Fu-xiang Tian
Dong-mei Wang- Department of Pediatrics, Yan’an People’s Hospital, Yan’an, China
Budesonide/formoterol is established as a foundational therapy for moderate-to-severe pediatric asthma, with extensive evidence supporting its efficacy in both maintenance and Maintenance and Reliever Therapy regimens. Its dual pharmacologic profile provides distinct advantages in exacerbation reduction and symptom control. However, clinical implementation faces persistent challenges, including diagnostic uncertainty in young children, technical difficulties in device use, variable adherence, and perceptual barriers among clinicians and caregivers. Future advancement requires targeted research into phenotype-specific treatment responses, integration of digital health technologies for personalized management, and systematic reform in education and policy. A multidisciplinary effort is essential to achieve more precise, effective, and sustainable asthma control in the pediatric population.
1 Introduction
1.1 Epidemiology and disease burden of pediatric asthma
Asthma is a predominant chronic respiratory condition among children globally, with increasing prevalence noted in numerous regions (1, 2). This disease imposes a considerable burden on healthcare systems, contributes to missed school days, and diminishes the quality of life of affected children (2, 3). Recurrent symptoms and exacerbations also place significant emotional and financial strain on families, underscoring the critical need for effective and sustainable management strategies (3, 4).
1.2 Stepwise management strategy in pediatric asthma
International guidelines, including the Global Initiative for Asthma (GINA), recommend a stepwise approach to asthma treatment (5, 6). This strategy involves adjusting therapeutic intensity according to the level of symptom control and exacerbation risk (5, 6). For children with moderate-to-severe asthma who experience persistent symptoms despite low- to medium-dose inhaled corticosteroids (ICS), the introduction of a long-acting beta2-agonist (LABA) in combination with ICS is advised (7). This approach underscores the importance of ICS + LABA therapy in achieving improved asthma control.
1.3 Pharmacological characteristics and theoretical advantages of budesonide/formoterol
Budesonide/formoterol combines budesonide, an inhaled corticosteroid with a favorable pharmacokinetic profile, and formoterol, a long-acting beta2-agonist characterized by its rapid onset of action (8–10). This combination offers complementary mechanisms: budesonide targets airway inflammation, while formoterol provides prolonged bronchodilation (10). Their concurrent rapid onset enables not only maintenance treatment but also effective relief of acute symptoms, forming the basis for the Maintenance and Reliever Therapy (MART) regimen (11, 12). This dual functionality supports flexible dosing and has the potential to enhance treatment adherence.
It is important to note that the budesonide/formoterol combination is available in several inhaler devices, such as the Turbuhaler®, Spiromax®, and Forspiro® (13, 14). These delivery systems possess distinct technical characteristics, but they share the core pharmacological combination of budesonide and formoterol (15, 16). This article focuses on the clinical evidence and therapeutic principles of the budesonide/formoterol combination as a pharmacological class, while specific device-related considerations are addressed in the context of practical implementation.
1.4 Objective and structure of this perspective
This perspective aims to critically evaluate the current evidence regarding the use of budesonide/formoterol in pediatric asthma management. Rather than providing a systematic review, it seeks to identify key challenges—such as safety concerns in long-term use, appropriate patient selection, and practical barriers to implementation—and to propose informed directions for future clinical research and guideline development. The structure reflects a progression from established concepts to emerging issues and forward-looking recommendations.
2 Current therapeutic status: an evidence-based perspective
2.1 Efficacy evidence
2.1.1 Evidence for maintenance therapy
Multiple randomized controlled trials (RCTs) and meta-analyses have established the efficacy of budesonide/formoterol as maintenance therapy in pediatric asthma. These studies consistently demonstrate its superiority to ICS monotherapy in improving lung function, reflected by significant increases in forced expiratory volume in 1 s (17, 18). Additionally, budesonide/formoterol has shown enhanced control of both daytime and nocturnal symptoms and a reduced reliance on short-acting beta2-agonists (SABA) for symptom relief, indicating effective overall disease management (18, 19).
