You Decide: Steroids for Bronchiolitis?

The fascination with steroids is second only to the fascination with antibiotics.  In other words, if antibiotics are the most overused medications in kids, steroids come in a very close second.  As with antibiotics, steroids definitely have a critical role in the treatment of certain illnesses, like asthma.  In fact, countless lives have been improved by short courses of steroids to control severe asthma symptoms.  More countless lives have probably even been saved by steroids.  However, it seems to me that doctors and patients alike are prescribing and asking for steroids for just about every little runny nose and cold these days.  Doctors are now prescribing these potent immune-suppressing medications for bronchiolitis, croup, strep throat, and the list goes on.  While there is strong evidence to support the use of steroids in certain critical illnesses, there is a paucity of data to support their use in bronchiolitis.  In fact, when I review the medical literature on this subject, I find again and again… steroids are not helpful for bronchiolitis.  But, I will let You Decide.

What are Steroids?

When we talk about steroids from a pediatric perspective, we are not talking about the steroids that build muscle or the “performance-enhancers” that baseball players use.  Rather we are talking about a special class of steroids called glucocorticoids.  These are strong medications that have very potent effects on almost every system in the body.  They have all different kinds of names, but here are a few of the most common:

1. Decadron
2. Dexamethasone
3. Prednisone
4. Prednisolone
5. Orapred

What Are the Side-Effects?

As I mentioned above, steroids affect just about every organ in your body.  They can increase your blood pressure, increase your weight gain, decrease your bone strength, suppress your growth, precipitate psychosis, and suppress your immune system.  These are potent medications and should only be used if there is good reason to think the benefits outweigh the risks.

Is There Any Benefit for Kids with Bronchiolitis?

Study #1

This study was published just this past month in the very well respected New England Journal of Medicine.  It looked at the benefit of using steroids in pre-school aged children who had a virus (like bronchiolitis) and wheezing.  There results are not surprising:

In preschool children presenting to a hospital with mild-to-moderate wheezing associated with a viral infection (like bronchiolitis), oral prednisolone was not superior to placebo (fake medicine).

Study #2

This study, also from the New England Journal of Medicine, was published a few years back and looks at the specific situation of the benefit of steroids in patients with bronchiolitis.  Again, their results are not all that surprising:

In infants with acute moderate-to-severe bronchiolitis who were treated in the emergency department, a single dose of 1 mg of oral dexamethasone per kilogram did not significantly alter the rate of hospital admission, the respiratory status after 4 hours of observation, or later outcomes.

Study #3

This study is a Cochrane Review of all the available studies published regarding the use of steroids in bronchiolitis.  Their conclusions:

Available evidence suggests that corticosteroid therapy is not of benefit in this patient group.

Is There Ever a Reason to Use Steroids in Bronchiolitis?

If you can find one, please forward it along to me.  Everything that I read brings me to the same conclusion:  Steroids are of zero benefit in bronchiolitis.  Despite what I would consider overwhelming evidence against their use in bronchiolitis, I see patients in the ER all the time who have been given steroids.

Now, as with my discussion on the use of breathing treatments, in rare situations some kids may have bronchiolitis and asthma.  These children may benefit from treatments with steroids.  However, the steroids are for treating their asthma, not their bronchiolitis.  Remember children with asthma tend to be over 6 months, have a history of wheezing every time they get a cold, and have multiple close family members with asthma.  Again, asthma plus bronchiolitis is rare.  Plain old bronchiolitis that does not need steroids is very common.

What I do in the ER.

I do not give steroids for bronchiolitis.

What’s Next?

Treatment Guidelines… What I tell my patients in the ER.

Related Posts & References

Understand Bronchiolitis

You Decide: Breathing Treatments for Bronchiolitis

NEJM 2009: Oral steriods for wheezing and virus

NEJM 2007: Dexamethasone for Bronchiolitis

Cochrane 2004: Steroids and Bronchiolitis