Should steroids be avoided in pediatric patients with asthma exacerbation and concomitant pneumonia?

Steroids in Pediatric Asthma Exacerbation with Concomitant Pneumonia

Systemic corticosteroids should not be avoided in pediatric patients with asthma exacerbation, even when concomitant pneumonia is present, as the benefits of treating the inflammatory component of asthma outweigh the risks. 1, 2

Rationale for Using Steroids

• Systemic corticosteroids are essential for treating the inflammatory component of asthma exacerbations and should be administered early, as their anti-inflammatory effects may take 6-12 hours to become apparent 2
• Oral corticosteroids are recommended for treating mild, moderate, and severe asthma exacerbations according to multiple guidelines 1
• For children with asthma exacerbations, prednisolone (1-2 mg/kg daily for 5 days) is an effective treatment that reduces hospital admissions and unscheduled returns to care 3

Evidence Supporting Steroid Use Despite Pneumonia

• Recent evidence shows that inhaled corticosteroid (ICS) therapy actually has a protective effect in children with asthma who develop Mycoplasma pneumoniae pneumonia, making them less likely to experience asthma exacerbations 4
• In a 2023 study, maintenance ICS treatment reduced the detection rates of Human Rhinovirus (mainly HRV-C) in school-age inpatients with asthma exacerbations 5
• Longer treatment periods with systemic corticosteroids (6-8 days) during virus-induced exacerbations were associated with better lung function outcomes compared to shorter treatment periods (3-5 days) 5

Potential Concerns and Precautions

• High doses of systemic steroids can predispose to opportunistic infections, including Legionella and Pneumocystis pneumonia, as reported in case studies of asthmatic children 6
• Three guidelines in a systematic review discouraged the routine use of antibiotics in asthma exacerbation treatment unless specific complications were recurring 1

Treatment Recommendations

• For moderate to severe asthma exacerbations with pneumonia:

  • Use systemic corticosteroids as the primary anti-inflammatory treatment 1, 2
  • Consider adding appropriate antibiotics only if bacterial pneumonia is confirmed or strongly suspected 1
  • Monitor closely for clinical improvement 1

• For mild to moderate asthma exacerbations with pneumonia:

  • Inhaled corticosteroids may be used alone or in combination with systemic corticosteroids 7
  • ICS has been shown to significantly reduce hospital admissions compared to placebo (odds ratio 0.63) 7
  • The combination of ICS and systemic corticosteroids showed better outcomes than systemic corticosteroids alone in moderate-to-severe asthma exacerbations (odds ratio 0.75) 7

Administration Routes

• Oral administration is preferred when gastrointestinal absorption is not compromised 2
• Intravenous administration may be preferable in patients with severe asthma where absorption might be compromised 2
• Intramuscular administration is an alternative when IV access is difficult 2

Monitoring and Follow-up

• Closely monitor response to treatment, particularly respiratory status and oxygen saturation 1
• Assess for potential complications of both the asthma exacerbation and the pneumonia 1
• Consider pulmonary function testing after resolution of the acute episode to assess recovery 5

Conclusion

The evidence strongly supports using corticosteroids in pediatric patients with asthma exacerbation even when pneumonia is present. The benefits of controlling the inflammatory component of asthma outweigh the potential risks, and some studies even suggest protective effects of corticosteroids against certain types of pneumonia in asthmatic children.