Steroid Treatment of Children's Wheezing Not Always Beneficial

Wheezing, a high-pitched whistling sound that usually occurs with exhaling, can be a frightening sound, especially when coming from a young child. Often a parents’ first thought is that their child can’t breathe, often sending them scurrying to the nearest hospital emergency room. There the child is commonly given steroids to open up their airways, a standard treatment for people with asthma. However, two new studies suggest that this widely used approach isn’t always beneficial, as many of these children may be wheezing due to viral infections rather than asthma itself.

One study, led by Dr. Jonathan Grigg, a professor of pediatric respiratory and environmental medicine at Queen Mary University London, followed the progress of 687 children aged 10 months to 5 years who were hospitalized with severe wheezing symptoms. Half were randomly assigned to receive either a five-day course of between 10 and 20 milligrams of prednisolone, depending on their age, while the other half received a placebo treatment for five days. The researchers found no significant difference between the two groups in the time spent in the hospital or the amount of other treatments needed. “Our results suggest that oral prednisolone should not be routinely given to preschool children presenting to the hospital with acute, mild-to-moderate virus-induced wheezing,” the researchers wrote.

As one expert explained, part of the problem is that it can be difficult to determine if small children actually have asthma, or if they’re just wheezing from a cold or some other virus. While babies generally wheeze due to viruses, and wheezing in school-aged children is often indicative of asthma, it can be hard to tell the difference in toddlers and preschoolers. “Wheeze in young children is, in many ways, very different from wheeze in older children and adults,” said Dr. Grigg. “We urgently need high quality research to investigate how best to treat young children who only wheeze in response to viral infections and to find ways of identifying the minority of wheezy pre-school children who will go on to develop asthma.”

In a second study, Canadian researchers assessed inhaled steroids for wheezing associated with a virus in 129 children between the ages of 1 and 6. The children were randomly assigned to receive either 750 micrograms of fluticasone proprionate (brand name Flovent), an inhaled steroid often used as a preventative medication for people with asthma, or a placebo at the first sign of nasal congestion, sore throat or other symptoms that would indicate an upper respiratory infection. They were treated twice daily for up to 10 days. They did this over the period of 6 to 12 months.

After 10 months, those who received Flovent had milder symptoms and required fewer repeat medications than the placebo group, but they also tended to grow less—a tenth of an inch less than those getting a placebo. These findings prompted lead author Dr. Francine Ducharme of the University of Montreal and colleagues to urge against using the drug for preventative purposes until the side effects could be better understood. “Because the adverse effects of pre-emptive treatment with fluticasone are still unknown, the potential risks associated with fluticasone treatment currently outweigh the identified benefit,” the researchers concluded. “This management strategy should not yet be recommended for use in clinical practice.”

Flovent’s maker, GlaxoSmithKline, which also helped fund the study, released a statement noting that the drug is not approved for treating wheezing and that the dose of Flovent was well above the recommended range for treating asthma in children of that age. However, the company did say that “these results may help inform future research efforts into viral-induced wheezing.”

Dr. Jennifer Appleyard, chief of allergy and immunology at St. John Hospital in Detroit, suggested that perhaps “viral-induced wheezing isn’t so much inflammation, but an irritability of the airways, so anti-inflammatories (like steroids) don’t work. Maybe it’s a different pathophysiology with similar symptoms.” Appleyard noted that children with a respiratory virus have intermittent wheezing, with no wheezing in between, where children with asthma wheeze at other times, not just when they have a virus.

“These are kids who are at the brink. We’re still trying to see if they’re just having viral-induced wheezing or if they really have asthma, and we’ve always treated these kids like they have asthma,” said Dr. Appleyard. “These studies suggest that maybe we don’t need to. Maybe we should treat viral-induced wheezing differently.”

Apparently, other experts agree. In an accompanying editorial, Dr. Andrew Bush of the Imperial School of Medicine and Royal Brompton Hospital in London wrote: “It is clear that on the basis of these two studies, current practice must change. It is disturbing to contemplate how many unnecessary courses of prednisolone have been given over the years, in good faith, because we all assumed that preschool children are little adults. There is certainly a lesson there for the use of other medications.” Dr. Bush also pointed out that earlier studies had shown that inhaled steroids, whether given intermittently or continuously in response to infection, do not prevent wheezing from progressing to full-blown asthma. “Treatment should be based solely on the relief of symptoms,” he said.

Wheezing in children is a common problem. Up to 50 percent of children will have at least one wheezing episode before they’re 3 years old. However, not all children who have wheezing episodes will develop asthma. At least 75 percent outgrow the problem by age 6.

Both studies were published in the January 22 issue of the New England Journal of Medicine.