Published online April 2, 2007
PEDIATRICS Vol. 119 No. 4 April 2007, pp. 864-865 (doi:10.1542/peds.2006-2888)

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LETTER TO THE EDITOR

High-Dose Systemic Corticosteroids May Be Effective Early in the Course of Bronchiolitis

Miles M. Weinberger, MD
Department of Pediatrics
University of Iowa Hospital
Iowa City, IA 52242
Department of Pediatrics
University of Iowa
Iowa City, IA 52242

To the Editor.—

In their published guidelines, the American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis¹ discounted studies that demonstrated benefit from systemic corticosteroids for bronchiolitis. In a randomized, double-blind, placebo-controlled trial of infants with bronchiolitis seen at the emergency department, Schuh et al² demonstrated that fewer than half as many infants with bronchiolitis required hospital admission among those given 1 mg/kg of dexamethasone as compared with those given placebo, which is a significant difference (P = .039). In another controlled clinical trial, Csonka et al³ found that 2 mg/kg prednisolone in the emergency department and 1 mg/kg twice daily for 3 more days was associated with significantly shorter hospital stays among those who subsequently required hospitalization and a shorter duration of symptoms, averaging 1 day less among the steroid-treated group as compared with randomized controls who received placebo. Although that study included both first- and second-time wheezers and included patients older than the more strict criteria in the study by Schuh et al, the response to prednisolone was similar among those having wheezing for the first time and those with a previous episode. A meta-analysis that included 6 controlled clinical trials of hospitalized patients with bronchiolitis concluded that there was a small but statistically significant benefit from prednisolone for bronchiolitis.⁴

Asked to write an editorial to accompany the Csonka et al article, I speculated that the differences in outcome for hospitalized infants with bronchiolitis, in whom little or no benefit has been demonstrated, and those treated before hospitalization relate to the timing of treatment with relation to the pathology.⁵ Perhaps there is reversible inflammation initially, whereas progression results in the characteristic dense plugs composed of alveolar debris and fibrin within the bronchioles.⁶ A high dose of corticosteroid early in the course of bronchiolitis may be effective in preventing that progression and thereby preventing hospitalization, as demonstrated by Schuh et al,² or at least modifying the course, as demonstrated with the lower doses of corticosteroids in the report by Csonka et al³ and a report by Goebel et al.⁷

The reported annual hospitalization rate for bronchiolitis has been 3 per 100 infants in the United States,⁸ and the latest available data give no indication that these hospitalizations are decreasing.⁹ Treatment that has the potential to decrease the hospitalization rate by >50%, as in the Schuh et al study,² warrants careful consideration in a guideline for treatment of bronchiolitis.

REFERENCES

1. American Academy of Pediatrics, Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics. 2006;118 :1774 –1793[Abstract/Free Full Text]
2. Schuh S, Coates AL, Binnie R, et al. Efficacy of oral dexamethasone in outpatients with acute bronchiolitis. J Pediatr. 2002;140 :27 –32[CrossRef][Web of Science][Medline]
3. Csonka P, Kaila M, Laippala P, Iso-Justajärvi M, Veskikari T, Ashorn P. 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[CrossRef][Web of Science][Medline]
4. Garrison MM, Christakis DA, Harvey E, Cummings P, Davis RL. Systemic corticosteroids in infant bronchiolitis: a meta-analysis. Pediatrics. 2000;105(4) . Available at: www.pediatrics.org/cgi/content/full/105/4/e44
5. Weinberger M. Corticosteroids for first-time young wheezers: current status of the controversy. J Pediatr. 2003;143 :700 –702[CrossRef][Web of Science][Medline]
6. Wohl MEB, Chernick V. State of the art: bronchiolitis. Am Rev Respir Dis. 1978;118 :759 –781[Web of Science][Medline]
7. Goebel J, Estrada B, Quinonez J, Nagji N, Sanford D, Boerth RC. Prednisolone plus albuterol versus albuterol alone in mild to moderate bronchiolitis. Clin Pediatr (Phila). 2000;39 :213 –220[Abstract/Free Full Text]
8. Shay DK, Holman RC, Newman RD, Liu LL, Stout JW, Anderson LJ. Bronchiolitis-associated hospitalizations among US children, 1980–1996. JAMA. 1999;282 :1440 –1446[Abstract/Free Full Text]
9. Center for Disease Control. Bronchiolitis-associated outpatient visits and hospitalizations among American Indian and Alaska Native Children: United States, 1990–2000. MMWR Morb Mortal Wkly Rep. 2003;52 :707 –710[Medline]

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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Weinberger, M. M. Search for Related Content PubMed PubMed Citation Articles by Weinberger, M. M. Related Collections Respiratory Tract Social Bookmarking                         What's this?