Children who grew up on Pulmicort end up a half inch smaller as adults.(Jakob Montrasio 孟亚柯/Flickr)
It turns out that the stunted growth associated with the use of budesonide, a long-term medication commonly used to control childhood asthma, is likely permanent. That's according to a study presented yesterday at the European Respiratory Society meeting in Vienna and published in the New England Journal of Medicine.
The authors, several of whom received consulting fees from drug companies, followed 943 children from the ages of 5 to 13 who were randomly treated with budesonide, nedocromil -- another asthma drug that was discontinued in the U.S. in 2008 -- or a placebo for a period of 4 to 6 years. A height deficit was observed with 1 to 2 years after children began taking budesonide, and by the age of 25, when they would be expected to have reached their full adult height, these same children were about half an inch shorter, on average, than the other participants in the study.
Known in the U.S. by the brand name Pulimicort, the glucocorticoid (steroid) is widely prescribed as a preventative medication. The key to its effectiveness is continuous use: taken twice daily through an inhaler, it reduces inflammation in the lungs and thus reduces the number and severity of asthma attacks. It is not used to treat an attack that is already underway.
In children who had not yet undergone puberty, higher doses by weight of budesonide taken within the first two years of treatment were directly associated with greater reductions in adult height. But neither their age at the trial's onset nor the duration for which they had suffered from asthma before beginning treatment had an effect on the ultimate growth deficit. Shorter adult height was also observed regardless of initial height, sex, and race or ethnicity.
On the other hand, studies have associated an early age of onset is also a risk factor for stunted growth, as is atopy, a skin condition that commonly presents in children with asthma. This new data supports the earlier findings that these are independent risk factors for growth deficits, and indicates that atopy-induced growth retardation persists into adulthood as well.
The effective management of asthma remains essential not only in controlling for the acute effects of the disease, severe attacks of which can require hospitalization, but also in ensuring that children with asthma are able to maintain a healthy lifestyle. Chronic coughing and difficulty breathing can prevent them from being physically active and from getting a good night's sleep. And another study presented at the Vienna conference found that poor asthma control and lack of participation in sports put children with asthma at an increased risk of being bullied.
It has more recently been determined that half the dosage of budesonide that was used in this trial is still able to control asthma symptoms in young children while being associated with a slightly lower reduction in height. Oral medications called leukotriene modifiers can also be prescribed for long-term asthma treatment, but the study's lead author told The New York Times that glucocorticoids are "the most effective therapy in the treatment of childhood asthma, and currently the only therapy we know of that decreases the risk of dying."
While height is widely regarded as desirable and may even be determinative of income and social capital, the half an inch -- when weighed against the effectiveness of budesonide in treating children with asthma -- will probably be something we look past, for now.