ORIGINAL ARTICLE
Topical intranasal corticosteroids and growth velocity in children: a
meta-analysis
David J. Mener, MD, MPH1 , Josef Shargorodsky, MD, MPH1 , Ravi Varadhan, PhD2 and Sandra Y. Lin, MD1
Background: There is no consensus regarding the effects
on growth velocity of intranasal topical corticosteroid (ITC)
use in children. The objective of this study was to deter-
mine whether ITC use reduces growth velocity in children
with allergic rhinitis (AR).
Methods: A literature search of the National Center for
Biotechnology Information PubMed, EMBASE, SCOPUS,
and Cochrane databases from January 1, 1988 to Octo-
ber 7, 2013. The study selection was composed of random-
ized clinical trials investigating ITC for treatment of AR in
children (age <18 years of age) with appropriate controls.
Studies must have included interval change in growth as an
outcome. Two authors independently extracted data and
assessed study quality. Eligible studies were pooled using
a random-effects approach.
Results: Eight studies with 755 participants from
3 countries provided data for the meta-analysis (knemome-
try, n =342 participants; stadiometry, n =413 participants).
Study duration ranged from 2 to 4 weeks for trials evalu-
ating knemometry outcomes, and 12 months for trials eval-
uating stadiometry outcomes. Age of participants ranged
from 3 to 12 years. The pooled standardized mean differ-
ence showed that among studies using knemometry, mean
A llergic rhinitis is 1 of the most common chronic ill-
nesses, affecting up to 40% of children,1 and estimated
to cause 2 million missed school days annually in the United
States.2 Children suffering from allergic rhinitis experience
symptoms consisting of nasal congestion, rhinorrhea, and
1 Departmentof Otolaryngology–Head and Neck Surgery, Johns
Hopkins School of Medicine, Baltimore, MD; 2 Department of Medicine,
Johns Hopkins School of Medicine, and Department of Biostatistics,
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
Correspondence to: Josef Shargorodsky, MD, MPH, Johns Hopkins
University, Department of Otolaryngology-Head and Neck Surgery, 601 N.
Caroline Street, 6th Floor, Baltimore, MD 21287; e-mail: jshargo1@jhmi.edu
Potential conflict of interest: None provided.
Received: 27 June 2014; Revised: 2 August 2014; Accepted: 20 August 2014
DOI: 10.1002/alr.21430
View this article online at wileyonlinelibrary.com.
95 International Forum of Allergy & Rhinology, Vol. 5, No. 2, February 2015
growth was statistically significantly lower among children
using ITC vs placebo (−.223 mm/week; 95% confidence in-
terval [CI], −0.429 to −0.017; p < 0.034).The pooled stan-
dardized mean difference showed that among studies us-
ing stadiometry, there was no significant growth difference
among children using ITC vs placebo (−0.053 cm/year; 95%
CI, −0.491 to 0.385; p = 0.813). The limitations of this study
were the difficulty in predicting longer-term or catch-up
growth in children.
Conclusion: Meta-analytic pooling of trials suggest that
short-term ITC for the treatment of AR in children may de-
crease short-term growth velocity using knemometry; how-
ever, the effect on longer-term growth velocity as mea-
sured by stadiometry is unclear. 
C 2014 ARS-AAOA, LLC.
Key Words:
allergic rhinitis; inhaled glucocorticoids; nasal spray;
nasal inhaler; glucocorticoid; fluticasone; budesonide; be-
clomethasone; androstadienes; steroids; budesonide
How to Cite this Article:
Mener DJ, Shargorodsky J, Varadhan R, Lin SY. Topical in-
tranasal corticosteroids and growth velocity in children: a
meta-analysis. Int Forum Allergy Rhinol. 2015;5:95–103.
nasal itching.3 Untreated allergic rhinitis has been shown to
have a negative impact on behavior, emotional well-being,
and school performance,4 and may precipitate asthma ex-
acerbations or sinusitis.5
Intranasal corticosteroids are considered the first-line
therapy for symptoms of moderate to severe allergic rhinitis
in adults and children, as recommended by current treat-
ment guidelines.6, 7 Intranasal corticosteroids in contrast
to oral corticosteroids have been considered to be effec-
tive and safe from significant side effects due to their low
systemic bioavailability after topical administration.8–10
Of the intranasal corticosteroids approved for use in the
United States for the treatment of allergic rhinitis, only
4 are specifically indicated for children younger than
6 years old: mometasone furoate, fluticasone propionate,
fluticasone furoate, and triamcinolone acetonide.11
The U.S. Food and Drug Administration (FDA)
Mener et al.

