Background: The use of steroids in preschool children with a viral-induced wheeze is a bit of a grey area. Our local protocols are silent on the issue, and I know that paediatricians differ in their approach. A large RCT by Panickar et al in 2009 found no difference in any clinically relevant outcome between prednisolone and placebo, but this study has been criticised for including children as young as 10 months, many of whom were likely to have had bronchiolitis. The current study directly addresses the issue of age and seeks to clarify this ongoing question.

 

The paper: A single-centre RCT involving 605 children aged 2-6 years old who presented to the ED with wheeze and symptoms or signs of a viral URTI. There was a range of severity represented in the study (assessed using the Pulmonary Score, which is similar to the Paediatric Asthma Score but briefer and not yet validated). However, children with oxygen saturations 5), where median length of stay was 5 hours shorter than placebo (10hr vs 15hr). Interestingly, family or personal history of atopy did not affect outcomes in this study. (The Lancet Respiratory Medicine, January 2018)

 

The bottom line: This study provides some evidence that prednisolone is effective at reducing the symptoms of viral-induced wheeze in children aged 2-6.

 

Note: SIGN guideline 153 (the Scottish Intercollegiate Guidelines Network, for the uninitiated), written in conjunction with the British Thoracic Society in 2016, recommends oral steroids for preschool children with moderate or severe wheeze, but cautions against prescribing multiple courses in children with frequent episodes.

 

Expert commentary:“In this study giving prednisolone only reduced hospital stay by 3 hours, so for for children who are well enough to go home the benefits of steroids do not outweigh the risks. After reading this paper I personally prescribe steroids only to those who have severe wheeze or have a strong personal or family background of atopy – 3 hours less in hospital does not seem worth it!”(Dr Emily Goodlad, Paediatric consultant)

 

Expert commentary:“The younger the child, the more cautious you have to be about prescribing steroids. Personally, I only give prednisolone to children aged 1-2 if I’m happy they don’t have bronchiolitis and they have shown a clear improvement with salbutamol (but are still struggling a little).”(Dr Mohsin Jafri, Paediatric Consultant)

 

Note: Please see also this post in The BREACH from August on dexamethasone vs prednisolone for asthma exacerbations in children