Steroid treatment, and side effects
An article in the Wilmington (Delaware) News Journal described two studies published recently, suggesting caution in using steroid medications in children. The new studies were published in the January 22, 2009 issue of the New England Journal of Medicine. Here is my interpretation of these studies.
There is no doubt that physicians should prescribe steroid medications carefully. However, I am not convinced that these studies should alter our standard treatment for wheezing and allergy in children.
One study enrolled 687 children younger than 6 years old, admitted to hospitals in England for wheezing. Those who received prednisolone (Orapred and other brands) stayed in the hospital 11 hours on average; those who received placebo stayed 14 hours on average. There was no difference in side effects. The authors concluded, despite the 20% reduction in hospital stay, that the prednisolone was unnecessary.
These results are puzzling. Typically, young children might wheeze from asthma, or from a viral infection. Many previous studies have found a big benefit from using prednisolone to treat wheezing children with known asthma, often quickly relieving their breathing difficulty. However, the benefit is less clear for children wheezing due to a viral infection. In my practice, I have found that prednisolone in short courses is effective in reducing wheezing in some, but not all children. Side effects have been minimal. I will prescribe it sometimes, if there is a family history of asthma, to try to keep a child out of the hospital.
I am concerned that this study lumped these two groups of wheezing children together, diluting the apparent benefit of the short course of prednisolone. Steroids have been used for decades as a safe and effective treatment for asthma-related wheezing, when carefully used along with albuterol and other treatments. Further research might show a diminished role for steroids in the future, or find better rescue treatments for children with asthma attacks, but the weight of evidence still leads me to feel comfortable treating asthmatic children with prednisolone for wheezing and difficulty breathing when necessary.
The second study, performed in Canada, enrolled 129 healthy toddlers and preschool children to receive 10 months of either high-dose inhaled fluticasone, or placebo, hoping that the fluticasone would prevent wheezing. It did; wheezing severe enough to require oral steroids was reduced from 18% to 8% of children. However, children receiving fluticasone gained less weight (1 pound) and less height (1/4 cm). The authors concluded that the benefits of preventative high-dose fluticasone might not outweigh the risks.
I agree with their conclusions, as far as they go. High dose fluticasone appears to carry potential risks of slowed growth. However, the study used doses of fluticasone that are 4 to 8 times higher than the standard doses of Flovent, Flonase and Veramyst that we use in children. Previous studies, with larger numbers of children over longer periods of time, have shown minimal or no measurable effect on height growth from daily use of the usual doses of steroids. This study does not persuade me to avoid using standard doses of fluticasone and other steroids for children who need them.
On the other hand, a more recent study followed children who received up to 4 short courses (under a week) of oral steroids per year; no side effects were found at all.
No medication should be prescribed without weighing the potential benefits against possible side effects, and discussing them with the family. And further research may change expert opinion. But as things stand now, I remain reassured that our usual, standard treatment of asthma and hay fever remains safe and effective, when used properly.
-- David M. Epstein MD