Abstract:WHAT'S KNOWN ON THIS SUBJECT: Viral wheezing is common in preschool-aged children. The efficacy of inhaled steroids in preventing viral wheezing is debated. Despite this debate, nebulized beclomethasone is widely prescribed (particularly in a few countries) to children with upper respiratory tract infections.
WHAT THIS STUDY ADDS:Findings from this study confirm that inhaled steroids are not effective in preventing viral wheezing. Moreover, no differences were found in the persistence of symptoms (eg, runny no… Show more
“…In terms of ED/doctor visits, only one study reported this outcome and shows an effect favoring ICS (RR = −0.70 [0.50 to 0.97]); in terms of hospital admissions, the effect of ICS was not significant different compared with placebo. However, a recently published parallel RCT [13] comparing intermittent beclomethasone by nebulizer (400 μg twice daily) vs. placebo for 10 days in 525 Italian preschoolers with mild EVW (had at least 1 episode of viral wheezing diagnosed by a physician in the preceding 12 months, and had no or minimal asthma-like symptoms between distinct airway infections) showed no group difference in % of wheezing diagnosed by the pediatrician during a upper respiratory tract infection episode (primary outcome) nor reducing severity of wheezing, asthma-like symptoms score, extra visits, ED attendance, prescription of rescue drugs.Fig. 2Pooled RRs (with 95 % CI) for exacerbation requiring oral steroids of eligible studies comparing episodic ICS vs placebo in infants or preschoolers [12].…”
In the present review, we focus on evidence-based data for the use of inhaled corticosteroids (ICS), leukotriene receptor antagonist (LTRA), long-acting beta2-agonits (LABA) and oral corticosteroids (OCS), with a special emphasis on well-performed randomized clinical trials (RCTs) and meta-analyses of such trials for the chronic management of asthma/wheeze in infants and preschoolers. Results: Seven meta-analyses and 14 RCTs were reviewed. Daily ICS should be the preferred drug for infants/preschoolers with recurrent wheezing, especially in asthmatics. For those with moderate or severe episodes of EVW, the use of high intermittent ICS doses significantly reduce the use of OCS. There is no evidence of effect of intermittent ICS at low-moderate dose in preschoolers with mild EVW episodes. In preschoolers with asthma, there were no significant differences between daily vs. intermittent ICS in terms of asthma exacerbations with insufficient power to conclude to equivalence; however, for other asthma control outcomes, daily ICS works significantly better than intermittent ICS for older children. Daily ICS is superior to daily or intermittent LRTA for reducing symptoms, preventing exacerbations, and improving lung function. No RCTs testing combination therapy with ICS and LABA (or LTRA) were published in infant/preschoolers. Parent-initiation of OCS at the first sign of symptoms is not effective in children with recurrent wheezing episode. In terms of ICS safety, growth suppression is dose and molecule-dependent but it’s effect is not cumulative beyond the first year of therapy and may be associated with some catch-up growth while on or off therapy. Linear growth must be monitored as individual susceptibility to ICS drugs may vary considerably.
“…In terms of ED/doctor visits, only one study reported this outcome and shows an effect favoring ICS (RR = −0.70 [0.50 to 0.97]); in terms of hospital admissions, the effect of ICS was not significant different compared with placebo. However, a recently published parallel RCT [13] comparing intermittent beclomethasone by nebulizer (400 μg twice daily) vs. placebo for 10 days in 525 Italian preschoolers with mild EVW (had at least 1 episode of viral wheezing diagnosed by a physician in the preceding 12 months, and had no or minimal asthma-like symptoms between distinct airway infections) showed no group difference in % of wheezing diagnosed by the pediatrician during a upper respiratory tract infection episode (primary outcome) nor reducing severity of wheezing, asthma-like symptoms score, extra visits, ED attendance, prescription of rescue drugs.Fig. 2Pooled RRs (with 95 % CI) for exacerbation requiring oral steroids of eligible studies comparing episodic ICS vs placebo in infants or preschoolers [12].…”
In the present review, we focus on evidence-based data for the use of inhaled corticosteroids (ICS), leukotriene receptor antagonist (LTRA), long-acting beta2-agonits (LABA) and oral corticosteroids (OCS), with a special emphasis on well-performed randomized clinical trials (RCTs) and meta-analyses of such trials for the chronic management of asthma/wheeze in infants and preschoolers. Results: Seven meta-analyses and 14 RCTs were reviewed. Daily ICS should be the preferred drug for infants/preschoolers with recurrent wheezing, especially in asthmatics. For those with moderate or severe episodes of EVW, the use of high intermittent ICS doses significantly reduce the use of OCS. There is no evidence of effect of intermittent ICS at low-moderate dose in preschoolers with mild EVW episodes. In preschoolers with asthma, there were no significant differences between daily vs. intermittent ICS in terms of asthma exacerbations with insufficient power to conclude to equivalence; however, for other asthma control outcomes, daily ICS works significantly better than intermittent ICS for older children. Daily ICS is superior to daily or intermittent LRTA for reducing symptoms, preventing exacerbations, and improving lung function. No RCTs testing combination therapy with ICS and LABA (or LTRA) were published in infant/preschoolers. Parent-initiation of OCS at the first sign of symptoms is not effective in children with recurrent wheezing episode. In terms of ICS safety, growth suppression is dose and molecule-dependent but it’s effect is not cumulative beyond the first year of therapy and may be associated with some catch-up growth while on or off therapy. Linear growth must be monitored as individual susceptibility to ICS drugs may vary considerably.
“…The AAP 2006 guideline reports that neither bronchodilators nor corticosteroids have significant efficacy in the treatment of bronchiolitis, which is supported by the current literature (Clavenna et al, 2014;Gadomski & Scribani, 2014). One prior study conducted in 2004, before the publication of the AAP 2006 guideline, demonstrated a synergistic effect of nebulized bronchodilators and systemic corticosteroids when used concurrently (Kuyucu, Unal, & Yilgor, 2004).…”
“…Our daily experience suggests that many wheezy children are treated with pre-emptive ICS, but at lower doses than have been proven to be effective 52. In practice, we suggest that the fluticasone dose should not exceed the licensed dose of 150 μg twice a day by a metered-dose inhaler and a spacer, given the number and duration of viral colds in normal preschool children and the risk of side effects including growth suppression and adrenal failure with higher doses.…”
Wheeze is a common symptom in young children and is usually associated with viral illnesses. It is a major source of morbidity and is responsible for a high consumption of healthcare and economic resources worldwide. A few children have a condition resembling classical asthma. Rarer specific conditions may have a wheezy component and should be considered in the differential diagnosis. Over the last half century, there have been many circular discussions about the best way of managing preschool wheeze. In general, intermittent wheezing should be treated with intermittent bronchodilator therapy, and a controller therapy should be prescribed for a young child with recurrent wheezing only if positively indicated, and only then if carefully monitored for efficacy. Good multidisciplinary support, attention to environmental exposition and education are essential in managing this common condition. This article analyses the pathophysiological basis of wheezing in infancy and critically discusses the evolution of the scientific progress over time in this unique field of respiratory medicine.
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