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Meta-Analysis
. 2014 Jul 17;2014(7):CD009878.
doi: 10.1002/14651858.CD009878.pub2.

Inhaled corticosteroids in children with persistent asthma: dose-response effects on growth

Aniela I Pruteanu  1 , Bhupendrasinh F Chauhan, Linjie Zhang, Sílvio O M Prietsch, Francine M Ducharme
Affiliations
Meta-Analysis

Inhaled corticosteroids in children with persistent asthma: dose-response effects on growth

Aniela I Pruteanu et al. Cochrane Database Syst Rev. .

Abstract

Background: Inhaled corticosteroids (ICS) are the first-line treatment for children with persistent asthma. Their potential for growth suppression remains a matter of concern for parents and physicians.

Objectives: To assess whether increasing the dose of ICS is associated with slower linear growth, weight gain and skeletal maturation in children with asthma.

Search methods: We searched the Cochrane Airways Group Specialised Register of trials (CAGR) and the ClinicalTrials.gov website up to March 2014.

Selection criteria: Studies were eligible if they were parallel-group randomised trials evaluating the impact of different doses of the same ICS using the same device in both groups for a minimum of three months in children one to 17 years of age with persistent asthma.

Data collection and analysis: Two review authors ascertained methodological quality independently using the Cochrane Risk of bias tool. The primary outcome was linear growth velocity. Secondary outcomes included change over time in growth velocity, height, weight, body mass index and skeletal maturation.

Main results: Among 22 eligible trials, 17 group comparisons were derived from 10 trials (3394 children with mild to moderate asthma), measured growth and contributed data to the meta-analysis. Trials used ICS (beclomethasone, budesonide, ciclesonide, fluticasone or mometasone) as monotherapy or as combination therapy with a long-acting beta2-agonist and generally compared low (50 to 100 μg) versus low to medium (200 μg) doses of hydrofluoroalkane (HFA)-beclomethasone equivalent over 12 to 52 weeks. In the four comparisons reporting linear growth over 12 months, a significant group difference was observed, clearly indicating lower growth velocity in the higher ICS dose group of 5.74 cm/y compared with 5.94 cm/y on lower-dose ICS (N = 728 school-aged children; mean difference (MD)0.20 cm/y, 95% confidence interval (CI) 0.02 to 0.39; high-quality evidence): No statistically significant heterogeneity was noted between trials contributing data. The ICS molecules (ciclesonide, fluticasone, mometasone) used in these four comparisons did not significantly influence the magnitude of effect (X(2) = 2.19 (2 df), P value 0.33). Subgroup analyses on age, baseline severity of airway obstruction, ICS dose and concomitant use of non-steroidal antiasthmatic drugs were not performed because of similarity across trials or inadequate reporting. A statistically significant group difference was noted in unadjusted change in height from zero to three months (nine comparisons; N = 944 children; MD 0.15, 95% CI -0.28 to -0.02; moderate-quality evidence) in favour of a higher ICS dose. No statistically significant group differences in change in height were observed at other time points, nor were such differences in weight, bone mass index and skeletal maturation reported with low quality of evidence due to imprecision.

Authors' conclusions: In prepubescent school-aged children with mild to moderate persistent asthma, a small but statistically significant group difference in growth velocity was observed between low doses of ICS and low to medium doses of HFA-beclomethasone equivalent, favouring the use of low-dose ICS. No apparent difference in the magnitude of effect was associated with three molecules reporting one-year growth velocity, namely, mometasone, ciclesonide and fluticasone. In view of prevailing parents' and physicians' concerns about the growth suppressive effect of ICS, lack of or incomplete reporting of growth velocity in more than 86% (19/22) of eligible paediatric trials, including those using beclomethasone and budesonide, is a matter of concern. All future paediatric trials comparing different doses of ICS with or without placebo should systematically document growth. Findings support use of the minimal effective ICS dose in children with asthma.

PubMed Disclaimer

Conflict of interest statement

Aniela Ignea Pruteanu, Bhupendrasinh Chauhan, Linjie Zhang and Sílvio OM Prietsch: none known.

Prof. Francine Ducharme has received travel support, research funds and fees for speaking from Glaxo SmithKline, Novartis, Nycomed and/or Merck Frosst Inc.

Figures

1
1
Flow diagram of screening of trials.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Forest plot of comparison: 1 Inhaled corticosteroids dose‐response effect, outcome: 1.1 Growth velocity (cm/y) by stadiometry from 0‐12 months.
4
4
Forest plot of comparison: 1 Inhaled corticosteroids dose‐response effect, outcome: 1.2 Subgroup analysis on the ICS molecules: growth velocity by stadiometry from 0‐12 months.
1.1
1.1. Analysis
Comparison 1 Inhaled corticosteroids dose‐response effect, Outcome 1 Growth velocity (cm/y) by stadiometry from 0‐12 months.
1.2
1.2. Analysis
Comparison 1 Inhaled corticosteroids dose‐response effect, Outcome 2 Subgroup analysis on the ICS molecules: growth velocity by stadiometry from 0‐12 months.
1.3
1.3. Analysis
Comparison 1 Inhaled corticosteroids dose‐response effect, Outcome 3 Growth velocity (cm/y) by stadiometry from 0‐3 months.
1.4
1.4. Analysis
Comparison 1 Inhaled corticosteroids dose‐response effect, Outcome 4 Growth velocity (cm/y) by stadiometry from 0‐6 months.
1.5
1.5. Analysis
Comparison 1 Inhaled corticosteroids dose‐response effect, Outcome 5 Growth velocity (cm/y) by stadiometry from 3‐6 months.
1.6
1.6. Analysis
Comparison 1 Inhaled corticosteroids dose‐response effect, Outcome 6 Change in growth velocity (cm/y) by stadiometry from 0‐12 months.
1.7
1.7. Analysis
Comparison 1 Inhaled corticosteroids dose‐response effect, Outcome 7 Change in height (cm) by stadiometry from 0‐3 months.
1.8
1.8. Analysis
Comparison 1 Inhaled corticosteroids dose‐response effect, Outcome 8 Change in height (cm) by stadiometry from 0‐6 months.
1.9
1.9. Analysis
Comparison 1 Inhaled corticosteroids dose‐response effect, Outcome 9 Change in height (cm) by stadiometry from 3‐6 months.
1.10
1.10. Analysis
Comparison 1 Inhaled corticosteroids dose‐response effect, Outcome 10 Change in height (cm) by stadiometry from 0‐12 months.
1.11
1.11. Analysis
Comparison 1 Inhaled corticosteroids dose‐response effect, Outcome 11 Change in SD scores (height) from 0‐12 months.
1.12
1.12. Analysis
Comparison 1 Inhaled corticosteroids dose‐response effect, Outcome 12 Change in weight (kg) from 0‐3 months.
1.13
1.13. Analysis
Comparison 1 Inhaled corticosteroids dose‐response effect, Outcome 13 Change in weight (kg) from 0‐6 months.
1.14
1.14. Analysis
Comparison 1 Inhaled corticosteroids dose‐response effect, Outcome 14 Change in weight (kg) from 0‐12 months.
1.15
1.15. Analysis
Comparison 1 Inhaled corticosteroids dose‐response effect, Outcome 15 Change in BMI (kg/m2) from 0‐6 months.
1.16
1.16. Analysis
Comparison 1 Inhaled corticosteroids dose‐response effect, Outcome 16 Change in BMI (kg/m2) from 0‐12 months.
1.17
1.17. Analysis
Comparison 1 Inhaled corticosteroids dose‐response effect, Outcome 17 Change in skeletal maturation (years) from 0‐12 months.
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References

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