2.1.2 Evidence for MART
A substantial body of evidence supports the use of budesonide/formoterol within the MART regimen in pediatric patients. Clinical trials specifically highlight its capacity to significantly reduce the frequency of asthma exacerbations compared to fixed-dose ICS-LABA combinations with separate SABA relievers (10, 20, 21). This effect is largely attributed to the complementary pharmacology of budesonide and formoterol, which together provide both sustained anti-inflammatory support and rapid bronchodilation, enabling early intervention during symptom worsening and preventing progression to full exacerbations (20, 22).
The MART regimen employs a flexible dosing strategy, combining a fixed maintenance dose (e.g., 1-2 inhalations of budesonide/formoterol twice daily) with as-needed reliever use (1 additional inhalation for acute symptom relief) (23). The total daily dose must be tailored to the patient’s asthma control and exacerbation frequency, while strictly adhering to the maximum licensed daily limit (e.g., 8 inhalations per day for the 160/4.5 μg formulation in pediatric patients) (9, 24). Successful implementation requires comprehensive education to ensure that patients and caregivers can distinguish symptoms requiring reliever doses and understand the core principle of flexible dosing within a predefined safety framework (9, 24–26).
2.2 Safety profile
Long-term studies support the acceptable safety profile of budesonide/formoterol in children. Assessments of growth parameters, including annual height velocity and adult height, indicate minimal and generally non-significant effects from budesonide at conventional therapeutic doses (27, 28). Similarly, evaluations of hypothalamic- pituitary-adrenal axis function have not revealed clinically relevant suppression (10). Among available ICS/LABA combinations, budesonide/formoterol is one of the most extensively studied in pediatric populations, with a well-documented and favorable long-term safety record (10, 27, 28).
2.3 Position in clinical guidelines
Based on this evidence, budesonide/formoterol is endorsed in several major international and national guidelines for pediatric asthma management. The GINA recommends budesonide/formoterol MART as a preferred treatment option for children aged 6 and above at treatment Step 3 or higher, particularly those whose symptoms remain uncontrolled despite medium-dose ICS (5). This recommendation emphasizes the regimen’s value in reducing exacerbation risk. Parallel guidance is provided by the Chinese Guidelines for Childhood Asthma, which recognize ICS-LABA combination therapy as a standard approach for school-aged children and adolescents with moderate-to-severe asthma that is inadequately controlled on medium-dose ICS, explicitly supporting MART strategy in eligible patients (29, 30). It is important to note that successful implementation requires not only meeting the clinical criteria but also ensuring the child’s ability to use the inhaler correctly and the family’s understanding of the MART regimen.
3 Clinical challenges and practical implementation barriers
3.1 Diagnostic accuracy and patient stratification
The initial challenge in utilizing budesonide/formoterol effectively lies in the accurate diagnosis of asthma and subsequent patient stratification. Particularly in preschool-aged children, distinguishing true asthma from transient viral-induced wheezing remains diagnostically challenging (31–33). This differentiation is crucial, as it determines the appropriateness of long-term controller therapy (31, 32). Furthermore, imprecise assessment of disease severity—a prerequisite for stepwise treatment allocation—may result in either inappropriate withholding of ICS/LABA therapy in eligible patients or its unnecessary use in mild cases, potentially altering risk-benefit considerations (32, 33).
3.2 Technical challenges in drug delivery
Optimal therapeutic outcomes with budesonide/formoterol Turbuhaler® are contingent upon achieving adequate inhaler technique (34). The device requires a rapid and deep inspiratory effort to disaggregate and deliver the powdered medication (34). Pediatric patients, especially those under age 8, often lack the coordination and inspiratory force to use dry powder inhalers correctly (35). Suboptimal inhalation technique significantly diminishes lung deposition and clinical efficacy (36). This necessitates repeated training sessions and frequent monitoring, imposing substantial demands on healthcare providers’ time and clinic resources.
3.3 Adherence and long-term management barriers
Sustaining treatment adherence represents a fundamental challenge in chronic asthma management (37). Discontinuation of therapy following symptom improvement is frequently observed, leading to uncontrolled inflammation and increased exacerbation risk (38). Additional systemic barriers include fragmented care between clinical and community settings, logistical challenges in maintaining regular follow-up, and socioeconomic factors such as treatment costs (37, 39). These elements collectively compromise the long-term effectiveness of budesonide/formoterol, despite its proven efficacy in controlled trial settings.
