Guidelines suggest daily use of inhaled steroid for persistent asthma with ‘step-down’ of treatment after control has been achieved. The exact nature of step-down treatment is, however open to debate. Researchers in the USA (Lancet 2011;377:650–7, see also Comment, ibid:614–16) have suggested that treatment with an inhaled steroid (beclomethasone) and a selective short-acting β2 agonist (salbutamol (albuterol)) only during exacerbations (rescue treatment) could be an appropriate choice. A total of 288 patients aged 5–18 years with mild persistent asthma responsive to twice daily inhaled beclomethasone dipropionate were randomly allocated to one of four treatment groups for 44 weeks. With a 2.2 factorial design the options were twice daily beclomethasone or placebo together with rescue salbutamol plus beclomethasone or placebo. The risk of asthma exacerbations during the study was significantly less in the twice daily beclomethasone groups compared with the twice daily placebo groups. In the groups allocated to rescue treatment only, combined treatment with beclomethasone and salbutamol (treatment failure rate 8.5%) was better than salbutamol alone (treatment failure rate 23.0%). These researchers suggest that step-down treatment with rescue salbutamol alone cannot be recommended but such treatment with rescue salbutamol plus beclomethasone may be effective. They call for trials to assess other step-down strategies.

Infantile hypertrophic pyloric stenosis (IHPS) occurs in about 1–8 per 1000 infants born alive. It has been considered a relatively benign …