Corticosteroids for Bronchiolitis in Young Children

Abstract & Commentary

Synopsis: A 3-day course of oral prednisolone for treatment of bronchiolitis in children aged 6-35 months decreased the median duration of symptoms and hospitalization and the need for additional asthma medications.

Source: Csonka P, et al. Oral prednisolone in the acute management of children age 6 to 35 months with viral respiratory infection-induced lower airway disease: A randomized, placebo-controlled trial. J Pediatr. 2003;143:725-730.

A randomized, double-blind, placebo-controlled trial of a 3-day course of oral prednisolone (2 mg/kg/d divided twice daily for 3 days) was conducted in an emergency department setting in Finland among 230 children aged 6-35 months with an apparent viral respiratory tract infection complicated by tachypnea, wheezing, or use of accessory muscles for breathing. Prednisolone did not affect the hospitalization rate but did decrease the median duration of symptoms (1 day vs 2 days) both among hospitalized (P = .001) and nonhospitalized children (P = .006), median duration of hospitalization (2 days vs 3 days; P = .06), and the need for additional asthma medications (18.0% vs 37.1%; P = .018).

Adverse reactions were mild and resolved without intervention and included vomiting (4 vs 9), diarrhea (6 vs 6), rash (0 vs 2), and restlessness (2 vs 3) in the placebo and prednisolone groups, respectively. Medication was discontinued in 15 children (4 receiving placebo and 11 receiving prednisolone) because of perceived adverse effects.

Comment by Hal B. Jenson, MD, FAAP

Bronchiolitis is a diagnosis that implies a viral respiratory tract infection accompanied by wheezing and is most often caused by respiratory syncytial virus. Other viruses less frequently responsible for bronchiolitis include adenovirus; parainfluenza viruses 1, 2, and 3; metapneumovirus; and influenza viruses A and B. It is extremely difficult to clinically distinguish bronchiolitis from a first episode of asthma. Furthermore, the causal relationship of bronchiolitis to asthma in children is a subject of much conjecture. There is an increased risk of asthma among children with bronchiolitis that requires hospitalization, which may reflect that children with hyper-reactive airways are more likely to require hospitalization with respiratory viral infection.

Clinical studies of the management of bronchiolitis have been plagued by difficulties in accurate virological diagnosis and inability to perform objective measurements of treatment effectiveness, such as pulmonary function tests. This study did not determine the viral etiology, which is a shortcoming, but does reflect some of the reality of clinical practice. Rapid tests for respiratory syncytial virus and influenza viruses are commonly used in the United States, but the causes of many cases of bronchiolitis still remain unidentified.

This is one of a series of studies of the value of corticosteroids for young children with bronchiolitis. Of 6 previous controlled trials, 5 showed little or no benefit, and only 1 showed accelerated improvement compared to placebo. A meta-analysis of these 6 studies concluded that there was a small but statistically significant benefit of prednisolone, reducing hospitalization by less than half a day.1 This new study differs from the previous studies by initiation of prednisolone earlier, upon admission to the emergency department, rather than after hospitalization. This difference typically is several hours, which suggests that earlier treatment with prednisolone may prevent progression of the inflammatory response, which soon becomes irreversible.

Bronchiolitis is an almost universal experience of childhood and accounts for a hospitalization rate of approximately 3 per 100 infants in the United States. Supportive measures of intravenous hydration and supplemental oxygen remain important. The value of bronchodilator therapy remains controversial; it may provide transient clinical improvement for some patients but does not alter the course of the disease. This study shows that oral prednisolone early in the course of bronchiolitis can have a small but discernible benefit and alters the course by reducing the duration of symptoms and subsequently the duration of hospitalization and need for additional asthma medications.

Dr. Jenson, Chair, Department of Pediatrics, Director, Center for Pediatric Research, Eastern Virginia Medical School and Children’s Hospital of the King’s Daughters, Norfolk, VA, is Associate Editor of Infectious Disease Alert.

Reference

1. Garrison MM, et al. Systemic corticosteroids in infant bronchiolitis: A meta-analysis. Pediatrics. 2000;105:e44.