The best questions often stem from the inquisitive learner. As educators, we love, and are always humbled by, those moments when we get to say, “I don’t know.” For some of these questions, you may already know the answers. For others, you may never have thought to ask the question. For all, questions, comments, concerns, and critiques are encouraged. Welcome to the Kids Korner.
Explore This IssueACEP Now: Vol 35 – No 11 – November 2016
Question 1: Are there differences in efficacy between PO and IV corticosteroids for acute moderate to severe asthma exacerbations in children?
In children, we’re unable to find any studies that show a benefit of IV steroids over PO steroids for asthma exacerbations. There is a paucity of pediatric-specific studies, and like adult studies, there are differences in dosing and types of steroids. For instance, one study shows that 2 mg/kg of oral prednisolone (max dose 120 mg BID) demonstrates no significant benefit compared to 1 mg/kg IV methylprednisolone (max dose 60 mg four times daily) in regard to hospital length of stay (LOS).1 These aren’t the most common dosing regimens, and while LOS is important, it isn’t an emergency department–specific outcome.
Barnett et al compared IV versus PO corticosteroids in 49 children with moderate to severe asthma exacerbations. The authors evaluated respiratory endpoints such as respiratory rate, oxygen saturations, and FEV1 exhalation volume as well as hospital admission rates. It was a randomized, double-blind, controlled trial comparing oral methylprednisolone (2 mg/kg) with IV methylprednisolone (2 mg/kg). In this study, there was no difference in hospital admissions between the two groups (48 percent PO versus 50 percent IV; P=0.88). All these patients had moderate to severe asthma exacerbations.2
As mentioned earlier, there’s a paucity of pediatric data comparing PO versus IV corticosteroids for moderate to severe asthma exacerbations. That said, there is a 2001 systematic review and meta-analysis addressing early administration of corticosteroids for acute asthma exacerbations. Early administration of systemic corticosteroids, whether IV, IM, or oral, significantly decreased hospital admissions in patients with acute asthma exacerbations. These results included 11 total studies with both children and adults (pooled odds ratio, 0.40; 95% CI, 0.21–0.78).3 Early administration of systemic corticosteroids appears to be important—potentially more than the particular route of administration.
Summary: We can find no studies that demonstrate a significant clinical benefit of IV over PO corticosteroids in children with moderate to severe asthma exacerbations. The data are very limited. However, there are studies that suggest early administration of systemic corticosteroids is important.
Question 2: In children, what’s the recurrence rate of intussusception after enema reduction, and can they be safely discharged from the emergency department after observation?
To begin, a limitation in looking at this topic of disposition is that a prospective study is unlikely unless a multicenter study is developed; we’re limited to retrospective data at this time.