© 2005 American Thoracic Society
Inhaled Corticosteroids in Wheezy InfantsFrom the Authors:
We thank Drs. Merkus and de Jongste for their letter discussing our study (1). We reassert that the functional response of infants with asthma to inhaled corticosteroids (ICS) has not yet been fully addressed. The discussants claim that we did not consider the five published studies using lung function as endpoint. We would like to address this point. Of the five, curiously, the first cited is ours. The second (2) did not find any functional difference (by body plethysmography) between infants who received a short-time dose of beclomethasone + albuterol and others that received only albuterol. The third (3) evaluated patients with bronchial obstruction after bronchiolitis; the objective of our study, on the other hand, was to evaluate the response to ICS in infants with risk factors to develop asthma. The fourth (4) we considered in the discussion section, where we proposed reasons for the difference in the results. Finally, the study by Hofhuis and coworkers (5) was published after our manuscript was submitted and thus was not timely to our article. The authors of this last article did not find significant changes in pulmonary function ( Drs. Merkus and de Jongste also commented that the studies that show clinical benefits of ICS in young children were performed for the most part in preschool children, whereas no study done in infants and children younger than 2 yr old showed a difference in symptoms when compared with placebo. However, they neglected to mention our previously published study of the clinical efficacy and safety of a 6-mo treatment with FP in children less than 2 yr of age (6). Also, Hofhuis and coworkers (5) found significant changes regarding the symptoms of cough, wheeze, and dyspnea using FP, compared with both baseline and placebo.
We fully agree with Drs. Merkus and de Jongste that our population was cautiously selected with regard to inclusion criteria. We purposely chose infants with risk factors to develop asthma. In addition, to find out whether use of ICS improves lung function, we chose only the subgroup of children that had a low airway caliber, having a Z score At the 2005 ATS International Conference, results were presented from an NIH-sponsored study named "Preventing Early Asthma in Kids (PEAK)." In this study, clinical and functional improvements were achieved in slightly older children with asthma receiving ICS. We agree that there is no simple and precise method to identify those children who will benefit from ICS treatment. Nevertheless, the group of infants who have major and/or minor risk factors to develop asthma (8) do have a clinical benefit from use of ICS treatment and, as we found, a functional benefit also. Future studies will have to evaluate if early intervention in this particular kind of patient could prevent the development of irreversible changes in the airways.
Ricardo Gutierrez Children's Hospital, Buenos Aires, Argentina FOOTNOTES Conflict of Interest Statement: None of the authors have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. REFERENCES
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maxFRC) after 13 wk of treatment with fluticasone propionate (FP) 200 µg/d. However, the graphic that illustrates the change in pulmonary function shows that many of the infants treated with ICS who have the lowest