nonprescription drugs advisory committee recently recom- and then tailored to the other electronic databases in simi-
mended on July 31, 2013 in a vote of 10 to 6 with 2 absten- lar fashion. The initial search incorporated use of Medical
tions that triamcinolone acetonide be switched from pre- Subject headings (MeSH) in addition to key text words
scription to over the counter in children older than 2 years extracted from relevant titles and abstracts (Table 1). A
of age.12 This recommendation was formally approved by medical librarian assisted in the development of the search
the FDA in October 2013. However, there is concern that strategies and reviewed them each for accuracy and pre-
intranasal corticosteroids, which are well established for cision. We reviewed reference lists from retrieved articles
the treatment of allergic rhinitis, may in fact be responsi- and reviews to identify further relevant studies. An abstract
ble for growth retardation in children through suppression review, followed by a full-text article review, was then per-
of the hypothalamic-pituitary-adrenal axis. This change of formed to assess for eligibility for inclusion. The search was
status from prescription to over-the-counter use will likely restricted to human subjects, age <18 years, English lan-
increase accessibility to young children without necessarily guage journals, and randomized controlled trials (RCTs).
the prior approval of pediatricians. Thus, this meta-analysis Expert guidance was sought to locate any other trials not
is of current interest and importance to clinicians and identified in the database search and potential unpublished
patients in elucidating the effects of intranasal corticos- trials. The title review then eliminated any studies where the
teroid on growth velocity in children. indication for topical steroids was any diagnosis other than
Knemometry, which measures linear leg growth with allergic rhinitis. The systematic review was planned, con-
an accuracy of 0.1 mm,13 is a particularly sensitive and ducted, and reported in adherence to standards of quality
reproducible measure of short-term growth velocity in chil- for reporting meta-analyses.23
dren. Stadiometry on the other hand, is a useful longer-term
measure of growth velocity that measures vertical height Study selection
from weeks to years. Thus, the detection of potential sys- This meta-analysis considered all RCTs investigating top-
temic adverse effects on growth in children can be evaluated ical nasal steroids for treatment of allergic rhinitis in chil-
in randomized controlled studies that examine short-term dren (age <18 years of age). To meet inclusion criteria,
(knemometry) or longer-term (stadiometry) growth veloc-
ity outcome measures.
Individual trials analyzing the associations between top- TABLE 1. Search strategy
ical nasal corticosteroids and growth velocity in chil-
dren have not produced conclusive results. Some stud- Major MeSH terms Key text words
ies have shown that short-term intranasal corticosteroids Anti-allergic agents Fluticasone
have no effect on growth velocity in children,14–17 while
other trials have shown growth suppression5 or potential Anti-asthmatic agents Steroids
but not statistically significant growth suppression.13, 18–21 Adrenal cortex hormones Androstadienes
The objective of this meta-analysis, therefore, is to evalu-
Androstadienes Beclomethasone
ate the association between intranasal corticosteroids and
growth velocity, using knemometry and stadiometry, in Beclomethasone Budesonide
children undergoing treatment for allergic rhinitis. To our Glucocorticoids Glucocorticoid
knowledge, this is the first comprehensive meta-analysis
Hydrocortisone Inhaled glucocorticoids
examining this issue.
Administration, inhalation Nasal spray
Metered dose inhaler Nasal inhaler
Materials and methods Growth and development
Literature search Child development
A quantitative meta-analysis was conducted of the pub-
Body height
lished English literature to broadly investigate the asso-
ciation between intranasal corticosteroid use in children Bone density
for allergic rhinitis and growth velocity. The Preferred Child growth
Reporting Items for Systematic Review and Meta-Analyses
Child development
(PRISMA)22 checklist was adhered to during the conduct
of these quantitative meta-analyses. Child
In October 2013, 4 large literature sources were searched: Adolescent
PubMed, EMBASE, the Cochrane Central Register of Con-
trolled Trials, and Scopus. Sources were queried for rel- Teen
evant publications within a 25-year time period ranging Pediatric
from January 1, 1988 through October 7, 2013. An initial
Pediatric
electronic search strategy was designed for use in PubMed

