Does altering the dose of inhaled corticosteroids (ICSs) make a difference in growth among children with asthma?
TYPE OF REVIEW
This is a Cochrane systematic review of 10 parallel-group randomized controlled trials that evaluated the relationship between ICS dose and growth impairment in children with mild-to-moderate, persistent asthma.
RELEVANCE FOR NURSING
Asthma is defined as a chronic inflammatory disorder of the airways. It can lead to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. ICSs are considered first-line treatment for persistent asthma. However, the systemic adverse effects of these drugs are a matter of concern, especially their impact on children's growth.
CHARACTERISTICS OF THE EVIDENCE
Ten studies with a total of 3,394 children between the ages of one and 17 years who were diagnosed with mild-to-moderate asthma were included in this review. The studies evaluated the impact of different doses (low, 50 to 100 μg; or low to medium, 200 μg) of the same ICS (beclomethasone, budesonide, ciclesonide, ﬂuticasone, or mometasone) on linear growth velocity in children with persistent asthma, using the same device for a minimum of three months.
The primary outcome was linear growth velocity, obtained by measuring height at a number of time points during the study and performing linear regression of height over time. Secondary outcomes included change over time in growth velocity, height, weight, body mass index (BMI), and skeletal maturation.
Four studies (n = 728) evaluated the dose effect of ICSs on linear growth velocity over 12 months. The mean growth velocity was lower in the higher-dose control group (5.74 cm/y) than in the lower-dose intervention group (mean 5.94 cm/y), for a mean difference (MD) of 0.2 cm/y. This was a small, but statistically significant difference favoring the lower dose of ICSs.
Nine studies (n = 944) evaluated the change in height over three months. The mean change was 1.34 cm in the higher-dose control group and 1.19 cm in the lower-dose intervention group, for an MD of −0.15. Four studies (n = 548) assessed the change in height over 12 months, and here the intervention group had a 0.25-cm higher change (mean, 4.81 cm) than the control group (mean, 4.56 cm). No statistically signiﬁcant group differences were reported in change in standard deviation scores over 12 months (assessed by three studies [n = 328]) or change in weight over 12 months or change in BMI over 12 months (both evaluated by one study [n = 408]). Change in skeletal maturation over 12 months was also evaluated by a single study (n = 181) and a statistically signiﬁcant group difference was reported in favor of the lower ICS dose.
BEST PRACTICE RECOMMENDATIONS
In children with mild-to-moderate persistent asthma, low doses of ICSs are more favorable in regard to growth velocity than low-to-medium doses. Therefore, until more data are available, such children should be prescribed the minimal effective ICS dose.
Long-term trials with adequate documentation of linear growth velocity in children with asthma treated with ICSs are needed to provide a fair comparison of the safety of different ICS dose options.
Pruteanu AI, et al. Inhaled corticosteroids in children with persistent asthma: dose-response effects on growth. Cochrane Database Syst Rev