Difficult-to-treat Asthma in Children

Background: Difficult-to-treat asthma (DTA) in children is associated with significant morbidity, frequent hospitalisations, increased corticosteroid exposure, and substantial healthcare costs. In low- and middle-income countries such as India, rapid urbanisation, air pollution, biomass fuel exposure, socioeconomic disparities, and limited access to objective diagnostic tools further complicate disease management. Objective: To summarise current evidence on paediatric difficult-to-treat asthma and propose a structured approach to its diagnosis and management. Methods: A comprehensive search of PubMed/MEDLINE, Scopus, and Google Scholar was conducted to identify relevant studies, systematic reviews, and international guidelines on paediatric DTA. Evidence was critically appraised and synthesised to develop a practical, evidence-based framework for diagnosis and management of DTA and differentiation from severe therapy-resistant asthma (STRA). Results: Most children labelled as having severe asthma do not have true STRA. Evidence indicates that more than two-thirds achieve good asthma control after systematic identification and correction of modifiable factors, including incorrect diagnosis, poor medication adherence, improper inhaler technique, untreated comorbidities, environmental exposures, and psychosocial barriers. Distinguishing DTA from STRA is essential to avoid unnecessary escalation to high-dose inhaled or systemic corticosteroids and biologic therapies. A structured, multidisciplinary assessment improves diagnostic accuracy and guides appropriate treatment. Conclusion: Paediatric difficult-to-treat asthma requires systematic evaluation to identify and correct modifiable factors before diagnosing severe therapy-resistant asthma. This approach improves asthma control, reduces treatment-related adverse effects and healthcare utilisation, and promotes appropriate use of advanced therapies, particularly in resource-constrained settings.