Sporadic Steroids May Be as Effective as Daily Dose for Some Preschoolers with Wheezing

Children aged 6 and under with intermittent wheezing triggered by colds may not need to take inhaled steroids on a daily basis to limit the flare-ups that can result in emergency treatment.

The news may be welcomed by some parents who are troubled by the side effects of inhaled steroids, despite studies indicating that they are minimal, due to the fact that the drug is delivered directly to the lungs.

The results of an analysis of 22 studies, published in the journal Pediatrics on May 26, found that inhaled steroids should be taken daily for children aged 6 and under with persistent wheezing, which is a common symptom of asthma – a condition caused by swelling of the airways that may not be diagnosed until a child is older.

While this finding is consistent with the current guidelines of the National Asthma Education and Prevention Program of the National Heart, Lung and Blood Institute, the results of the analysis took a departure from them in addressing young children whose intermittent wheezing is brought on by a cold.

“These children don’t experience wheezing between colds and for them limiting frequency of inhaled steroids to the duration of a cold was as effective,” said lead author Sunitha Kaiser, MD, of the Department of Pediatrics at UCSF.

Guidelines Out of Date for Second Group of Patients

The researchers analyzed data from studies of more than 4,500 children aged 6 and under who had suffered at least two episodes of asthma or wheezing in the last year, by comparing incidences of severe flare-ups that require higher-dose systemic steroids that may need to be administered in a hospital’s emergency department.

Data from 15 studies showed that among children on inhaled steroids taken daily, most of whom had persistent asthma or wheezing, there was a 30 percent reduction in the risk of serious flare-ups, compared to placebo.

The researchers looked at six studies that focused on sporadic use of inhaled steroids, in children whose wheezing was provoked by a cold. They found a 35 percent reduction in severe flare-ups among treated children, compared to placebo.

Two studies contrasting the effects of daily inhaled steroids with intermittent inhaled steroids in children whose wheezing resulted from a cold found no difference in the amount of severe flare-ups. There were no studies that contrasted daily and intermittent inhaled steroid dosing in children with persistent asthma or wheezing.

“It makes sense that these children with frequent symptoms require daily treatment, whereas those who wheeze just during viral illnesses may only need treatment during illnesses,” said Kaiser.

Reducing Frequency Reduces Risk of Side Effects

The researchers examined conflicting data on the impact of inhaled steroids on height, a side effect that makes many parents skeptical of the drug. Studies showed mild growth suppression that generally improved over time.

“We have no definitive data to indicate that intermittent dosing of inhaled steroids impacts growth differently than daily dosing, but it’s generally accepted that reducing frequency of a drug will minimize side effects. Children should be followed closely to monitor benefits and side effects,” said Kaiser.

“Our analysis confirms that inhaled steroids are first-line treatment for children with asthma and wheezing. The more we can control their symptoms with inhaled steroids, the less the need to treat children with systemic high-dose steroids.”

Approximately 20 million people including 9 million children have asthma, according to the National Institutes of Health. Half of all children aged 5 and under have had one or more episodes of wheezing.

Senior author is Michael Cabana, MD, MPH, of the departments of Pediatrics, Epidemiology and Biostatistics at UCSF and the Philip R. Lee Institute for Health Policy Studies also at UCSF. Co-authors are Tram Huynh of UC Berkeley; Leonard Bacharier, MD, of Washington University School of Medicine, St. Louis; Jennifer Rosenthal, MD, of UC Davis; Leigh Anne Bakel, MD, of University of Colorado, Denver; and Patricia Parkin, MD, FRCPC, of University of Toronto.

Senior author Cabana has served as a consultant for Genentech and Merck; and co-author Bacharier has received consulting fees from Merck and Teva, and lecture payments from AstraZeneca and Teva.

UC San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It includes top-ranked graduate schools of dentistry, medicine, nursing and pharmacy; a graduate division with nationally renowned programs in basic, biomedical, translational and population sciences; and a preeminent biomedical research enterprise. It also includes UCSF Health, which comprises top-ranked hospitals, UCSF Medical Center and UCSF Benioff Children’s Hospitals in San Francisco and Oakland – and other partner and affiliated hospitals and healthcare providers throughout the Bay Area.