Inhaled corticosteroids as asthma treatment stunt kids' growth - NEJM
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Jan 032013
 
randomized controlled trials n engl j med review outpatient pulmonology review asthma review  Inhaled corticosteroids stunt growth of Americas youth by a half inch
Daily Inhaled Steroids Stunt Kids’ Growth, Study Shows

If you’re a half-inch shy of six feet, the next time you’re getting your jump shot blocked by your non-asthmatic friend, you can blame the inhaled corticosteroids your Mom made you take as a kid.

Studies have consistently showed children’s height slows down for a few years after starting daily inhaled steroids as an asthma treatment; at these snapshots in time, they lag behind their peers by about 1 cm. Eminent physicians have long sung the soothing song that this reduction in growth velocity is temporary — and that kids under treatment for asthma make it up in a longer growth spurt later, reaching (on average) equal height with their non-inhaled-steroid-using peers.

But that’s a “glass half full” interpretation of the conflicting trials, some of which suggested a permanent reduction in adult height among childhood users of inhaled corticosteroids.

Now, the large, expensive, combined randomized / longitudinal observational CAMP trial, following children for as long as 20 years to adulthood after starting inhaled steroids, shows the cold, short truth: children who use daily inhaled budesonide for 5 years can expect to lose about a half-inch (1.2 cm) of their final adult height. H. William Kelly, Alice  Sternberg, and Robert Strunk report the results in the September 6 2012 New England Journal of Medicine.

What They Did

Starting way back in 1993, the CAMP study investigators randomized 1,041 children aged 5 – 13 with mild-to-moderate asthma to take inhaled placebo, nedocromil (now discontinued) or budesonide 200 μg b.i.d. for 4 years. The kids were then followed with regular height measurements until they were about 25 years old.

This is the only good-quality prospective longitudinal trial on inhaled corticosteroids for asthma treatment in existence — the others either did not follow children long enough, or lost too many of them to follow-up, to answer this question.

What They Found

Average adult height was 1.2 cm lower (0.47 inch) in the budesonide group than in the placebo group (171.1 cm vs. 172.3 cm, P=0.001), with 95% of the participants ending up between 0.5 and 1.9 cm shorter (0.2 – 0.75 inch). There was a clear dose-response relationship, with −0.1 cm in adult height lost for each additional μg / kg of inhaled budesonide, P=0.007.

There was no “late growth spurt” as had been supposed: Participants “lost” 1.3 cm of height (compared to their placebo-peers) within 2 years of starting inhaled budesonide, and only gained a millimeter back in final adult height (to the average net deficit of 1.2 cm).

Nature was kind, at least, in stealing more height from girls (mean -1.8 cm) than boys (-0.8 cm), thereby preventing junior high dances from being even more awkward.

What It Means

At what age should a child be allowed to decide the life-altering question, “Would you rather have a few less asthma attacks, or be a half inch taller for the rest of your life?” That’s the tradeoff suggested by the CAMP trial and a randomized trial in Lancet last year testing beclomethasone as a symptom-driven (not daily) therapy in 843 kids.

Don’t tell me that half-inch doesn’t matter. As someone who used to describe himself as five-foot-nine “and a half,” I’m pretty sure I’d have taken the asthma attacks.

That’s without even counting the extra $400 per year in earnings a half-inch of height will bring you. And what did the steroids do to these kids’ vertical leaps, 40-meter sprint times, college ball prospects?

No doubt, many kids with persistent asthma will have their lives, education, and sports performance improved by daily inhaled corticosteroids, and these decisions should be always made with a wise and well-read doctor. But with the CAMP trial, the Lancet study, and the BASALT trial suggesting as-needed inhaled steroids may be equivalent to daily use in adults with mild-to-moderate asthma, pediatricians might think twice about continuing a kid with mild asthma — and a half-decent fastball — for years on a growth-stunting daily inhaled corticosteroid.

H. William Kelly et al. Effect of Inhaled Glucocorticoids in Childhood on Adult Height. NEJM 2012; 367: 904-912.

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