International Forum of Allergy & Rhinology, Vol. 5, No. 2, February 2015 96

Topical intranasal corticosteroids and growth velocity
the trials had to include (1) an intervention group that
received treatment with topical nasal steroids, and (2) a
control group in which an appropriate placebo treatment
was applied. Crossover trials and RCTs considering multi-
ple different intranasal steroids independently were consid-
ered acceptable so long as an appropriate placebo treatment
was applied to all groups equally. Crossover trial method-
ology is particularly useful in evaluating growth velocity
in children since participants can serve as their own con-
trols. This is potentially an important issue since compar-
ing growth velocity among children with a variety of ages
and among different stages of puberty may be challenging.
Trials where participants were given short-term oral corti-
costeroids (<7 days per incident) for asthma exacerbations
in children were included. Patients could not have had ex-
posure to intranasal steroids prior to study commencement
unless an adequate washout period was described in the
RCT.
Outcome measures
The primary outcome in this meta-analysis was mean
growth velocity, as measured by stadiometry or knemom-
etry, in children, following administration of intranasal
steroids or placebo for allergic rhinitis. Any length of
follow-up was considered acceptable.
Quality assessment
Two authors (J.S. and D.J.M.) independently assessed
study quality using the Centre for Evidence Based
Medicine levels of evidence for primary research question
(http://www.cebm.net).
Data extraction
Two reviewers (J.S. and D.J.M.) independently extracted
and cross-checked data from all RCTs included in the meta-
analysis. For trials that used stadiometry and knemome-
try measurements, variables extracted included intranasal
steroid type, daily dosing, baseline height, height at termi-
nation of the trial, and mean growth velocity parameters.
When available, standard errors and standard deviations of
growth parameters were reported.
Statistical analysis
Two independent meta-analyses were conducted evaluat-
ing the association of intranasal steroids and (1) knemome-
try and (2) stadiometry. Among RCTs and crossover trials
that evaluated the clinical effects and/or outcomes of the
same intranasal steroid at multiple doses, only the partic-
ipants using the highest daily dose were included in the
analysis. Sample size for crossover trials was calculated by
adding the total number of participants treated with each
individual topical intranasal corticosteroid, in addition to
the number of participants in the control group. This is a
conservative approach that underweights crossover trials.24
97 International Forum of Allergy & Rhinology, Vol. 5, No. 2, February 2015
Meta-analyses were performed using the Comprehensive
Meta-analysis program version 2 (Englewood, NJ). For
each meta-analysis, the standardized difference in means
was calculated as the mean difference in growth velocity
for treatment effect using random effects modeling based
on the crude, study-specific growth velocities and 95% con-
fidence intervals. Forest plots were then constructed for (1)
knemometry and (2) stadiometry. Study heterogeneity was
assessed by using the I2 statistic, which measures the de-
gree of inconsistency. Two-sided p < 0.05 was considered
statistically significant.
Results
Literature results
The results of our literature search are summarized in
Figure 1. After using the outlined literature search strategy,
623 records were identified. Of these, 454 records were
initially excluded based on title review, the vast majority
being nonhuman studies (397 articles). Many of the re-
maining records were irrelevant to the primary research
question (102 articles), were nonrandomized trials (eg, sys-
tematic and narrative reviews, clinical guidance documents,
commentaries, letters, and press releases, or had no con-
trol/placebo group) (8 articles). This left 59 articles that
were assessed in more detail for eligibility. Nearly half
of these included adult participants only (27 articles). Of
the remaining articles, 10 studies met the inclusion crite-
ria. Two studies did not report sufficient data on growth
velocity to be included.11, 17 The remaining articles were
then included in the meta-analyses for stadiometry5, 14, 18, 21
(N = 4) and knemometry13, 15, 19, 20 (N = 4). Eight trials
were included and the summary characteristics appear in
Table 2.
Clinical trial characteristics
The characteristics of the included studies are listed in
Tables 2 to 4. Eight studies with 755 participants from
3 countries provided data for the meta-analysis (knemome-
try meta-analysis, n = 342 participants; stadiometry meta-
analysis, n =413 participants). Study duration ranged
from 2 to 4 weeks for trials evaluating knemometry out-
comes, and 12 months for trials evaluating stadiometry
outcomes. Age of participants ranged from 3 to 12 years.
Regarding controls/placebos, all trials were double-blinded
and used placebo insufflators. Three trials were designed
using double-blinded randomized crossover methodology,
and the remaining 5 trials were designed using double-
blinded parallel group methodology. Two trials evaluated
stadiometry growth velocity of 2 different intranasal corti-
costeroid preparations, each of which was included in the
analysis.15, 19 Intranasal steroids examined with stadiom-
etry outcomes included Fluticasone 200 mg/day, budes-
onide 64 μg/day, and mometasone 100 μg/day. Intranasal
Mener et al.

