The controversial question of whether preschool children with virus-associated wheeze benefit from oral corticosteroids has been answered by a randomised controlled trial from Western Australia.
Emergency department stays are cut by about three hours when wheezy children are given oral prednisolone, clinicians at the Princess Margaret Hospital, Perth, have shown.
In a study of more than 600 children aged two and five presenting to an emergency department with a presumed virus-associated wheezing episode, the use of oral steroids was associated with a 20% reduction in length of hospital stay (540 vs 370 minutes) compared to placebo.
Children randomised to the active treatment group were given a three day course of prednisolone (1 mg/kg per day). In a post-hoc analysis the likelihood of hospital stay exceeding 12 hours was reduced by one third with steroid treatment (38% for placebo vs 25% for prednisolone)
“The absolute reduction in the percentage of patients with a length of stay exceeding 12 hours (13%) represents a number needed to treat of about eight patients to prevent the length of stay of one patient exceeding 12 hours,” the study authors noted in Lancet Respiratory Medicine.
Benefits of oral steroid were described as “compelling” in children who had severe features of wheeze, had received salbutamol before presentation, or had a prior history of asthma.
The researchers, led by paediatric emergency medicine specialist Dr Meredith Borland, said corticosteroids were currently not recommended in guidelines as first-line therapy for preschool children with wheeze because a previous large study had shown no benefit compared to placebo.
However that study may have been biased because it included children with mild wheeze and did not exclude younger infants, who were likely to have bronchiectasis rather than viral-associated wheeze, she noted.
The new randomised controlled trial showed a clear benefit for oral prednisolone, which “should be administered early in the management of virus-associated wheeze in preschool aged children presenting to the emergency department,” the researchers concluded.
Their recommendations were backed by an accompanying commentary, which said the study answered an important clinical question, given that almost half of all children have an episode of wheeze by age of six.
“These results support treating these children similarly to older children with established asthma,” it said.
Dr Borland told thelimbic that emergency departments currently followed NICE and Australian national asthma guidelines with respect to viral wheeze in pre-schoolers in Australia of not routinely administering steroids.
“Steroids have been used for more severe disease intuitively but not necessarily for those being admitted to hospital,” she said.
She said it was notable that the presence and type of virus did not seem to affect steroid response
“We are still to analyse the effect of virus and steroids on three month data relating to development of recurrent wheeze and/or diagnosed asthma,” she said.
“Obviously results need to confirmed in another centre, and investigate the potential role of a single dose of dexamethasone vs three days prednisolone,” she added.