Source: Fernandes RM, Bialy LM, Vandermeer B, Tjosvold L, Plint AC, Patel H, Johnson DW, Klassen TP, Hartling L. Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database Syst Rev. 2013 Jun 4;6:CD004878. doi: 10.1002/14651858.CD004878.pub4. PubMed PMID: 23733383.
Plint AC, Johnson DW, Patel H, Wiebe N, Correll R, Brant R, Mitton C, Gouin S, Bhatt M, Joubert G, Black KJ, Turner T, Whitehouse S, Klassen TP; Pediatric Emergency Research Canada (PERC). Epinephrine and dexamethasone in children with bronchiolitis. N Engl J Med. 2009 May 14;360(20):2079-89. doi: 10.1056/NEJMoa0900544. PubMed PMID: 19439742
Efficacy Endpoints: Rate of hospital admission, length of stay (LOS), clinical severity scores, O2 saturation, respiratory rate and heart rate, hospital re-admissions (inpatient studies only), return healthcare visits, pulmonary function tests, symptoms and quality of life.
Harm Endpoints: Short- and long-term adverse events (occurrence of vomiting, GI bleeding, hypertension, pneumonia or varicella).
Narrative: Bronchiolitis is a common airway illness, typically caused by respiratory syncytial virus (RSV) and seen in children <2 years of age. Despite its ubiquity, there remains wide variation in treatment patterns. Based on similarities in the clinical presentation of bronchiolitis and asthma, glucocorticoids are thought to be potentially beneficial.
This review of 17 trials involving 2596 subjects found no significant difference between glucocorticoid and placebo groups among primary or secondary outcomes. Statistically nonsignificant differences for the primary outcomes did slightly favor glucocorticoid groups however these differences, even if found to be statistically significant with the addition of power (a higher ‘n’) still appeared to represent clinically unimportant absolute values.
The authors note that a single, high quality RCT suggested that combined therapy with oral dexamethasone and nebulized epinephrine resulted in a significant reduction in admissions by day 7 (NNT 11, 95% CI 7 to 76). and reduced time to normal feeding and quiet breathing.
Caveats: Combined therapy results should be interpreted cautiously as these were seen in a single study (Plint 2009), published in a major journal. This is a common pattern (extreme results published in major impact journals) that calls outsize attention to results often shown later to be outliers.1 Indeed we would urge particular caution here given not only the lack of effect in multiple other trials, but also the use of multiple (four) group comparisons in this trial, the lack of statistical benefit after adjustment for multiple comparisons, and the biologic implausibility of a combined effect given the trial’s results according to individual components.
Despite a finding of no short- or long-term adverse effects, it should also be kept in mind that the majority of trials did not closely record adverse outcome data and that there exist no well-described long-term pharmacoepidemiologic data for the impact of short term steroid dosing in children.
Author: Manpreet Singh, MD
Published/Updated: June 3, 2014
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