FIGURE 1. Search strategy flow diagram for meta-analyses.

steroids examined with knemometry outcomes included Meta-analysis 1: knemometry

Budesonide (200 μg/day and 400 μg/day), triamcinolone Figure 2 shows a forest plot of the individual and overall
(100 μg/day and 220 μg/day), fluticasone 200 mg/day, associations between intranasal steroid use and knemome-
and mometasone (100 μg/day and 200 μg/day). try. Among the 4 studies using knemometry as an outcome

International Forum of Allergy & Rhinology, Vol. 5, No. 2, February 2015 98

Topical intranasal corticosteroids and growth velocity

TABLE 2. Characteristics of studies included in meta-analysis

Age range Intranasal Daily Intranasal steroid Quality Study Growth

Study (year) Location (years) n steroid dose duration score design outcome

Allen et al.18 (2002) USA 3.5–9 83 Fluticasone 200 mg 1 year 1 RCT Stadiometry
21
Murphy et al. (2006) USA 4–8 168 Budesonide 64 μg 1 year 1 RCT Stadiometry
14
Schenkel et al. (2000) USA 3–9 82 Mometasone 100 μg 1 year 1 RCT Stadiometry
5
Skoner et al. (2000) USA 6–9.5 80 336 μg 1 year 1 RCT Stadiometry
Beclomethasone
Wolthers and Pedersen13 (1994) Denmark 5–15 23 Budesonide 400 μg 4 weeks 1 RCT Knemometry
19
Skoner et al. (2003) USA 4–10 49 Triamcinolone 110 μg 2 weeks 1 Crossover Knemometry
49 Triamcinolone 220 μg 2 weeks
49 Fluticasone 200 μg 2 weeks
Agertoft and Pedersen15 (1999) Denmark 7–12 22 Budesonide 400 μg 2 weeks 1 Crossover Knemometry
22 Mometasone 200 μg 2 weeks
Gradman et al.20 (2007) UK 6–11 53 Fluticasone 110 μg 2 weeks 1 Crossover Knemometry

RCT = randomized controlled trial.

