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.
A 2010 retrospective review by Whitehouse et al evaluated kids over a 12-year period (309 total children younger than or equal to 18 years of age) who had been diagnosed with intussusception. They admitted 261 (84.5 percent) and discharged 48 (15.5 percent) from the emergency department. During this period, 138 of 261 children were reduced by enema, and the rest (123/261) were reduced surgically. Recurrence after enema reduction occurred in 10 of 138 (7.2 percent) admitted patients and 4 of 48 (8.3 percent) discharged patients. Of the 14 children overall who had intussusception recurrences, six (42.8 percent) of the recurrences happened within 72 hours. The average LOS was 1.6 days; four of the recurrences happened within this time frame. The remainder of recurrences happened between 10 days and 21 months. There was no significant difference in delayed complications, defined as perforation or intestinal ischemia, between the discharged group and the admitted group.4 In terms of morbidity, the two groups appear similar.
In another, 10-year retrospective study with 568 total children at two tertiary care hospitals, 239 (42 percent) got emergency department “early discharge” where the average LOS was 7.2 hours, while 329 (58 percent) were admitted with an average LOS of 40 hours. The recurrence rate of intussusception was 8.8 percent (21/239) in the discharge group and 8.5 percent (28/329) in those admitted. There was a statistical difference in recurrences that were caught prior to discharge (20 of 28 in the admitted group versus 2 of 21 in the discharge group; P=0.004). There were no significant differences in morbidity between the discharge and admitted groups.5
A 2014 meta-analysis by Gray et al included 69 studies (15,163 total patients) in children. Overall, the recurrence rate of intussusception after enema reduction, whether contrast, ultrasound-guided, or air-contrast, was 12.7 percent (95% CI, 11.1%–14.4%). The recurrence rate within 24 hours was 3.9 percent (95% CI, 1.5%–10.1%); within 48 hours, it was 5.4 percent (95% CI, 3.7%–7.8%). The authors argue that “the vast majority of recurrences will not be identified by overnight hospitalization.”6
Conversely, a more recent 26-year retrospective study including 464 total children by Lessenich et al found a similar recurrence rate (5.6 percent) while noting that 18.5 percent of children required some form of hospital-level intervention defined as imaging/interventions for recurrence or suspected recurrence, or administration of parenteral narcotics or antiemetics.7
Summary: Intussusception recurrence rate after enema reduction, overall, appears to be about 5 to 12 percent. The majority of these recurrences don’t present within the first 24 to 48 hours. It might be reasonable under certain instances (eg, good follow-up, reasonable distance from home, etc.) to discharge these children from the emergency department after a successful enema reduction and appropriate symptom-free observation period. Practitioners should at least recognize that this may be a change in practice when discussing these cases with our surgical colleagues.
Dr. Jones is assistant professor of pediatric emergency medicine at the University of Kentucky in Lexington.
Dr. Cantor is professor of emergency medicine and pediatrics, director of the pediatric emergency department, and medical director of the Central New York Poison Control Center at Upstate Medical University in Syracuse, New York.
- Becker JM, Arora A, Scarfone RJ, et al. Oral versus intravenous corticosteroids in children hospitalized with asthma. J Allergy Clin Immunol. 1999;103(4):586-590.
- Barnett PL, Caputo GL, Baskin M, et al. Intravenous versus oral corticosteroids in the management of acute asthma in children. Ann Emerg Med. 1997;29(2):212-217.
- Rowe BH, Spooner C, Ducharme FM, et al. Early emergency department treatment of acute asthma with systemic corticosteroids. Cochrane Database Syst Rev. 2001;(1):CD002178.
- Whitehouse JS, Gourlay DM, Winthrop AL, et al. Is it safe to discharge intussusception patients after successful hydrostatic reduction? J Pediatr Surg. 2010;45(6):1182-1186.
- Beres AL, Baird R, Fung E, et al. Comparative outcome analysis of the management of pediatric intussusception with or without surgical admission. J Pediatr Surg. 2014;49(5):750-752.
- Gray MP, Li SH, Hoffmann RG, et al. Recurrence rates after intussusception enema reduction: a meta-analysis. Pediatrics. 2014;134(1):110-119.
- Lessenich EM, Kimia AA, Mandeville K, et al. The frequency of postreduction interventions after successful enema reduction of intussusception. Acad Emerg Med. 2015;22(9):1042-1047.