Commentary

The randomised controlled trial by Csonka et al showed some dramatic reductions in duration of symptoms and hospital stay and need for additional asthma medications in children with VILAD who received OP. A major difficulty in interpreting the study was the mixed population. Enrolling children with a previous history of wheezing and age ≤ 36 months (most of whom actually had asthma) is likely to lead to a systematic overestimate of benefits from including those known to benefit from steroids. However, subgroup analysis by history of wheezing showed that the effect of steroids may be greater in the subgroup of children without previous wheezing. This finding contradicts previous trials¹ as well as a meta-analysis by Patel et al² on steroids in this population.

Most of the endpoints are not strictly objective, including the indication for hospital admission, requirement for additional medications, and the decision to discharge. However, it is important to note that by design and definition, “need for additional medication on the ward” was determined for only a hospitalised subset, because children not admitted to hospital were not treated on the ward but discharged directly from the emergency room.

Although more adverse events were observed in the OP group than in the placebo group, the only notable one was vomiting because of the bitter taste. Long term adverse events will need to be considered in decisions regarding recurrent use of such agents in young children. These concerns will be even greater as ever younger infants with wheezing are considered for steroid courses.