3.4 Knowledge gaps and perceptual barriers
The implementation of evidence-based strategies, particularly MART, is often hindered by perceptual and educational barriers. Some practitioners remain cautious due to unfamiliarity with MART principles or concerns regarding off-label dosing in younger children (40, 41). Concurrently, parental apprehensions regarding inhaled corticosteroid safety—often termed “corticophobia”—may lead to deliberate dose reduction or therapy avoidance (42, 43). Bridging these gaps requires targeted educational initiatives for both healthcare providers and families to align perceptions with current evidence and guidelines (40, 44).
4 Future directions and strategic development
4.1 Evidence generation and research priorities
Future research must address critical evidence gaps to optimize budesonide/formoterol’s application in pediatric asthma. A primary focus should be placed on conducting large-scale, methodologically robust RCTs specifically targeting preschool populations, where diagnostic ambiguity often complicates treatment decisions (45, 46). Research should also investigate differential treatment responses across various asthma endotypes—particularly T2-high versus T2-low phenotypes—to establish predictive biomarkers for therapy selection (33, 45). Additionally, comprehensive longitudinal studies are essential to further elucidate the long-term safety profile, with specific attention to potential effects on neurodevelopmental trajectories and final adult height (45, 46).
4.2 Advancing personalized treatment approaches
In an era of expanding biological therapies, defining budesonide/formoterol’s role requires a more nuanced understanding of patient-specific factors. Future efforts should focus on identifying clinical and biomarker profiles that predict optimal response to budesonide/formoterol therapy (47, 48). Systematic investigation of biomarkers such as fractional exhaled nitric oxide and peripheral blood eosinophil counts could facilitate more precise patient selection and dosing strategies (47, 49). This approach would enable stratification of patients who benefit most from budesonide/formoterol versus those who might require alternative therapies, thereby advancing personalized treatment protocols (49, 50).
4.3 Technological innovations in disease management
Digital health technologies offer transformative potential for addressing persistent management challenges. Integration of smart inhaler devices with embedded sensors can provide objective data on medication adherence, inhalation technique, and environmental exposures (51). These data systems should be coupled with interoperable digital platforms that enable remote monitoring, automated medication reminders, and telehealth consultations (52). Such technological integration can bridge the gap between clinical encounters and daily disease management, facilitating more responsive and data-driven asthma care (53).
4.4 Health system and educational initiatives
Strategic health system reforms are necessary to maximize budesonide/formoterol’s therapeutic potential. Policy review should focus on expanding insurance coverage for MART regimens to improve treatment accessibility and reduce financial barriers (54, 55). Concurrently, enhanced professional education programs must be developed for frontline healthcare providers, emphasizing practical skills in device training, patient selection for MART, and addressing corticosteroid-related concerns (55, 56). Complementary public health initiatives should develop validated educational resources to improve health literacy and self-management skills among patients and caregivers, ultimately supporting more effective implementation of evidence-based asthma management strategies (56, 57).
5 Summary
Budesonide/formoterol represents a well-established therapeutic option for moderate-to-severe pediatric asthma, with a substantial evidence base demonstrating its efficacy in both maintenance and MART regimens. Its dual pharmacological profile offers unique benefits for exacerbation reduction and symptom control. Nevertheless, several implementation barriers persist, including diagnostic uncertainties across developmental stages, technical challenges associated with inhaler use, variable treatment adherence, and knowledge gaps among healthcare providers and families regarding its optimal application.
Addressing these challenges requires a coordinated multidimensional approach. Future progress depends on generating more precise evidence through phenotype-stratified clinical trials, particularly in preschool populations. Furthermore, integrating digital health technologies for monitoring and adherence support, coupled with enhanced educational initiatives for both medical professionals and caregivers, will be crucial. Through these concerted efforts, the pediatric asthma community can advance toward more personalized, effective, and safer asthma management strategies that maximize therapeutic outcomes while minimizing risks.
Data availability statement
The original contributions presented in this study are included in this article/supplementary material, further inquiries can be directed to the corresponding author.
Author contributions
F-xT: Conceptualization, Data curation, Methodology, Resources, Validation, Visualization, Writing – original draft, Writing – review & editing. X-pW: Conceptualization, Data curation, Methodology, Resources, Validation, Visualization, Writing – original draft, Writing – review & editing. D-mW: Conceptualization, Data curation, Investigation, Methodology, Project administration, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing.
