The Breath of Life

By Christine Gorman

Doctors have long been aware that daily treatment with inhaled steroids is critical to saving the lives of patients with severe asthma--both children and adults. Although the drugs cannot stop an asthma attack that has already started (different medications are needed for that), inhaled steroids are very good at counteracting the chronic inflammation that predisposes the lungs to asthma attacks in the first place. Until now, however, many physicians have hesitated to use inhaled steroids to treat milder cases of asthma in children. The drugs have side effects--most notably an apparent slowing of bone growth--that make them seem less than ideal for youngsters, whose bones are still developing.

But two reports published last week in the New England Journal of Medicine conclude that the benefits of inhaled steroids outweigh the risks in children after all. In the first study, which tracked more than 1,000 North American kids ages 5 to 12 suffering from mild to moderate asthma, researchers found that boys and girls on inhaled steroids were much less likely to be rushed to the emergency room or to need treatment with even more powerful drugs. While these kids were indeed about 0.4 in. shorter than children on nonsteroid drugs after the first year of treatment, the lag in growth rates quickly disappeared. Results from the children's X rays indicate there should be no measurable difference in adult height. Similarly, in the second study, of 211 adults from Denmark who started treatment with inhaled steroids as children, researchers found no long-term effect on height.

These results should reassure parents who have been told their son or daughter needs inhaled steroids. "The word steroid is scary and confusing to people," says Dr. Gail Shapiro, a clinical professor of pediatrics at the University of Washington School of Medicine in Seattle and a co-author of one of the papers. The first problem is that corticosteroids (the scientific name of the asthma drugs) sounds an awful lot like the anabolic steroids used by some body builders. They aren't. Not only are corticosteroids safer but the inhaler makes them especially effective as well. Breathing in the drug allows most of it to settle in the lungs, where it does the most good and causes fewer side effects.

There was one surprise from the North American study. Contrary to expectations, children on inhaled steroids did not fare better than the control group in tests that measure lung capacity. Researchers speculate that there was already some permanent damage that the steroids could not counteract, as study subjects had been found to have asthma an average of five years before they started treatment. Some experts believe that for optimal results, steroid therapy should begin within two or three years of the initial symptoms. If that's the case, doctors may need to give inhaled steroids to children as young as one and two years old.

Before that can happen, new studies--some already under way--must determine if the benefits of inhaled steroids outweigh the risks for toddlers. Until then, doctors and parents of the youngest patients are going to face some tough decisions.

For more information on asthma, visit time.com/personal or nhlbi.NIH.gov You can e-mail Christine at gorman@time.com