Older children who use inhaled steroids to treat asthma symptoms do not
have to worry about stunted growth, according to new studies in the United
States, Canada and Denmark.
Two articles in the Oct. 12 issue of the Boston-based New England Journal
of Medicine also conclude that while inhaled steroids do reduce the growth
rate of children by about 20 percent during the first year of treatment,
the growth rate subsequently recovers, so children should reach their expected
normal adult height.
The researchers also found that inhaled steroids provide better treatment
for children 5 years old and older with mild to moderate asthma than non-steroidal
therapies.
One of the studies was conducted on 211 children by the University of Southern
Denmark and Kolding Hospital in Denmark. The other was conducted on 1,041
children by the Childhood Asthma Management Program, or CAMP, at eight
medical centers in the United States and Canada.
Earlier studies have shown moderate doses of inhaled steroids did stunt
the growth of children by 1 centimeter per year. But because some patients
may need to be on medications for 10 years or more, there was a possibility
they could have grown up to be four-inches shorter than their classmates
without asthma, said Dr. N. Franklin Adkinson, one of the researchers who
ran the CAMP study and a professor of allergy and clinical immunology at
Johns Hopkins School of Medicine in Baltimore.
"The CAMP study shows that the best asthma drug can be given children without
having to worry about any long-term adverse effects on growth and development,"
Adkinson said, adding that the Danish study supports that finding.
"Current medical guidelines recommend a variety of medications for controlling
mild asthma, including inhaled corticosteroids such as budesonide or non-steroidal
drugs like nedocromil.
"The CAMP trial is a major step forward in terms of understanding the risks
and benefits of treating asthma with corticosteroids," said Dr. Robert
Lemanske Jr., an asthma specialist and professor of pediatrics and medicine
at the University of Wisconsin Medical School in Madison, Wis. "We knew
that changes could be seen in patients having one year of treatment, but
we did not know the progress over five years of study. So the results are
reassuring."
Dr. Scot Laurie, an allergy and asthma clinical fellow at the University
of Texas Southwestern Medical Center in Dallas, agrees. "This study concludes
corticosteroids are safe. There's been a steroid phobia. But parents have
to think about the effects of untreated asthma and hospitalization, which
are far more deleterious than a transient decrease in the child's growth
rate."
The CAMP researchers studied more than 1,000 children with mild to moderate
asthma aged 5 to 12 years and gave them the inhaled budesonide steroid,
the non-steroid nedocomil or a placebo over four to six years. Adkinson
said that the 311 children who inhaled the steroid into their lungs showed
stunted growth of about four-tenths of an inch after the first year, but
by the fourth year, all the children in the group had the same height,
weight, bone density, sexual maturation and psychological development for
children of their age.
However, neither medication improved lung growth. Previous studies have
suggested that asthma can harm lung growth in children and lead to reduced
breathing function in adulthood. While the CAMP researchers had hoped inhaled
steroids would slow the loss of lung function caused by asthma, they didn't
find that to be the case, said Dr. Peyton Eggleston, professor of pediatrics
and immunology at Johns Hopkins.
But the steroidal drug did provide better treatment than the non-steroidal
drug or placebo in the form of significantly reduced hospital and urgent
care visits and less need for additional asthma medications.
"We found patients taking the inhaled steroid had 43 percent fewer hospitalizations
and 41 percent fewer ER visits, and the patients needed half as many doses
of albuterol," Eggleston said. Albuterol is an inhalant used for acute
asthma attacks. All children in the study were taking albuterol.
The Danish study on more than 200 children also concluded that children
with asthma who have received long-term treatment with the inhaled steroid
budesonide do attain normal adult height. The study followed the children
into adulthood.
Adkinson said this is good news for parents, who have been concerned about
exposing their children to a potentially risky treatment, and for physicians,
who might be less reluctant now to use inhaled steroids in milder asthmatic
children.
But a New England Journal of Medicine editorial in the same issue urges
caution about the results of the two studies. Dr. Mary Ellen Wohl and Dr.
Joseph Majzoub of Children's Hospital in Boston write that while the studies
are reassuring in finding the growth rate reduction from the inhaled steroid
budesonide is basically confined to the first year of treatment, the CAMP
study did not report on the children's puberty status. The level of sexual
maturation could have influenced growth, regardless of treatment, they
say. Children have a big growth spurt just before puberty.
They also write that the reassuring message about skeletal growth may not
apply to the growth of other organs, such as the brain and the lung.
"Until more is known about the influence of corticosteroids on the development
of the lung and other organs, and until better tools are developed to assess
organ growth, it may be prudent to avoid the use of inhaled corticosteroids
in young children with mild asthma," Wohl and Majzoug say. Very few studies
have been done on younger children using corticosteroids.
Eggleston of Johns Hopkins said the CAMP researchers did account for puberty
in their study. "Every four months, the kids had to take off all their
clothes and have their testicles and breasts measured," he said. Almost
all the CAMP participants had not yet undergone puberty before joining
the study, but almost all had started to enter it by the time the testing
was completed.
Eggleston does, however, agree with the Children's Hospital doctors about
using caution in giving children younger than age 5 inhaled steroids.
"At the age the children entered our study, most of their lung growth was
over," he said. "But if you take preschoolers less than 5 years old, you
don't know the effects of the steroids on lung growth."
Laurie of the University of Texas Southwestern Medical Center said he does
give younger children corticosteroids if warranted. "Parents should watch
what their children are being given, but not at the expense of treating
asthma," he said.
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