Managed asthma with inhaled corticosteroids.
If your child has been coughing a lot lately and his rescue inhaler (albuterol) is not working as well as before, your health care provider may prescribe an inhaled corticosteroid. You may wonder about its safety and how it will help your child’s asthma.
Asthma is a chronic disease that results in changes in the breathing tubes in the lungs.
* Muscles become tight around the airways.
* Airway walls thicken.
* Thick mucous is produced in the airways.
* Airways become twitchy or react easily to triggers such as smoke or allergens.
According to the Environmental Protection Agency, asthma affects an estimated 7.1 million children nationally. Poorly controlled asthma is the leading cause of children missing school, with 10.5 million school days missed annually.
The goal of asthma care is asthma control by decreasing symptoms and helping children live full, active lives. This is done by starting an inhaled medicine, also called an inhaled corticosteroid, at low doses and stepping up the dose if necessary. The dose can also be stepped down again if your child is doing well. Inhaled corticosteroids may be prescribed either daily or for use only when your child needs them most: with colds or, for some children, during their allergy seasons.
Asthma is managed by following best practice guidelines as outlined in the National Asthma Education & Prevention Program (NAEPP, 2007). These guidelines summarize ideal asthma management. A stepwise approach is used in caring for children with asthma. Step 1 is intermittent care (meaning no daily asthma controller medicine use); step 2 and above means that your child would benefit from a daily asthma medicine.
One easy tool to use in deciding if your child’s asthma is controlled is the Rules of Two® developed by Baylor Health Care System, which includes the following.
* Using a rescue or albuterol inhaler more than two times per week (other than for exercise).
* Waking up at night more than two times per month with asthma symptoms.
* Filling a rescue inhaler more than two times per year.
If any of the above applies to your child, your child may benefit from starting a daily asthma medicine called a controller.
Inhaled corticosteroids are the preferred daily asthma controller medicine for both adults and children based on the NAEPP asthma guidelines.
Inhaled corticosteroids have been used in treating asthma for over 40 years and are considered the best medicine for treating inflammation (swelling) of the airways, as stated in the European Journal of Pediatrics (2011).
Inhaled corticosteroids help asthma and decrease symptoms by:
* Making airways less twitchy.
* Decreasing airway swelling.
* Decreasing mucous.
Inhaled corticosteroids are available in both inhaler and nebulized forms. Inhaled corticosteroids are different from oral corticosteroids, which are taken by mouth and have more side effects.
Generic names of inhaled corticosteroids include:
Inhaled corticosteroids may also be combined with a long-acting form of albuterol in one inhaler. These combination medicines include:
* Fluticasone and salmeterol.
* Budesonide and formoterol.
* Mometasone and formoterol.
Clinical use and research support the effectiveness of inhaled corticosteroids.
The safety of inhaled corticosteroids, especially in children, has been frequently addressed and explored. The safety of these medicines depends on the dose and the type of inhaled corticosteroid used. At low-dose daily strengths, long-term side effects are limited. Some types of inhaled corticosteroids may work better than others.
The most common side effects of low-dose inhaled corticosteroids include thrush and throat irritation with hoarseness of voice. Occasionally, parents report behavior changes in children, though this side effect is very rare. If this happens, the type of inhaled steroid is changed or the dose is adjusted to improve these behavioral concerns. Less commonly seen is a possible delay in linear growth (height).
Thrush, also called candidiasis, is a yeast or fungal infection in the mouth. Thrush is rarely seen in children who use low-dose inhaled corticosteroids. To help prevent thrush, have your child:
* Use a spacer (a tube that holds the medicine between the inhaler and the mouth) with the inhaler. This helps the medicine get into the lungs with less inside the mouth.
* Rinse with water after using an inhaled corticosteroid.
Throat irritation with hoarseness of voice occurs more often with dry powder inhalers but has been seen with metered dose inhalers. This symptom can worsen if your child has a cold and is coughing. To help prevent throat irritation and hoarseness:
* Make sure your child is rinsing after using an inhaled corticosteroid.
* Use a spacer when using a metered dose inhaler containing an inhaled corticosteroid.
* If your child is using a dry powder inhaler, ask your provider if it can be changed to a metered dose inhaler.
A delay in linear growth or height is a common concern among parents when their child is prescribed an inhaled corticosteroid. This concern has been researched in several long-term asthma studies:
* At low doses, the risk of a height delay is unlikely. It is more likely to be seen at medium-to-high daily doses.
* This delay in height averages about one centimeter. For most children, their height catches up when looking at their predicted adult height, though this may not always be the case.
Talk to your provider about the best type and dose of inhaled corticosteroid for your child.
Medium-to-High-Dose Inhaled Corticosteroids
Medium-to-high-dose inhaled corticosteroids can have more significant side effects, which can include:
* Bone loss or osteoporosis.
* Adrenal suppression (a decrease in natural steroids the body makes).
An asthma specialist should follow children who are taking medium-to-high-dose inhaled corticosteroids closely due to the risk of these side effects.
Helping Children Live Full, Active Lives
The benefits of inhaled corticosteroids outweigh the risks when prescribed appropriately in children.
As stated by O’Bryne et al. in Chest (2013), children with poorly controlled asthma:
* Have more asthma attacks.
* Are less physically fit and less active.
* Are more likely to be overweight.
* Are more likely to have learning disabilities and academic concerns.
* Have more stress, which can lead to depression and anxiety.
Using inhaled corticosteroids for asthma has helped children achieve better asthma control, resulting in a higher quality of life.
Though there may be risks, the benefits of using inhaled corticosteroids include: fewer school absences, better sleep, improved learning in school, confidence in being active in daily life and overall less strain on the family.
Kathleen Kelly Shanovich, APNP, is a PNP for the University of Wisconsin School of Medicine and Public Health, Pediatric Allergy. She is a member of NAPNAP and the American Academy of Allergy, Asthma & Immunology and co-directs the Madison Asthma Camp.
Kate Swenson, APNP, is a PNP for the University of Wisconsin Medical Foundation, Pediatric Pulmonology. Her special interest is the use of technology to improve adherence to asthma medications. She participates as a group leader for Madison Asthma Camp.