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Oral prednisolone did not improve outcomes in preschool children with an attack of virus-induced wheezing

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QUESTION

Does a short course of oral prednisolone improve outcomes in preschool children with an attack of wheezing associated with upper respiratory viral infection?

METHODS

Design:

randomised placebo-controlled trial. ISRCTN58363576.

Allocation:

concealed.

Blinding:

blinded (patients, parents, healthcare providers, and outcome assessors).

Follow-up period:

1 month.

Setting:

3 hospitals in the UK.

Patients:

700 children 10–60 months of age (mean age 26 mo, 64% boys) who presented to hospital with an attack of wheezing associated with a clinically diagnosed upper respiratory viral infection. Exclusion criteria included shock, bacterial sepsis, heart or lung disease, immunodeficiency or immunosuppressive therapy, and varicella infection or recent exposure.

Intervention:

oral prednisolone (10 mg/d if ⩽24 mo of age or 20 mg/d if >24 mo) once daily for 5 days (n = 343) or placebo (n = 344).* All patients received inhaled salbutamol as required and other treatment at the discretion of the attending physician.

Outcomes:

time to discharge, puffs of salbutamol in hospital, symptom severity at 4 hours, time to return to normal activities, and hospital readmission for wheezing within 1 month.

Patient follow-up:

98% (intention-to-treat analysis).

MAIN RESULTS

Prednisolone was not better than placebo for any outcome (table). In the subgroup of 124 children considered to be at high risk of asthma, prednisolone did not reduce time to discharge, and treatment effect did not differ by asthma risk status (p for interaction 0.3).

Oral prednisolone v placebo in preschool children with an attack of virus-induced wheezing*

CONCLUSION

A short course of oral prednisolone did not improve outcomes in preschool children with an attack of wheezing associated with upper respiratory viral infection.

*Treatment group was not provided for 13 excluded children.

A modified version of this abstract appears in Evidence-Based Medicine.

ABSTRACTED FROM

Panickar J, Lakhanpaul M, Lambert PC, et al. Oral prednisolone for preschool children with acute virus-induced wheezing. N Engl J Med 2009;360:329–38.

Clinical impact ratings: Emergency 5/7; Family/general practice 6/7; Paediatrics 5/7; Respirology 5/7

Commentary

Interpretation and comparison of studies of corticosteroid treatment for preschool children with wheeze are hindered by the heterogeneity of patients in relation to age, phenotype, diagnosis, and outcome variables,1 as well as dose, route, and duration of treatment. Phenotypes such as “transient infant wheeze,” viral wheeze, multitrigger “atopic” wheeze, and atypical wheeze have been defined, but they have considerable overlap in this age group and are not fixed over time.2 3

The methodologically robust, double-blind, randomised trial by Panickar et al, using the validated Preschool Respiratory Assessment Measure, found no benefit from a course of oral prednisolone for preschoolers presenting to hospital with mild-to-moderate virus-induced wheeze. However, as the authors acknowledged, the results cannot be generalised to children with moderate-to-severe symptoms, nor to those with a strongly atopic phenotype.

This trial should be of interest to child health nurses and nurse practitioners in primary and emergency care settings who take histories, determine asthma severity scores, and initiate and evaluate effectiveness of inhaled β2 agonists and steroid treatment. The implication of the findings is that we should educate families that steroid use is of no clear clinical benefit to young children with mild-to-moderate wheeze primarily triggered by colds. In addition, nurses could provide recording templates for parents to note symptoms, effective doses and duration of treatments, and clinical outcomes over time, enabling clinicians to identify children who may still benefit from a short course of prednisolone.

View Abstract

Footnotes

  • Source of funding: Asthma UK.

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