Funding
The author(s) declare financial support was received for the research and/or publication of this article. This study was supported by the Yan’an Science and Technology Program Project (grant no. 2024-SFGG-222).
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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The authors declare that no Generative AI was used in the creation of this manuscript.
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Abbreviations
GINA, Global Initiative for Asthma; ICS, inhaled corticosteroids; LABA, long-acting beta2-agonist; MART, Maintenance and Reliever Therapy; RCTs, randomized controlled trials; SABA, short-acting beta2-agonists.
References
1. Serebrisky D, Wiznia A. Pediatric asthma: a global epidemic. Ann Glob Health. (2019) 85:6. doi: 10.5334/aogh.2416
2. Wang Z, Li Y, Gao Y, Fu Y, Lin J, Lei X, et al. Global, regional, and national burden of asthma and its attributable risk factors from 1990 to 2019: a systematic analysis for the Global Burden of Disease Study 2019. Respir Res. (2023) 24:169. doi: 10.1186/s12931-023-02475-6
3. Yang F, Zhou J, Xiao H, Wu X, Cui Y, Huang H, et al. Caregiver burden among parents of school-age children with asthma: a cross-sectional study. Front Public Health. (2024) 12:1368519. doi: 10.3389/fpubh.2024.1368519
4. Toyran M, Yagmur I, Guvenir H, Haci I, Bahceci S, Batmaz S, et al. Asthma control affects school absence, achievement and quality of school life: a multicenter study. Allergol Immunopathol. (2020) 48:545–52. doi: 10.1016/j.aller.2020.05.005
5. Reddel H, Bacharier L, Bateman ED, Brightling C, Brusselle G, Buhl R, et al. Global initiative for asthma strategy 2021. Executive summary and rationale for key changes. Arch Bronconeumol. (2022) 58:35–51. doi: 10.1016/j.arbres.2021.10.003
6. Roh E. Comparison and review of international guidelines for treating asthma in children. Clin Exp Pediatr. (2024) 67:447–55. doi: 10.3345/cep.2022.01466
7. Pitrez P, Nanthapisal S, Castro A, Teli C. Managing moderate-to-severe paediatric asthma: a scoping review of the efficacy and safety of fluticasone propionate/salmeterol. BMJ Open Respir Res. (2023) 10:e001706. doi: 10.1136/bmjresp-2023-001706
8. Bateman, Fairall L, Lombardi D, English R. Budesonide/formoterol and formoterol provide similar rapid relief in patients with acute asthma showing refractoriness to salbutamol. Respir Res. (2006) 7:13. doi: 10.1186/1465-9921-7-13
9. Reddel H, Bateman, Schatz M, Krishnan J, Cloutier MM. A practical guide to implementing SMART in asthma management. J Allergy Clin Immunol Pract. (2022) 10:S31–8. doi: 10.1016/j.jaip.2021.10.011
10. Bisgaard H, Le Roux P, Bjåmer D, Dymek A, Vermeulen J, Hultquist C. Budesonide/formoterol maintenance plus reliever therapy: a new strategy in pediatric asthma. Chest. (2006) 130:1733–43. doi: 10.1378/chest.130.6.1733
11. Bateman, Harrison T, Quirce S, Reddel H, Buhl R, Humbert M, et al. Overall asthma control achieved with budesonide/formoterol maintenance and reliever therapy for patients on different treatment steps. Respir Res. (2011) 12:38. doi: 10.1186/1465-9921-12-38
12. Kew K, Karner C, Mindus S, Ferrara G. Combination formoterol and budesonide as maintenance and reliever therapy versus combination inhaler maintenance for chronic asthma in adults and children. Cochrane Database Syst Rev. (2013) 2013:CD009019. doi: 10.1002/14651858.CD009019.pub2
13. Virchow J, Rodriguez-Roisin R, Papi A, Shah T, Gopalan G. A randomized, double-blinded, double-dummy efficacy and safety study of budesonide-formoterol Spiromax® compared to budesonide-formoterol Turbuhaler® in adults and adolescents with persistent asthma. BMC Pulm Med. (2016) 16:42. doi: 10.1186/s12890-016-0200-x
