Dexamethasone and bronchiolitis: A new look
at an old therapy?
In this issue of The Journal, Schuh et
al1 challenge the widely, but not univer-
sally, held view that corticosteroids
have no role in the treatment of previ-
ously well children with bronchiolitis.
Few aspects of the treatment of infants
with bronchiolitis have been studied as
often or as well. First, corticosteroids
are of unquestioned benefit for infants
and young children with asthma and
bronchopulmonary dysplasia, clinically
similar wheezing illnesses. Second,
while bronchiolitis, like asthma, is a
common and apparently growing prob-
lem,2 the pediatrician’s therapeutic
armamentarium is remarkably thin.
Ribavirin is available as specific treat-
ment for infants with RSV (respiratory
syncytial virus) infection, but its high
cost and the absence of studies that ad-
dress contentious issues of indications,
environmental exposure of health care
workers, potential side effects, and even
efficacy, remain problematic. Some
bronchodilators are of benefit to certain
children with bronchiolitis, but they do
not have a major effect on the overall
course of the illness. The remaining
treatments for infants with bronchiolitis
are supportive.
Physicians treating children with
bronchiolitis and investigators studying
its management need to recognize that
an important subset of children with
viral bronchiolitis, those with underly-
Reprint requests: John T. McBride, MD,
Department of Pediatrics, Children’s Hospital
Medical Center of Akron, 1 Perkins Square,
Akron, OH 44308.
J Pediatr 2002;140:8-9.
Copyright © 2002 by Mosby, Inc.
0022-3476/2002/$35.00 + 0 9/18/121691
doi:10.1067.mpd.2002.121691
8
ing airway diseases, benefit predictably
from corticosteroid therapy. This is im-
portant because infants with underly-
ing diseases like bronchopulmonary
dysplasia or asthma may be at higher
risk than previously well infants of de-
veloping respiratory failure with respi-
ratory viral infections. A physician
treating a child with bronchiolitis and
respiratory compromise who also has
underlying airway disease should
strongly consider corticosteroid thera-
py regardless of the questionable effica-
cy of corticosteroids in previously well
children with viral-associated wheez-
ing. This issue may have influenced the
conclusions of some studies of the effi-
cacy of corticosteroids in bronchiolitis,
including that of a recent meta-analysis
by Garrison et al.3 Several studies in-
cluded in the meta-analysis that sug-
gested that corticosteroid treatment is
beneficial did not exclude children with
previous episodes of wheezing. This
problem, however, is not pertinent to
the study of Schuh et al1, who did ex-
clude such children.
See related article, p 27.
Schuh et al1 found a benefit 4 hours
after a single large dose of dexametha-
sone in 2 outcome variables: respiratory
status as measured by a respiratory as-
sessment change score (RACS) and
hospitalization rate. Both parameters
have strengths and weaknesses. The
RACS is made on the basis of a clinical
assessment tool that has previously
been well validated. Hospitalization
rate is a useful outcome variable be-
cause of the importance of bronchioli-
tis-associated hospitalization for the
affected infant/family and for the health
care system. Hospitalizations for RSV
stress the family, challenge the re-
sources of pediatric inpatient services
during the yearly epidemic, and account
for RSV’s major economic cost to soci-
ety. The likelihood that the statistically
RACS Respiratory assessment change score
RSV Respiratory syncytial virus
significant change in clinical status
found was also clinically important is
suggested by the associated decrease in
the hospitalization rate. On the other
hand, indications for hospitalization for
infants with bronchiolitis are subjective
and vary dramatically from area to
area,4 physician to physician, and, po-
tentially, with time through the epidem-
ic. In fact, the clinical value of
hospitalization for the majority of in-
fants with RSV who do not have serious
respiratory compromise is unclear.
Most supportive therapies could be
equally well provided at home and the
risk of deterioration after hospitaliza-
tion in most infants admitted is low.5
Schuh et al1 are to be congratulated
for addressing an important aspect of
bronchiolitis therapy with a well-
designed study. However, physicians
should consider waiting before adding a
single dose of dexamethasone to the
routine treatment of previously well in-
fants arriving at the emergency depart-
ment with bronchiolitis. The authors
present a number of possible explana-
tions for the fact that they were able to
demonstrate an effect of corticosteroid
treatment, whereas many previous
careful investigators have not. They
treated infants upon arrival to the emer-
gency department rather than some-
what later in their course, after
admission. By enrolling outpatients,
THE JOURNAL OF PEDIATRICS
VOLUME 140, NUMBER 1
they probably studied a less severely af-
fected population than studies that have
enrolled inpatients. They used a larger
dose of corticosteroid than many previ-
ous studies. However persuasive the
findings of the present study, the
thoughtful pediatrician would do well
to maintain a healthy skepticism, partic-
ularly when the therapy of so many in-
fants throughout the country and the
world may be altered. Any change in
therapy that affects so many patients
demands careful consideration of po-
tential side effects (even uncommon
ones) and possible alternative explana-
tions for experimental findings.
The dose of dexamethasone used was
large (1 mg/kg). Although the authors
outline reasons that they chose this dose
and that such a dose should be well tol-
erated, one wonders if the widespread
use of this dose in the large population
of infants that will meet criteria for
treatment might result in an increased
risk of serious bacterial superinfection
in a small number of particularly sus-
ceptible individuals. Such a small risk
might be justified if it were shown that
early corticosteroid treatment prevent-
ed serious morbidity in children with
bronchiolitis, but the majority of infants
who require intensive care for RSV in-
fection are already recognized as being
critically ill when they arrive at the
emergency department and so would
not have been included in the present
study.5
There is a possibility that the effect
of the dexamethasone observed was
nonspecific. The authors argue that
this treatment might have decreased
airway edema within 4 hours. It is un-
likely that there would be such an ef-
fect so soon. If resolution of airway
edema was the mechanism, it would be
surprising that such an effect would
not also benefit infants later in their
course, after admission.
The antipyretic effect of cortico-
steroids needs to be taken into careful
consideration by investigators planning
to replicate the study of Schuh et al.1
Nearly 60% of the corticosteroid treat-
ed patients were febrile at enrollment
and dexamethasone is an antipyretic.
Fever, through its effect on metabolic
rate, increases minute ventilation. This
is accomplished by an increase in respi-
ratory rate, a component of the RACS,
and an increase in respiratory effort as
reflected in retractions, an important
part of the Respiratory Disease Assess-
ment Instrument. Dexamethasone
might have benefitted the treated pa-
tients by decreasing fever rather than
by affecting airway edema or some
other specific aspect of airway obstruc-
tion. If so, alternative antipyretics
would be preferred.
Infants, their families, their physi-
cians, and our health care system sorely
need new and effective approaches to
the management of bronchiolitis. Fortu-
nately and unfortunately, there is no
lack of patients available to researchers
interested in investigating new (or old)
therapies for this common illness. Stud-
ies to confirm the conclusions of Schuh
EDITORIALS
et al1, that corticosteroids benefit previ-
ously well infants with bronchiolitis ar-
riving at the emergency department,
should be forthcoming. If a benefit of
corticosteroid treatment in these infants
is confirmed, further studies that docu-
ment the absence of side effects in large
numbers of patients and that define op-
timal dosing strategies should follow.
John T. McBride, MD
Vice-Chair, Department of Pediatrics
Director, Robert T. Stone
Respiratory Center
Children’s Hospital Medical
Center of Akron
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Liu LL, Stout JW, Anderson LJ. Born-
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among US children, 1980-1996. JAMA
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Cummings P, Davis RL. Systemic corti-
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