Alleviating Pediatric Fracture Risk Concerns With Asthma ICS, With Lynchi Nguyen

Children with asthma treated with inhaled corticosteroids (ICS) for asthma did not face a higher risk of fractures—in fact, those managed with short-acting beta agonists (SABA) alone had an 18% higher fracture risk compared with children receiving ICS therapy, according to new data analyzing more than 210,000 pediatric patients.

Asthma remains the most common chronic allergic and respiratory condition in children, and ICS is foundational to long-term asthma control. However, patient and family concerns about the potential skeletal effects of corticosteroids, particularly extrapolated from data on systemic steroids, continue to influence prescribing patterns and parental acceptance.

Lynchi Nguyen, a medical student at John Sealy School of Medicine, University of Texas Medical Branch in Galveston, addressed this concern at the American Academy of Allergy, Asthma & Immunology (AAAAI) 2026 Annual Meeting held in Philadelphia, Pennsylvania, where she presented data from a large retrospective cohort study aiming to clarify ICS and fracture risk using the TriNetX U.S. Collaborative Network. The analysis included more than 210,000 children aged 6–18 years with asthma. Patients were categorized into 3 mutually exclusive groups: SABA-only therapy, ICS-only therapy, and ICS combined with a long-acting beta agonist (ICS + LABA). To ensure accurate comparisons, cohorts were propensity score matched for age, sex, and comorbidities, with exclusions for obesity, cystic fibrosis, autoimmune disease, and metabolic bone disorders.

The primary outcome was first-time pediatric-specific fracture occurring at least 1 year after medication initiation, including Salter-Harris fractures, torus fractures, greenstick fractures, and bent bone fractures, which are injuries particularly relevant to growing children.

Nguyen and colleagues found that compared with SABA-only controls, children in the ICS-only group demonstrated a lower fracture risk, with a relative risk (RR) of 1.18 (95% CI, 1.11–1.26) for the SABA-only cohort, indicating an 18% higher fracture risk among children treated with SABA alone. In contrast, there was no statistically significant difference in fracture risk between ICS + LABA therapy and SABA-only therapy (RR, 1.05; 95% CI, 0.95–1.15), nor between ICS + LABA and ICS-only regimens (RR, 0.97; 95% CI, 0.86–1.09).

Importantly, ICS use, whether alone or in combination, was not associated with increased fracture risk. In fact, the data suggest that children managed without ICS may face modestly higher fracture risk, potentially reflecting poorer asthma control or greater systemic steroid exposure from exacerbations.

These results reinforce international guideline recommendations that encourage early incorporation of ICS and move away from SABA monotherapy. Nguyen emphasized that inhaled corticosteroids are not equivalent to systemic steroids in their skeletal effects, and these findings should help clinicians confidently counsel families, address misconceptions, and support evidence-based asthma management in children.

“ICS use is not equivalent to systemic steroid use, [it doesn’t] confer the same risks, and that it's safe for our children to be on these medications…[It’s important for clinicians to incorporate] this into their counseling with parents so they don't feel as hesitant to adhere to these asthma regimens that include ICs,” Nguyen said.

Reference

Nguyen L, Lee A, Carmichael K, Acevado JA. Fracture Risk Among Pediatric Asthma Patients Treated With Inhaled Corticosteroids: A Retrospective Cohort Study. Presented at: AAAAI 2026 Annual Meeting, February 27-March 2, Philadelphia, Pennsylvania. Poster #L04