The article “Assessing wheeze in pre-school children”, BPJ 56 (Nov, 2013),
covers the management of wheeze in young children without a diagnosis of asthma. The dose of salbutamol in the section
“Treating acute episodes of wheeze” was intended to refer to the at-home management of wheeze in a young child with
an acute, self-limiting viral illness. In such a child, the maximum recommended daily dose of salbutamol, as suggested
in the medicine data sheets, is 200 micrograms, four times daily, i.e. 800 micrograms per day. The dosing advice for
salbutamol was not meant to refer to the management of an emergency situation in a child with asthma requiring hospitalisation.
In retrospect, our use of the term “acute episode of wheeze” in the title of this section was ambiguous, and the intention
of the section should have been explicitly stated.
The correspondent is correct that in a severe or life-threatening acute episode of breathlessness in a child with
asthma, the dose of salbutamol given can be significantly higher than 800 micrograms. In this scenario the adverse effects
of insufficient treatment will almost always outweigh any adverse effects of high-doses of salbutamol. The New Zealand
Formulary for Children states the recommended initial acute treatment in a child with a moderate, severe or life-threatening
asthma attack is salbutamol, six puffs from a 100 microgram inhaler via a spacer.4 Each puff should be inhaled
separately, and five breaths taken between each puff.4 This regimen should then be repeated every ten to
twenty minutes for one to two hours, with the frequency reduced to hourly if the child’s symptoms improve. Oxygen, corticosteroids
(usually oral, but in life-threatening situations IV can also be used) and potentially ipratropium are also recommended
where available. Referral to hospital should be considered depending on the child’s response to salbutamol.
As stated in the article, evidence of the efficacy of oral corticosteroids for the treatment of wheeze in children
aged under five years is conflicting.1, 2 This is likely to be a reflection of the many potential causes
of wheeze in pre-school children. There is evidence that children with episodic viral wheeze will not respond to corticosteroids
(both inhaled and systemic) as well as children with atopic wheeze but as discussed in the article, it is difficult
to make this distinction in pre-school children.3
Short courses (i.e. up to five days) of low-dose oral corticosteroids do not appear to be associated with adrenal
or immune suppression, bone mineral density loss or reduced height growth.5, 6 However, there has been only
limited investigation of repeated short courses of corticosteroids in children.5 The few available studies
indicate that most adverse biochemical changes, such as reductions in bone-forming proteins, following a single short
course of oral steroids in a child return to baseline levels within one month.5, 6 Adverse effects may be
more likely to occur if increasing numbers of courses are given, but it is difficult to say how often is “too often”.
Giving four to six short courses (as the correspondent queried) of corticosteroid to a child in one year, while not
ideal, does not appear to be associated with significant long-term adverse effects.
So what is the role of oral corticosteroids in young children with wheeze? Oral corticosteroids are recommended in
a child who requires hospitalisation for wheeze or breathlessness, however, if the child does not require hospitalisation,
the decision to prescribe oral corticosteroids should be based on the clinician’s judgement. If a child has an acute
episode of wheeze that cannot be controlled with salbutamol, oral corticosteroids will produce a more rapid clinical
response than an inhaled corticosteroid. If the child is presenting frequently with acute episodes of wheeze requiring
oral corticosteroids, however, other management options, such as regular inhaled corticosteroid (ICS) use, should be
considered. An additional option, as outlined in the article, is the use of montelukast which is now funded under Special
Authority criteria for the prevention and management of exacerbations of wheeze in pre-school children, either alone
or in combination with an ICS.
- Panickar J, Lakhanpaul M, Lambert P, et al. Oral prednisolone for preschool children with acute virus-induced
wheezing. N Engl J Med 2009;360:329–38.
- Bhatt J, Smyth A. The management of pre-school wheeze. Paediatr Respir Rev 2011;12:70–7.
- Brand P, Baraldi E, Bisgaard A, et al. Definition, assessment and treatment of wheezing disorders in preschool
children: an evidence-based approach. Eur Respir J 2008;32:1096–110.
- New Zealand Formulary for Children (NZFC). NZFC v18. 2013. Available from:
- Rieder M. The child with multiple short courses of steroid therapy. Paediatr Child Healt 2003;8:226.
- Ducharme F, Chabot G, Polychronakos C, et al. Safety profile of frequent short courses of oral glucocorticoids
in acute pediatric asthma: impact on bone metabolism, bone density, and adrenal function. Pediatrics 2003;111:376–83.