Weigh up risks and benefits of daily inhaled steroids
Daily budesonide therapy produces effective control in children with mild persistent asthma but may impair growth.
A randomised, controlled study evaluated 176 children aged 5-10 who were newly diagnosed with asthma, with typical symptoms and diurnal reversibility on peak flow testing.
Participants were randomised to three interventions. Two groups were treated with budesonide 800µg daily for one month, then 400µg daily for five months. At six months the groups diverged, with one prescribed budesonide 200µg daily and the other using a placebo inhaler for months 7-18. The third group was prescribed sodium cromoglicate 30mg daily.
All exacerbations were treated with budesonide 800µg daily for two weeks in place of the study medication.
Children treated with daily budesonide had fewer exacerbations and a greater improvement in FEV1 than those treated with sodium cromoglicate or placebo. There was no significant difference in symptom-free days between the groups.
However, the standing height velocity of children treated with daily budesonide was 2cm per year slower than children treated with sodium cromoglicate during the first six months of the study (P=<0.001). Growth velocity returned to normal during continuous low-dose budesonide and budesonide given
as needed was associated with catch-up growth. At 18 months, children in the continuous budesonide group had grown 1cm less than children using sodium cromoglicate (P=0.008) and 0.4cm less than children who changed to placebo at six months (P=0.048).
We are all aware of the potential hazards of medium to high dose inhaled steroids in children, but current guidance1,2 clearly defines their importance in treating children inadequately controlled on beta agonists alone. This study provides some important insight into the relative benefits of different treatment regimens in children aged 5-10 years.
The authors suggest that the dose of inhaled steroids could be reduced as soon as the asthma is controlled. They also comment that some children do not appear to need continuous treatment.
Despite the guidance recommending regular steroid treatment when control is poor, I think all options should be presented to parents when discussing management.
Turpeinen M, Nikander K, Pelkonen AS et al. Daily versus as-needed inhaled corticosteroid for mild persistent asthma (the Helsinki early intervention childhood asthma study). Arch Dis Child 2008;93:654-9Reviewer
Dr Peter Saul
GP, Wrexham and hospital practitioner in paediatrics (asthma and allergy)