14. Backer V, Bjermer L, Refvem O, Søderman A, Jones S. A multicenter, open-label, noninterventional study to evaluate the impact on clinical effects, user-friendliness and patients’ acceptance of AirFluSal Forspiro in the treatment of asthma under real-life conditions (ASSURE). Pragmat Obs Res. (2019) 10:29–39. doi: 10.2147/POR.S200654
15. Chrystyn H, Safioti G, Keegstra J, Gopalan G. Effect of inhalation profile and throat geometry on predicted lung deposition of budesonide and formoterol (BF) in COPD: an in-vitro comparison of Spiromax with Turbuhaler. Int J Pharm. (2015) 491:268–76. doi: 10.1016/j.ijpharm.2015.05.076
16. De Simón Gutiérrez R, Castro R. Narrative review of the role of patient-reported outcomes and inhaler handling errors in the control of asthma and COPD. Curr Allergy Asthma Rep. (2022) 22:151–61. doi: 10.1007/s11882-022-01041-2
17. Pearlman D, Eckerwall G, McLaren J, Lamarca R, Puu M, Gilbert I, et al. Efficacy and safety of budesonide/formoterol pMDI vs budesonide pMDI in asthmatic children (6-<12 years). Ann Allergy Asthma Immunol. (2017) 118:489–99.e1. doi: 10.1016/j.anai.2017.01.020
18. Tal A, Simon G, Vermeulen J, Petru V, Cobos N, Everard M, et al. Budesonide/formoterol in a single inhaler versus inhaled corticosteroids alone in the treatment of asthma. Pediatr Pulmonol. (2002) 34:342–50. doi: 10.1002/ppul.10173
19. Lundborg M, Wille S, Bjermer L, Tilling B, Lundgren M, Telg G, et al. Maintenance plus reliever budesonide/formoterol compared with a higher maintenance dose of budesonide/formoterol plus formoterol as reliever in asthma: an efficacy and cost-effectiveness study. Curr Med Res Opin. (2006) 22:809–21. doi: 10.1185/030079906X100212
20. Beasley R, Bruce P, Houghton C, Hatter L. The ICS/formoterol reliever therapy regimen in asthma: a review. J Allergy Clin Immunol Pract. (2023) 11: 762–72.e1. doi: 10.1016/j.jaip.2023.01.002
21. Beasley R, Harrison T, Peterson S, Gustafson P, Hamblin A, Bengtsson T, et al. Evaluation of budesonide-formoterol for maintenance and reliever therapy among patients with poorly controlled asthma: a systematic review and meta-analysis. JAMA Netw Open. (2022) 5:e220615. doi: 10.1001/jamanetworkopen.2022.0615
22. Selroos O. A smarter way to manage asthma with a combination of a long-acting beta(2)-agonist and inhaled corticosteroid. Ther Clin Risk Manag. (2007) 3:349–59. doi: 10.2147/tcrm.2007.3.2.349
23. Patel M, Pilcher J, Pritchard A, Perrin K, Travers J, Shaw D, et al. Efficacy and safety of maintenance and reliever combination budesonide-formoterol inhaler in patients with asthma at risk of severe exacerbations: a randomised controlled trial. Lancet Respir Med. (2013) 1:32–42. doi: 10.1016/S2213-2600(13)70007-9
24. Di Marco F. Today’s improvement in asthma treatment: role of MART and Easyhaler. Multidiscip Respir Med. (2020) 15:649. doi: 10.4081/mrm.2020.649
25. Pinnock H. Supported self-management for asthma. Breathe. (2015) 11:98–109. doi: 10.1183/20734735.015614
26. Pegoraro F, Masini M, Giovannini M, Barni S, Mori F, du Toit G, et al. Asthma action plans: an international review focused on the pediatric population. Front Pediatr. (2022) 10:874935. doi: 10.3389/fped.2022.874935
27. Agertoft L, Pedersen S. Effect of long-term treatment with inhaled budesonide on adult height in children with asthma. N Engl J Med. (2000) 343:1064–9. doi: 10.1056/NEJM200010123431502
28. Sharek P, Bergman D. The effect of inhaled steroids on the linear growth of children with asthma: a meta-analysis. Pediatrics. (2000) 106:E8. doi: 10.1542/peds.106.1.e8
