COMMENTARY

5 Best of 2018: Pediatrics Viewpoints

William T. Basco, Jr, MD, MS

Disclosures

January 11, 2019

In This Article

Asthma Exacerbations and Steroids

Guidelines suggest use of systemic steroids for pediatric asthma exacerbations.[4] The traditional approach is a 5-day course of oral prednisone or prednisolone, but recent studies have demonstrated that dexamethasone has better acceptability to patients and thereby might represent a better option, particularly for young children.[5]

A study published late in 2017[6] sought to determine whether two doses of dexamethasone were as effective as a 5-day course of prednisolone/prednisone in the management of asthma exacerbations in children. The 590 children in the trial were aged 12 months to 14 years, seen in one ED, and had active asthma symptoms at enrollment; those with severe exacerbations were excluded. Virtually all (95%) of the children in each group completed the trial.

Study children were treated by protocol on presentation, generally receiving two or three beta agonist treatments within the first 60 minutes as well as supplemental treatments with ipratropium bromide. Children with oxygen saturations less than 93% were given supplemental oxygen. Children assigned to dexamethasone received an oral dose of 0.6 mg/kg (maximum dose, 12 mg) at enrollment as well as a second dose at 24 hours. Patients assigned to the prednisone/prednisolone group received 1.5 mg/kg in the ED followed by 1 mg/kg daily, divided into two doses on days 2-5. The research team members contacted the families by phone on day 7 and day 15 to determine outcomes.

There was no difference in the percentage of patients in each group who still experienced symptoms on day 7 (56.6% of the dexamethasone group and 58.3% of the prednisone/prednisolone group). There was also no difference in the percentage of children who received subsequent steroids (7.8% of the dexamethasone group compared with 6.2% of the prednisone/prednisolone group). Return visits occurred for 4.6% of the dexamethasone group and 3.2% of the prednisone/prednisolone group, a nonsignificant difference. Adherence was slightly better in the dexamethasone group (99.3% compared with 96% of the prednisone/prednisolone group). The investigators concluded that dexamethasone is a viable option for treating acute asthma exacerbation in children, and it performed as well as prednisone/prednisolone in this trial.

Viewpoint

A randomized trial to answer this question was most welcome, and in general the findings were very similar to earlier research, suggesting that dexamethasone was a good alternative. However, now, just as in my original post, I feel compelled to caution that this study compared two doses of dexamethasone with 5 days of prednisone. These compelling data show that a two-dose course of dexamethasone appears to be a very attractive option for treating children and young teens with asthma exacerbations. A 2014 meta-analysis examined earlier studies comparing oral or intramuscular dexamethasone given in an ED with a 5-day course of prednisone. The studies varied in size and design but the meta-analysis authors concluded that one to two doses of dexamethasone was just as effective—with the bonus of less vomiting.

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