Contemporary pharmacotherapeutic management of severe pediatric asthma

Severe asthma affects a small proportion of children but causes disproportionate morbidity, corticosteroid exposure, educational and family disruption, and concern about growth and development. Management requires diagnostic confirmation, optimization of inhaled therapy, and age-appropriate use of targeted biologics. This narrative review examines diagnostic reassessment, biomarker-informed treatment selection, optimization of non-biologic therapy, and corticosteroid stewardship. It discusses the mechanisms, regulatory status, pediatric evidence, effectiveness, and safety of omalizumab, mepolizumab, benralizumab, depemokimab, dupilumab, and tezepelumab, and addresses response assessment, switching, remission, withdrawal, and immunogenicity. PubMed and ClinicalTrials.gov were searched for English-language evidence published from 1 January 2006 through 31 August 2026; guidelines and Food and Drug Administration (FDA) and European Medicines Agency (EMA) documents were also reviewed. Biologics reduce severe exacerbations and systemic-corticosteroid exposure in eligible children, but the directness of pediatric evidence differs substantially among agents. Biomarkers and type 2 comorbidities inform eligibility and the probability of response but do not establish a treatment hierarchy. Selection should be individualized and evaluated as a therapeutic trial against prespecified multidimensional targets. Key priorities are age-specific comparative and withdrawal studies, harmonized pediatric remission criteria, and prospective registries addressing developmental safety and long-term treatment strategies.