In a study of asthmatic children 5-12 years of age, those treated with budesonide administered via a dry powder inhaler 200 mcg twice daily (n=311) had a -centimeter reduction in growth compared with those receiving placebo (n=418) at the end of one year; the difference between these two treatment groups did not increase further over three years of additional treatment. By the end of four years, children treated with the budesonide dry powder inhaler and children treated with placebo had similar growth velocities. Conclusions drawn from this study may be confounded by the unequal use of corticosteroids in the treatment groups and inclusion of data from patients attaining puberty during the course of the study. The growth of pediatric patients receiving inhaled corticosteroids, including Pulmicort RESPULES, should be monitored routinely (., via stadiometry). The potential growth effects of prolonged treatment should be weighed against clinical benefits obtained and the risks and benefits associated with alternative therapies. To minimize the systemic effects of inhaled corticosteroids, including Pulmicort RESPULES, each patient should be titrated to his/her lowest effective dose [see Dosage and Administration (2) , Warnings and Precautions () ] .
Oral theophylline initially seemed promising in the prophylactic treatment of childhood asthma. When compared with placebo, it significantly increased the mean morning peak expiratory flow rate and reduced the mean number of acute nighttime attacks and doses of bronchodilator used. 37 However, it proved to be less promising when its use over one year was compared with the use of inhaled corticosteroids. Although there was no significant difference between theophylline and inhaled corticosteroids in reduction of asthma symptoms, there was an increased use of short-acting beta 2 agonists and oral corticosteroids in children receiving theophylline. 38 In summary, its use in children cannot be recommended because of the potential for serious side effects, such as cardiac arrhythmias or convulsions, if therapeutic blood levels are exceeded. 39
Tissue irritation caused by local anesthetics is related to the acidity of the infiltrated solution; therefore, increasing the pH of the mixture can decrease associated discomfort. The addition of epinephrine to an anesthetic solution decreases the pH of the solution, making it more acidic (pH -) and leading to a more painful injection. The solution can be neutralized by the addition of sodium bicarbonate % to minimize discomfort. For example, sodium bicarbonate % can be added to lidocaine with epinephrine in a 1:10 ratio to achieve a solution pH similar to that of tissue fluid (pH -).