTS AND MAIN RESULTS

Eosinophil protein X in the urine of the asymptomatic 1-month-old neonates was significantly associated with development of allergic sensitization (odds ratio, 1.49; 95% confidence interval [CI], 1.08–1.89), nasal eosinophilia (odds ratio, 3.2; 95% CI, 1.2–8.8), and eczema (hazard ratio, 1.4; 95% CI, 1.0–2.0), but not with allergic rhinitis, asthma, or blood eosinophilia. Neither leukotriene-C4/D4/E4 nor 11β-PGF2α was associated with any of the atopic phenotypes.

CONCLUSIONS

Eosinophil protein X in urine from asymptomatic neonates is a biomarker significantly associated with later development of allergic sensitization, nasal eosinophilia, and eczema during the first 6 years of life. These findings suggest activation of eosinophil granulocytes early in life before development of atopy-related symptoms.

Clinical spectrum of acute rhinosinusitis among atopic and nonatopic children in Taiwan

BACKGROUND

Rhinitis and sinusitis are very common medical conditions and have been shown to be frequently associated. The role of allergies in the pathogenesis of chronic rhinosinusitis has been confirmed; however, the role of allergies in acute rhinosinusitis is debatable. Nonetheless, allergies are an important factor in the development of rhinosinusitis.

OBJECTIVE

To evaluate the incidence of allergic rhinitis in patients with acute rhinosinusitis and identify the clinical spectrum in Taiwan.

METHODS

This study randomly recruited 69 participants between 3 and 12 years of age with acute rhinosinusitis over the period of one and a half years. All participants underwent a nasal peak expiratory flow rate (nPEFR) test, skin-Prick test (SPT), nasal smear examination, nasal culture, radiography (Water's projection) and were requested to complete the Pediatric Rhinoconjunctivitis Quality of Life Questionnaire (PRQLQ) as well as provide their allergic history.

RESULTS

Among the 69 participants in the study, 27 (39.1%) participants were shown to have allergic rhinitis. The most troublesome symptoms among the 69 participants with acute rhinosinusitis were postnasal drip (3.00 ± 1.29), nasal obstruction (2.94 ± 1.39) and cough (2.67 ± 1.42). The most troublesome symptoms among the 27 participants with acute rhinosinusitis combined with allergic rhinitis were nasal obstruction (3.33 ± 1.24), postnasal drip (3.22 ± 1.09) and itchy eyes (2.74 ± 1.43) and with the higher values. In addition, the participants (≧ 6 y/o) with acute rhinosinusitis combined with allergic rhinitis had significantly lower nPEFR values compared with the nonatopic children (75.2 ± 18.2 vs 96.6 ± 21.4, p<0.05). If nPEFR is below 75 mL/min, the positive predict value in the patients of acute rhinosinusitis is 75.0% combined with allergic rhinitis (sensitivity 63.2%; specificity 85.7%). Streptococcus pneumoniae (29.0%), Haemophilus influenzae (20.3%), and Moraxella catarrhalis (17.4%) were the major isolated pathogens in this study. The prevalence of colonization with Staphylococcus aureus in the 69 participants with acute rhinosinusitis was 23.2%, and 15.9% for methicillin-resistant S. aureus (MRSA).

CONCLUSION

This study demonstrated that the bacteriological properties of acute rhinosinusitis among children in Taiwan are the same as those in other parts of the world; however, the prevalence of colonization by MRSA was higher than among healthy children. Second, atopic children were more likely to develop acute rhinosinusitis than nonatopic children. Third, most Taiwanese children with acute rhinosinusitis complained of postnasal drip, nasal obstruction and cough. If a child suffering from acute rhinosinusitis complained of severe nasal obstruction (nPEFR≦75 mL/min), the doctor should be alerted to atopic conditions requiring further treatment. The issues dealt with in this study may require further research with a larger sample population over an extended period of time to verify these conclusions.

Natural course and comorbidities of allergic and nonallergic rhinitis in children

BACKGROUND

Not much data are available from large, unselected, birth cohort studies on the natural course and comorbidities of rhinitis in children.

OBJECTIVE

To study phenotypes of rhinitis in relation to the natural course and comorbidities of allergic diseases in preschool-age and early school-age children.

METHODS

We analyzed data from a birth cohort of 2024 children, for whom information on IgEs against 8 common inhaled allergens was available, collected at age 4 and 8 years. The children were assigned to groups of allergic rhinitis (rhinitis with sensitization to allergens), nonallergic rhinitis (rhinitis without sensitization), allergic sensitization but no rhinitis, or neither rhinitis nor sensitization.

RESULTS

The proportion of children with allergic rhinitis increased from 5% to 14% from age 4 to 8 years, whereas the proportion of children with nonallergic rhinitis decreased slightly over the same period of development, from 8% to 6%. Of the children with allergic rhinitis when they were 4 years old, 12% underwent remission by the time they were 8 years old; of the children with nonallergic rhinitis, 73% underwent remission during this period of development. Among 4-year-olds without rhinitis who were sensitized to allergen, 56% had allergic rhinitis when they were 8 years old. Among 4- and 8-year-olds, allergic rhinitis and nonallergic rhinitis were associated with asthma, eczema, and food hypersensitivity. Twenty-five percent of 8-year-olds with allergic rhinitis also had oral allergy syndrome.

CONCLUSIONS

Fewer preschool-age children with allergic rhinitis undergo remission than do those with nonallergic rhinitis. Sensitization to inhaled allergens at an early age (4 years) precedes the development of allergic rhinitis, whereas symptoms of rhinitis do not. Oral allergy syndrome is common among 8-year-olds with allergic rhinitis.

Advances in pediatric asthma in 2010: addressing the major issues

Last year's "Advances in pediatric asthma" concluded with the following statement: "If we can close these [remaining] gaps through better communication, improvements in the health care system and new insights into treatment, we will move closer to better methods to intervene early in the course of the disease and induce clinical remission as quickly as possible in most children." This year's summary will focus on recent advances in pediatric asthma that take steps moving forward as reported in Journal of Allergy and Clinical Immunology publications in 2010. Some of these recent reports show us how to improve asthma management through steps to better understand the natural history of asthma, individualize asthma care, reduce asthma exacerbations, and manage inner-city asthma and some potential new ways to use available medications to improve asthma control. It is clear that we have made many significant gains in managing asthma in children, but we have a ways to go to prevent asthma exacerbations, alter the natural history of the disease, and reduce health disparities in asthma care. Perhaps new directions in personalized medicine and improved health care access and communication will help maintain steady progress in alleviating the burden of this disease in children, especially young children.