ICS in Children With BPD and Asthma Risk

Source: Leon C, Martin A, Young LR, et al. Outpatient inhaled corticosteroid use in bronchopulmonary dysplasia. Pediatr Pulmonol. 2024;59(11):2815-2822; doi: 10.1002/ppul.27134.Investigators from the Children’s Hospital of Philadelphia (CHOP), Philadelphia, PA, and Johns Hopkins University, Baltimore, MD, conducted a retrospective study to evaluate the association between outpatient inhaled corticosteroid (ICS) use in children with bronchopulmonary dysplasia (BPD) and a subsequent diagnosis of asthma. Study participants were patients with a diagnosis of BPD who were seen in the pulmonary clinic at CHOP between 2016 and 2021. The medical records of these children were reviewed and information on their NICU stay, prescriptions for ICS, family history of asthma, emergency department (ED) visits, and hospitalizations and subsequent diagnosis of asthma abstracted. Patients were categorized as being prescribed an ICS at NICU discharge, prescribed an ICS before or at their first pulmonary clinic visit, or not prescribed an ICS. Study outcomes included a subsequent diagnosis of asthma, ≥1 ED visit, and ≥1 hospitalization. Differences in outcomes between children in each ICS group (at NICU discharge or as an outpatient) and those never prescribed an ICS were assessed separately using logistic regression. Kaplan-Meier analysis was used to compare time to asthma diagnosis between groups.Data were analyzed on 661 children with BPD. Overall, the mean gestational age at birth in these patients was 26.3 ±2.4 weeks. A total of 199 (30.1%) study children were prescribed an ICS, including 61 at NICU discharge and 138 as an outpatient. Infants prescribed ICS at NICU discharge had significantly lower birth weights than those who were not and were more likely to be discharged on oxygen, but there was no significant difference in severity of BPD. These patients were less likely to have a family history of asthma than infants not prescribed ICS at NICU discharge. Conversely, infants prescribed ICS as an outpatient were significantly more likely to have a family history of asthma than those never prescribed ICS (64.9% vs 47.5%; P <0.001) and had shorter NICU stays; there were no significant differences between groups in BPD severity. Both children prescribed ICS at NICU discharge or as an outpatient were significantly more likely to be subsequently diagnosed with asthma than those never prescribed ICS (adjusted odds ratio [aOR], 1.97; 95% confidence interval [CI], 1.03, 3.77 and aOR, 3.58; 95% CI, 2.25, 5.68, respectively). Age at time of diagnosis was significantly younger in those prescribed ICS as an outpatient (P <0.001). Those prescribed ICS as an outpatient had a higher likelihood of an ED visit (aOR, 2.68; 95% CI, 1.69, 4.49) or hospitalization (aOR, 4.81; 95% CI, 3.00, 7.72), but the risk of an ED visit or hospitalization was not significantly different between patients prescribed an ICS at NICU discharge and those never prescribed ICS.The authors conclude that an outpatient prescription for an ICS in children with BPD is a risk factor for a subsequent diagnosis of asthma.Dr Chan has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Infants born preterm, especially those with BPD, have increased airflow obstruction compared to term infants.1-3 ICS are often prescribed to manage airflow obstruction in these infants, though evidence is lacking to suggest a clear benefit.4The current investigators sought to determine if there is an association between the timing of ICS initiation in children with BPD with different clinical presentations of small airway obstruction. They performed a large retrospective electronic medical record review between 2016 and 2021. The authors found that children who were prescribed an ICS as an outpatient had characteristics different from children who were not prescribed ICS or who were prescribed ICS at NICU discharge. For children initiated on ICS as outpatients, they had more ED visits, hospital admissions, and higher likelihood of an asthma diagnosis. More than 70% of children started on ICS after NICU discharge and before the first pulmonary evaluation had a diagnosis of asthma, which the authors postulate may be due to genetic and environmental factors. Initiation of ICS in the NICU was associated with degree of prematurity and respiratory disease, though there was no association between BPD severity scores in the NICU and outpatient ICS clinical presentations.Strengths of the current study include a large sample size and thoughtful design to clarify different BPD phenotypes. Limitations include a potential lack of generalizability due to its single center localization and inherent nature of practice variations for ICS prescription.Understanding use and timing of ICS initiation in outpatient NICU graduates may assist in earlier identification and remediation of small airway obstruction.