Short-Term Increases in Inhaled Steroid Doses Do Not Prevent Asthma Flare-Ups in Children

NIH-funded findings challenge common practice of increasing doses at early signs of worsening symptoms

Researchers have found that temporarily increasing the dosage of inhaled steroids when asthma symptoms begin to worsen does not effectively prevent severe flare-ups, and may be associated with slowing a child’s growth, challenging a common medical practice involving children with mild-to-moderate asthma.   

The study, funded by the National Heart, Lung, and Blood Institute (NHLBI), part of the National Institutes of Health (NIH), appeared online on March 3 in the New England Journal of Medicine (NEJM) to coincide with its presentation at a meeting of the 2018 Joint Congress of the American Academy of Allergy, Asthma & Immunology (AAAAI) and the World Allergy Organization (WAO) in Orlando, Florida. It will appear in print on March 8.

Jacqueline Pongracic, MD, was the lead investigator for the study at Ann & Robert H. Lurie Children’s Hospital of Chicago. Dr. Pongracic and her team participated in this important study as part of an NIH grant in partnership with Northwestern University Feinberg School of Medicine. She is the Division Head of Allergy and Immunology at Lurie Children’s and a Professor of Pediatrics and Medicine at Northwestern University Feinberg School of Medicine.

Asthma flare-ups in children are common and costly, and to prevent them, many health professionals recommend increasing the doses of inhaled steroids from low to high at early signs of symptoms, such as coughing, wheezing, and shortness of breath. Until now, researchers had not rigorously tested the safety and efficacy of this strategy in children with mild-to-moderate asthma.

"These findings suggest that a short-term increase to high-dose inhaled steroids should not be routinely included in asthma treatment plans for children with mild-moderate asthma who are regularly using low-dose inhaled corticosteroids,” said study leader Daniel Jackson, M.D., associate professor of pediatrics at the University of Wisconsin School of Medicine and Public Health, Madison, and an expert on childhood asthma. "Low-dose inhaled steroids remain the cornerstone of daily treatment in affected children."

The research team studied 254 children 5 to 11 years of age with mild-to-moderate asthma for nearly a year. All the children were treated with low-dose inhaled corticosteroids (two puffs from an inhaler twice daily). At the earliest signs of asthma flare-up, which some children experienced multiple times throughout the year, the researchers continued giving low-dose inhaled steroids to half of the children and increased to high-dose inhaled steroids (five times the standard dose) in the other half, twice daily for seven days during each episode.

Though the children in the high-dose group had 14 percent more exposure to inhaled steroids than the low-dose group, they did not experience fewer severe flare-ups. The number of asthma symptoms, the length of time until the first severe flare-up, and the use of albuterol (a drug used as a rescue medication for asthma symptoms) were similar between the two groups.

Unexpectedly, the investigators found that the rate of growth of children in the short-term high-dose strategy group was about 0.23 centimeters per year less than the rate for children in the low-dose strategy group, even though the high-dose treatments were given only about two weeks per year on average.  While the growth difference was small, the finding echoes previous studies showing that children who take inhaled corticosteroids for asthma may experience a small negative impact on their growth rate. More frequent or prolonged high-dose steroid use in children might increase this adverse effect, the researchers caution.

The study did not include children with asthma who do not take inhaled steroids regularly, nor did it include adults. 

“This study allows caregivers to make informed decisions about how to treat their young patients with asthma,” said James Kiley, Ph.D., director of the NHLBI’s Division of Lung Diseases. “Trials like this can be used in the development of treatment guidelines for children with asthma.” 

This work was supported by the following NHLBI grants:  HL098102, HL098075, HL098090, HL098177, HL098098, HL098107, HL098112, HL098103, HL098115, HL098096. The NHLBI-funded study, Step Up Yellow Zone Inhaled Corticosteroids to Prevent Exacerbations (STICS) (NCT02066129), is part of the NHLBI AsthmaNet program, a nationwide clinical research network that explores new approaches in treating asthma from childhood to adulthood. 

Part of the National Institutes of Health, the National Heart, Lung, and Blood Institute (NHLBI) plans, conducts, and supports research related to the causes, prevention, diagnosis, and treatment of heart, blood vessel, lung, and blood diseases; and sleep disorders. The Institute also administers national health education campaigns on women and heart disease, healthy weight for children, and other topics. NHLBI press releases and other materials are available online at

About the National Institutes of Health (NIH): NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit

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Research at Ann & Robert H. Lurie Children’s Hospital of Chicago is conducted through the Stanley Manne Children’s Research Institute. The Manne Research Institute is focused on improving child health, transforming pediatric medicine and ensuring healthier futures through the relentless pursuit of knowledge. Lurie Children’s is ranked as one of the nation’s top children’s hospitals in the U.S.News & World Report. It is the pediatric training ground for Northwestern University Feinberg School of Medicine. Last year, the hospital served more than 208,000 children from 50 states and 58 countries.


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