Published online April 2, 2007
PEDIATRICS Vol. 119 No. 4 April 2007, pp. 865-866 (doi:10.1542/10.1542/peds.2007-0030)

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LETTER TO THE EDITOR

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

Allan S. Lieberthal, MD
Chair
AAP Subcommittee on Diagnosis and Management of Bronchiolitis

The American Academy of Pediatrics (AAP) Subcommittee on Diagnosis and Management of Bronchiolitis thanks Dr Weinberger for his comments on the corticosteroid recommendation in the clinical practice guideline "Diagnosis and Management of Bronchiolitis."¹ He raises many points that were discussed by the subcommittee as we formed our recommendations.

Schuh et al² performed a well-designed study of the effect of 1 mg/kg oral dexamethasone in the emergency department using the Respiratory Distress Assessment Instrument (RDAI) and the related Respiratory Assessment Change Scale (RACS) to evaluate clinical response at 240 minutes. The mean RACS score showed a significant difference between those in the dexamethasone group and those in the placebo group. Although the mean RDAI score did show a trend in favor of dexamethasone, statistical significance was not achieved. There was a significant difference in hospitalization rate in favor of the treatment group. This study was included in the meta-analysis by both the Agency for Healthcare Research and Quality³ and the Cochrane Database of Systematic Reviews⁴ with a Jadad quality score of 5. Two other studies of comparable quality (Jadad quality score 4–5) in the Cochrane meta-analysis^{5, 6} showed no difference in hospital admission rate.

In contrast, the Csonka et al study⁷ was excluded from these reviews because of methodologic issues. The age group included by Csonka et al was 6 to 35 months, with a mean age of 16.8 months, which is not the typical age for the majority of children with clinical bronchiolitis. The guideline only applies to children who are 2 to 24 months of age. In addition, 136 (59%) of the 230 subjects in the study had a previous history of wheezing.

The 2000 Garrison et al meta-analysis⁸ included 6 studies with 347 patients. The more recent Cochrane review, most recently updated in 2005,⁴ included these 6 studies plus 7 additional studies for a total of 1198 patients. As noted in the guideline, the Cochrane review concluded that "[n]o benefits were found in either length of stay or clinical score in infants and young children treated with systemic glucocorticoids as compared with placebo." The subcommittee agreed with this conclusion and, thus, recommended against the routine use of corticosteroids for bronchiolitis.

Subsequent to the submission of the guideline and not included in the subcommittee's deliberations, the Pediatric Emergency Care Applied Research Network presented emergency department data at the 2006 AAP National Conference and Exhibition that showed no difference in rate of hospitalization of 1 mg/kg dexamethasone versus placebo. Full details of this large multicentered study will be published in the future. Also nearing completion is a similar study by the Pediatric Emergency Research Canada group.

As with all clinical practice guidelines produced by the AAP, the bronchiolitis guideline will be updated periodically as new literature becomes available.

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. Agency for Healthcare Research and Quality. Management of Bronchiolitis in Infants and Children. Rockville, MD: US Department of Health and Human Services; 2003. Evidence report/technology assessment No. 69; AHRQ publication No. 03-E014
4. Patel H, Platt R, Lozano JM, Wang EE. Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database Syst Rev. 2004;(3) :CD004878
5. Berger I, Argaman Z, Schwartz SB, et al. Efficacy of corticosteroids in acute bronchiolitis: short-term and long-term follow-up. Pediatr Pulmonol. 1998;26 :162 –166[CrossRef][Web of Science][Medline]
6. 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]
7. 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]
8. 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

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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) Submit a response 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 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 Lieberthal, A. S. Search for Related Content PubMed Articles by Lieberthal, A. S. Related Collections Respiratory Tract Social Bookmarking                         What's this?