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“Pediatric Asthma Exacerbation and Oral Steroids,” Annals of Emergency Medicine, October, 2015

Summary:

This was a randomized trial to determine if a single dose of dexamethasone (0.3 mg/kg) was as effective as prednisone (1mg/kg per day for 3 days) in patients aged 2-16 years having an asthma exacerbation.  The outcomes were evaluated based upon a Pediatric Respiratory Assessment Measure (PRAM) scoring at day four.  There was no difference in PRAM scores at day four between the two groups.  Adverse effects were much more common in the prednisone than in the dexamethasone group (vomiting was ~12% prednisolone vs. 0% dexamethasone).  Those taking dexamethasone had a slightly higher risk of needing further steroids within 14 days of being enrolled in the trial compared to the prednisone group (13% vs. 4.2%, 95% CI, 1.9%-16%).  There were no differences in hospital admission rates or number of unscheduled follow-up visits.

Conclusion:

Use of dexamethasone as a single dose of 0.3 mg/kg in an emergency setting was equivalent to using prednisone in improving symptoms.  The benefit of decreased side effects need to be weighed with the need for close follow-up due to the higher risk for need of more steroids at 14 days.

 Discussion:

Pediatric asthma is often treated aggressively with beta agonists and sometimes with antibiotics, but not adequately with oral steroids, which along with beta agonists, are most important.  This study makes it a hallmark of the treatment and finds one single dose at the time of presentation to be highly effective and have minimal side effects. 

While this study was done in a tertiary care medical setting, it provides good insight into how we in the clinical community can address pediatric asthma.  Inclusion criteria focused on those who had a known history of asthma or those who had at least one previous episode of beta agonist responsive wheeze.  Thus applying this approach to patients who are presenting with their first time of wheezing may not be appropriate.  Nonetheless, for the vast majority of children with asthma, this study demonstrates  dexamethasone may be very effective in managing acute reactive airway disease in a child.

When weighing the benefits of one dose and lack of adverse effects vs. the need for follow-up steroids, the clinician should consider the ability for the child to follow-up and the parents’ ability to maintain good contact should the child worsen rather than improve. 

Interestingly, there is a similar data set in the adult literature adult asthma suggesting a 2 day course of dexamethasone is as effective as a longer course of prednisone.  

Consider adding dexamethasone (which tastes much better than liquid prednisone) when seeing children with acute asthma. Dexamethasone comes as 0.5 mg/5 ml.