Methodology and implications of knemometry in growth assessment of inhaled glucocorticoids

Measurement of the growth of children at weekly intervals: Results

In our previous paper [M. Rępalska et al., Rev. Sci. Instrum. 90, 024103 (2019)], a new method for measuring the growth of children based on the measurement of the lower leg length during foot movement was described. This current paper presents more measurements being conducted to ensure the effectiveness of the proposed arrangement. The study was carried out at weekly intervals with a research group amounting to 20 participants. The presented results show that the method allows for the identification of even a weekly increase in the lower leg length at different velocities of growth. In addition, the method enables the estimation of the trend characterizing each individual and can distinguish the periods of time during which perturbative factors in the process of growth may arise. A metrological analysis was also conducted, allowing a qualitative evaluation of the results, which are presented together with the measurement uncertainties.

Questionnaire about the risk of growth suppression of inhaled corticosteroids

BACKGROUND

Inhaled corticosteroids are associated with a risk of growth suppression in children. The aim of the present study was to assess what children with asthma, lay people and paediatricians feel about the risk of growth suppression by inhaled corticosteroids.

METHODS

A questionnaire was completed by seven populations consisting of 9-19 years old children and adolescents with asthma; 9-19 year olds with another chronic illness; healthy 9-19 year olds; parents to children with chronic conditions; parents to healthy schoolchildren; young adults; and paediatricians.

RESULTS

A total of 1216 individuals completed the questionnaire. A total of 867 individuals (74.6%) would not worry about a risk of 1-year growth suppression in the range of 0.5-2 cm (range: 233 (63.3%) in parents to patients in a secondary referral centre to 59 (86.8%) in the group of paediatricians (χ 2 53.3, df 12, p<0.001; γ -223, error 0.042, p<0.001). A total of 745 individuals (64.3%) said that a loss in final height of 0.5-2 cm would not worry them (range: 34 (54.0%) in paediatricians to 119 (76.3%) in parents to healthy children (χ 2 49.5, df 12, p<0.001; γ -0.073, error 0.039, p=0.06).

CONCLUSIONS

Most children with asthma, lay people and paediatricians do not worry about the risk of growth suppression of inhaled corticosteroids in the range up to 2 cm. Paediatricians worry less about the risk of 1-year growth suppression but more about final height suppression than children with asthma and other groups of children and adults. Paediatricians need to address the different concerns of some of their patients on this issue.

Measurement of the growth of children at weekly intervals

A new method for measuring the growth of children is presented, based on the measurement of the lower leg length during foot movement. This is a touch measurement, but the obtained characteristic of the measured lower leg length, as a function of the pressure force, is reduced to a non-contact measurement. A setup prototype is built and preliminary research conducted. Based on the results obtained, it is concluded that the method allows the observation of increases in child lower leg length at frequent intervals (e.g., weekly). The developed measurement method has a high accuracy, and the results allow for differentiation between periods of child good health and indisposition.

Tradeoffs between immune function and childhood growth among Amazonian forager-horticulturalists

Immune function is an energetically costly physiological activity that potentially diverts calories away from less immediately essential life tasks. Among developing organisms, the allocation of energy toward immune function may lead to tradeoffs with physical growth, particularly in high-pathogen, low-resource environments. The present study tests this hypothesis across diverse timeframes, branches of immunity, and conditions of energy availability among humans. Using a prospective mixed-longitudinal design, we collected anthropometric and blood immune biomarker data from 261 Amazonian forager-horticulturalist Shuar children (age 4-11 y old). This strategy provided baseline measures of participant stature, s.c. body fat, and humoral and cell-mediated immune activity as well as subsample longitudinal measures of linear growth (1 wk, 3 mo, 20 mo) and acute inflammation. Multilevel analyses demonstrate consistent negative effects of immune function on growth, with children experiencing up to 49% growth reduction during periods of mildly elevated immune activity. The direct energetic nature of these relationships is indicated by (i) the manifestation of biomarker-specific negative immune effects only when examining growth over timeframes capturing active competition for energetic resources, (ii) the exaggerated impact of particularly costly inflammation on growth, and (iii) the ability of children with greater levels of body fat (i.e., energy reserves) to completely avoid the growth-inhibiting effects of acute inflammation. These findings provide evidence for immunologically and temporally diverse body fat-dependent tradeoffs between immune function and growth during childhood. We discuss the implications of this work for understanding human developmental energetics and the biological mechanisms regulating variation in human ontogeny, life history, and health.

