Running head: INTEGRATIVE LITERATURE REVIEW 1

Integrative Literature Review

Kelly W. Bayless

Bon Secours Memorial College of Nursing

NUR 4122

March 22, 2018

Christine Turner, PhD, RN

“I Pledge….”
 INTEGRATIVE LITERATURE REVIEW 2

Abstract

Purpose: The purpose of this integrative review is to identify the relationship between the long-

term use of corticosteroids and growth suppression in asthmatic pediatric patients.

Background: Corticosteroids are commonly prescribed to asthmatic children. The long-term

effects of these drugs on the growth of these pediatric patients has yet to be completely

determined and agreed upon.

Method: This is an integrative review in which a literature analysis was conducted through

online databases. The articles discussed are quantitative studies that were chosen based on

applicable criteria. This information was then used to determine the effect on growth in

asthmatic pediatric patients.

Limitations: The greatest limitation of this review is in the authors inexperience in conducting

an integrative review. Other limitations include criteria utilized to locate articles.

Results and Findings: The findings accumulated for this integrative review offer a mixed notion

on corticosteroid use affecting the growth of asthmatic children.

Implications and Recommendations: More research is recommended on this topic due to the

mixed consensus by researchers. Future areas of study include expanding the number of

corticosteroids and corresponding dosages studied.

 INTEGRATIVE LITERATURE REVIEW 3

Integrative Literature Review

The purpose of this integrated review is to identify the relationship between long-term

corticosteroid use in asthmatic children and suppressed growth rate. Asthma is one of the most

common chronic disease of children with over 7 million diagnosed cases in the United States

(Singh, Weinberger, Zimmerman, & Starner, 2013). Long courses of corticosteroids are

frequently prescribed to children to manage chronic conditions such as asthma (Alijebab,

Choonara, & Conroy, 2017). Although there are various adverse drug reactions (ADRs) that are

associated with the use of corticosteroids, such as weight gain and headaches, there has not been

a general consensus by researchers on the effect of growth rate in children.

Being such a common affliction among children, it is important to research and ensure

that the methods prescribed by pediatricians are doing more good than harm to the patients and

not leaving them with long-term, irreversible side effects. Due to the frequent use of

corticosteroids as a common treatment option for asthma in children, researchers have already

identified the need for these studies. The intention of this review is to examine and discuss

published data related to the researchers PICO question: In adolescents with asthma will inhaled

corticosteroids suppress normal growth as compared to treatment without corticosteroids?

Design and Methods

This integrative review focuses on five research articles. The researcher utilized

EBSCO’s Nursing Resource Center, Google Scholar, and Academic Search Complete databases.

The key search words were child, asthma, corticosteroids, and growth. These keywords resulted

in over 60,000 articles. The articles were filtered by publication year, peer-review, and

application to the PICO question. The researcher expanded the date range to 2008-2018 due to a
 INTEGRATIVE LITERATURE REVIEW 4

high volume of meta-analyses and reviews. Full-text accessibility was a significant limiting

factor in obtaining articles.

These articles were then evaluated by the researcher for relevance to the PICO question.

Quantitative articles were a necessity due to the nature of the PICO question. Articles by

appropriate and qualified authors were then prioritized. Examples of relevant qualifications

include Medical Doctor (MD), Doctor of Pharmacy (Pharm. D.), and Master of Health Science

(M.H.S.). Five articles were selected for inclusion in this integrative review, four of which were

quantitative studies (Kelly et al., 2012; Renosto et al., 2017; Singh et al., 2013; Skoner, Maspero,

& Banerji, 2008) and one systematic review of literature (Alijebab et al., 2017).

Findings

The results and findings of the articles identified a mixed consensus on the connection

between corticosteroid use and growth suppression in asthmatic children. Three of the five

research articles found a direct correlation between corticosteroid use and growth retardation

(Alijebab et al., 2017; Kelly et al., 2012; Singh et al., 2013). The two remaining articles did not

find a direct correlation between the two variables (Renosto et al., 2017; Skoner et al., 2008). A

summary of the compiled research articles is presented in Table 1 – Article Evaluation.

