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Bronsky et al. 1998), and a long-term effect over a period of years (Anonymous 2000).
However, observational studies have suggested that despite long term IHCS in moderate
doses, final adult height is not affected (Agertoft and Pedersen 2000; Peters 2006). While all
guidelines recommend regular monitoring of the child's height, isolated growth failure is not
a reliable indicator of adrenal suppression @unlop, Carson et al. 2004).
On higher doses (800pg/day of beclomethasone dipropionate or equivalent) of IHCS or oral
steroids, blood pressure should be monitored, bone density assessed and cataracts should be
screened for, if being used for greater than a few months. Children may be more at risk of
developing cataracts and glaucoma @enfro and Snow 1992; Nootheti and Bielory 2006),
though one study disagreed (Simons, Persaud et al. 1993). IHCS at the recorrmended levels,
and in some studies even high doses of fluticasone, had minimal effects on bone mineral
density (Hopp, Degan et al. 1995; Kelly, Clee et al. 1995; Agertoft and Pedersen 1998;
Griffiths, Sim et al.2004). However others found that after years of treatment, asthmatics had
lower total body bone mineral density than controls (Boot, de Jongste et al. 1997; Allen,
Thong et al. 2000) with a negative relationship between this density and the total cumulative
doses of IHCS used (Wong, Walsh et al. 2000). Oral candidiasis has been found in up to 5Vo
of adult patients with asthma with positive mouth cultures up to 25Vo and dysphonia is also
said to occur in up to 58Vo of patients at some time (Barnes, Pedersen et al. 1998).
The issues regarding side effects of these medications should also be considered in two other
populations. Firstly, healthy subjects (for example if the diagnosis is not secure) may have
greater systemic side effects to IHCS and oral steroids than asthmatics (Brindley, Falcoz et al.
2000; Brutsche, Brutsche et al. 2000; Falcoz, Oliver et al. 2000; Mackie, McDowall et al.
2000). Secondly, in the last years, treatment with IHCS has been assessed in younger
children; those with preschool and infant wheeze and/or bronchiolitis. Most of the studies in
the preschool group have tried to target those who are more likely to develop asthma over
time - with either recurrent wheezy episodes, personal history of atopy, a family history of
asthma or a positive asthma predictive index (Castro-Rodriguez, Holberg et al. 2000;
Guilbert, Morgan et aI.2006). These have enrolled between 31 and 625 children aged six to
47 months have received doses from 40pglkg to 1000ug via nebuliser or 300-800pg/day via
metered dose inhaler with a spacer and face mask for between 6 and 26 weeks. Improvements
were seen in symptom free days (Bisgaard, Gillies et al. 1999; Roorda, Mezei et al. 2001;
Teper, Colom et al.20[.4; Guilbert, Morgan et al.2N6), in lung function parameters @ao and
McKenzie 2OO2; Teper, Colom et al.20O4), in bronchial hyper-reactivity (Stick, Burton et al.
1995) and in use of additional 'rescue' medication @isgaard, Gillies et al. 1999; Teper,
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