Inhaled corticosteroids in children. Is there a 'safe' dosage?

Inhaled corticosteroids are effective for the treatment of asthma. Because of the appreciation of the importance of airway inflammation in the pathogenesis of the disease, these drugs are being used more frequently not only in severe but also in moderate asthma. Treatment rarely has to be stopped because of topical adverse effects since oropharyngeal candidiasis and dysphonia are uncommon in children. However, paediatricians need to remain alert for the possibility of systemic adverse effects. With sensitive techniques, dose-dependent adrenal suppression has been documented in children treated with inhaled steroids but generally this effect has no clinical relevance. Although suppression of short term growth velocity has been reported, long term studies have shown that when growth impairment occurs in a child with asthma it is more likely to reflect poor asthma control than the administration of inhaled corticosteroids. Calcium supplementation may be necessary in children with asthma treated with inhaled steroids since this treatment may cause reduction in osteocalcin, a marker of osteoblast activity and bone formation. Other systemic adverse effects have been reported in case reports. The use of a large spacer device has been shown to reduce the incidence of both topical and systemic adverse effects from inhaled steroids and their use should be encouraged. In any child with asthma who really needs inhaled steroids, the lowest dose possible should be prescribed; however, the mistake of prescribing doses too low to be therapeutically effective should be avoided.