When is prednisone indicated in a child over 1 year old with difficulty breathing, suspected to be due to an inflammatory condition such as croup or asthma?

When to Use Prednisone for Work of Breathing in Children Over 1 Year

Prednisone is indicated for children over 1 year with increased work of breathing when the underlying cause is croup or asthma exacerbation, but should NOT be used for bronchiolitis or isolated cough without wheeze. 1, 2, 3

Specific Clinical Scenarios for Prednisone Use

Croup (Laryngotracheobronchitis)

• Give prednisolone 1.0 mg/kg orally for mild to moderate croup with characteristic barking cough, inspiratory stridor, and hoarse voice 3
• Prednisolone is FDA-approved for respiratory diseases and reduces hospital admissions in croup 1, 4
• Single-dose treatment is effective; symptoms typically resolve within 48 hours 4
• For severe or life-threatening croup, give nebulized adrenaline 4 mL of 1:1000 (undiluted) in addition to steroids and arrange immediate hospital transfer 3

Asthma Exacerbations

• Prednisolone 1 mg/kg/day for 3 days is indicated for acute asthma exacerbations in children with documented asthma diagnosis 5, 2
• Corticosteroids reduce relapses, subsequent hospital admissions, and need for β2-agonist therapy in acute asthma 5
• The FDA approves prednisone for "bronchial asthma" and "control of severe or incapacitating allergic conditions" 1

Critical Diagnostic Requirements Before Using Prednisone

Do NOT Use Prednisone Based on Symptoms Alone

• Asthma should never be diagnosed based on breathing difficulty or cough alone - these symptoms are highly nonspecific 6
• The European Respiratory Society strongly recommends against diagnosing asthma without objective evidence (spirometry with bronchodilator response, FeNO testing, or documented wheeze) 6, 7
• Children with chronic cough as the only symptom are unlikely to have asthma and should be investigated according to chronic cough guidelines, not treated empirically with steroids 8, 9

Key Diagnostic Features Required

• Recurrent wheeze (polyphonic whistling sound during expiration) is the most important symptom suggesting asthma or reactive airway disease 6, 9
• Document wheeze by auscultation or parental report of recurrent episodes 9
• In children under 5 years, diagnosis relies primarily on clinical assessment since spirometry is not feasible 9

When NOT to Use Prednisone

Bronchiolitis

• Oral corticosteroids are NOT effective for bronchiolitis and should not be used 2
• This is a viral lower respiratory infection typically in infants and young children

Isolated Cough Without Wheeze

• Do NOT give prednisone for chronic cough without documented wheeze or airway obstruction 8, 7
• "Cough variant asthma is probably a misnomer for most children in the community who have persistent cough" 8
• Only 3 of 23 children with isolated chronic cough had asthma-type airway inflammation in research studies 8

Upper Respiratory Infections

• Recurrent upper respiratory infections with cough do not warrant corticosteroid treatment unless accompanied by wheeze or stridor 8

Practical Algorithm for Decision-Making

Step 1: Identify the Clinical Presentation

• Barking cough + stridor + hoarse voice = Croup → Give prednisolone 1 mg/kg 3
• Recurrent wheeze + breathing difficulty + known asthma = Asthma exacerbation → Give prednisolone 1 mg/kg/day × 3 days 5
• Isolated cough without wheeze = NOT asthma → Investigate other causes, do not give prednisone 8, 7

Step 2: Assess Severity

• Mild-moderate croup: Prednisolone 1 mg/kg, reassess in 1 hour 3
• Severe croup or asthma: Add nebulized bronchodilators, consider hospital admission 3, 5

Step 3: Avoid Common Pitfalls

• Do not use labels like "reactive airway disease" or "wheezy bronchitis" to justify empirical steroids without proper evaluation 8
• Do not assume all breathing difficulty represents asthma - breathing difficulty has very poor specificity for asthma diagnosis 6
• Do not start inhaled or oral corticosteroids without objective confirmation or documented wheeze 7

Important Caveats

Age-Specific Considerations

• In children under 5 years, objective testing (spirometry) is not feasible, so diagnosis relies on documented wheeze, pattern of symptoms, and response to bronchodilator treatment 9
• Inhaled corticosteroids via MDI and spacer are preferred over oral steroids for chronic management to minimize systemic side effects 6

Alternative Corticosteroid Options

• Dexamethasone 0.3 mg/kg as a single dose may be used instead of 3-day prednisolone course for asthma exacerbations, improving compliance 5
• Nebulized budesonide 2-4 mg is as effective as oral dexamethasone for croup and may be preferred in some settings 10, 4

Monitoring for Adverse Effects

• Long-term corticosteroid use can cause growth retardation, increased blood pressure, osteoporosis, and adrenal suppression 6
• Short courses (3-5 days) for acute exacerbations have minimal long-term effects 2, 5