Monday, September 23, 2013

Small Effect of Inhaled Steroids on Height in Children with Asthma

- Jennifer Middleton, MD, MPH

Childhood asthma is a frequent diagnosis in many Family Medicine offices, and inhaled corticosteroids are often the mainstay of treatment for kids with moderate or severe persistent disease.  Previous retrospective studies were reassuring regarding how these inhaled medications might affect height; children may not grow quite as fast when they're using inhaled steroids for asthma - but these studies suggested that, once the steroids are stopped, children catch up without any lifelong loss of height.

A recent randomized controlled trial, reviewed in this month's Journal of Family Practice (JFP), challenges this notion. The researchers found that children (ages 5-13 years at the beginning of the study) on long-term budesonide treatments for moderate persistent asthma did lose about half-an-inch (actually 0.47 inches or 1.2 cm, to be precise) of height during the 4-6 year trial that was sustained when they were followed up in their mid-20s.

The JFP authors point out that the enrolled children were on the same dose of budesonide throughout this lengthy study, which may be a bit atypical. The Expert Panel Review 3 (EPR-3) recommends that physicians consider tapering down chronic asthma therapy for adults and children if their symptoms have been controlled for three months (see page 288 of this document). This trial does add a bit of additional weight to that recommendation; we don't know whether intermittent use of these medications would mitigate this height loss, but it's probably still reasonable to limit their use when possible.

On the flip side, I wouldn't like to see 0.47 inches of height get in the way of adequately treating a child with moderate persistent asthma, either. (The researchers intentionally didn't include children with severe persistent asthma, assuming that the benefit of inhaled steroids for them would absolutely outweigh the risk of a few millimeters of height.) Like so many things in medicine, our discussion of this trial's finding with parents and families should include both the risks and benefits of these medications.  But this trial is a good example of how important it is to follow-up assumptions from retrospective studies with more rigorous, prospective trials.

AFP By Topic has a rich collection of resources on asthma which includes several articles related to the care of children with asthma.

Will this trial affect how you prescribe inhaled corticosteroids to children and adolescents?