Management of severe asthma in children: current insights and future directions

Introduction: Severe pediatric asthma represents a critical challenge in respiratory medicine, affecting a small but significant subset of children with disproportionate morbidity and healthcare burden. Its complexity arises from diverse phenotypes, endotypes, and inflammatory pathways that complicate diagnosis and management. Recent advances in precision medicine, particularly biologic therapies targeting Type 2 inflammation, offer new opportunities for improved outcomes. Areas covered: This review synthesizes current knowledge on severe pediatric asthma, emphasizing the pathophysiology, clinical phenotypes, and therapeutic advancements. It explores the role of biomarkers and endotypes in guiding personalized therapy and critically examines challenges such as non-Type 2 inflammation, barriers to biologic access, and variability in treatment response. A comprehensive literature search was conducted, focusing on biologic therapies, diagnostic innovations, and emerging care models. Expert opinion: Despite progress, challenges remain in achieving standardized treatment response definitions, validating biomarkers, and addressing cost barriers. Early biologic initiation in high-risk children and multidisciplinary care are critical to advancing outcomes. Future efforts should prioritize predictive algorithms, innovative therapies, and equitable access to shift from symptom control to disease prevention, potentially redefining the pediatric asthma care paradigm.