Should I give prednisolone (corticosteroid) syrup to a 14-month-old, 10.5kg patient with persistent wheezing after nebulization?

Should You Give Prednisolone to This 14-Month-Old with Persistent Wheezing?

No, do not give prednisolone syrup to this 14-month-old child with persistent wheezing after nebulization. The highest quality evidence shows that oral corticosteroids are ineffective in preschool children under 2 years with viral-induced wheezing, and this child's age (14 months) falls squarely in the group where prednisolone provides no benefit. 1, 2

Evidence Against Prednisolone in This Age Group

The most definitive trial specifically addressing your clinical scenario found that prednisolone was not superior to placebo in preschool children (10-60 months) presenting with mild-to-moderate viral-induced wheezing. 1 This large randomized controlled trial of 687 children showed:

• No difference in duration of hospitalization (13.9 hours placebo vs 11.0 hours prednisolone) 1
• No difference in symptom scores, albuterol use, or adverse events 1
• No benefit across any measured outcome 1

Even more relevant to your 14-month-old patient, an earlier trial specifically in children under 18 months (mean age 9.8 months) found that prednisolone 2 mg/kg/day showed:

• No significant difference in symptom scores of cough, wheeze, or breathlessness 2
• No difference in rate of improvement or overall outcome 2
• Parents could not distinguish prednisolone from placebo in effectiveness 2

A 2021 trial confirmed these findings, showing prednisolone does not alter respiratory outcomes at 24 hours or beyond in preschool wheezers. 3

What You Should Do Instead

Continue aggressive bronchodilator therapy:

• Repeat nebulized salbutamol (2.5 mg for this weight, or 5 mg standard dose) every 4 hours initially 4
• If not improving after 15-30 minutes, increase frequency to every 15-30 minutes 4
• Add ipratropium 100-250 mcg to the nebulizer if inadequate response 4

When to Consider Hospital Admission

Assess for features requiring admission: 4

• Too breathless to feed 4
• Respiratory rate >50/min 4
• Heart rate >140/min 4
• Use of accessory muscles 4
• Poor response to initial nebulization 4

Critical Exception: When Prednisolone IS Indicated

Prednisolone becomes appropriate if this child has established asthma diagnosis or meets criteria for acute severe asthma. 4 In that scenario:

• Dose: 1-2 mg/kg/day (for 10.5 kg = 10.5-21 mg daily, maximum 40 mg) 4, 5, 6
• Duration: Continue for 3-5 days or until complete remission 5, 6
• Must be combined with aggressive bronchodilator therapy 4

Why Guidelines Recommend Prednisolone Despite Negative Evidence

The British Thoracic Society guidelines 4 recommend prednisolone for acute severe asthma in children, but these guidelines predate the high-quality trials showing ineffectiveness in viral-induced wheezing in very young children. 1, 2 The distinction is critical:

• Viral-induced wheezing (likely in your 14-month-old): prednisolone ineffective 1, 2, 3
• Established asthma with acute exacerbation: prednisolone indicated 4

Common Pitfall to Avoid

Do not reflexively prescribe prednisolone for every wheezing infant. 1, 2 The evidence clearly shows that in children under 2 years with viral wheezing, corticosteroids provide no benefit and expose the child to unnecessary medication. 1, 2, 3 Focus instead on optimizing bronchodilator delivery and assessing need for escalation of care. 4

Follow-Up Required

• Reassess response to bronchodilators within 15-30 minutes 4
• Arrange primary care follow-up within 48 hours 5, 7
• Provide clear instructions to parents about when to return (worsening breathlessness, inability to feed, lethargy) 4