You are on page 1of 9

Dexamethasone for Acute Asthma Exacerbations in Children: A Meta-analysis

Grant E. Keeney, Matthew P. Gray, Andrea K. Morrison, Michael N. Levas, Elizabeth
A. Kessler, Garick D. Hill, Marc H. Gorelick and Jeffrey L. Jackson
Pediatrics 2014;133;493; originally published online February 10, 2014;
DOI: 10.1542/peds.2013-2273

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/133/3/493.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2014 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org at Pakistan:AAP Sponsored on March 1, 2014

coordinated and supervised data collection.09.a Jeffrey L. National Institutes of Health. MD. Levas. and drafted the initial manuscript.aappublications.20. Keeney. df = 2. 10–14 days RR 1.29. 999 North 92nd St.133:493–499 FUNDING: Supported by the National Center for Advancing Translational Sciences. prednisone. Morrison.78. WI 53226. Morrison. Although multiple small trials exist. Medical College of Wisconsin. This systematic review and meta-analysis aimed to determine whether intramuscular or oral dexamethasone is equivalent or superior to a 5-day course of oral prednisone or prednisolone. I2 = 0.32. and reviewed and revised the manuscript. 2014 493 . by using the keywords dexamethasone or decadron and asthma or status asthmaticus identified potential studies. The primary outcome of interest was return visits or hospital readmissions. I2 = 4. 2013. 0031-4005. Wisconsin. I2 = 0.org at Pakistan:AAP Sponsored on March 1.a Elizabeth A. Levas. Milwaukee.0%. and all authors approved the final manuscript as submitted.86. MS. Milwaukee.90. 95% CI 0. Copyright © 2014 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. MS. MD. E-mail: gkeeney@mcw.67. 95% CI 0. df = 3.2013-2273 doi:10.14. MD. 95% CI 0.pediatrics. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health.74. Funded by the National Institutes of Health (NIH). Milwaukee.a Garick D. Q = 2. and cZablocki VAMC. Gray. clear consensus data are lacking. MD. MD. designed the data collection instruments. Dr Jackson participated in study design. MD. Keeney.0%. RESULTS: There was no difference in relative risk (RR) of relapse between the 2 groups at any time point (5 days RR 0. MPHb. Kessler and Hill conceptualized and designed the study. df = 2. CONCLUSIONS: Practitioners should consider single or 2-dose regimens of dexamethasone as a viable alternative to a 5-day course of prednisone/prednisolone. Drs Gray.a Michael N. Data were abstracted by 4 authors and verified by a second author. 2013 Address correspondence to Grant E. 95% CI 0. Six randomized controlled trials in the emergency department of children #18 years of age comparing dexamethasone with prednisone/prednisolone for the treatment of acute asthma exacerbations were included.2%).a Marc H.77–1.14–0. prednisolone. MD. and bGeneral Internal Medicine.1542/peds.1542/peds. Two reviewers evaluated study quality independently and interrater agreement was assessed. Medical College of Wisconsin. I2 = 20. Gorelick. carried out the initial analyses. Q = 1.2013-2273 Accepted for publication Dec 4. df = 3.REVIEW ARTICLE Dexamethasone for Acute Asthma Exacerbations in Children: A Meta-analysis AUTHORS: Grant E. Jackson. MD. Q = 0. abstract BACKGROUND AND OBJECTIVE: Dexamethasone has been proposed as an equivalent therapy to prednisone/prednisolone for acute asthma exacerbations in pediatric patients.7%) or at home (RR 0.46–1.a Andrea K. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose. www.78.org/cgi/doi/10.12–0. Kessler. asthma. MS. Number 3. Pediatrics 2014.c Departments of aPediatrics. 95% confidence interval [CI] 0. MSCE. Hill.84. Keeney.93). Department of Pediatrics.69. MD. through grant 8UL1TR000055. Q = 3.edu PEDIATRICS (ISSN Numbers: Print. status asthmaticus ABBREVIATIONS CI—confidence interval ED—emergency department IM—intramuscular PO—per os RR—relative risk Dr Gorelick conceptualized the study. or 30 days RR 1. Online.03–56. March 2014 Downloaded from pediatrics.a Matthew P. PEDIATRICS Volume 133. Patients who received dexamethasone were less likely to experience vomiting in either the emergency department (RR 0. METHODS: A search of PubMed (Medline) through October 19. 1098-4275). Wisconsin KEY WORDS dexamethasone.

