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The Informed Parent

Inhaled Steroids and Slow Growth

by John H. Samson, M.D., F.A.A.P.
Published on Jun. 21, 1999

Asthma and allergic rhinitis have probably plagued man from the beginning of time. It was not until the 1970's that a real breakthrough appeared in the prevention of allergic asthma. This came in the form of inhaled microdose cortisone preparations. They were administered as a nebulized powder. This was followed by the preparation coming in an intranasal inhaler for patients who had allergic rhinitis (hay fever).

The response was amazing! Patients who had suffered from recurrent wheezing and coughing were controlled for the first time. The sneezy, drippy and headachy nasal allergy patients saw symptoms melt away.

These intranasal inhalers were protective from airborne allergies (i.e. dust, mold, pollen, danders and mites). But they were of no value to patients with food allergies. Nevertheless, control of allergies, related to inhaled allergens, was greatly appreciated by patient and physician alike.

In the beginning we were erroneously informed that these cortisone compounds were not absorbed, and, therefore, were free of side effects usually associated with cortisone therapy. Experience proved, however, that these compounds were indeed absorbed, and the same side effects associated with cortisone therapy appeared if administered in large doses. In the late 1980's world literature supported this view. It showed that eight or less sprays per day of beclomethasone would provoke an effect on the adrenal gland. Nine-to-twelve sprays could cause side effects in a few patients, and greater than 12 sprays was similar to taking oral cortisone. It was obviously clear that dosage administration had to be limited.

This information failed to reach general circulation. These products (beclomethasone and triamcinolone) were used freely and with ever increasing daily dosage. Two sprays, three times per day or more were commonly used by oral inhalers to send the medicine into the lungs.

When intranasal use came into play, more was administered via that route. Since many patients had both asthma and nasal allergies, these steroids were received by nose and lung. They could easily exceed the side effect free dose. If a patient took six sprays orally for asthma and two sprays in each nostril twice per day, the patient was well over the safe dose.

The development of the spacer for inhaled cortisone made administration more efficient. Now, more steroid was available for absorption. Less medication would leak from the mouth around the inhaler to transfer into the atmosphere.The medical world finally became aware of the situation. Now comes the demand for a notice to be placed on the canisters used to provide the medication.

This is not new information. The informed physician has been aware of the fact that these cortisone compounds are systemically absorbed for years. If they are administered at a dosage beyond safe standards, problems will occur. Slow growth rate may develop in the preadolescent. Very large doses can mimic the effects of taking daily oral cortisone.

In recent years more potent microdose steroids have been made available for lung and nasal inhalation. Accordingly, current research cautions for a safe lower maximum dose to be used.

The specific question currently receiving publicity asks about the ability of these preparations to slow down the growth rate of boys and girls. One must not develop tunnel vision as seen with drug phobia. The control of serious disease that these preparations provide cannot be abandoned.
All the aspects of the problem must be carefully weighed.

Can inhaled cortisone preparations impair growth? Some studies show they can, to a small degree, but they do not have to if:

  1. the lowest dose of the inhaled steroid is used, and the dose does not exceed 400 micrograms/day of beclomethasone or budesonide, or 200 micrograms/day of fluticasone.
  2. it is remembered that the dose taken in the lung and the nose must be totaled to evaluate the daily dose. (i.e. 400 mcg/day taken with an asthma inhaler plus 400 mcg/day taken intranasally is 800 mcg/day total; TWICE THE SAFE DOSE.
  3. the child should have the height/growth rate monitored every 3-4 months. If it falls below 4 cm/year, evaluation of dose and necessity of the microsteroid must occur.

It must be remembered that severe, chronic asthma, in and of itself, can provoke debilitating pulmonary disease. This can lead to recurrent infection, undernutrition and impaired growth and development. We must be sure we do not throw out the baby with the bath water.

I hope this article causes parents to be informed and act accordingly. Talk to your child's pediatrician before you decide to stop inhaled steroids for asthma. Such a unilateral move could have significant, deleterious health implications. If you think your child is receiving a daily dose above that which is felt safe, talk to your pediatrician before you reduce it on your own. If you find your child's growth rate drops below 4 cm/year, once again, discuss it with your child's physician. If your child receives both intranasal and intrapulmonary microcortisone, ask your pediatrician to double check the total dose, insuring that it is below the maximum safe dose.

With all the media attention on inhaled corticosteroids and impaired growth I fear that patients who need the medication would be deprived of it. They then would suffer the serious problem of uncontrolled asthma. To avoid this, make an informed decision with the help of your pediatrician.

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