The Use of Montelukast in Pediatric Asthma and Anti-Inflammatory Effects - Easy Choice or a Balancing Act?

Montelukast is a selective cysteinyl leukotriene receptor 1 antagonist with an established, though nuanced, role in the management of asthma and allergic rhinitis. By inhibiting leukotriene-mediated signaling, montelukast targets a pathway involved in bronchoconstriction, mucus secretion, vascular permeability, eosinophil recruitment, cytokine release, and airway remodeling. Available evidence indicates that montelukast may reduce several markers of allergic inflammation, including fractional exhaled nitric oxide, peripheral and tissue eosinophilia, eosinophil-derived mediators, adhesion molecules, selected cytokines, and markers related to airway remodeling. These effects are most consistently demonstrated in asthma and allergic rhinitis, while evidence in chronic urticaria, atopic dermatitis, and other inflammatory conditions remains limited or exploratory. Montelukast's once-daily oral administration and age-adjusted pediatric formulations make it a practical option in selected children, particularly when inhaled therapy is difficult or adherence is problematic. However, montelukast should not be regarded as a direct substitute for corticosteroid-based anti-inflammatory therapy. Current evidence and guideline positioning support its use mainly as an add-on controller, or an alternative when more efficacious treatment is contraindicated. The benefit-risk balance is further shaped by concerns regarding neuropsychiatric adverse events, especially in children, although evidence remains heterogeneous. Current data show no increased risk of severe, diagnostically coded neuropsychiatric events, yet milder sleep-related and behavioral symptoms are consistently reported, so that caution and active monitoring remain warranted. Overall, montelukast remains a biologically plausible and clinically useful therapy, but its value depends on appropriate patient selection and realistic expectations of its anti-inflammatory potential.