Oct. 11, 2000 -- Parents may breathe a little easier now when it comes to giving their asthmatic children corticosteroids.
While these are effective medications, worrisome research has suggested that children who use these drugs may not grow properly. But two new studies in this week's New England Journal of Medicine suggest that long-term use of inhaled corticosteroids does not keep asthmatic children from reaching a normal adult height.
"The take-home message is that the concern outweighs the risk," says study author Stanley Szefler, MD. Concern about the adverse effects of medications is one of the reasons asthma tends to be undertreated. Szefler is director of the Division of Clinical Pharmacology and of Pediatric Clinical Trials Center at the National Jewish Research and Medical Center in Denver.
Corticosteroids are potent drugs used to reduce inflammation and should not be confused with anabolic steroids, which are occasionally used illegally by athletes. Corticosteroids are used to treat asthma in both adults and children and work by reducing irritation and swelling in the airways. This, in turn, helps a person breathe easier. Asthmatics usually use corticosteroids in an inhaled form, which delivers the drug directly to the lungs.
Research, though, has shown that using this type of medicine may slow a child's growth. In fact, the FDA requires companies that manufacture these drugs to put this information on the drugs' labels, to alert health care providers. But thus far, it has been unclear whether the slowed growth rate might be permanent, or if an affected child will eventually reach his or her normal adult height.
The first study, done by researchers from several medical centers and led by Szefler, compared a corticosteroid, Pulmicort, with Tilade, which is another, nonsteroidal type of asthma drug. The researchers also evaluated the effects of Pulmicort on the children's growth.
More than 1,000 children who had mild to moderate asthma were randomly divided into three groups. One group was treated with Pulmicort, the second group got Tilade, and the third was given a placebo, or dummy pill. All of the children, who ranged in age from 5 to 12 years old, also used another drug called Proventil when they developed acute asthma symptoms.
The researchers found that neither drug was better than the placebo in helping overall lung function, but that the corticosteroid, Pulmicort, helped the children to control their asthma better. They had fewer hospitalizations and fewer urgent visits to their doctors. Pulmicort also reduced their need for other asthma medications.
When evaluating growth rates, the researchers found only a very slight difference in the children who were using Pulmicort. The slower growth rate occurred mostly within the first year that they used the drug. At the end of the study, which lasted from four to six years, the three groups all had similar growth rates.
In the second study, Danish researchers Lone Agertoft, MD, and S?ren Pedersen, MD, DrMedSci, of the department of pediatrics at Kolding Hospital in Kolding, Denmark, evaluated the height of 200 adults who had used inhaled Pulmicort as children. Their findings were similar to those of the other study: While the medication affected growth initially, the effect was temporary and did not affect their adult height.
If a child has mild asthma with periodic episodes that require emergency care, hospitalization, or courses of oral steroids, says Szefler, then "there is a distinct possibility that these life-threatening episodes could be alleviated" by using an inhaled corticosteroid.
"Since there are children with very severe asthma who do require steroids, it is very reassuring that the growth rate -- while it goes down in the first year -- is not sustained," says Ira Finegold, MD. "These children are very sick and need their medication, so this may help relieve anxiety about [these medications]." Finegold, who was not involved in the study, is chief of allergy and immunology at St. Luke's-Roosevelt Hospital Center in New York.
But should all children with asthma, regardless of the severity of the disease, use these drugs? In an editorial accompanying the studies, Mary Ellen B. Wohl, MD, and Joseph A. Mazjoub, MD, both professors of pediatrics at Harvard Medical School, still recommend caution when using corticosteroids. One concern is that the steroids may affect the growth of other organs, such as the brain and the lungs.
Until more is known about the effects of these drugs on the body's other organs, they write, 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 very mild asthma."
Bob Lanier, MD, who commented on the studies for WebMD, disagrees. He says that people do need to weigh the risks and benefits of corticosteroid therapy but that the health of children's lungs outweighs the possible risk of growth problems.
"Studies have demonstrated a loss of lung function of at least 1% a year in poorly managed asthma," he says. "I think parents should first be worried about the growth of lungs." Lanier is vice president of the American College of Allergy Asthma and Immunology.
But Finegold says that the editorialists' suggestions are valid. "When we're dealing with mild asthma, especially in very young children, I agree with the editorial that caution is warranted," he says. "In this population, alternate therapies should be assessed."
He points out that for an asthmatic child who also has allergies, for example, parents should consider allergy shots. "Allergy shots have no effect on growth and can decrease the severity of asthma," he says.
"The take-home message is that if your child has asthma, do not be afraid that inhaled steroids will give short stature," says Finegold. "Certainly for moderate to severe asthma, one should use the inhaled steroids without worrying that you're going to have short children."
The Danish study was supported by grants from the Vejle County Hospitals Research Fund; the multicenter study was supported by contracts with the National Heart, Lung, and Blood Institute and General Clinical Research Center grants from the National Center for Research Resources.
Szefler has served as a consultant or advisory panel member for drugmakers Astra USA and Glaxo Wellcome, both of which supplied drugs for his study.