29. Hong J, Bao Y, Chen A, Li C, Xiang L, Liu C, et al. Chinese guidelines for childhood asthma 2016: major updates, recommendations and key regional data. J Asthma. (2018) 55:1138–46. doi: 10.1080/02770903.2017.1396474
30. Zhou X, Qin Z, Lu J, Hong J. Efficacy and safety of salmeterol/fluticasone compared with montelukast alone (or add-on therapy to fluticasone) in the treatment of bronchial asthma in children and adolescents: a systematic review and meta-analysis. Chin Med J. (2021) 134:2954–61. doi: 10.1097/CM9.0000000000001853
31. Beigelman A, Bacharier L. Management of preschool recurrent wheezing and asthma: a phenotype-based approach. Curr Opin Allergy Clin Immunol. (2017) 17:131–8. doi: 10.1097/ACI.0000000000000344
32. Castro-Rodriguez J, Cifuentes L, Martinez F. Predicting asthma using clinical indexes. Front Pediatr. (2019) 7:320. doi: 10.3389/fped.2019.00320
33. Licari A, Castagnoli R, Brambilla I, Marseglia A, Tosca M, Marseglia G, et al. Asthma endotyping and biomarkers in childhood asthma. Pediatr Allergy Immunol Pulmonol. (2018) 31:44–55. doi: 10.1089/ped.2018.0886
34. Liang L, Huang R, Li Y, Wang Z, Peng K, Lin J, et al. Technical evaluation of Turbuhaler® use in children with bronchial asthma: combination of a checklist and inhalation parameters. BMC Pulm Med. (2025) 25:381. doi: 10.1186/s12890-025-03834-3
35. De Boeck K, Alifier M, Warnier G. Is the correct use of a dry powder inhaler (Turbohaler) age dependent? J Allergy Clin Immunol. (1999) 103:763–7. doi: 10.1016/s0091-6749(99)70417-3
36. Weers J. Suboptimal inspiratory flow rates with passive dry powder inhalers: big issue or overstated problem? Front Drug Deliv. (2022) 2:855234. doi: 10.3389/fddev.2022.855234
37. Averell C, Laliberté F, Germain G, Slade D, Duh M, Spahn J. Disease burden and treatment adherence among children and adolescent patients with asthma. J Asthma. (2022) 59:1687–96. doi: 10.1080/02770903.2021.1955377
38. McCrossan P, Shields M, McElnay J. Medication adherence in children with asthma. Patient Prefer Adherence. (2024) 18:555–64. doi: 10.2147/PPA.S445534
39. McQuaid E. Barriers to medication adherence in asthma: the importance of culture and context. Ann Allergy Asthma Immunol. (2018) 121:37–42. doi: 10.1016/j.anai.2018.03.024
40. Alyas S, Hussain R, Ababneh B, Ong S, Babar Z. Knowledge, perceptions, facilitators, and barriers towards asthma self-management among patients: a systematic review of the literature. Explor Res Clin Soc Pharm. (2024) 17:100558. doi: 10.1016/j.rcsop.2024.100558
41. Chapman K, Hinds D, Piazza P, Raherison C, Gibbs M, Greulich T, et al. Physician perspectives on the burden and management of asthma in six countries: the Global Asthma Physician Survey (GAPS). BMC Pulm Med. (2017) 17:153. doi: 10.1186/s12890-017-0492-5
42. Petric Duvnjak J, Lozo Vukovac E, Ursic A, Matana A, Medvedec Mikic I. Perception of illness and fear of inhaled corticosteroid use among parents of children with asthma. Children. (2023) 10:1597. doi: 10.3390/children10101597
43. Özçeker D, Uçkun U, İslamova D, Tamay Z, Güler N. Corticosteroid phobia among parents of asthmatic children. Turk J Pediatr. (2018) 60:142–6. doi: 10.24953/turkjped.2018.02.004
44. Parikh K, Paul J, Fousheé N, Waters D, Teach S, Hinds P. Barriers and facilitators to asthma care after hospitalization as reported by caregivers, health providers, and school nurses. Hosp Pediatr. (2018) 8:706–17. doi: 10.1542/hpeds.2017-0182
45. Di Cicco M, Peroni D, Marseglia G, Licari A. Unveiling the complexities of pediatric asthma treatment: evidence, controversies, and emerging approaches. Paediatr Drugs. (2025) 27:393–404. doi: 10.1007/s40272-025-00694-6