In a systematic literature review conducted by Alijebab et al. (2017), the authors aim to

identify the most likely ADRs from long-term corticosteroid use in children. The design was a

systematic literature search from six databases. The academic databases were searched by using

keywords, such as “corticosteroid” and “adverse drug reaction”. The researchers accumulated

7,714 articles total in which 101 met the appropriate inclusion criteria. The Cochrane

Collaborations tool was used to detect bias in the randomized controlled trials. A meta-analysis

of the randomized controlled trial was performed by RevMan 5.3 software. There were a
 INTEGRATIVE LITERATURE REVIEW 5

combined 6,817 children involved in the studies that reported 4,321 ADRs. The children of these

studies were commonly afflicted with inflammatory conditions such as asthma. Growth

retardation was reported in 18.1% of cases, showing a correlation between the long-term use of

corticosteroids and growth suppression in children.

Kelly et al. (2012) conducted a double-blind, placebo-controlled Childhood Asthma

Management Program (CAMP) trail to research the long-term effects on growth in relation to

long-term inhaled corticosteroid (ICS) use. This study aimed to investigate a previously

neglected area of research in long-term growth suppression as opposed to during and shortly

after use. There were 1,041 pediatric participants, of which 943 completed the trial. Children

were divided into three different groups: Budesonide, Nedocromil, and placebo. These children

ranged in age from 5-13 years old and their height was measured every 6 months for the first 4.5

years. For the subsequent 8 years, participants were measured 1 to 2 times a year. Adult height

was determined at a mean of 24.9 years of age. A multiple linear regression was used to compare

mean height of the participants. The researchers revealed that the Budesonide group had a mean

height deficit of 1.2cm less than the placebo group. This correlation was also directly linked with

a higher dosage of this medication required by the participant. The Nedocromil group and the

placebo were unremarkable in terms of height deficits. Researchers discovered a positive

correlation between the use of a particular ICS as well as higher dosage and growth suppression.

In a retrospective cohort study conducted by Renosto et al. (2016) growth velocity and

weight gain were investigated in prepubertal asthmatic children. These researchers also took into

account the use of ICS and all ICS used by participants were converted into beclomethasone as a

reference for dosage considerations. The researchers had a sample of 85 pediatric patients

diagnosed with asthma according to the Global Initiative for Asthma guidelines. These patients
 INTEGRATIVE LITERATURE REVIEW 6

were between 2 to 9 years of age, represented both sexes, and had been monitored for a

minimum of 12 months by the Division of Allergy, Clinical Medicina de Universidade Federal

de São Paulo (EPM-Unifesp) in São Paulo Brazil. A z-score of body mass index for age was

calculated using height and weight data with the use of WHO Anthro Plus® Software. Tanner &

Whitehouse curves were used to analyze growth rate. The researchers did not find an association

between ICS use and growth rate. However, they did find a positive correlation between asthma

severity and decreased prepubertal growth rate regardless of ICS use.

Singh et al. (2013) conducted a retrospective cohort study on the effects of daily ICS in

preschool age children. The purpose of this research was to study an age group that had been

previously neglected in ICS use and the effects on children. These researchers had a sample of

145 children all under the age of 5. The participants were divided into 3 groups that were

administered different medications: Beclomethasone by metered dose inhaler (MDI), Fluticasone

by MDI, and Montelukast sodium orally. The use of intranasal steroids (INS) was also monitored

and recorded as well. These participants visited the Pediatric Allergy and Pulmonary Clinic at

the University of Iowa a minimum of every 3 weeks over the course of 12 months. A random

coefficient regression model was used for comparing growth during treatment course. The

clinical height measurements were converted to z-scores and then the slopes of linear growth

were utilized. The researchers found no significant effects on growth with ICS use. They did,

however, find an unexpected correlation between INS use and growth suppression.

A random, double-blind, multicenter, placebo-controlled, parallel-group study was

conducted by Skoner et al. (2008) on the long-term safety with inhaled Ciclesonide on growth in

asthmatic children. The researchers aimed to see if using Ciclesonide, a newer ICS, would have

the adverse reaction of growth suppression effects. The researchers had 1,127 patients screened
 INTEGRATIVE LITERATURE REVIEW 7

at 85 centers in 4 different countries. Of these, 661 were selected and 609 completed the study.