We examined the potential for undue influence of any given study by looking at the percentage of total weight to the final pooled results for each study and by examining meta-influence plots. All analyses were performed by using Stata version 12.. College Station TX).) and all data were verified by a second author. Articles were excluded at the title and abstract phase by 2 authors (M.11–16 All of the included studies were performed in EDs and had a mean of 171 participants (range 15–272).5%). adverse effects (vomiting). They systemically reduce inflammation.18 years of age.K. asthma severity score.aappublications. Application of inclusion and exclusion criteria resulted in 6 studies that were included in our analysis (Fig 1). and 2 additional items describing the presence of industry sponsorship in the trial and whether intent to treat analysis was performed. and enhance the effects of b-agonists. and less vomiting with dexamethasone. ethnicity). asthma score at ED discharge. Data were abstracted by 4 authors (G.9) months. and 30 days). subjective improvement.H.2 As such. and relapse rate as defined by an unscheduled visit to a clinic. In addition to bronchodilators. OR “decadron” AND “asthma” OR “status asthmaticus” in all search fields.M. making it the most common chronic disease of childhood. the 6-question instrument created and validated by Jadad and colleagues. Included studies were from the United States (n = 5) and Canada (n = 1).4 Current treatment regimens consist of oral prednisone or prednisolone taken onceor twicedaily for 5days.. The final search was conducted on October 19.6 Two reviewers (G. Potential advantages include a longer half-life requiring a shorter course. M. corticosteroids are the cornerstone of therapy for acute asthma exacerbations. National Institutes of Health. OBJECTIVE The purpose of this systematic review and meta-analysis of randomized clinical trials is to determine whether PO or IM dexamethasone is equivalent or superior to a 5-day course of oral prednisone or prednisolone. and E.L. asthma accounts for 2% of all ambulatory care and emergency department (ED) visits by patients . 10–14 days. The primary outcome of interest was unscheduled return visits (clinic visit.11 and as multiple oral doses in 2 studies13.5. participants were KEENEY et al Downloaded from pediatrics.5–64.P.16 (Table1). or an unplanned hospital admission related to their initial asthma exacerbation. including only human trials without language restriction. increased compliance with a single dose. bronchoconstriction and airway hyperresponsiveness. All studies were among children with a mean age of 53. RESULTS Our search identified 667 articles. Although multiple small trials exist. Trials were identified using PubMed (Medline)withsearchtermsof“dexamethasone” Data were pooled using a fixed-effects model.) evaluated study quality independently. Patients hospitalized during the initial study encounter were not included in the analysis of return visits.8 We assessed for small study effects (publication bias) using the methods of Peters et al9 for dichotomous outcomes and Egger et al10 for continuous outcomes.14.H. 2014 .12. or a hospitalization). Studies were included in the metaanalysis if they were a randomized controlled trial of treatment of acute asthma exacerbation in either an ambulatory or ED setting comparing dexamethasone with prednisone or prednisolone in children #18 years of age. 2013. Outcomes were extracted as either dichotomous or continuous variables based on study report.12 Among the remaining studies. Reference lists from review articles and those studies included in the meta-analysis were reviewed by hand without identification of additional articles meeting criteria. Secondary outcomes included vomiting in the ED and vomiting at home. Dexamethasone was given as a single IM dose in 3 studies. Relapse rates were reported 494 at different time intervals and combined for meta-analysis only when similar time intervals were reported (5 days. gender. return ED visit. and clinical outcomes (hospitalization during initial ED visit. Participants were mostly boys (63.3 Asthma is a chronic inflammatory disease characterized by airway edema.org at Pakistan:AAP Sponsored on March 1. Potential sources of heterogeneity were explored by using stratified analysis.L. ED.G. Differences between groups were tested using random effects meta-regression.1. M.7 Heterogeneity was assessed using the I2 method. or hospital admission) foracuteasthmaexacerbation inpediatric patients.K. A. This study was supported by a grant from the National Center for Advancing Translational Sciences.15 as a single oral dose in 1 study. ED visit. All studies but one (Gordon et al12) defined relapse as an unplanned clinic visit.).6 million children in the United States. clear consensus data are lacking.Oral (PO)or intramuscular (IM) dexamethasone has been proposed as an equivalent therapy. decrease mucus production.2 National and international guidelines advise early administration of systemic corticosteroids for moderate or severe exacerbations and for mild exacerbations that do not immediately and completely respond to short-acting b-agonists.1 (Stata Corp. Abstracted data included subject characteristics (age in months. and G.Asthma affects . treatment characteristics (number of albuterol treatments in the ED)..1.2 (95% confidence interval [CI] 41. METHODS Study quality of the included trials was assessed using the Cochrane risk of bias tool. One of the studies included a predominantly Hispanic population (80%).