The timing of administration of exogenous glucocorticoid affects 24hour growth hormone secretion in children

Exogenous glucocorticoids may suppress linear growth by affecting the diurnal secretory rhythm of GH.

OBJECTIVE

To assess whether the timing of exogenous glucocorticoid administration affects GH secretion in children.

DESIGN

Four girls and four boys aged 10.6 to 15.8 (mean 13.2) years with normal weight and height and pubertal stages I-IV were studied in an open randomized 2-period cross-over trial, with a 1-day un-in, and two 4-day periods of 5mg prednisolone in the morning or in the evening, respectively, separated by a 3-week washout period. At run-in and on the last day of each treatment period serum was collected every 20min for 24h for assessment of GH. Secondary analyses were serum levels of IGF-I and IGFBP-3 (measured every 8h), and IGFBP-1, insulin, and collagen markers PICP, PINP, ICTP and PIIINP (measured every 2h).

RESULTS

Evening prednisolone suppressed 24hour GH secretion (P=0.016), overnight GH secretion (P=0.023) and IGF-I (P=0.024) when compared to morning prednisolone, but not when compared to run-in. Evening prednisolone also increased nocturnal insulin levels as compared to run-in (P=0.010). Irrespective of time of day, prednisolone increased serum collagen markers PICP, PIINP, ICTP and PINP (all P<0.05).

CONCLUSIONS

Short-term prednisolone 5mg administered in the morning may alleviate nocturnal GH suppression as compared to evening administration. In analogy, growth rates are less affected by morning as compared to evening administration of exogenous glucocorticoids. In contrast, collagen markers and metabolic indices were not affected by the timing of prednisolone administration.

Knemometry Assessment of Short-term Growth in Children With Asthma Receiving Fluticasone Furoate for 2 Weeks: A Randomized, Placebo-controlled, Crossover Trial

PURPOSE

A dry powder inhaler formulation of the inhaled corticosteroid fluticasone furoate (FF) is being evaluated for use in children. An important potential risk associated with the use of inhaled corticosteroids in children is growth suppression. Therefore, the aim of this study was to assess the short-term lower leg growth in children with asthma treated for 2 weeks with inhaled FF versus placebo from the ELLIPTA inhaler.

METHODS

Prepubertal children with persistent asthma (n = 60; aged 5 to <12 years) were recruited into a randomized, double-blind, placebo-controlled, 2-way crossover, noninferiority study. The study consisted of four 2-week periods: run-in, 2 treatment periods, 1 washout period, and a 1-week follow-up period. Interventions were FF 50 µg and placebo once daily in the evening. Lower leg length was measured by using knemometry.

FINDINGS

The randomized ITT population comprised 36 boys and 24 girls with a mean age of 8.7 (standard deviation, 1.5; range, 5-11) years; 58% had a duration of asthma ≥5 years. Fifty-eight subjects completed both treatment periods. The least squares mean growth rate was 0.31 mm/week during treatment with FF and 0.36 mm/week during the placebo period. The difference in adjusted least squares mean growth rates between FF and placebo was -0.052 mm/week with a 95% CI of -0.122 to 0.018. This finding was greater than the prespecified noninferiority margin of -0.20 mm/week. The overall incidence of adverse events was 35% with placebo and 22% with FF.

IMPLICATIONS

Inhaled FF 50 µg provided once daily for 2 weeks was noninferior to placebo in terms of effects on short-term lower leg growth in children with asthma. To further quantify the risk of growth suppression in children, intermediate-term growth studies should be conducted. Inhaled FF 50 µg was well tolerated in this study population. ClinicalTrials.gov identifier: NCT02502734.

Short-Term Growth During Treatment with Inhaled Fluticasone Propionate/Formoterol, Fluticasone and Beclomethasone Treatment

BACKGROUND

Fluticasone propionate/formoterol (FP/FORM) is a pressurized metered-dose inhaler (pMDI; Flutiform^®) approved for use in adolescents and adults and under development for pediatric use.

