Inhaled corticosteroids were designed to avoid the numerous adverse effects of oral corticosteroids in the treatment of asthma. In children, inhaled corticosteroids have been proved to be highly effective and it was initially thought that the risk of adrenal suppression was low.1 As a result, high “off-licence” doses (eg, ⩾1000 μg/day of fluticasone proprionate) were recommended in difficult cases by national guidelines.2 The efficacy and safety of such high doses has been seriously questioned by the reporting of around 30 cases of life threatening acute adrenal crisis, including one death, in children maintained on inhaled corticosteroids (largely high dose fluticasone proprionate).3

Current guidelines therefore caution that doses ⩾400 μg/day of fluticasone proprionate …