Inhaled corticosteroid therapy (ICT) has a long and for the most part honourable history in the management of asthma. Introduced in an attempt to minimise the side effects associated with systemic treatment, early trials with nebulised hydrocortisone showed little if any added benefit,¹ but with the introduction of beclomethasone dipropionate,² ICT rapidly assumed a central rôle in the management of asthma, transforming the lives of millions of sufferers.

Early studies were reassuring, but it soon became apparent that ICT did have measurable systemic effects on the hypothalamo-pituitary-adrenal axis,³ although there was little evidence that these translated into clinically significant problems, overt corticosteroid toxicity being a rare and apparently idiosyncratic reaction.⁴ Worries about the very real effects of ICT on growth⁵ have been largely banished by the demonstration of normal adult height at follow up.⁶ Posterior subcapsular cataract formation has been reported in children on ICT, but mainly in children who have also received systemic corticosteroids.^7,8 Local reactions such as oral candidiasis and hoarseness occur on ICT,^9,10 but usually respond to simple measures such as mouth washing and the use of a spacer.

Thus, in recommended doses, ICT has had an excellent safety record,¹¹ but encouraged by reports of the apparent safety of high dose ICT in adults,¹² paediatricians became increasingly bold in ignoring the manufacturers’ dosage recommendations, sometimes using doses that might have been more appropriate in the stable than the paediatric ward. Alas, it was all to end in tears. Several alarming reports of symptomatic adrenal insufficiency in children receiving high dose inhaled corticosteroid therapy appeared in the literature, including two in Archives.^13,14 The second of these reported the results of a …