Inhaled corticosteroids, known commonly and for the rest of this discussion as ‘inhaled steroids,’ have been the preferred daily treatment since the 1980s to prevent asthma symptoms for those who would otherwise have asthma more than two days every week. The basis for creating this class of medication in the 1970s was to achieve the same effect as the oral steroids—Prednisone and Medrol— but without the same long-term risks of oral steroids.
However, one of these risks—the effect on final adult height—has not been consistently defined over the years since study of this question began in the late 1980s with patients using inhaled beclomethasone. When I finished my training in the mid-1990s, the prevailing opinion was that there was no effect of inhaled steroids on final adult height. Furthermore, uncontrolled asthma itself can lead to a reduced final adult height. A study published in the New England Journal of Medicine in 1993 was often cited then. The conclusion from that study of fifteen children ages 3 to 7 who received a low daily dose of budesonide for three to five years was they had a normal increase in height. A 1997 epidemiologic study from the Mayo Clinic also concluded that there was no effect of inhaled steroids on final adult height.
At the start of the millennium, two more studies in the New England Journal again addressed the topic. The conclusion from these reports was that the effect of the specific inhaled steroid studied—budesonide—on height could be likened (Attention Blackhawks fans who are enduring this season!) to that of a hockey stick. When you look at the hockey stick, the blade can angle downward. This would correspond to the decline in growth by 1cm in the first year of using an inhaled steroid. Afterward, though, there would be a rebound effect—just as the handle of the hockey stick shoots upward— and the ultimate adult height would be predicted to be unchanged.
The trend then became to consider using budesonide, preferentially, in children who needed an inhaled steroid for asthma control because budesonide was well-studied. The effect of other inhaled steroid products was a relatively open question, but the belief was that the effect seen with budesonide would also occur with the other inhaled steroids. However, in this decade, we are starting to see different conclusions.
In a 2012 follow-up study to one of the two 2000 New England Journal articles, 943 children who participated in one of those studies actually had their adult height measured. The mean, or average, adult height was 1.2 cm (about a ½ inch) lower in the budesonide group than in the placebo group. The authors of the follow-up study concluded that the initial decrease in the height of those children who started to use inhaled steroids before puberty led to a persistent reduction in adult height. But, the reduction seen in the first two years of using inhaled steroids did not progress each year.
Slower growth in height has been shown to occur now with most inhaled steroids. The expert opinion now is that there is a small decrease in the final adult height from inhaled steroids. The decrease is considered to be 1 cm on average, but the range of decrease during the first few years of treatment is 0.5 cm to 3.0 cm (0.2 inch to 1.2 inches). Approaches we can take about trying to limit the effect from inhaled steroids include these:
- Use the lowest effective dose that would prevent flare-ups, when asthma symptoms would otherwise clearly be frequent.
- Monitor the height of children every 3 to 6 months.
- Consider a trial of a different anti-inflammatory asthma medication, namely Singulair (generic name Montelukast).
- Consider reducing the amount of steroid by using a combination inhaler that contains a lower dose of steroid plus a long-acting bronchodilator. Two combination inhalers—Symbicort and Advair—have forms of the inhaler that are now FDA-indicated for children.
A recurrent theme over many of the blogs we’ve posted so far is that scientific knowledge changes. We need to keep an open mind about what we observe and what it means. For children, Ralph Waldo Emerson’s quote “Men are what their mothers make them” is a reminder to both physicians and all parents that we all need to decide carefully about what is best for them.
Dr. Klein