OBJECTIVE

To compare short-term growth in asthmatic children treated with FP/FORM, FP pMDI with valved holding chamber, and beclomethasone dipropionate (BDP) in a breath-actuated device.

METHODS

Children with persistent asthma (n = 48; 5 to <12 years) participated in an assessor-blinded, randomized, three-way crossover trial with run in, wash out, and active treatment periods, each of 2 weeks duration. Interventions were FP/FORM 100/10 μg b.i.d. with an AeroChamber Plus^® Flow-Vu^® Spacer, FP pMDI (Flixotide^®) 100 μg b.i.d. with a Volumatic^® spacer, and extra-fine BDP breath-actuated inhaler (Aerobec^®/QVAR^® Autohaler^®) 100 μg b.i.d. Lower leg growth rate (LLGR) was measured by knemometry.

RESULTS

The least square (LS) mean difference in LLGR between FP/FORM and FP (per protocol population) was -0.006 mm/week (95% CI: -0.095 to 0.084; p < 0.001 for noninferiority [noninferiority margin -0.200 mm/week]). Both treatments elicited no change from baseline off-treatment growth rate. The LS mean treatment difference of FP/FORM versus BDP was 0.116 mm/week (95% CI: -0.004 to 0.235; p = 0.057) and of FP versus BDP 0.163 mm/week (95% CI: 0.078-0.249; p < 0.001). Results in the full analysis population were: FP/FORM versus FP -0.012 mm/week (95% CI: -0.080-0.056; p < 0.001); FP/FORM versus BDP 0.143 mm/week (95% CI: 0.064-0.222; p < 0.001); FP versus BDP 0.163 mm/week (95% CI: 0.093-0.233; p < 0.001).

CONCLUSIONS

FP/FORM pMDI with AeroChamber and FP pMDI with Volumatic spacer did not affect lower leg growth, measured by knemometry, in asthmatic children. Conversely, extra-fine BDP from a breath-actuated inhaler resulted in short-term growth suppression.

Knemometry is more sensitive to systemic effects of inhaled corticosteroids in children with asthma than 24-hour urine cortisol excretion

BACKGROUND

Pharmacodynamic assessment of the systemic effect of inhaled corticosteroids (ICSs) is often done by measuring 24-hour urine free cortisol (UFC) excretion. Knemometry assessing short-term lower-leg growth rate (LLGR) is a more rarely used alternative.

OBJECTIVE

The primary aim of this study was to compare the sensitivity of LLGR and 24-hour UFC excretion for evaluating systemic exposure to ICSs in prepubertal children with asthma. The secondary aim was to evaluate factors influencing the precision of LLGR calculated by the traditional 1 leg nonparametric method versus a new 2 leg parametric method.

METHODS

The study evaluated 60 children with mild asthma aged 5 to 12 years participating in a randomized controlled trial of ICSs with longitudinal concomitant assessments of LLGR and 24-hour UFC excretion. The sensitivity of the safety assessments was analyzed by comparing LLGR and 24-hour UFC in the placebo run-in period with values in the ICS treatment period by using paired t tests. Factors with a potential influence on LLGR were analyzed by means of ANOVA and the Levene test of homogeneity.

RESULTS

The mean LLGR was significantly reduced during the ICS versus placebo run-in periods: 0.18 mm/wk (SD, 0.55 mm/wk) versus 0.45 mm/wk (SD, 0.39 mm/wk), with a mean difference of 0.27 mm/wk (95% CI, 0.05-0.48 mm/wk; P = .02). In contrast, there was no difference in 24-hour UFC excretion: 6.91 nmol/mmol (SD, 4.67 nmol/mmol) versus 7.58 nmol/mmol (SD, 6.17 nmol/mmol), with a mean difference of 0.67 nmol/mmol (95% CI, -1.13 to 2.48 nmol/mmol; P = .46). We observed no significant difference in parametric determined LLGR caused by the child's age or sex, investigator, or season of measurement, whereas some differences were observed for the nonparametric LLGR.

CONCLUSION

These findings suggest that knemometry is a more sensitive pharmacodynamic measure of systemic effects of ICSs than 24-hour UFC excretion and that a parametric determination of LLGR increases the sensitivity of the method. These findings should be considered by legislative authorities in the future.