These participants were between the ages of 5 and 8.5 and had an asthma diagnosis for at least 3

months. This study took place over the course of 12 months with measurements taken every 6

months. Each clinic location was provided the same stadiometer which was required to be

calibrated within 4 hours of measuring a participant. Growth rate was measured as a linear

regression of the slope height versus time. The linear regression was analyzed by using the

analysis of covariance (ANCOVA) model. The researchers found no significant delay in growth

rate over the one-year course of Cicelsonide; the growth rates were comparable to the placebo.

Discussion/Implications

The articles selected for review show both a correlation between corticosteroid use and

growth suppression and no correlation between the two. The researcher outlined the review

according to the following categories: non-corticosteroid related growth suppression,

corticosteroid related growth suppression, and medication and dosage. The following is a

discussion on the implications of the articles and is organized by common themes.

Non-Corticosteroid Related Growth Suppression

One particular study made a connection that the others did not: asthma severity itself, as

opposed to its prescribed medications, may have a consequential effect on growth in children

afflicted (Renosto et al., 2017). Although these researchers still investigated use of ICS and

growth suppression, they were only successful in finding a strong connection between more

severe asthma forms and growth rate. The researcher believes that this is a semi-neglected and

vastly important area of research. This theme is one that has major implications for future

research studies and should be further investigated. This finding suggests that the perceived

correlation between ICS use and suppressed growth rate could potentially be attributed to severe
 INTEGRATIVE LITERATURE REVIEW 8

asthma. ICS use is assumed in patients with severe asthma and therefore the direct causation may

not be accurately ascertained.

Corticosteroid Related Growth Suppression

Two studies did find a direct correlation between the use of corticosteroids and growth

suppression in asthmatic children (Aljebab et al., 2017; Singh et al., 2013). Researchers from the

systematic review were unique in stating the implications from their conclusions should be taken

into consideration for pediatrician practice (Aljebab et al., 2017). Researchers stated that the idea

of growth suppression due to the use of these corticosteroids has often been overlooked by

pediatricians and has not been emphasized to parents when prescribing these medications to their

children. These researchers believe their findings indicate a need for more transparency in

pediatric practice. Singh et al., (2013), even expanded their research to a younger age group that

has so far been neglected. This study was especially important and relevant in looking at the

route of the corticosteroid as well. The implications behind this are massively important in

realizing that intranasal steroids may not be as strong of an option for younger children due to

their adverse effects of growth.

Medication and Dosage

Researchers from two separate studies expanded the approach to this topic by analyzing

differences among diverse corticosteroids (Skoner et al., 2008) and the dosage of corticosteroids

(Kelly et al., 2012). The researcher noticed a lack of studies that investigated such aspects of

corticosteroid use in children. These researchers realized that for some pediatric asthmatic

patients, there were not as many effective options for treating their asthma outside of

corticosteroids. These researchers aimed to find these patients a way to use the medications they

needed while hopefully avoiding the adverse effects on growth suppression. Researchers of
 INTEGRATIVE LITERATURE REVIEW 9

Skoner et al., (2008) found that Ciclesonide, a newer ICS on the market, would be a viable

alternative to asthmatic children as it did not appear to have adverse reactions, including growth

suppression. It is important to note, however, that these researchers were financed by Altana

Pharma US, Inc. Kelly et al., (2012) opened up the idea of future research investigating careful

dosages to prevent the growth suppression in asthmatic children. The researchers provided two

studies that imply research could be greatly expanded on corticosteroid use in asthmatic children,

especially in the types and amount.

Limitations

In the execution of this integrative review, the researcher encountered various limitations.

A significant limitation is in the researcher’s deficit of knowledge and experience in the process

of conducting an integrative review. The requirement of a maximum of 5 articles published

within the past 10 years was also a limitation in that it did not allow for an exhaustive review of

the subject. The researcher was only able to offer a limited review of the topic presented by the

PICO question. The researcher was instructed to find articles within a 5-year time frame, but this

had to be expanded to 10 years due to the vast amount of meta-analysis and reviews on the topic.

The greatest limitation determined by the author in regard to the 5 articles was the narrow

focus of their conclusions. More comprehensive studies are needed to address the large number

of variables that can play a role in growth suppression of asthmatic children. Many of the

researchers addressed this issue in the discussion of their findings, suggesting investigating

greater number of corticosteroids and varying dosages for future research. Renosto et al. (2016)

and Singh et al. (2013) both admitted a strong limitation of their research was in its retrospective

nature that allowed for possible research bias.