TABLE 3. Evidence table of stadiometry studies included in meta-analysis

(+) Intranasal steroids (intervention) (−) Intranasal steroids (control)

Study (year) n Baseline height (cm) End height (cm) Mean growth (cm/year) n Baseline height (cm) End height (cm) Mean growth (cm/year)

Allen et al.18 (2002) 44 118.7 ± 0.85 SE 125.5 ± 0.18 SE 6.32 ± 0.16 SE 39 118.9 ± 0.88 SE 125.4 ± 0.19 SE 6.20 ± 0.17 SE
Murphy et al.21 (2006) 110 122.9 ± 8.9 SD 128.8 ± 8.7 SD 5.91 ± 0.11 SE 58 122.1 ± 8.7 SD 128.2 ± 8.8 SD 6.19 ± 0.16 SE
Schenkel et al.14 (2000) 42 120.2 6.95 ± 0.225 SE 40 120.9 6.35
5
Skoner et al. (2000) 45 127.7 5.0 ± 0.23 SE 35 125.1 5.9

Values are mean ± SE or mean ± SD, as indicated.

SD = standard deviation; SE = standard error.

measure (Table 3), the overall effect showed that Discussion

mean growth velocity was statistically significantly lower
among children using intranasal steroids vs placebo
(−0.223 mm/week; 95% confidence interval [CI], −0.429
to −0.017; p < 0.034). None of the individual studies
demonstrated a statistically significant difference in growth
velocity on knemometry measurement. Heterogeneity was
low across trial findings (I2 = 8.75%, p = 0.36).
Meta-analysis 2: stadiometry
Figure 3 shows a forest plot of the individual and overall as-
sociations between intranasal steroid use and stadiometry.
Among the 4 studies using stadiometry as an outcome mea-
sure (Table 4), the overall effect showed that there was no
significant growth velocity difference among children using
intranasal steroids vs placebo (−0.053 cm/year; 95% CI,
−0.491 to 0.385; p = 0.813). However, effects were highly
heterogeneous across studies (I2 = 78.51%, p = 0.003),
with individual trials results having inconsistent growth
velocities.
Overall, the meta-analysis demonstrated a significant
decrease in mean growth velocity using knemometry
measurements among children receiving topical intranasal
corticosteroids compared to those receiving placebo,
despite the fact that none of the individual knemom-
etry trials demonstrated a statistically significant
effect of intranasal steroids on growth velocity. However,
the effect on longer-term growth velocity, as measured
by stadiometry, is unclear since heterogeneity was large
and statistically significant, with individual trial results
demonstrating inconsistent growth velocity parameters.
The pooled meta-analysis knemometry growth velocity
findings are concerning given the widespread use of
intranasal corticosteroid in children with allergic rhinitis.
This analysis adds to existing reviews and provides the
first comprehensive meta-analysis on this important topic.
Important points that can be drawn from this analysis
include (1) even short-term intranasal corticosteroid use
in children may have deleterious effects on short-term

99 International Forum of Allergy & Rhinology, Vol. 5, No. 2, February 2015

Mener et al.

TABLE 4. Evidence table of knemometry studies included in meta-analysis

(+) Intranasal steroids (intervention) (−) Intranasal steroids (control)

Study (year) n Intranasal steroid (daily dose) Growth velocity (mm) n Growth velocity (mm)

Wolthers and Pedersen13 (1994) 14 Budesonide (200 μg) 0.27 ± 0.20 SDa 10 0.34 ± 0.20 SDa
13 Budesonide (400 μg) 0.22 ± 0.19 SDa
Skoner et al.19 (2003) 49 Triamcinolone (110 μg) 0.37 ± 0.42 SEa 49 0.47 ± 0.06 SEa
49 Triamcinolone (220 μg) 0.32 ± 0.42 SEa
49 Fluticasone (200 μg) 0.37 ± 0.42 SEa
Agertoft and Pedersen15 (1999) 22 Mometasone (100 μg) 0.58b 22 0.35b
22 Mometasone (200 μg) 0.48 ± 0.304 SEb
22 Budesonide (400 μg) 0.37 ± 0.302 SEb
Gradman et al.20 (2007) 53 Fluticasone (100 μg) 0.41 ± 0.06 SDa 53 0.43 ± 0.06 SDa

Values are mean ± SE or mean ± SD, as indicated.

a
Values are millimeters per week (mm/week).
b
Values are millimeters every 2 weeks (mm/2 weeks).
SD = standard deviation; SE = standard error.