The application of knemometry to measure childhood short-term growth among the indigenous Shuar of Ecuador

OBJECTIVES

Knemometry, the precise measurement of lower leg (LL) length, suggests that childhood short-term (e.g., weekly) growth is a dynamic, nonlinear process. However, owing to the large size and complexity of the traditional knemometer device, previous study of short-term growth among children has been restricted predominantly to clinical settings in industrialized Western nations. The aim of the present study is to address this limitation and promote broader understandings of global variation in childhood development by: (1) describing a custom-built portable knemometer and assessing its performance in the field; and (2) demonstrating the potential application of such a device by characterizing childhood short-term LL growth among the indigenous Shuar of Amazonian Ecuador.

MATERIALS AND METHODS

Mixed-longitudinal LL length data were collected weekly from 336 Shuar children age 5-12 years old using the custom portable knemometer (n = 1,145 total observations). Device performance and Shuar short-term LL growth were explored using linear mixed effects models and descriptive statistics.

RESULTS

The portable knemometer performed well across a range of participant characteristics and possesses a low technical error of measurement of 0.18 mm. Shuar childhood LL growth averages 0.47 mm/week (SD = 0.75 mm/week), but exhibits large between- and within-individual variation.

DISCUSSION

Knemometry can be reliably performed in the field, providing a means for evaluating childhood short-term growth among genetically and ecologically diverse populations. Preliminary findings suggest that Shuar weekly LL growth is comparable in mean magnitude but likely more variable than reported for healthy Western children. Future work will further explore these patterns. Am J Phys Anthropol 160:353-357, 2016. © 2016 Wiley Periodicals, Inc.

Extra-fine particle inhaled corticosteroids, pharma-cokinetics and systemic activity in children with asthma

During recent years, extra-fine particle inhaled corticosteroids with a median aerodynamic diameter ≤2 μm have been introduced in the treatment of asthma. The aim of this paper was to review pharmacokinetics and systemic activity of extra-fine particle hydroalkane pressurized metered dose inhaled (pMDI) ciclesonide and beclomethasone dipropionate in children. A literature review was performed. Systemic bioavailability of oral and pulmonary deposition of extra-fine ciclesonide and beclomethasone dipropionate was 52% and 82%, the half-life in serum 3.2 and 1.5 h and first-pass hepatic metabolism >99% and 60%, respectively. Secondary analyses of urine cortisol/creatinine excretion found no effects of ciclesonide pMDI between 40 and 320 μg/day or of beclomethasone dipropionate pMDI between 80 and 400 μg/day. Ciclesonide pMDI 40, 80 and 160 μg/day caused no effects on short-term lower leg growth rate as assessed by knemometry. Ciclesonide 320 μg/day was associated with a numerically short-term growth suppression equivalent to 30% which was similar to 25% and 36% suppression caused by beclomethasone dipropionate HFA and CFC 200 μg/day, respectively. Consistent with the differences in key pharmacokinetic features, beclomethasone dipropionate is associated with a systemic activity detected by knemometry at a lower dose than ciclesonide. Whether that correlates with a clinically important difference remains to be explored. Assessments of systemic activity of beclomethasone dipropionate <200 μg/day and of ciclesonide >180 μg/day as well as head-to-head comparisons are warranted. Preferably, such studies should apply the sensitive method of knemometry.

[Inhaled corticosteroids and growth: should we be worried?]

Inhaled corticosteroids (ICSs) are the cornerstone and the first stage of asthma treatment. The objective of this study was to synthesize data on the potential effects of ICSs on growth in children. Studies on the short-term impact of ICSs on growth evaluated by knemometry cannot be extrapolated to the medium or long term and therefore have no utility in real life for a given person. In the medium term, the various ICSs given at the usual doses cause a small reduction in growth after 6 months of treatment. This slowdown occurs at the beginning of treatment, especially in younger children, and the growth velocity corrects itself later but without catching up. In the long term, the prolonged use of ICSs seems to induce a small reduction in the final size in adulthood (close to 1cm) occurring in the first 2 years of treatment without worsening over time. The impact of gender, age at onset of treatment, different ICSs, modes of inhalation, and severity of asthma should also be studied further. The benefit of ICSs in asthma treatment is greater than the risk of side effects, including on growth. The majority of the therapeutic effect is obtained for small to moderate doses of ICSs. Regular adjustment of ICS dose for optimal asthma control should also reduce ICS dose and the impact on growth.

