Pro-con debate: Inhaled corticosteroids should not be prescribed in primary care to children under two years of age - the case for

Inhaled corticosteroids (ICS) are effective treatment for older children and adults with asthma. Pathological studies have established that eosinophilic inflammation is important especially in mild to moderate asthma, thus providing a rationale for ICS treatment. However, we have wrongly concluded in the past that early and aggressive treatment of asthma is needed to prevent irreversible scarring and airflow obstruction. We have increasing evidence from all age groups that there are non-eosinophilic asthma phenotypes, that remodelling is independent of inflammation, and that steroids do not prevent children developing progressive airflow obstruction. Asthma treatments that are valuable in adults may not be effective in children, and safe prescribing requires paediatric clinical trials. In young preschool children, the evidence for any eosinophilic airway inflammation is scant, the symptomatic benefit of inhaled steroids is meagre, and there is clear evidence that ICS do not modify the natural history. There is also the potential for steroids to interfere with the developing lung. Thus, we believe that ICS should not be prescribed in primary care for children under two years of age, and that if these children are thought to need more than intermittent therapy with beta-agonists or possibly leukotriene antagonists, specialist referral is mandatory.