term inhaled corticosteroid (ICS) treatment on bone Long-term Budesonide or Nedocromil mineral accretion over a period of years. Treatment, Once Discontinued, Does Not Alter the Course of Mild to Moderate Asthma in STUDY POPULATION. Cohort follow-up study for a median Children and Adolescents of 7 years with 877 children 5 to 12 years of age who Strunk RC, Sternberg AL, Szefler SJ, et al. J Pediatr. had mild-to-moderate asthma and initially were ran- 2009;154(5):682–687 domly assigned in the Childhood Asthma Management Program. PURPOSE OF THE STUDY. To determine whether long-term, METHODS. Serial dual-energy x-ray absorptiometry scans continuous use of inhaled antiinflammatory medications of the lumbar spine to assess bone mineral density were affects asthma outcomes in children with mild-to-mod- performed for all patients. Annual bone mineral accre- erate asthma after use is discontinued. tion was calculated for 531 boys and 346 girls. STUDY POPULATION. A total of 941 children, 5 to 12 years of RESULTS. Oral corticosteroid bursts produced dose- age, who had previously participated in the Childhood dependent reductions in bone mineral accretion (0.052, Asthma Management Program (CAMP). 0.049, and 0.046 g/cm2 per year with 0, 1–4, and Ն5 courses, respectively) and increases in the risk for osteo- METHODS. During the CAMP trial, subjects received treat- penia (10%, 14%, and 21%, respectively) in boys but ment with budesonide, nedocromil, or placebo for 4.3 not girls. Cumulative ICS use was associated with a small years. During the posttrial period, asthma manage- decrease in bone mineral accretion in boys but not girls ment was provided by primary care physicians ac- but no increased risk for osteopenia. cording to National Asthma Education and Prevention Program guidelines. Posttrial evaluations included spi- CONCLUSIONS. Multiple oral corticosteroid bursts over a rometry, methacholine challenge, measurements of period of years can produce dose-dependent reductions height, weight, and bone density, the Child Behavior in bone mineral accretion and increased risk for Checklist, and the Pediatric Asthma Quality of Life osteopenia in children with asthma. ICS use has the Questionnaire. potential to reduce bone mineral accretion in male children progressing through puberty, but this risk is RESULTS. Treatment for asthma was similar for all 3 likely to be outweighed by the ability to reduce the groups. The budesonide group had 29% fewer pred- amounts of orally administered corticosteroids used for nisone courses (P ϭ .05) and 36% fewer urgent care these children. visits (P ϭ .05), compared with the placebo group, REVIEWERS COMMENTS. One of the goals for prescribing an ICS but the rates of these events were low in all groups. is to decrease the chances of acute exacerbations, which The statistically significantly decreased height in the often require oral corticosteroid treatment for asthma budesonide group, relative to the placebo group, at the control. The findings of this long-term treatment study end of the CAMP trial (1.1 cm; P ϭ .005) persisted, highlight one of the several reasons to strive to minimize with a decrease of 0.9 cm (P ϭ .01) at the end of the repeat doses of orally administered corticosteroid in chil- posttrial follow-up period. This height decrease was ob- dren, especially during times of peak bone mineral ac- served in girls but not boys. No significant differences cretion. Interestingly, the effects of decreased bone min- between the groups were observed in mean percentage eral accretion with orally administered corticosteroid of time receiving inhaled corticosteroid, mean percent- and ICS were not seen for girls in this study. Girls might age of time using no medications, end-of-trial percent- have been less susceptible because of estrogen effects age of predicted forced expiratory volume in 1 second and/or being on the flat portion of their bone mineral and percentage of predicted forced vital capacity, accretion curve during the study period, but this topic bronchodilator reversibility, methacholine responsive- will require additional study. The finding of no increased ness, rate of fractures, sexual maturation, or any of the risk for osteopenia with regular use of ICS is somewhat psychological or asthma-specific quality of life measures reassuring, although most of the children in this study examined. were receiving low doses of ICS, and additional studies with children receiving medium or high doses ICS are CONCLUSIONS. During the posttrial follow-up period, warranted. asthma morbidity and medication use were not appre- ciably affected by earlier long-term use of budesonide or URL: www.pediatrics.org/cgi/doi/10.1542/peds.2009-1870SSS nedocromil. The reductions in prednisone course and Jaime Olenec, MD urgent care visits seen in the budesonide group do not James E. Gern, MD seem relevant, on the basis of the overall rates of these Madison, WI events in all groups.