Conclusions
INTEGRATIVE LITERATURE REVIEW 10

The evidence compiled for this integrative review both supports and opposes the idea that

long-term corticosteroid use suppresses growth in asthmatic pediatric patients (Aljebab et al.,

2017; Kelly et al., 2012; Renosto et al., 2016; Singh et al., 2013; Skoner et al., 2008). Themes

that emerged during this review were: non-corticosteroid related growth suppression,

corticosteroid related growth suppression, and medication and dosage. Researchers supported the

notion that growth suppression was directly correlated to corticosteroid use, did not find a

correlation between the two, or found that it was dosage/medication dependent. From this

integrative review, the researcher believes that different types of studies with larger samples,

medications, and dosages need to be conducted in order to have a better understanding of a

presence of a correlation or not. In relation to the PICO question being addressed, whether long-

term corticosteroid use has negative effects on growth rate in asthmatic children, the literature

reflects mixed findings.

 INTEGRATIVE LITERATURE REVIEW 11

References

Aljebab, F., Choonara, I., & Conroy, S. (2017). Systematic review of the toxicity of long-course oral

corticosteroids in children. Plos One,12(1). doi:10.1371/journal.pone.0170259

Kelly, H. W., Sternberg, A. L., Lescher, R., Fuhlbrigge, A. L., Williams, P., Zeiger, R. S., . . .

Strunk, R. C. (2012). Effect of inhaled glucocorticoids in childhood on adult height. The New

England Journal of Medicine,367(10), 904-912. doi:10.1056/NEJMoa1203229

Renosto, L. C., Acatauassu, C., Andrade, I., Neto, M. R., Paulino, T. L., Suano-Souza, F. I., . . .

Sarni, R. O. (2017). Growth velocity and weight gain in prepubertal asthmatic children. Revista

Da Associação Médica Brasileira,63(3), 236-241. doi:10.1590/1806-9282.63.03.236

Singh, S. B., Weinberger, M. M., Zimmerman, M. B., & Starner, T. D. (2013). Growth of preschool

age children receiving daily inhaled corticosteroids. Allergy and Asthma Proceedings,34(6), 511-

518. doi:10.2500/aap.2013.34.3700

Skoner, D. P., Maspero, J., & Banerji, D. (2008). Assessment of the long-term safety of inhaled

ciclesonide on growth in children with asthma. Pediatrics,121(1). doi:10.1542/peds.2006-2206