FIGURE 2. Forest plot of knemometry growth velocity effect size for intranasal corticosteroids.

measures of growth, and (2) it is unclear whether these
effects translate into long-term suppression of growth. An
advantage of assessing knemometry to evaluate the effect
of intranasal steroids on growth include the relatively easy
ability to observe short periods of growth in children, which
then enables investigators to design trials using crossover
designs and randomized controlled clinical trials. To date,
there has only been 1 systematic review evaluating topical
nasal steroids for intermittent and persistent allergic rhini-
tis in children.25 This study did not demonstrate or report
adverse events in any of the 3 trials, finding that the data
analysis was flawed in 2 of the trials and incomprehensible
in the third.25
Topical intranasal corticosteroids act directly on the
nasal mucosa to produce optimal effects, but older
trials have shown that dexamethasone, beclometha-
sone, and betamethasone may induce moderate adrenal
suppression.26–28 The primary response of corticosteroids
on the hypothalamic pituitary axis is negative feedback
caused by suppression of corticotrophin-releasing hormone
and adrenocorticotropic hormone levels, resulting in de-
creased cortisol secretion.29 While intranasal steroids pro-
vide direct delivery to the nasal mucosa, much of the
medication dose is in fact transported into the gastroin-
testinal tract through mucociliary clearance, which must
then become inactivated by first-pass hepatic metabolism.30

International Forum of Allergy & Rhinology, Vol. 5, No. 2, February 2015 100
Topical intranasal corticosteroids and growth velocity
FIGURE 3. Forest plot of stadiometry growth velocity effect size for intranasal corticosteroids.
Absorption into systemic circulation may occur through
airway or gastrointestinal pathways, which may be in-
creased with formulations with high water solubility
such as budesonide in contrast to formulation with high
lipophilic properties such as mometasone or fluticasone.30
In ascending order of increased growth suppression in
children, high-dose budesonide, fluticasone, triamcinolone,
and mometasone, may demonstrate decrease growth
velocity by knemometry measurement. However, in
contrast, prior pharmacokinetic and pharmacodynamics
research have shown that intranasal fluticasone and
mometasone are actually predicted to have the least short-
term growth suppression effects compared to triamcinolone
and budesonide intranasal preparations.31 Possible differ-
ences in bioavailability, with mometasone and fluticasone
having the lowest systemic bioavailability, may be con-
tributing factors.29, 32 Our results may indicate that, despite
differences in bioavailability, different intranasal corticos-
teroid preparations may vary in actual growth suppression
potential in children.
Suppression of growth in children may occur through
any of several potential mechanisms. These include
decreased release of growth hormone, inhibition of insulin-
like growth factor 1 activity, blunting of pulsatile growth
hormone release, downregulation of growth hormone re-
ceptor expression, and suppression of collagen synthesis
and adrenal androgen production. However, there appears
to be no evidence of other systemic effects of intranasal cor-
ticosteroids in children for the treatment of allergic rhini-
tis, including electrolyte imbalances, alterations in protein,
lipid, or carbohydrate metabolism, or alterations in differ-
ential white blood cell counts.5 Short-term evaluation of
mean growth velocity using knemometry may in fact be a
more sensitive indicator of systemic corticosteroid effects
than traditional measures of hypothalamic-pituitary axis
suppression.
101 International Forum of Allergy & Rhinology, Vol. 5, No. 2, February 2015
Intranasal corticosteroid preparations may be more likely
to cause growth suppression with twice-daily vs once-daily
administration or with formulations that have a more com-
plete first-pass hepatic inactivation.31 Our data support this
hypothesis, with higher-dose corticosteroids causing con-
sistently more growth velocity suppression by knemometry
measurement. While our meta-analysis demonstrated de-
creases in short-term growth velocity, intranasal steroids
may in fact have no significant effect on final adult height.33
Stadiometry studies that span at least 12 months may
in fact provide the most clinically useful information
about the association of growth velocity and intranasal
corticosteroids.
The strengths and limitations of this study should be con-
sidered. First, only a relatively small number of RCTs were
available for analysis. Nevertheless, the individual trials
analyzing knemometry measurements were fairly consis-
tent in demonstrating decreased growth velocity among
children using intranasal topical corticosteroids compared
to placebo; however, none of the individual trial analy-
ses showed statistical significance. The consistency of the
pooled analysis among the knemometry trials and the
individual study results adds credibility to the pooled re-
sults. However, the pooled meta-analysis among the sta-
diometry trials did not provide any inference due to sub-
stantial heterogeneity in treatment effects. We could have
taken advantage of including nonrandomized or uncon-
trolled studies in order to acquire more data. However,
we chose systematically to choose only RCTs in order
to select trials that were of high quality with strong
methodology.
Growth evaluation by knemometry provides accu-
rate and precise measurements of short-term lower leg
growth is less prone to systematic observer variation
than stadiometry,34, 35 but does not provide insight into
longer-term growth rates. A longer duration of
Mener et al.

