Children with severe asthma who do not respond to maximum maintenance medication have a problem with their asthma (PSA). Prior to contemplating medication escalation, a step-by-step strategy that includes objective adherence monitoring and a full multidisciplinary team assessment to identify modifiable variables leading to poor control is required. Pathophysiological phenotyping in patients with real severe therapy-resistant asthma (STRA) will be explored, as will the current variety of add-on medications. Adherence monitoring with technological equipment has revealed that only around 20–30% of children with PSA have STRA and require further treatment. Omalizumab and mepolizumab are approved for children ages 6 and above with STRA. Mepolizumab has paediatric safety data, however effectiveness data for those aged 6–11 years are uncertain, and data for those 12 years and beyond are limited. Neutrophilia is present in a subset of children with STRA, although its clinical relevance and impact to illness severity is unknown.

The majority of children with PSA have steroid-sensitive illness that improves with continued use of inhaled corticosteroids. Only a small percentage of people with STRA require further treatment. There is a shortage of paediatric effectiveness evidence for innovative biologics and biomarkers that indicate the best add-on for each kid. Pragmatic clinical studies of biologics in precisely phenotyped children are required if we are to advance toward customised therapy for STRA.