First Author Aljebab, F., Choonara, I., & Conroy, S. (2017). Systematic review of the toxicity of long-
(Year)/Qualifications course oral corticosteroids in children. Plos One,12(1). doi:10.1371/journal.pone.0170259
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
TALE 1 – ARTICLE EVALUATION
 Long term corticosteroid use in children has been associated with adverse drug
reactions
 This article designed a review to identify the most common and serious adverse
drug reactions
 The researchers want to identify the most likely adverse drug reactions from long-
term corticosteroid use in children and have this information incorporated into
medication teaching from pediatricians
 Systematic literature search from six databases
 7, 714 articles retrieved, 101 met the inclusion criteria
 The authors identified a conflict of interest in Imti Choonara is an Academic Editor
of Plos One
 Adverse Corticosteroid effects – Weight gain, growth retardation, and Cushingoid
features
 Academic databases searched using key words
 Age limited from 28 days to 18 years
 Studies used included corticosteroid use greater than 15 days
 Quality of randomized controlled trials was assessed using the Cochrane
collaborations tool to detect bias
 Prospective cohort studies were assessed using the STROBE checklist. Anything
with a score of less than 70% was not included
 Meta-analysis of the randomized control trial was done by RevMan 5.3 software
 Weight gain, delayed growth, and Cushingoid features were the top three adverse
drug reactions
 The most serious ADR was infection, with Varicella zoster being the most common
  Behavioral changes were found to be the most common reason for discontinuing
corticosteroids
 Growth delay was greater with Prednisolone and more prominent in boys
 One study found oral corticosteroids to delay growth more in comparison to
inhaled
Appraisal/Worth to  The adverse drug reactions of long term corticosteroid used by children is
practice “underappreciated” by pediatricians. Pediatricians as well as parents, need to be
aware of the long-term effects, such as delayed growth.
 First Author
(Year)/Qualifications . . Strunk, R. C. (2012). Effect of inhaled glucocorticoids in childhood on adult height. The
New England Journal of Medicine,367(10), 904-912. doi:10.1056/NEJMoa1203229
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
Kelly, H. W., Sternberg, A. L., Lescher, R., Fuhlbrigge, A. L., Williams, P., Zeiger, R. S., .
 While the effects of inhaled glucocorticoids (ICS) have shown temporary growth
delays in children, these researchers aim to see if this growth delay becomes a
decrease in adult height
 Researchers want to provide more long-term effects on growth in relation to long-
term childhood ICS use
 Double-blind, placebo-controlled Childhood Asthma Management Program
(CAMP) trial
 Children divided into three groups: Budesonide use, Nedocromil use, and placebo
 Height and weight were measure every 6 months for the first 4.5 years
 For the next 8 years, these were measured 1 to 2 times a year
 Adult height determined at a mean age of 24.9.
 1041 children from the ages of 5 to 13
 Children had mild to moderate asthma
 Studies approved by institutional review board at each study center
 Participants of age provided consent; Minors provided assent and informed
consented by a parent or guardian
 Long term height deficit due to childhood ICS use
 Children were assessed by their primary care physicians under the advisement
from the CAMP physicians
 At each clinic, there was a trained technician to measure height of the patients
 Detailed history of participants health and medication use was obtained
 Multiple linear regression model was used to compare mean height
 Obtained adult height for 943 or the 1041 particpants
 The Budesonide group has a mean height 1.2 cm less than the placebo group
 The Nedocromil and Placebo groups were similar
  When taking into consideration the dosage of Budesonide, the larger dose
correlated with a lower adult height
Appraisal/Worth to  ICS may be a the most effective treatment for some pediatric patients with
practice asthma. This study shows that growth delay and short adult height could possibly
be avoided through careful dosage
 First Author
(Year)/Qualifications F. I., . . . Sarni, R. (2016). Growth velocity and weight gain in prepubertal asthmatic
children. Revista Da Associacao Medica Brasileira, 63(3), 236-241. doi:10.1590/1806-
9282.63.03.236
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
Renosto, L. C., Acatauassu, C., Andrade, I., Rafael, M. N., Paulino, T. L., Suano-Souza,
 Aims to evaluate growth rate and weight gain of prepubertal asthmatic children
 The use of inhaled corticosteroids and the severity of asthma was taken into account
of the measured outcomes.
 The clinical longitudinal standards for height and weight were applied to the
analysis of the growth rate
 Retrospective cohort study that evaluated 85 medical records of children
 85 pediatric patients diagnosed with asthma according to the Global Initiative for
Asthma guidelines
 Patients were between 2-9 years of age, represented both sexes, and had been
regularly monitored for a minimum of a year by the Division of Allergy, Clinical
Immunology and Rheumatology of the Pediatrics Department of Escola Paulista
de Medicina da Universidade Federal de Sao Paulo (EPM-Unifesp)
 Approval granted by the Research Ethics Committee of EPM-Unifesp
 The association between growth rate (GR) and asthma severity
 The association between use of Inhaled Corticosteroids (IC) and a significant
impact of the GR of asthmatic children
 Patient data was collected from medical records at EMP-Unifesp