9–3. RR 0. Patients who received dexamethasone were less likely to experience vomiting in either the ED (Fig 3.0–2. Number 3. 95% CI 0. Both PO and IM dexamethasone were associated with less vomiting in the ED (PO 0.93). 95% CI 0.6 vs 65.93–1.75).14. P = . although the 30-day relapse rate was reported in only 1 study.78.0%).95) with oral dexamethasone still resulting in less vomiting than prednisolone (RR 0. Similarly. 95% CI 0. In the prednisone/prednisolone group the 5-day relapse rate was 3. although the benefit was lost for the single trial of IM dexamethasone (RR 0.5.69.0%.91.aappublications. 95% CI 0. I2 = 0. There were no differences in the likelihood of improvement in asthma scores during the initial ED visit between groups (relative risk [RR] 1. no study contributed .75).7%) of the variance in this outcome.56.9% African American.3% –10.47). P = . There was no difference in rates of hospitalization during the initial ED visit (RR 0.REVIEW ARTICLE at home (Fig 4.2%). 10–14 days RR 1.37).90.7%) or The paucity of studies limited our ability to perform sensitivity analyses.32. Dexamethasone was administered orally in 3 studies and IM in 3 studies. There was no difference in route of dexamethasone administration for vomiting at home (P = .2%).4%) by 2 weeks. 4 studies). there was a 6. Q = 0.6% (95% CI 1.30.6% (95% CI 0. 95% CI 0. 95% CI 1.66–1. 34. 95% CI 0. suggesting lack of undue influence.56).29). vomiting in the ED (P = .32. Q = 2.22.3–16. I2 = 20.91. df = 2. hospitalization (P = .84 vs 2.46–1. I2 = 0.94).1.29% of the total weight to any pooled analysis.4 vs 56. I2 = 0.13– 0.27.56. I2 = 4. FIGURE 1 Study selection.71.77). 95% CI 0. There was no difference in relapse rate between the 2 groups at any time point (5 days RR 0. increasing to 13.7 months. Q = 1. Q = 1. increasing to 11.5. df = 2.85).0%.7). or vomiting at home (P = .74. P for difference = 0. There was no difference in the average amount of improvement in asthma scores between In the dexamethasone group.29. or initial asthma severity score (standardized mean 3. There was no difference in likelihood of relapse for dexamethasone compared with prednisone/prednisolone. 4 studies).90.32.77–1. In comparing the group receiving dexamethasone to prednisone. However. IM 0. 14 days: P = . df = 3.38.12–0.78. making subanalyses tentative.7% white and 37.0–2. improvement in asthma severity scores (P = .87. P for difference = 0. or in posttreatment asthma severity scores (RR 1. 95% CI 0. 95% CI 1.9% (95% CI 0. or 30 days RR 1.8% (95% CI 11. 95% CI 2. There was no evidence of publication bias for any of our outcomes. df = 3.81 vs 1.20. groups (standard mean difference 2. 95% CI 0.9%–14. there were no differences at baseline in age (44.03–2. regardless of the route of dexamethasone administration (P = .84.03–56.10.67. I2 = 0.27–2. or likelihood of improvement in asthma score (P = .1%–6.38. P = . Study quality ranged from 3 to 8 on the Jadad scale (Table 1) and assessments using the results of the Cochrane risk of bias tool are presented in Table 2. including relapse rates (5 days: P = .38. Route of administration accounted for only a small portion (26.01.003– 0.0%) relapse rate by 5 days. 95% CI 0. the studies reported outcomes at different time points.72).86. There was no evidence of undue influence on any of these outcomes from any particular study on meta-influence plots. df = 4. 95% CI 0.43).5 vs 3.32.0%).68. 95% CI 2. P for difference = .14– 0.06.78).84. df = 2.7. March 2014 Downloaded from pediatrics. 2014 495 . 95% CI 0.8–3.8. Q = 0.26.org at Pakistan:AAP Sponsored on March 1.66). the number of albuterol treatments received in the ED (2. Interrater agreement was excellent with a k of 0. RR 0. CONCLUSIONS This meta-analysis examined whether intramuscular or oral dexamethasone is equivalent or superior to a 5-day course of prednisone/prednisolone for acute asthma exacerbations in pediatric PEDIATRICS Volume 133. proportion of boys (63.01–7.93).2 vs 2. Q = 3.11–0. there were no differences for hospitalization (P = . 95% CI 0.4) by 2 weeks (Fig 2).

