Steroid Treatment for Discharge of an Asthmatic Child
For an asthmatic child being discharged from the emergency department or hospital, prescribe oral prednisolone 1-2 mg/kg/day (maximum 60 mg/day) for 3-10 days, with no need to taper if the course is less than 10 days. 1
Discharge Steroid Regimen
The standard outpatient burst regimen is prednisolone 1-2 mg/kg/day (maximum 60 mg/day) given as a single dose or divided into 2 doses daily for 3-10 days. 1, 2 This dosing applies to children of all ages being discharged after an acute exacerbation. 1
Key Dosing Points:
- No tapering is required for courses lasting less than 1 week, and probably unnecessary even for courses up to 10 days, especially if the child is concurrently taking inhaled corticosteroids. 1
- The total duration should continue until symptoms resolve or peak expiratory flow reaches 70% of predicted or personal best. 1
- Oral therapy is equally effective as intravenous administration, provided gastrointestinal absorption is not impaired. 1, 3
Route of Administration Options
Oral prednisolone is the preferred route for discharge, as it is equally effective as intravenous methylprednisolone and more practical for outpatient management. 1, 3
Alternative for Compliance Concerns:
- A single intramuscular dose of dexamethasone 0.6 mg/kg (maximum 15 mg) is a reasonable alternative if adherence to a multi-day oral course is questionable, as it shows equivalent efficacy to 5 days of oral prednisolone. 4
- This single-dose approach eliminates the risk of non-compliance with a 5-10 day oral regimen. 4
Concurrent Inhaled Corticosteroid Initiation
Inhaled corticosteroids should be started at discharge (or can be started at any point during treatment of the exacerbation) at a higher dose than the child was taking before admission. 1, 5 This provides ongoing anti-inflammatory control as the systemic steroids are completed. 5
Discharge Readiness Criteria
Before discharging on oral steroids, ensure: 1, 5
- The child has been on discharge medications for at least 24 hours 1, 5
- Peak expiratory flow is >75% of predicted or personal best (if measurable by age) 1, 5
- Inhaler technique has been checked and documented 1, 5
- A written asthma action plan has been provided to parents 6, 5
Follow-Up Requirements
Schedule primary care follow-up within 1 week of discharge (ideally within 48 hours if treated and released from ED). 1, 6, 5 This is mandatory to assess response to the steroid burst and adjust long-term controller therapy. 6, 5
Common Pitfalls to Avoid
- Underuse of corticosteroids at discharge is a major factor in preventable asthma deaths and readmissions. 6 Do not hesitate to prescribe the full recommended dose and duration.
- Inadequate corticosteroid dosing at discharge leads to symptom recurrence. 5 The 1-2 mg/kg/day dosing should not be reduced out of steroid-phobia in this acute setting.
- Failing to provide written instructions significantly increases relapse risk. 5 Parents must know when to increase treatment and when to return for care.
- There is no advantage to using higher "stress doses" (such as 4 mg/kg/day) over the standard 1-2 mg/kg/day for acute exacerbations. 1, 7 The evidence shows no benefit from massive doses over conventional doses.