 Exclusion and inclusion criteria were applied
 All IC use was converted to beclomethasone as a reference
 A z-score of body mass index for age was calculated from weight and height data
with the use of WHO Anthro Plus® Software. These values were compared to the
WHO reference values.
 Tanner & White house curves were used to analyze growth rate
 SPSS 19.0 was used for statistical analysis
Findings/Discussion  The researchers found an association between lower growth rate and asthma
severity, regardless of the use of IC
 Children with more severe asthma had greater impaired growth rate
 Several side effects of asthma could lead to lower growth rate in these children:
hypoxemia, sedentary behavior, or metabolic demands due to increased
respiratory effort
Appraisal/Worth to  Children afflicted with severe asthma will have impaired growth rates
practice  There was a direct correlation found between severity of asthma and the impaired
growth rate in children
 Use of steroids was not associated with the growth rate
 First Author
(Year)/Qualifications preschool age children receiving daily inhaled corticosteroids. Allergy and Asthma
Proceedings,34(6), 511-518. doi:10.2500/aap.2013.34.3700
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
Singh, S. B., Weinberger, M. M., Zimmerman, M. B., & Starner, T. D. (2013). Growth of
 The effect of daily use of inhaled corticosteroids on the growth of children less
than 5 years of age
 The researchers of this study narrow the focus on children less than 5 years of
age and the effects of daily inhaled corticosteroids (ICS) on their growth rates
 The researchers aim to
 Retrospective cohort
 145 children, < 5 years old, divided into 3 different treatment groups that visited
the Pediatric Allergy and Pulmonary Clinic at the University of Iowa
 Researchers received funding from Teva Pharmaceutical Industries, Inc.
 Authors declare that they have no conflict of interest
 Study approved by the University of Iowa Institutional Review Board
 Children <5 years old on ICS asthma symptoms
 Measured height (growth) over treatment period
 Minimum of three height measurements taken each visit 3 weeks apart for 6
months
 Nursing personnel measure the height and recorded them during clinic visits
 Measurements taken with stadiometers
 Medications were reviewed at each visit
 Each medication needed to be continued for the 6 month period
 Linear mixed model analysis for a random coefficient regression model
 Clinical height measurements were converted to z scores
 The z score slopes of linear growth were used
 There were no significant effects on growth with low to medium ICS use
 The study did find a correlation between intranasal corticosteroid (INS) use and
growth suppression
Appraisal/Worth to  There have been few studies performed on childhood inhaled corticosteroid use
practice with an age group of less than 5 years old
 First Author
(Year)/Qualifications inhaled ciclesonide on growth in children with asthma. Pediatrics,121(1).
doi:10.1542/peds.2006-2206
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Skoner, D. P., Maspero, J., & Banerji, D. (2008). Assessment of the long-term safety of
 Long term use of inhaled and intranasal corticosteroids has been proven to cause
growth suppression in pediatric patients
 Researchers aim to study if Ciclesonide, a newer ICS, will cause this same
adverse reaction
 Researchers wanted to see if Ciclesonide could be a better ICS alternative for
asthmatic children due to decreased adverse events
 Random, double-blind, multicenter, placebo-controlled, parallel-group study
 3 phases: run-in, double-blind treatment, and follow-up
 Compliance monitored by patient diaries and canister weight
 Study centers had employees attend training and workshops on proper
stadiometer measurement taking
 Stadiometers were calibrated within 4 hours of each measurement
 1127 patients screened at 85 centers in 4 countries – of which 661 were selected
 609 patients resulted as the final population of this study due to discontinuation of
medication
 Children between the ages of 5-8.5 who had been diagnosed with mild to
persistent asthma for greater than 3 months
 Written informed consent was obtained from parents or legal guardians
 Study conducted in accordance with the principles of the Declaration of Helsinki
 Patients were required to demonstrate use of an MDI device
 Researchers designed this study in accordance with the FDA guidance on the
conduct of growth studies
 Financed by Altana Pharma US, Inc
 Adverse events reported from Ciclesonide administration
 Growth suppression as a result of yearlong Ciclesonide treatment
Measurement Tool/Data  Trained staff took the measurements of these participants, with clinics attempting
Collection Method to have the same staff with the same patient every time
 Patients had to be educated on the proper use of an MDI device to ensure proper
medication administration
 Each clinic was supplied with the same stadiometer. These were calibrated within
4 hours of each measurement taken
Data Analysis  Growth velocity was measured as a linear regression of the slope of height versus
time
 Analysis of covariance (ANCOVA) model of linear regression used

Findings/Discussion  There was not a significant delay in growth rate over a year in children that used
Ciclesonide – the growth rates were comparable to the placebo
 There also were no significant adverse effects reported

Appraisal/Worth to  The majority of ICS therapy have shown some growth suppression in pediatric
practice patients
 The use of Ciclesonide could be an alternative to traditional ICS use that would
not have the negative growth suppression effects