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Inhaled steroids for asthma suppress growth in children, review finds

GPs advised to use minimum effective dose in children because inhaled steroids stunt growth by 0.5cm in first year

Ingrid Torjesen

Friday, 18 July 2014

Corticosteroid drugs that are given by inhalers to children with asthma may suppress their growth, according to new systematic reviews published in The Cochrane Library. The authors found children’s growth slowed in the first year of treatment, although the effects were minimised by using lower doses.

Seven inhaled corticosteroid are currently available worldwide: beclomethasone, budesonide, ciclesonide, flunisolide, fluticasone, mometasone and triamcinolone. Ciclesonide, fluticasone and mometasone are newer and supposedly safer drugs.

The first systematic review* focused on 25 trials involving 8,471 children up to 18 years old with mild to moderate persistent asthma. These trials tested all available inhaled corticosteroids except triamcinolone and showed that, as a group, they suppressed growth rates when compared to placebos or non-steroidal drugs. Fourteen of the trials, involving 5,717 children, reported growth over a year. The average growth rate, which was around 6-9 cm per year in control groups, was reduced by about 0.5 cm in treatment groups.

Lead author of the review, Dr Linjie Zhang, from the the faculty of medicine at the Federal University of Rio Grande in Brazil, said: “The evidence we reviewed suggests that children treated daily with inhaled corticosteroids may grow approximately half a centimetre less during the first year of treatment. This effect is less pronounced in subsequent years, is not cumulative, and seems minor compared to the known benefits of the drugs for controlling asthma and ensuring full lung growth.”

In the second review**, the same authors, working with two others, reviewed data from 22 trials in which children were treated with low or medium doses of inhaled corticosteroids. These trials tested different doses of all drugs except triamcinolone and flunisolide.

Three trials followed 728 children for a year or more, with one of these trials testing three different dosing regimens. In these three trials, using lower doses of the inhaled corticosteroids, by about one puff per day, improved growth by a quarter of a centimetre at one year.

The researchers found that growth suppression varied across studies, and that some of the variation could be explained by the different drugs used. “Conclusions about the superiority of one drug over another should be confirmed by further trials that directly compare the drugs,” Dr Zhang said.

As well as comparing different drugs, long-term trials were also needed that look at different dosages, particularly in children with more severe asthma, the authors said. Senior author of the second review, Dr Francine Ducharme, of the department of paediatrics at the University of Montreal in Canada, said: “Only 14% of the trials we looked at monitored growth in a systematic way for over a year. This is a matter of major concern given the importance of this topic. We recommend that the minimal effective dose be used in children with asthma until further data on doses becomes available. Growth should be carefully documented in all children treated with inhaled corticosteroids, as well in all future trials testing inhaled corticosteroids in children.”

* Linjie Zhang L, Prietsch S O M, Ducharme F M. Inhaled corticosteroids in children with persistent asthma: effects on growth. The Cochrane Library, 2014. DOI: 10.1002/14651858.CD009471.pub2

** Pruteanu A I, Chauhan B F, Zhang L, Prietsch S O M, Ducharme F M. Inhaled corticosteroids in children with persistent asthma: dose-response effects on growth. The Cochrane Library, 2014. DOI: 10.1002/14651858.CD009878.pub2

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