administration, however, was analyzed using stadiome-
try. Difficulty arises in evaluating the growth of children,
since growth occurs in spurts, interspersed with periods of
low growth velocity.36 While the individual studies were
all careful about matching the ages of the treatment and
control groups, variability among the ages of children
between the individual studies may affect the results. The
heterogeneity among the stadiometry studies may at least
partially be explained by the above, in addition to dif-
ferences in individual trials among treatment and placebo
arms with respect to baseline height among children, small
differences in the proportion of children diagnosed with
asthma who may have required rescue corticosteroid medi-
cations, differences in the proportion of children advancing
developmentally with respect to puberty, and differences in
compliance among intranasal corticosteroid preparations.
Additional difficulty arises in predicting longer-term
growth velocity in children. Even consistent knemom-
etry measurements by clinicians over a 4-month pe-
riod have been shown to have variable predictive value
in predicting overall 6-month growth velocity among
children.34 Limitations of individual studies in the anal-
ysis include the occasional need to give limited dura-
tion oral corticosteroids for acute asthma exacerbations;
however, this likely did not affect the standardized dif-
ference in means of growth velocity since all trials were
randomized and the need for rescue oral corticosteroids
was likely balanced between intervention and placebo
groups.
Timing of intranasal corticosteroid administration may
be an important consideration to preventing adverse ef-
fects on growth velocity. Since growth hormone secretion
in prepubertal children is pulsatile and foremost noctur-
nal, absorption of exogenous corticosteroids during those
times may have increased effect on growth suppression
and growth hormone release. Timing of intranasal corti-
costeroids in the morning may partially mitigate this effect
and should be considered an important factor in design-
ing future RCTs assessing growth velocity, in addition to
assessing Tanner stage at fixed timed intervals throughout
the study duration, when evaluating potential confounders.
Finally, the long-term growth outcomes, overall lifetime
reduction in growth velocity, and bearing on final adult
height in children using intranasal corticosteroids are not
well elucidated.
Conclusion
Our findings suggest that short-term intranasal corticos-
teroids for the treatment of allergic rhinitis in children
may decrease short-term growth velocity, as measured by
knemometry. Thus, we advocate that children using in-
tranasal corticosteroids should be monitored carefully by
pediatricians. Potential adverse effects on growth vs im-
provement in symptoms of allergic rhinitis must be carefully
assessed. When intranasal corticosteroids are selected, the
lowest effective dose to achieve the desired clinical outcome
should be used.

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UPCOMING MEETING ANNOUNCEMENT 2015

The 16 World Congress of Rhinology, combining the 34th ISIAN meeting (International Society of Inflammation and
th

Allergy of the Nose), with the 16th IRS meeting (International Rhinologic Society) will be held in Sao Paulo, Brazil, April
30th –May 2nd 2015, under the leadership of Aldo Stamm, M.D. Pre and post congress tours are planned and the meeting
will build on Dr. Stamm’s prior reputation for outstanding international rhinology meetings. For more information, please
go to http://www.rhinology2015.com/

103 International Forum of Allergy & Rhinology, Vol. 5, No. 2, February 2015