What is the role of hydrocortisone in the treatment of asthma in pediatric patients?

Hydrocortisone for Pediatric Asthma

Hydrocortisone is reserved exclusively for children who are vomiting, seriously ill, or unable to take oral medications during acute asthma exacerbations—oral corticosteroids (prednisolone or prednisone) are strongly preferred when the child can swallow. 1

Route Selection: Oral vs. Intravenous

Oral corticosteroids should be the first-line systemic steroid for pediatric asthma exacerbations when gastrointestinal transit is normal, as there is no advantage to intravenous administration in children who can swallow and are not vomiting. 1

• Intravenous hydrocortisone is indicated only when the child cannot take oral medications due to vomiting, severe illness, or inability to swallow 1
• This distinction is critical because oral prednisolone has superior reliability, simplicity, convenience, and lower cost compared to IV hydrocortisone 2

Hydrocortisone Dosing When IV Route is Required

When IV therapy is necessary, the dosing is:

• 200 mg IV every 6 hours for children requiring intravenous therapy 1
• Alternative weight-based dosing: 4 mg/kg/dose every 6 hours (though the 200 mg fixed dose is more commonly cited in guidelines) 1
• This should be administered immediately upon recognition of acute severe asthma, without delay 1, 3

Preferred Oral Corticosteroid Regimen

For children who can take oral medications:

• Prednisolone 1-2 mg/kg/day (maximum 60 mg/day) given as a single dose or in 2 divided doses 1, 4
• The maximum dose was specifically increased from 30 mg to 60 mg for children 0-4 years in updated guidelines 1
• Treatment should continue until peak expiratory flow reaches 80% of personal best or symptoms resolve, typically requiring 3-10 days 4
• No evidence supports tapering the dose after improvement to prevent relapse 4

Clinical Context and Evidence Strength

The evidence strongly favors oral over IV corticosteroids:

• Systemic corticosteroids reduce hospitalizations with an odds ratio of 7.00 (95% CI: 2.98-16.45) and number needed to treat of 3 5
• Early administration of oral corticosteroids reduces hospital length of stay by 8.75 hours and decreases relapse rates within 1-3 months (OR 0.19,95% CI: 0.07-0.55) 5
• Children treated with systemic steroids in hospital have significantly fewer relapses with NNT of 3 5

Treatment Algorithm for Acute Severe Asthma

Step 1: Assess ability to take oral medications

• If child can swallow and is not vomiting → Give oral prednisolone 1-2 mg/kg (max 60 mg) immediately 1
• If child is vomiting, seriously ill, or unable to swallow → Give IV hydrocortisone 200 mg 1

Step 2: Concurrent essential therapy

• High-flow oxygen via face mask to maintain SaO₂ >92% 1, 3
• Nebulized salbutamol 5 mg (age >2 years) or 2.5 mg (age ≤2 years) via oxygen-driven nebulizer 1
• Add ipratropium 100 mcg to nebulizer, repeat every 6 hours 1, 3

Step 3: Reassess at 15-30 minutes

• Repeat peak expiratory flow measurement 1, 3
• Continue monitoring oxygen saturation continuously 3

Long-Term Controller Therapy Context

While hydrocortisone/oral corticosteroids are critical for acute exacerbations, inhaled corticosteroids are the preferred long-term controller medication for children ≥5 years with mild or moderate persistent asthma (Evidence A) 6:

• Inhaled corticosteroids improve prebronchodilator FEV1, reduce hyperresponsiveness, improve symptom scores, and reduce urgent care visits compared to as-needed beta2-agonists 6
• For children <5 years, low-dose inhaled corticosteroids via nebulizer, DPI, or MDI with holding chamber are preferred for persistent asthma 6

Critical Pitfalls to Avoid

• Never delay systemic corticosteroids while giving repeated albuterol doses alone—failure to respond to initial beta-agonist treatment mandates immediate corticosteroid administration 1
• Underuse of corticosteroids is a major factor in preventable asthma deaths—give steroids early in acute exacerbations 3
• Do not use antibiotics unless bacterial infection is confirmed, as viral triggers are most common in pediatric asthma exacerbations 1
• Avoid using inadequate oxygen delivery (nasal cannula)—high-flow oxygen via face mask is essential in severe exacerbations 3

Monitoring During Treatment

• Chart peak expiratory flow before and after each bronchodilator dose, at least 4 times daily 3
• Maintain continuous pulse oximetry with target SaO₂ >92% 3
• Repeat clinical assessment 15-30 minutes after starting treatment, then after each bronchodilator set 1