Steroids Reduce Time to Discharge from Observation Unit in Infants with Acute Bronchiolitis and Suspected Asthma

Reference: (Pediatrics 2013 Oct;132(4):e810) (level 1 [likely reliable] evidence)

Bronchiolitis commonly affects young children, and is the most frequent cause of hospitalization among infants during winter months. A recent Cochrane review (Cochrane Database Syst Rev 2013 Jun 4;(6):CD004878) found that systemic and inhaled corticosteroids do not reduce rates of hospital admission or readmission in children with acute bronchiolitis, and current guidelines do not recommend routine use of steroids in this patient population (Pediatrics 2006 Oct;118(4):1774-93). However, some infants initially presenting with bronchiolitis are subsequently diagnosed with asthma, where corticosteroids are used for long-term symptom control. Data evaluating efficacy of steroids in infants with bronchiolitis who are at high risk for asthma have been limited thus far. Now, a recent randomized trial has compared oral dexamethasone vs. placebo in 200 such infants.

Infants (median age 3.5 months) presenting for emergency care with acute bronchiolitis were randomized to dexamethasone (1 mg/kg orally on day 1 followed by 0.6 mg/kg orally once daily for 4 more days) vs. placebo. All infants were at high risk for asthma based on either the presence of eczema or history of asthma in a first-degree relative. All infants received nebulized salbutamol 2.5 mg 4 times over first 2 hours and every 2 hours until discharge, and infants could receive nebulized epinephrine or other treatments at the discretion of the treating physician. Infants were evaluated for readiness for discharge from an observation unit at least every 6 hours, and were followed for 1 week after discharge.

A modified intention-to-treat analysis was used to assess the efficacy of dexamethasone after excluding 10 infants for admission to intensive care unit, failure to meet inclusion criteria, or withdrawal after randomization. The mean time to readiness for discharge was 18.6 hours with dexamethasone vs. 27.1 hours with placebo (p = 0.015), and the dexamethasone group had a lower rate of nebulized epinephrine use (19% vs. 34.4%, p = 0.03, NNT 7). However, the frequency of return visit within 1 week of discharge was 22% for dexamethasone vs. 21% for placebo (not significant). No hospitalizations or adverse events occurred in either group.

Collectively, these results suggest that oral dexamethasone may be useful for treatment of bronchiolitis in the emergency department in this subpopulation by substantially decreasing the amount of time infants spend under observation. The increased turnaround associated with short-term dexamethasone treatment may be particularly beneficial during winter months, when cases of bronchiolitis in the emergency department are at their maximum frequency. However, these data do not support continued treatment for 5 days, since there was no reduction in return visits in the week following discharge.

For more information, see the Bronchiolitis topic in DynaMed.

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