or need for IV Use of steroid in previous month. no telephone for follow-up. previous history of asthma. active varicella.6mg/kg (max 18 mg) PO 3 1 dose.6mg/kg (max 16 mg) PO once daily 3 2 d Dexamethasone 0. varicella exposure.496 KEENEY et al Downloaded from pediatrics.3 mg/kg (max 15 mg) IM 3 1 dose Klig. complete recovery after 1 bronchodilator. significant recent hospitalization for asthma or ICU stay in the past year. concurrent stridor. 88% on room air. mild to moderate asthma exacerbation Age 18 mo-7 y. 2014 Dexamethasone 0. placebo PO twice daily 3 5 d Dexamethasone 0. or HSV infections Use of steroid in previous 2 wk. history of intubation. possible foreign body aspiration.6 mg/kg (max 15 mg) IM 3 1 dose Dexamethasone 1. previous enrollment.aappublications. or documented RSV infection Use of steroid in previous month. previous history of asthma. major coexisting illness. fever . severe asthma exacerbation (requiring hospitalization). TB. a First dose of medication provided in the ED. herpes simplex virus. previous enrollment. pectus excavatum. then 1 mg/kg (max 30 mg) PO twice daily 3 4 d Prednisone or prednisolone 1 mg/kg (max 30 mg) PO 3 1 dose. major coexisting illness. varicella exposure. previous history of asthma. previous history of asthma. or $2 episodes of emesis after steroid dose in ED Use of steroid in previous 4 wk.org at Pakistan:AAP Sponsored on March 1. 7 d of prednisone in past year. maximum. previous history of asthma. concern for intrathoracic foreign body. history of acute allergic reaction. max. 200813 Dexamethasone 0. 200611 Dexamethasone 0. then 1 mg/kg (max 60 mg) PO daily 3 4 d Prednisone 2 mg/kg (max 80 mg) PO 3 1 dose. Qureshi. mild to moderate asthma exacerbation Age 6 mo-7 y. allergy to steroid. TB or varicella exposure. tuberculosis. acute exacerbation. previous history of asthma and mild to moderate asthma exacerbation Age 3–16 y. O2 saturation . or need for immediate airway intervention Use of steroid in previous 2 wk. 200116 Multiple Oral Doses Greenberg. then 1 mg/kg PO twice daily 3 5 d Prednisone 2 mg/kg (max 100 mg) PO 3 1 dose then 1 mg/kg PO daily 3 2 d Prednisolone 2 mg/kg (max 50 mg) PO daily 3 5 d Prednisone or prednisolone 1 mg/kg (max 20 mg) PO twice daily 3 5 d Comparisona HSV. significant respiratory distress. 200014 Author TABLE 1 Included Studies Age 2–18 y. history of previous intubation or PICU admission. and acute exacerbation asthma Age 2–16 y. oxygen saturation # 95% on room air. and required at least 2 b-agonist treatments in ED Age 2–18 y.101. 200712 Single IM dose Gries. 199715 Single Oral Dose Altamimi. RSV. major coexisting illness. major coexisting illness. mild to moderate asthma exacerbation Inclusion Criteria Use of steroid in previous month. or major coexisting illness Exclusion Criteria 3 4 8 3 4 3 Jadad Score . respiratory syncytial virus.7 mg/kg (max 36 mg) IM 3 1 dose Interventiona Gordon.6 mg/kg (max 16 mg) PO once daily 3 2 d Prednisone or prednisolone 2 mg/kg (max 60 mg) PO 3 1 dose. history of intubation.

