Considerations for using inhaled corticosteroids for asthma in children
Inhaled corticosteroids (ICS) are the mainstay of therapy for asthma. It is common for parents and carers to be concerned about potential growth suppression caused by ICS therapy, and this can be a barrier to therapy. Explain to parents and carers that poorly controlled asthma is also associated with growth suppression, and that the benefits of good asthma control outweigh the risk of growth suppression related to ICS.
The effect of ICS on growth velocity appears to be dose dependent, and is most pronounced during the first year of treatment. A Cochrane review showed daily low- to medium-dose ICS was associated with a mean reduction in linear growth velocity of 0.48 cm per year, and 0.61 cm less growth after 1 year of treatment, compared with placebo or nonsteroidal treatment1. Although growth velocity returns to normal within a few years of starting an ICS, one study found that the mean adult height was 1.2 cm lower in patients who used ICS during their childhood compared with placebo2.
The difference in effect on growth between individual ICS is uncertain. A Cochrane review found that fluticasone propionate had a smaller impact on growth than equivalent doses of budesonide or beclometasone3. Another study found no significant difference in effect on height between ciclesonide and fluticasone propionate4. More evidence is needed to inform a clear recommendation about which steroid has the least effect on growth.
To minimise the risk of all adverse effects, use the minimum effective dose of ICS; see Stepping down asthma therapy in children for information about reducing therapy. Recommend that children rinse their mouth with water and spit out straight after using the ICS to minimise the risk of oropharyngeal candidiasis and systemic absorption.
Although corticosteroid therapy can cause adrenal suppression and reduce bone density, these effects are unlikely with the recommended doses of ICS for asthma in children.
If starting an ICS for asthma in a child, discuss the goals of therapy with child and their parent or carer. Explain that prioritising good control of asthma is crucial to minimise the impact of asthma on the child’s quality of life, and avoid exacerbations.