A Comparison of Short-Term Growth During Treatment with Two Dry Powder Combinations of Inhaled Corticosteroids and Long-Acting β₂-Agonists

BACKGROUND

A combination of the inhaled corticosteroid budesonide and the long-acting β2-agonist formoterol has been formulated in a novel dry powder inhaler, Spiromax(®). The objective was to compare lower leg growth in children with asthma treated with inhaled budesonide+formoterol (BF) delivered from the Spiromax inhaler with BF from the Symbicort Turbohaler(®).

METHODS

Prepubescent children with persistent asthma (n=75, aged 6-11 years) were included in a randomized, double-blind, double-dummy, placebo-controlled, three-way crossover study with active treatment and placebo periods of 2 weeks duration. Lower leg length was measured every second week. As a secondary outcome parameter, 24-hr urine was collected for assessment of free cortisol. Interventions were dry powder BF 160+9 μg twice daily (b.i.d.; delivered dose) from the Spiromax inhaler and dry powder BF 200+12 μg b.i.d. (metered dose) from the Symbicort Turbohaler.

RESULTS

The least squares mean difference in lower leg growth rates (LLGR) between BF Spiromax and Symbicort Turbohaler was -0.086 mm/week [95% confidence interval (CI) -0.203, 0.032]. The pre-specified non-inferiority margin was -0.200 mm/week, so the lower limit of the 95% CI was just outside this margin. The difference between BF Spiromax and placebo was -0.20 mm/week (95% CI: -0.322, 0.086); p<0.001), between Symbicort Turbohaler and placebo -0.118 mm/week (95% CI: -0.236, -0.001; p=0.048). No statistically significant differences were seen in urine free cortisol assessments.

CONCLUSIONS

As the lower limit of the CI of LLGR was marginally outside of the pre-specified non-inferiority margin between BF Spiromax 160+9 μg b.i.d. and Symbicort Turbohaler 200+12 μg b.i.d., non-inferiority could not be demonstrated. Further studies may be needed for comparison of systemic activity of BF Spiromax and Symbicort Turbohaler in children before firm conclusions about their comparability may be drawn.

From knemometry to final adult height: inhaled corticosteroids and their effect on growth in childhood

Growth impairment in children with asthma, as a consequence of inhaled corticosteroids (ICS), is a major issue. Adverse systemic effects of ICS have been reviewed extensively, but no clinically relevant effects are reported if they are used in an appropriate dose as advocated in most guidelines. Growth studies can be divided into knemometry studies, intermediate term studies, and long term studies up to final adult height. These different studies provide different information. Knemometry demonstrates a dose dependent systemic effect, while all intermediate term studies demonstrate growth reduction of approximately one cm after one year of treatment. Most reassuring is that this delay seems to be temporary. The one study with a follow-up to final height shows no differences between the ICS and non-ICS treated children. The studies suggest that the use of ICS with respect to growth is safe if these drugs are used in a low to medium dose.

Systemic activity of inhaled beclomethasone dipropionate: a double-blind comparison of volume spacers

BACKGROUND

To which extent volume spacers may influence systemic activity of inhaled beclomethasone dipropionate (BDP) has not been evaluated.

AIM

To assess whether the AeroChamber Plus™ spacer is equivalent to the Volumatic™ spacer for administration of inhaled hydroflouroalkane 134a propelled BDP in terms of lower leg growth rate (LLGR).

PATIENTS AND METHODS

Prepubertal children with mild asthma (n = 26, aged 6-14 years) were included in a 3-time periods of 2 weeks duration randomized double-blind cross-over study with a single-blind placebo run-in and two washout periods. LLGR was measured with the knemometer. Interventions were inhaled BDP hydroflouroalkane 134a pressurized metered dose inhaler 100 μg and 200 μg b.i.d. with the AeroChamber Plus and 200 μg b.i.d. with the Volumatic spacer.

RESULTS

Beclomethasone dipropionate 200 μg b.i.d. from the AeroChamber Plus was non-inferior to BDP 200 b.i.d. from the Volumatic spacer as the lower margin of confidence interval of the difference between treatments (-0.18 to 0.13 mm/week) was greater than the prespecified lower limit for non-inferiority (-0.20 mm/week). UFC/creatinine data showed no statistically significant variations.

