Parent-initiated treatment with prednisolone can reduce symptoms for children with acute asthma exacerbations

Article Outline

• Question
• Design
• Setting
• Participants
• Intervention
• Outcomes
• Main Results
• Conclusions
• Commentary
• Copyright

Vuillermin P, Robertson C, Carlin J, Brennan S, Biscan M, South M. Parent initiated prednisolone for acute asthma in children of school age: randomised controlled crossover trial. BMJ 2010;340:c843.

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Question 

Among school-age children with an acute asthma exacerbation, does a short course of parent-initiated oral prednisolone reduce asthma symptoms?

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Design 

Randomized, double-blind, placebo-controlled trial.

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Setting 

The Barwon region of Victoria, Australia.

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Participants 

Two hundred thirty children, ages 5 to 12 years, with a history of recurrent episodes of acute asthma.

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Intervention 

A short course of parent-initiated treatment with prednisolone (1 mg/kg per day) or placebo.

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Outcomes 

The primary outcome was the mean daytime symptom score over 7 days. Secondary outcomes were mean nighttime symptom score over 7 days, use of health resources, and school absenteeism.

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Main Results 

Over a 3-year period, 131 (57%) of the participants contributed a total of 308 episodes of asthma that required parent initiated treatment: 155 episodes were treated with parent-initiated prednisolone and 153 with placebo. The mean daytime symptom score was 15% lower in episodes treated with prednisolone than in those treated with placebo (geometric mean ratio, 0.85; 95% CI, 0.74 to 0.98; P = .023). Treatment with prednisolone was also associated with a 16% reduction in the night time symptom score (geometric mean ratio, 0.84; 95% CI, 0.70 to 1.00; P = .050), a reduced risk of health resource use (odds ratio, 0.54; 95% CI, 0.34 to 0.86; P = .010), and reduced school absenteeism (mean difference, −0.4 days; 95% CI, −0.8 to 0.0 days; P = .045).

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Conclusions 

A short course of parent-initiated oral prednisolone for children with an episode of acute asthma may reduce asthma symptoms, health resource use, and school absenteeism. However, the modest benefits of this strategy must be balanced against potential side effects of repeated short courses of an oral corticosteroid.

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Commentary 

This valuable study shows that parent-initiated prednisolone in the management of asthma exacerbations in school-aged children confers modest but significant benefit. The study was done in a single center with an estimated 60% of all eligible children in the area included in the trial. All subjects had their eligibility confirmed and their self-management plan explained by a single clinician, the lead author. Randomization was by episode, and outcome ascertainment rates were very high. Self-management advice included use of up to 1200 μg of albuterol at a time but no increase in inhaled steroid dosage. The study thus shows that in well-managed children, advice to use up to 12 puffs of albuterol at a time in treating acute wheeze appeared safe in a series of exacerbations where one third of all episodes were treated without any use of systemic steroids; this is important because many doctors are still reluctant to give this advice. Of note, the study results do not apply to wheezing in preschool children — the group accounting for most hospital admissions. The benefits of prednisolone used in this way may be greater in children whose baseline asthma management is less good than in this study, but use of this treatment modality should be carefully monitored given the possible harms of repeated courses of oral corticosteroids.