11. March 2014 Downloaded from pediatrics. Significantly fewer patients receiving dexamethasone vomited in the ED or at home after discharge. ED. The lower rate of vomiting with dexamethasone possibly reflects a difference in palatability that has been shown in previous studies. or hospitalization. This is supported by the fact that 5-day courses of oral corticosteroids have not been shown to be superior to 3-day courses for outpatient management of children with acute exacerbations. the group of studies that used oral dexamethasone PEDIATRICS Volume 133. Our decision to combine studies with different routes and dosing of dexamethasone was an effort to increase generalizability.12. or 30 days’ follow-up. Number 3. A subgroup analysis failed to show statistically significant differences regardlessofthefollow-up periods. Finding no differences in a fixed effects model is a more conservative choice when comparing 2 different treatment options. The pooled results failed to demonstrate a statistically significant difference between the 2 therapies for the primary outcome of relapse rate to clinic.aappublications.19 However. Fixed effects methods increase the chance of finding differences.15 Five days was the most common follow-up duration and is the most clinically relevant period in which to detect treatment failure. 10 to 14.17 There was no difference detected in studies reporting recurrence rates at 5. patients discharged to home from the ED. The4studies that reported 5-day follow-up relapse rates all used a single dose of IM or PO dexamethasone.18.REVIEW ARTICLE TABLE 2 Cochrane Risk of Bias Quality Assessment Study Allocation Sequence Adequate Allocation Concealed Blinding of Participants Blinding of Outcomes Outcome Data Adequately Addressed Free From Selective Outcome Reporting Free From Other Problems Altamimi11 Gordon12 Qureshi16 Greenberg13 Gries14 Klig15 Yes Yes No Uncleara Unclear Unclear Yes Yes No Uncleara Unclear Unclear Yes No No Yes No No Yes No No Unclear No No No Yes Yes No Yesa Yes Unclear No Unclear Unclear Unclear Unclear Yes Yesa Yesa Yes Yes Yes a Disagreement between reviewers. 2014 497 .14.org at Pakistan:AAP Sponsored on March 1. suggesting that the 2 therapies are equivalent. This finding has clinical significance for improving patient and parental satisfaction. FIGURE 2 Relapse rates.

as well as trial registries. single or 2-dose regimens may increase 498 compliance with systemic corticosteroid administration in acute asthma exacerbations compared with longer treatment courses. FIGURE 4 Vomiting at home. we were unable to address KEENEY et al Downloaded from pediatrics. To further address possible study selection bias. Attempts to contact the first and corresponding authors for all unpublished study results were unsuccessful in obtaining additional data for the metaanalysis.FIGURE 3 Vomiting in the ED. Unpublished clinical trials are more likely to confirm the null hypothesis and would support our pooled estimate for the primary outcome of interest. A systematic and comprehensive search of the published literature. There are potential limitations to this analysis.aappublications.org at Pakistan:AAP Sponsored on March 1. and excellent interrater agreement. was conducted to avoid bias. was a heterogeneous group in that each used a different preparation for their oral medications. Additionally. had clear inclusion and exclusion criteria. 2014 . we used 2 independent reviewers. For example. Two additional unpublished studies were identified. including publication bias and study quality. An additional limitation is that the paucity of trials made it difficult to examine important potential differences.

