Childhood growth and inhaled steroids

• in comparison with otherwise healthy children, those children with asthma tend to have a later onset of puberty, slower pubertal growth velocity, and a relatively delayed bone maturation - this is seen in children with asthma whether they receive treatment with a corticosteroid or not. However growth retardation is exaggerated if a child has severe or poorly controlled asthma and by exposure to oral corticosteroid (a dose and duration dependent effect)
• there is evidence that beclomethasone diproprionate, in a daily dose of 400 mcg, can slow the rate of statural growth in the medium term
• the British Guideline on the Management of Asthma recommends that
  • in children under five years (1)
    • the dose of ICS should not exceed 400mcg/day beclometasone dipropionate (BDP) or equivalent (e.g. 400mcg/day budesonide, or 200mcg/day fluticasone propionate)
  • in children aged five to 12 years, the dose should not exceed 400mcg/day BDP or equivalent, unless the patient’s asthma remains uncontrolled despite add-on therapy (initially a long-acting ß2-agonist, followed by trials of other therapies e.g. a leukotriene receptor antagonist or sustained-release theophylline)
    • In such cases the dose may be increased to 800mcg/day BDP or equivalent
    • however, higher, unlicensed doses of ICS should only be initiated and supervised by specialists, and therapy should be reviewed regularly and titrated down to the lowest dose at which effective control of asthma is maintained
  • steroid treatment cards should be issued routinely for patients, including children, who require prolonged, high, unlicensed doses of ICS, because they may need corticosteroid cover during an episode of stress (e.g. an operation)

Reference:

1. Scottish Intercollegiate Guidelines Network/The British Thoracic Society. British Guideline on the Management of Asthma. Revised edition November 2005.
2. MeReC Extra March 2007.
3. Drug and Therapeutics Bulletin 1999; 37 (10):73-77
4. Editorial NEJM 2000; 343(15):1113.