Steroid Treatment for a 5-Year-Old with Cough
Steroids are generally NOT indicated for nonspecific cough in a 5-year-old child, but may be warranted only if there are clear risk factors for asthma present, in which case a short 2-4 week trial of low-dose inhaled corticosteroids (400 mcg/day beclomethasone equivalent) should be used with mandatory reassessment. 1
When Steroids Should NOT Be Used
Oral steroids have no proven benefit for nonspecific cough in children and may actually increase hospitalizations. An RCT in 200 children aged 1-5 years found that parent-initiated oral steroids conferred no benefit but were associated with a non-significant increase in hospitalizations (P = 0.058). 1
Dexamethasone provides no significant benefit for cough associated with pertussis. 1
There are no published RCTs supporting the use of oral steroids for nonspecific cough in children. 1
Inhaled corticosteroids for subacute cough (2-4 weeks duration) show no significant difference from placebo. A Cochrane review found no evidence to support ICS use for subacute cough in children. 2
For chronic nonspecific cough without asthma features, inhaled corticosteroids at standard doses (400 mcg/day beclomethasone) are no different from placebo. 3
When a Trial of Inhaled Steroids MAY Be Considered
A short trial of inhaled corticosteroids is only appropriate when specific risk factors for asthma are present. 1
Risk Factors for Asthma That Would Support a Trial:
- Personal history of atopy or allergic sensitization 1
- Family history of asthma 1
- Presence of wheeze (though even with wheeze, oral steroids are not beneficial) 1
- Documented airflow obstruction or bronchodilator response on spirometry (if age-appropriate) 1
Specific Protocol for ICS Trial:
Dose: Use 400 mcg/day equivalent of budesonide or beclomethasone (NOT higher doses, as adverse events occur with high-dose ICS) 1
Duration: 2-4 weeks maximum for initial trial 1
Delivery: Use nebulizer or metered-dose inhaler with valved holding chamber (spacer) for a 5-year-old 4
Mandatory reassessment: Child MUST be re-evaluated at 2-4 weeks 1
If no response: Stop the medication immediately—do NOT increase the dose 1
If cough resolves: Re-evaluate the child OFF asthma treatment, as resolution may be due to spontaneous resolution (period effect) rather than true asthma 1
Acute Asthma Exacerbation (Different Scenario)
If the 5-year-old presents with an acute asthma exacerbation (dyspnea, wheeze, respiratory distress), systemic corticosteroids ARE indicated:
Oral dexamethasone: 0.3 mg/kg (maximum 12 mg) as a single dose, OR 0.6 mg/kg/day (maximum 16 mg/day) for 2 days 5
Oral prednisolone: 1-2 mg/kg/day (maximum 40-60 mg) for 3-10 days until symptoms resolve 5, 6
IV methylprednisolone or dexamethasone: Only for severe exacerbations where oral route is not tolerated 5
Common Pitfalls to Avoid
Do not prescribe oral steroids for simple cough without clear evidence of asthma exacerbation. 1
Do not use prolonged courses of inhaled corticosteroids without documented benefit. Both published RCTs on ICS for chronic nonspecific cough cautioned against prolonged use. 1
Do not increase ICS doses if cough is unresponsive to initial trial. This indicates the diagnosis is not asthma. 1
Do not assume cough equals asthma. Most children with nonspecific cough do not have asthma, and cough often resolves spontaneously. 1
Always re-evaluate after stopping ICS if cough resolved. The child may not actually have asthma. 1
Alternative Considerations
Environmental factors: Address exposure to tobacco smoke, dust, and pets, which is more important than medication in many cases. 1
Antimicrobials: Consider if there is persistent nasal discharge or radiographically confirmed sinusitis. 1
Watchful waiting: Many cases of nonspecific cough resolve spontaneously within 2-4 weeks without any treatment. 1