Background: Systemic corticosteroids are used routinely in the management of children with severe acute asthma. There is a lack of consensus regarding the agent, dose and route of corticosteroid administration.
Objectives: To determine the benefit of systemic corticosteroids (oral, intravenous, or intramuscular) compared to placebo and inhaled steroids in acute paediatric asthma.
Search strategy: All controlled trials were identified from the Cochrane Airways Review Group Register, hand searching of respiratory journals, reference lists and contacts with experts and pharmaceutical companies.
Selection criteria: Studies were included if they described a randomised controlled trial (RCT) involving children aged 1-18 years with severe acute asthma who received oral, inhaled, intravenous or intramuscular corticosteroids. Only studies in which patients required hospital admission were included.
Data collection and analysis: Two reviewers using a standard form extracted all data. All data, numeric calculations and graphic extrapolations were independently confirmed.
Main results: Seven trials were included with a total of 426 children studied (274 with oral prednisone vs. placebo, 106 with intravenous steroids vs placebo and 46 with nebulised budesonide vs prednisolone). A significant number of steroid treated children were discharged early after admission (>4 hours) with an OR of 7.00 (95% CI: 2.98 to 16.45) and NNT of 3 (95%CI: 2 to 8). The length of stay was shorter in the steroid groups with a WMD of -8.75 hours (95% CI: -19.23 to 1.74). There were no significant differences between groups in pulmonary function or oxygen saturation measurements. Children treated with steroids in hospital were less likely to relapse within one to three months with OR 0.19 (95%CI: 0.07 to 0.55) and NNT of 3 (95%CI: 2 to 7). The single small study that compared nebulised budesonide to oral prednisone failed to demonstrate equivalence or a difference between each therapy.
Reviewer's conclusions: Systemic corticosteroids produce some improvements for children admitted to hospital with acute asthma. The benefits may include earlier discharge and fewer relapses. Inhaled or nebulised corticosteroids cannot be recommended as equivalent to systemic steroids at this time. Further studies examining differing doses and routes of administration for corticosteroids will clarify the optimal therapy.