S150 BEST ARTICLES RELEVANT TO PEDIATRIC ALLERGY AND IMMUNOLOGY Downloaded from www.aappublications.org/news by guest on September 26, 2021 REVIEWER COMMENTS. Inhaled corticosteroids are safe and ef- duration of hospitalization. Secondary outcomes were fective for long-term control of asthma, but this study Preschool Respiratory Assessment Measure scores, use of shows that continued benefit requires ongoing use. We albuterol, and 7-day symptom scores. must continue to consider factors such as symptoms, RESULTS. There was no significant difference in the dura- spirometry findings, and biochemical markers and to use our clinical judgment to determine which children will tion of hospitalization between the placebo group and benefit from continued treatment. It is hoped that future the prednisolone group (13.9 vs 11.0 hours) or in the phenotype and genotype studies will shed more light on interval between hospital admission and signoff for dis- this issue. charge by a physician. There was also no significant difference in any of the secondary outcomes or in the URL: www.pediatrics.org/cgi/doi/10.1542/peds.2009-1870TTT number of adverse events. John E. Duplantier, MD Indianapolis, IN CONCLUSIONS. In preschool-aged children presenting to a hospital with mild-to-moderate wheezing associated with a viral infection, oral prednisolone treatment was not superior to placebo. Oral Prednisolone for Preschool Children With Acute Virus-Induced Wheezing REVIEWER COMMENTS. I fondly remember my numerous rota- Panickar J, Lakhanpaul M, Lambert PC, et al. tions in the emergency department during my residency N Engl J Med. 2009;360(4):329–338 at St Louis Children’s Hospital, when one of my goals PURPOSE OF THE STUDY. To determine the efficacy of a short was to quickly assess wheezing children and to just as course of oral prednisolone treatment for wheezing in- quickly give them oral steroids. This report suggests that duced by upper respiratory viral infections in preschool- we should think twice before giving that oral steroid. aged children. However, it must be pointed out that the dose of pred- nisolone used in the trial was substantially less than 2 STUDY POPULATION. The study included 700 children be- mg/kg and the lack of effect may reflect, in part, the tween 10 and 60 months of age who were hospitalized at dose. Furthermore, most of the patients in this trial did 3 different centers in England with attacks of wheezing not have atopy. Wheezing children with allergies do associated, by the judgment of an examining physician, respond to oral corticosteroid treatment. This trial does with viral infection. Most of these patients did not have raise very important questions about commonly ac- the classic phenotype of atopic asthma. cepted norms of treatment, but “real-world” practice METHODS. This was a randomized, double-blind, placebo- may be different. controlled trial. In the nonplacebo arm of the study, children 10 to 24 months of age received 5 days of URL: www.pediatrics.org/cgi/doi/10.1542/peds.2009-1870UUU prednisolone treatment at 10 mg/day, whereas the older Brian A. Smart, MD children received 20 mg/day. The primary outcome was Glen Ellyn, IL

PEDIATRICS Volume 124, Supplement 2, November 2009 S151 Downloaded from www.aappublications.org/news by guest on September 26, 2021 Long-term Budesonide or Nedocromil Treatment, Once Discontinued, Does Not Alter the Course of Mild to Moderate Asthma in Children and Adolescents John E. Duplantier Pediatrics 2009;124;S150 DOI: 10.1542/peds.2009-1870TTT

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Downloaded from www.aappublications.org/news by guest on September 26, 2021 Long-term Budesonide or Nedocromil Treatment, Once Discontinued, Does Not Alter the Course of Mild to Moderate Asthma in Children and Adolescents John E. Duplantier Pediatrics 2009;124;S150 DOI: 10.1542/peds.2009-1870TTT

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