327(7414):557–560 9. Sharp S. Based on our findings. 7. 2006.org. In: Higgings J. Single-dose oral dexamethasone in the emergency management of children with exacerbations of mild to moderate asthma. J Pediatr. Kim MK. Zaritsky A. 2008. Counselman FL. Klig JE. Carlsen KH. Comparison of two methods to detect publication bias in meta-analysis. BMJ. all our results are based on ED-based studies. Cochrane handbook for systematic reviews of interventions. Chapter 8: Assessing risk of bias in included studies.315 (7109):629–634 11. Allergy. and dexamethasone. Robertson G. Papadopoulos NG. Abrams KR.120(suppl 5): S94–S138 2. March 2014 Downloaded from pediatrics. 2008. Garbe PL. Chang AB. Roosevelt GE. Acad Emerg Med. emergency physicians should consider single or 2-dose dexamethasone regimens over 5-day prednisone/prednisolone regimens for the treatment of acute asthma exacerbations. J Allergy Clin Immunol. Tompkins T.org at Pakistan:AAP Sponsored on March 1. Friedlaender E. 1996. Meta-analysis regression. Schneider M. 2001. Peters JL. Clark R. Rutherford MW. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials. Comparative efficacy of oral dexamethasone versus oral prednisone in acute pediatric asthma. Hennes HM. 1998. Randomized trial of single-dose intramuscular dexamethasone compared with prednisolone for children with acute asthma. Future research should focus on these important questions. 2006. Symptomatic improvement following emergency department management of asthma: a pilot study of intramuscular dexamethasone versus oral prednisone. Egger M. 2013 6. prednisolone.22(12):786–793 12. Jadad AR.67(8):976– 997 5. Measuring inconsistency in meta-analyses. 2007.139(1):20–26 17. A comparison of oral dexamethasone with oral prednisone in pediatric asthma exacerbations treated in the emergency department. Moffitt DR. Sloots TP. and whether there are differences in efficacy and palatability between different formulations of oral prednisone/prednisolone.19(5):355–361 3. 123(suppl 3):S131–S145 4. Number 3. Thompson SG. Jones DR. Altman D. 2003. National Asthma Education and Prevention Program. Moore RA. and it is unclear whether this would translate to the ambulatory clinic setting. Nelson TJ.REVIEW ARTICLE whether IM and PO dexamethasone are equally effective. Expert panel report 3 (EPR-3): Guidelines for the diagnosis and management of asthma-summary report 2007. A single dose of intramuscularly administered dexamethasone acetate is as effective as oral prednisone to treat asthma exacerbations in young children. Akinbami LJ. BMJ. 2012. Kerby G. Hodge D III. Moorman JE.cochrane-handbook. Minder C.42:16–22 8. Pulos E. Stata Tech Bull. Yen K. Davey Smith G. Furthermore. Scarfone RJ. Higgins JP.47(8): 817–823 14. Green S. JAMA. Pediatr Emerg Care. 2014 499 . et al. Higgins J. Accessed May 12. Greenberg RA. J Pediatr. Redman RL. 1997. Gordon S. Sutton AJ.136(3):298–303 15.23(8):521–527 13. graphical test. Arakawa H. J Asthma. 2003. Brandos J. et al. A 5.10(4):400–403 REFERENCES 1. 2003. Gries DM. Corticosteroids in acute asthma: past. version 5. Carroll D.295(6):676–680 10. Pediatr Emerg Care. Med J Aust.1. Rushton L. Pediatrics. 2009. Vomiting of liquid corticosteroids in children with asthma.34 (5):419–425 16. Deeks JJ. 2011. present.aappublications. Carter ER. Poirier MP. A taste comparison of three different liquid steroid preparations: prednisone. 1980–2007. International consensus on (ICON) pediatric asthma. 1997. Sondik EJ. Pediatr Emerg Care. Bias in meta-analysis detected by a simple. eds.22(6):397–401 19.189(6):306–310 18. et al.0 [updated March 2011]. Pediatr Emerg Care. Status of childhood asthma in the United States. Qureshi F. Clin Pediatr (Phila). Sterne A. 2007. et al. Dayan PS. Available at: www. 2006. Altman DG.versus 3-day course of oral corticosteroids for children with asthma exacerbations who are not hospitalised: a randomised controlled trial. and future. The Cochrane Collaboration. whether a single oral dexamethasone dose is equivalent to multiple doses. 2000. Altamimi S. Jastaniah W. Mitchell JC.17(1):1–12 PEDIATRICS Volume 133.

full. Marc H.xh tml Reprints Information about ordering reprints can be found online: http://pediatrics.aappublications.133.493. PEDIATRICS is owned. Jackson Pediatrics 2014. Print ISSN: 0031-4005.aappublications.aappublications. Andrea K. All rights reserved. Elizabeth A. can be found at: http://pediatrics.org/content/133/3/493. Kessler. Hill. tables) or in its entirety can be found online at: http://pediatrics. published. Keeney. Levas. Michael N.Dexamethasone for Acute Asthma Exacerbations in Children: A Meta-analysis Grant E. originally published online February 10. Illinois. Elk Grove Village.full. it has been published continuously since 1948. Gorelick and Jeffrey L. 60007. 2014 .2013-2273 Updated Information & Services including high resolution figures. DOI: 10.1542/peds.xhtml PEDIATRICS is the official journal of the American Academy of Pediatrics. 141 Northwest Point Boulevard.org at Pakistan:AAP Sponsored on March 1.aappublications.ht ml References This article cites 18 articles. Copyright © 2014 by the American Academy of Pediatrics. A monthly publication. Downloaded from pediatrics. Matthew P. Online ISSN: 1098-4275.org/site/misc/reprints. Gray.ht ml#ref-list-1 Permissions & Licensing Information about reproducing this article in parts (figures. 2014. Morrison. 4 of which can be accessed free at: http://pediatrics. and trademarked by the American Academy of Pediatrics.org/content/133/3/493.org/site/misc/Permissions.aappublications. Garick D.