CONCLUSION

The systemic activity of BDP, via the Volumatic™, and AeroChamber Plus™ spacers is similar. The AeroChamber Plus spacer may be used in children without risk of increasing systemic activity of BDP.

Serum Fructosamine, Total Cholesterol, and High-Density Lipoprotein in Children with Asthma during Glucocorticoid Treatment

Background/Aims. Glucocorticoids may have adverse effects on carbohydrate and lipid metabolism. The present study was conducted to investigate possible effects on carbohydrate and lipid metabolism of inhaled and oral glucocorticoids in children with asthma. Methods. Two randomised controlled trials with blinded crossover designs were performed. Active treatment was 400  μ g inhaled budesonide or 5 mg prednisolone orally daily during one week. The budesonide trial included 17 and the prednisolone trial 20 school children. Serum fructosamine, total cholesterol and high-density lipoprotein were assessed. Results. Serum fructosamine was increased during active treatment (prednisolone 252.3  μ M versus placebo 247.3  μ M; P = 0.03 and budesonide 228.1  μ M versus no treatment 223.1  μ M; P = 0.02). Total cholesterol and high-density lipoprotein were not statistically significantly increased. Conclusion. Short-term treatment with oral prednisolone and inhaled budesonide may adversely affect mean blood glucose concentration. Possible long-term consequences require further investigations.

Short-term lower leg growth in 5- to 11-year-old asthmatic children using beclomethasone dipropionate inhalers with chlorofluorocarbon or hydrofluoroalkane propellants: a 9-week, open-label, randomized, crossover, noninferiority study

BACKGROUND

Beclomethasone dipropionate-hydrofluoroalkane (BDP-HFA) is a non-chlorofluorocarbon (CFC)-propelled metered dose inhaler. Data is needed to support the registration of BDP-HFA in pediatric populations for countries in the European Union.

OBJECTIVE

The aim of the study was to assess short-term lower leg growth in children with asthma during treatment with BDP-HFA 100 μg BID compared with BDP-CFC 200 μg BID.

METHODS

Children with asthma were included in this open-label, randomized, crossover study with 2-week run-in, active treatment, and washout periods. Lower leg length was measured every second week. As a secondary outcome parameter, 24-hour urine was collected for assessment of free cortisol. Interventions were inhaled BDP-HFA 100 μg BID with AeroChamber Plus spacer and BDP-CFC 200 μg BID with Volumatic spacer.

RESULTS

In 63 patients with asthma aged 5 to 11 years, BDP-HFA 100 μg BID was noninferior to BDP-CFC 200 μg BID, as the lower margin of CI (-0.03 to 0.10 mm/wk) of the estimated difference (0.03 mm/wk) was greater than the prespecified lower limit for noninferiority of -0.12 mm/wk. Mean (SD) lower leg growth rate during run-in, BDP-HFA 100 μg BID, and BDP-CFC 200 μg BID was 0.36 (0.17), 0.27 (0.21), and 0.23 (0.18) mm/wk, respectively (BDP-HFA estimate of difference, -0.09 [95% CI, -0.16 to -0.03 mm/wk; P < 0.01]; BDP-CFC estimate of difference, -0.13 [95% CI, -0.19 to -0.06 mm/wk; P < 0.001]). No statistically significant differences were seen in urinary free cortisol assessments. Eight and 6 mild to moderate adverse events in 10 children were reported during treatment with BDP-HFA and BDP-CFC, respectively. One event in each group was judged to be probably related to the study medication; no others were judged to be related.

CONCLUSIONS

No statistically significant differences were found in lower leg growth between BDP-HFA 100 μg BID with AeroChamber Plus spacer and BDP-CFC 200 μg BID with Volumatic spacer during 2-week treatment. Evidence of differences in systemic activity between the treatments was not found. EudraCT registration: 2007-007455-14.

Growth suppression caused by corticosteroid eye drops

Scarce data on systemic activity of corticosteroid eye drops are available in children. Two weeks treatment with fluorometholone eye drops in a case series of five children caused growth suppression detected by knemometry. The suppression had no impact on height growth during the following year.