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Three Part Question

In [infants with bronchiolitis] do [oral steroids] reduce [clinical severity or length of hospital stay].

Clinical Scenario

A 6 month old baby is admitted to hospital with a 4 day history of coryzal symptoms, cough, wheeze and decrease in feeds. Respiratory syncytial virus is detected in nasopharyngeal secretion. She is needing oxygen and is on a nasogastric feed. You wonder whether starting oral steroids will improve her clinical condition.

Search Strategy

Medline 1966-2008
Embase 1980-2008
Cochrane database of systematic reviews and Cochrane central register of controlled trials
(Oral steroids or prednisolone) AND (bronchioloitis or RSV bronchiolitis) limit to human, english and randomised controlled trails

Search Outcome

35 hits, 6 relevant papers.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Zhang L et al 2003 Brazil	52 patients, aged less than 12 months. Oral prednisolone (1mg/kg/day) for 5 days plus standard care vs. standard care	Randomised controlled trial	Length of hospital stay	No significant difference	No microbiological confirmation of diagnosis. Small study.
			Duration of oxygen therapy	No significant difference
			Time to clinical resolution	No significant difference
			Prevalence of post bronchiolitis wheezing	No significant difference
Corneli HM et al 2007 USA	600 patients aged 2-12 months. Oral dexamethasone (1 mg/kg) 1 dose vs placebo	Randomised double-blind placebo-controlled trail	Hospital admission	No significant difference	No microbiological confirmation of diagnosis
			Respiratory assessment change score	No significant difference
			Later medical visits	No significant difference
Berger I et al. 1998 Israel	38 patients (1-18 months). Oral prednisolone (2 mg/kg/d) for 3 days vs placebo. All patients received nebulised salbutamol	Randomised double blind placebo controlled trial	Clinical score	No significant difference	Microbiological confirmation of diagnosis in only 50 % of cases. Inappropriate use of the mean as measure of distributions in small samples. No power calculation regarding chronic symptoms.
			Oxygen saturation	No significant difference
			Development of chronic respiratory symptoms (at 2 year follow up)	No significant difference
Goebel J et al. 2000 USA	48 children (less than 23 months). Oral prednisolone (2mg/kg/d) for 5 days vs placebo. All patients received nebulised salbutamol.	Clinical trial	Bronchiolitis score	Significant improvement in prednisolone group by day 2 but no difference later on	Exclusion of mild and severe cases of bronchiolitis. Selection bias: only patients with wheeze not responding to nebulised salbutamol were included. 54% of cases and 37% of controls without microbiological confirmation of diagnosis.
			Length of hospital stay	No significant difference
Klassen TP et al. 1997 Canada	67 patients (6 weeks-15 months) Oral dexamethasone(0.5mg/kg/d- day 1, 0.3mg/kg/d- day 2 & 3) vs placebo	Randomised double blind placebo controlled trial	Oxygen saturation	No significant difference	Short duration (3 days) of treatment. Application of mean and t-test to ordinal scale data inappropriate. No microbiological confirmation in 12 % of controls and 14 % of cases. No justification of choice of primary outcome. Treatment given for 2 days beyond time of primary outcome assessment.
			Respiratory rate	No significant difference
			RDAI score	No significant difference
			Length of hospital stay	No significant difference
Van Woensel JB et al. 1997 Netherlands	54 patients aged less than 2 years. Oral prednisolone (1mg/kg/d) for 7 days vs placebo	Randomised double blind placebo controlled trial	Symptom score (non ventilated patients)	Significantly faster improvement in prednisolne group (day 3)	No power calculation for ventilated patients. Small number of ventilated patients.
			Length of hospital stay (non ventilated patients)	No significant difference
			Duration of mechanical ventilation(ventilated patients)	No significant difference
			Length of hospital stay (ventilated patients)	Significantly less in prednisolone group

Comment(s)

The largest of the studies (Corneli et al) was conducted in the Emergency Department. Neither the primary outcome measure (hospital admission) nor the secondary outcomes (length of hospital stay and clinical score) showed any significant improvement with steroids. In the first 2 days of treatment prednisolone seems to accelerate the improvement of clinical scores transiently without impact on overall outcomes, such as, duration of hospitalisation or chronic symptoms.

Clinical Bottom Line

Current evidence does not support bronchiolitis as an indication for oral steroids.

References

1. Zhang L, Ferruzzi E, Bonfanti T, Auler MI, D'Avila NE, Faria CS, Costa MM Long and short-term effect of prednisolone in hospitalized infants with acute bronchiolitis J Paediatr Child Health 2003; 39(7):548-51
2. Corneli HM, Zorc JJ, Majahan P, Shaw KN, Holubkov R, Reeves SD et al of the Bronchiolitis Study Group of the Pediatric Emergency Care Applied Reserach Network (PECARN) A multicenter, randomized, controlled trial of dexamethasone for bronchiolitis New England Journal of Medicine 2007; 357(4):331-9
3. Berger I, Argaman Z, Schwartz SB, Segal E, Kiderman A, Branski D, Kerem E . Efficacy of corticosteroids in acute bronchiolitis: Short term and long term follow up. Pediatric Pulmonology 1998;26(3):162-166.
4. Goebel J, Estrada B, Quinonez J, Nagji N, Sanford D, Boerth RC. Prednisolone plus albuterol versus albuterol alone in mild to moderate bronchiolitis. Clinical Pediatrics 2000;39(4):213-220.
5. Klassen TP, Sutcliffe T, Watters LK, Wells GA, Allen UD, Li MM. Dexamethasone in salbutamol- treated inpatients with acute bronchiolitis: a randomised controlled trial. The Journal of Pediatrics 1997;130(2):191-196.
6. van Woensel JB, Wolfs TF, van Aalderen WM, Brand PL, Kimpen JL. Randomised double blind placebo controlled trial of prednisolone in children admitted to hospital with respiratory syncytial virus bronchiolitis. Thorax 1997;52(7):634-637.