46. Salehian S, Fleming L, Saglani S, Custovic A. Phenotype and endotype based treatment of preschool wheeze. Expert Rev Respir Med. (2023) 17:853–64. doi: 10.1080/17476348.2023.2271832
47. Rabinovitch N, Mauger D, Reisdorph N, Covar R, Malka J, Lemanske R, et al. Predictors of asthma control and lung function responsiveness to step 3 therapy in children with uncontrolled asthma. J Allergy Clin Immunol. (2014) 133:350–6. doi: 10.1016/j.jaci.2013.07.039
48. Pavord I, Holliday M, Reddel H, Braithwaite I, Ebmeier S, Hancox R, et al. Predictive value of blood eosinophils andexhaled nitric oxide in adults with mild asthma: a prespecified subgroup analysis of an open-label, parallel-group, randomised controlled trial. Lancet Respir Med. (2020) 8:671–80. doi: 10.1016/S2213-2600(20)30053-9
49. Pavord I, Corren J. Biomarkers of Type 2 airway inflammation in airway disease: and then there were two. J Allergy Clin Immunol Pract. (2020) 8:2640–2. doi: 10.1016/j.jaip.2020.04.047
50. Thangavel R, James S, Palani A, Sivaprakasam E. Correlation of fractional exhalation of nitric oxide values with asthma control test score and spirometric parameters in steroid naïve asthmatic children at 6-8 weeks follow up. J Family Med Prim Care. (2025) 14:2552–7. doi: 10.4103/jfmpc.jfmpc_3_25
51. Sportel E, Thio B, Movig K, van der Palen J, Brusse M. The correlation between the level of therapy adherence and inhalation technique in children with uncontrolled asthma using a smart inhaler: the IMAGINE study. Ther Adv Respir Dis. (2025) 19:17534666251346363. doi: 10.1177/17534666251346363
52. Mosnaim G, Carrasquel M, Ewing T, Berty A, Snedden M. Remote monitoring in asthma: a systematic review. Eur Respir Rev. (2025) 34:240143. doi: 10.1183/16000617.0143-2024
53. Kaye L, Vuong V, Patel U, Mager D, Barrett M. Clinically-enhanced digital health program for respiratory care associated with better medication use and retention. NPJ Prim Care Respir Med. (2024) 34:46. doi: 10.1038/s41533-024-00404-8
54. Zaeh S, Zimmerman Z, Eakin M, Chupp G. Adoption and implementation of maintenance and reliever therapy for adults with moderate-to-severe asthma. Ann Allergy Asthma Immunol. (2024) 133:318–24. doi: 10.1016/j.anai.2024.06.011
55. Arora N, Zhou S, Baptist A. Regulatory and insurance challenges must be overcome in the United States to meet global standards for asthma management. J Allergy Clin Immunol Pract. (2024) 12:624–6. doi: 10.1016/j.jaip.2023.10.027
56. Volerman A, Balachandran U, Zhu M, Akel M, Hull A, Siros M, et al. Evaluating inhaler education interventions for hospitalized children with asthma: a randomized controlled trial. Ann Allergy Asthma Immunol. (2023) 131: 217–23.e1. doi: 10.1016/j.anai.2023.02.023
Keywords: pediatric asthma, budesonide, formoterol, asthma management, treatment adherence, personalized medicine
Citation: Tian F-x, Wang X-p and Wang D-m (2025) Budesonide/formoterol for pediatric asthma: bridging the gap between evidence and practice in Maintenance and Reliever Therapy. Front. Med. 12:1712238. doi: 10.3389/fmed.2025.1712238
Received: 24 September 2025; Accepted: 15 October 2025;
Published: 30 October 2025.
Edited by:
Zorica Momcilo Zivkovic, University Hospital Center Dr Dragiša Mišović, SerbiaReviewed by:
Vesna Veković, University Hospital Center Dr Dragiša Mišović, SerbiaMilena Bjelica, Institut za zdravstvenu zaštitu dece i omladine Vojvodine Klinika za pedijatriju, Serbia
Copyright © 2025 Tian, Wang and Wang. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Dong-mei Wang, ZG9uZy1tZWl3YW5nQG91dGxvb2suY29t