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Three Part Question

In children with asthma [patient] do parent-initiated oral corticosteroids (OCS) [intervention] reduce the likelihood of hospital presentation or admission [outcome].

Clinical Scenario

You are a paediatric specialist registrar giving discharge advice to the parents of a 7 year old girl who is recovering from an episode of acute asthma. She has a frequent episodic pattern of asthma and normally receives 100mcg of fluticasone morning and night. Her parents ask you if they should wait to see a doctor before commencing her on prednisolone if she has another 'asthma attack'?

Search Strategy

Medline via Pubmed
(prednisolone OR prednisone OR methyl-prednisolone OR methylprednisolone OR MP OR corticosteroid* OR glucocorticoid* OR *steroid* OR solucortef OR solu-cortef OR solumedrol OR dexamethasone) AND (asthma OR wheez*) AND (parent* OR mother* OR father* OR famil* OR carer* OR caregiver* OR guardian* OR home* OR ambulat*). Limits: all child: 0-18 years, English language, core clinical journals.
Search date: August 2006.

Search Outcome

170 papers identified, however only two papers were relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Grant 1995 United States	86 children aged 2 to 14 years identified as having asthma from clinic records.	Randomised double blind cross-over study: participants observed for two consecutive six month periods.	Unscheduled medical review	Mean (SD) number of unscheduled medical reviews during intervention period 1.2(1.8) vs. control period 0.68(1.1), p=0.004.	Unable to extract or obtain raw data in order to calculate 95% confidence intervals. Unable to determine severity of the children's illnesses or the parent's ability to assess clinical status.
			Hospital admission	9 admissions during the intervention period vs. 7 admissions during the control period (p=0.73)
Oommen 2003 United Kingdom	217 children aged 1 to 5 years old who had been admitted to hospital with an episode of 'viral wheeze'.	Randomised double blind parallel study	Mean 7-day daytime respiratory symptomscore.	Mean score in treatment group 0.95 vs. control group 0.96 (mean difference=-0.01, 95% CI –0.12 to 0.32)	Unable to determine severity of the children's illnesses or the parent's ability to assess clinical status.
			Hospital admission	6 out of 52 episodes treated with prednisolone vs. 2 out of 69 episodes treated with placebo (OR=4.4, 95%CI 0.8 to 22.6)

Comment(s)

Oral corticosteroids (OCS) commenced following physician review are effective in the treatment of acute asthma in children [Rowe, 2003], and it would seem logical that parent-initiated OCS may be an effective strategy. However, it is important to recognise two important limitations of this theory. First, only a minority of episodes of acute wheeze that occur in the community result in an emergency department review [Robertson, 2003], and it is likely that many episodes of acute wheeze that occur in the community are too minor to justify OCS therapy. Second, parent-initiated therapy relies on the ability of the parent to make an accurate assessment of their child's clinical status, and there are a number of studies which have demonstrated that parents have some difficulty in making this assessment [Levy, 2004. Lowe, 2004]. It is also important to recognise that parent-initiated treatment with OCS is likely to result in more frequent administration of OCS. This may have important implications for growth, osteoporosis, and adrenal suppression (although the existing data is reassuring [Ducharme, 2003]). The limited amount of published data available do not show a benefit from parent-initiated OCS in terms of hospital admissions, unscheduled medical reviews, symptom scores, or the use of bronchodilators in children treated with parent-initiated prednisolone compared with placebo. Moreover, there is evidence from at least one trial [Grant, 1995], that such an intervention actually increases medical visits, at least in pre-school age children - this may be related to OCS-induced behavioral and emotional changes [Kayani, 2002]. There are a number of limitations in the existing literature. The included studies lack sufficient power to confidently exclude a benefit from parent-initiated OCS. The disease severity of the trial participants in the included studies is difficult to quantify, and the majority of data relate to preschool aged children only. It is also difficult to know if parents in the included studies commenced study medication for an appropriate indication. Therefore, it is possible that the effectiveness of parent-initiated OCS have been diluted by the inclusion of (1) data from children with mild disease, (2) data from minor episodes of wheeze, and (3) data from illnesses misdiagnosed by the parents. In summary, OCS have a clearly defined role in the management of acute asthma in the hospital setting, and it is likely that parent-initiated OCS are appropriate for some children with severe disease. However, widespread use of parent-initiated OCS cannot be recommended until the benefits and harms can be clarified further.

Editor Comment

Comment by author 23/01/07 The data included in this Best Bet entitled 'Parent-initiated oral corticosteroids for acute asthma' have been previously published/accepted under the following titles: 1. 'Parent-initiated oral corticosteroid therapy for intermittent wheezing illnesses in children' in issue 3, 2006 of the Cochrane Database of Systematic Reviews (July). 2. "Parent-initiated oral corticosteroid therapy for intermittent wheezing illnesses in children: systematic review", Journal of Paediatrics and Child Health (in press). Our Best Bet represents a brief, clinical take on the information from the systematic review. We believe that it is sufficiently different from the manuscripts listed above to be a useful Best Bet. The authors, Dr Peter Vuillermin and Professor Mike South and Professor Colin Robertson, contributed significantly and are in agreement with the content of the manuscript. The authors are currently involved in a clinical trial to assess the effectiveness of parent-initiated oral prednisolone in primary school aged children with asthma (ISRCTN 26232583). Yours sincerely, Dr Peter Vuillermin

Clinical Bottom Line

(1) Oral corticosteroids are effective in the treatment of acute asthma in the emergency department (Grade A). (2) Parent-initiated OCS may be appropriate for some children with severe asthma, however, there is insufficient evidence to recommend widespread use of parent-initiated OCS in children with asthma (Grade D).

References

1. Grant CC, Duggan AK, DeAngelis C. Independent parental administration of prednisone in acute asthma: a double-blind, placebo-controlled, crossover study. Pediatrics 1995;96(2 Pt 1):224-9.
2. Oommen A, Lambert PC, Grigg J Efficacy of a short course of parent-initiated oral prednisolone for viral wheeze in children aged 1-5 years: randomised controlled trial. Lancet 2003;362(9394):1433-8.