What type of steroids are given in pediatric asthma?

Types of Steroids Used in Pediatric Asthma

Inhaled corticosteroids (ICS) are the preferred first-line maintenance therapy for children with persistent asthma, while systemic corticosteroids (oral or parenteral) are used for acute exacerbations. 1

Inhaled Corticosteroids (ICS) for Long-Term Control

Inhaled corticosteroids are the cornerstone of maintenance therapy for persistent asthma in children:

• Strong evidence establishes that inhaled corticosteroids improve long-term outcomes for children with mild or moderate persistent asthma compared to as-needed beta2-agonists 1
• ICS therapy results in improved lung function, reduced hyperresponsiveness, better symptom scores, fewer courses of oral corticosteroids, and fewer urgent care visits or hospitalizations 1
• For children 5 years and older with mild persistent asthma, low-dose inhaled corticosteroids are the preferred therapy 1
• For children younger than 5 years with persistent asthma, low-dose inhaled corticosteroids delivered via nebulizer, dry powder inhaler (DPI), or metered-dose inhaler (MDI) with holding chamber (with or without face mask) are recommended 1

FDA-Approved Inhaled Corticosteroids for Young Children:

• Budesonide nebulizer solution (approved for children 1-8 years) 1
• Fluticasone DPI (approved for children 4 years and older) 1

Systemic Corticosteroids for Acute Exacerbations

Systemic corticosteroids are essential for managing acute asthma exacerbations:

Oral Corticosteroids:

• Prednisolone/prednisone is the most commonly used oral corticosteroid for acute asthma exacerbations 2, 3
• Typical dosing for prednisone/prednisolone in children with asthma exacerbations is 1-2 mg/kg/day in single or divided doses 2
• Treatment duration is typically 3-10 days or until the child achieves 80% of personal best peak flow or symptoms resolve 2
• There is no evidence that tapering the dose after improvement prevents relapse 2

Parenteral Corticosteroids:

• Methylprednisolone can be administered intravenously for severe exacerbations 4
• The recommended dosing for IV methylprednisolone in pediatric patients with asthma uncontrolled by inhaled corticosteroids and long-acting bronchodilators is 1-2 mg/kg/day 4
• Dexamethasone (intramuscular or oral) has been studied as an alternative to prednisolone for acute exacerbations, with the advantage of requiring fewer doses due to its longer half-life 5, 6

Comparative Effectiveness

• Studies comparing inhaled corticosteroids to cromolyn, nedocromil, theophylline, or leukotriene receptor antagonists (LTRAs) show that none of these alternative long-term control medications is as effective as inhaled corticosteroids in improving asthma outcomes 1
• For acute exacerbations requiring hospitalization, systemic corticosteroids produce improvements including earlier discharge and fewer relapses compared to placebo 3
• A single dose of oral dexamethasone (0.3 mg/kg) has been shown to be noninferior to a 3-day course of oral prednisolone (1 mg/kg per day) for acute exacerbations, which may improve adherence due to fewer doses and less vomiting 5
• Inhaled or nebulized corticosteroids cannot be recommended as equivalent to systemic steroids for acute exacerbations 3, 7

Considerations for Different Age Groups

• For children under 5 years with persistent asthma, treatment recommendations are based on extrapolation from studies in older children 1
• For infants and young children with recurrent wheezing (more than three episodes in the past year affecting sleep) and risk factors for persistent asthma, inhaled corticosteroids are the preferred treatment option 1
• For moderate persistent asthma in children under 5 years not controlled on low-dose ICS, options include increasing to medium-dose ICS or adding a long-acting beta2-agonist to low-dose ICS 1

Monitoring and Follow-up

• Response to therapy should be carefully monitored; if no clear benefit is observed within 4-6 weeks, alternative therapies or diagnoses should be considered 1
• When benefits are sustained for 2-4 months, a step down in therapy should be attempted 1
• For acute exacerbations treated with systemic steroids, follow-up should assess for symptom resolution and potential need for adjustment of maintenance therapy 3, 5