What is the role of steroids in treating pediatric respiratory viral infections?

Steroids in Pediatric Respiratory Viral Infections

Systemic corticosteroids should be considered for children with viral respiratory infections ONLY when there is moderate-to-severe asthma exacerbation or a history of severe virus-triggered exacerbations; they are NOT indicated for acute bronchiolitis or simple viral upper respiratory infections without underlying asthma. 1

Clinical Context Determines Steroid Use

The role of steroids in pediatric viral respiratory infections depends entirely on whether the child has underlying asthma or reactive airway disease versus simple bronchiolitis:

Children WITH Asthma or Recurrent Wheezing

For children with established asthma experiencing viral respiratory infections:

• Systemic corticosteroids should be initiated if the exacerbation is moderate to severe or at the onset of a viral respiratory infection in patients with a history of severe exacerbations 1
• Early administration of prednisone (1 mg/kg) at the first symptoms of upper respiratory tract infection—before wheezing develops—can reduce wheezing days by 65%, attacks by 56%, emergency visits by 61%, and hospitalizations by 90% in preschool children with virus-triggered asthma 2
• Inhaled corticosteroids as maintenance therapy are the most effective long-term control for persistent asthma, reducing exacerbations, rescue oral corticosteroid needs, urgent visits, and hospitalizations by approximately 50% 3
• Low-dose inhaled corticosteroids should be started as first-line controller therapy for children with recurrent wheezing (≥2 episodes in past year lasting >1 day) and evidence of atopic disease 4

Critical distinction: Maintenance inhaled corticosteroids are NOT beneficial in children with intermittent respiratory virus-induced wheezing without persistent symptoms between episodes 3

Children WITHOUT Asthma (Acute Bronchiolitis)

For infants with acute viral bronchiolitis (typically RSV):

• Systemic corticosteroids should NOT be prescribed 5
• A randomized controlled trial of 147 infants with RSV infection showed prednisolone (2 mg/kg daily for 5 days) had no effect on hospital duration, acute symptoms, or outcomes at 1-month and 1-year follow-up 5
• Neither systemic nor inhaled corticosteroids are indicated for acute RSV bronchiolitis 5

One notable exception: Post-hospitalization inhaled corticosteroids for 6-8 weeks after RSV infection may reduce subsequent asthma development (12% vs 24%) and severe respiratory morbidity, though this requires further validation 6

Special Populations

MIS-C and COVID-19-Related Hyperinflammation

For the specific context of SARS-CoV-2-related illness:

• Methylprednisolone (1-2 mg/kg/day IV) combined with IVIG (2 gm/kg) is first-line treatment for multisystem inflammatory syndrome in children (MIS-C) 1
• For refractory MIS-C, escalate to high-dose methylprednisolone (10-30 mg/kg/day) 1
• Children with severe COVID-19 and hyperinflammation (elevated CRP, ferritin, IL-6, d-dimer) should be considered for glucocorticoid therapy, though evidence is limited in pediatrics 1

Pediatric ARDS

• Steroids should NOT be given routinely for pediatric acute respiratory distress syndrome 7
• The only pediatric ARDS patients likely to benefit are those with concurrent active asthma or reactive airway disease of prematurity 7

Practical Algorithm

Step 1: Identify the clinical scenario

• Asthma exacerbation triggered by viral infection → Consider systemic steroids 1
• Recurrent viral-triggered wheezing with atopy → Start maintenance inhaled corticosteroids 4
• Acute bronchiolitis in infant without asthma history → NO steroids 5
• MIS-C or severe COVID-19 with hyperinflammation → YES, systemic steroids 1

Step 2: For asthmatic children with viral infections

• Mild exacerbation → Continue maintenance inhaled corticosteroids, use bronchodilators 1
• Moderate-severe exacerbation OR history of severe virus-triggered attacks → Add systemic corticosteroids 1
• Consider early prednisone at first URI symptoms in high-risk children 2

Step 3: Monitor and adjust

• Reassess response within 4-6 weeks 4
• Step down therapy after 2-4 months of good control 1
• Young children have high spontaneous remission rates 4

Common Pitfalls to Avoid

• Do not prescribe steroids for simple viral bronchiolitis in infants without underlying asthma—this is ineffective and exposes children to unnecessary risks 5
• Do not rely solely on bronchodilators in children with persistent asthma symptoms—they do not address underlying inflammation 4
• Do not use maintenance inhaled corticosteroids in children with only intermittent viral-triggered wheezing without symptoms between episodes 3
• Ensure proper inhaler technique with spacer devices, especially for inhaled corticosteroids 1
• Monitor growth in children on inhaled corticosteroids >400 µg/day, though short-term reductions in growth rate cannot be extrapolated long-term 1