Should a child with asthma and Respiratory Syncytial Virus (RSV) infection be given steroids?

Should You Give Steroids to a Child with Asthma and RSV?

Yes, you should give systemic corticosteroids to a child with asthma who develops an RSV-triggered exacerbation, using the same dosing and indications as for any viral-induced asthma exacerbation. The key is recognizing that the child has asthma experiencing an acute exacerbation—the viral trigger (RSV) doesn't change the fundamental treatment approach for the asthmatic component.

Clinical Decision Framework

When to Initiate Steroids

Systemic corticosteroids are indicated when the child with asthma presents with any of the following during RSV infection 1:

• Progressive worsening of symptoms day by day
• Peak expiratory flow (PEF) falls below 60% of the child's best (if measurable)
• Sleep disturbance from asthma symptoms
• Morning symptoms persisting until midday
• Diminishing response to inhaled bronchodilators
• Severe features: too breathless to talk or feed, respirations >50/min, pulse >140/min, PEF <50% predicted 1

Dosing Regimen

Prednisolone 1-2 mg/kg body weight daily (maximum 40 mg) for 3-5 days, with no tapering required 1, 2, 3, 4. The British Thoracic Society and American Academy of Pediatrics both recommend this approach for acute exacerbations in children 2, 3.

For immediate treatment of acute severe asthma with RSV:

• Give the first dose immediately upon recognition 3
• Continue daily dosing each morning until control is established 1
• No tapering is necessary for courses under 10 days 3

Critical Distinction: Asthma vs. Bronchiolitis

The decision hinges on whether the child has established asthma experiencing a viral exacerbation versus pure RSV bronchiolitis in a previously non-asthmatic infant:

For children with known asthma + RSV:

• Treat the asthma exacerbation with systemic steroids as outlined above 1, 2, 3
• The viral trigger doesn't negate the inflammatory asthma component requiring corticosteroid therapy 5

For infants with RSV bronchiolitis without asthma:

• Ribavirin has not been shown to reduce hospital stay or need for ventilation and is not routinely used 1
• However, evidence suggests that inhaled corticosteroids for 6-8 weeks post-hospitalization may reduce subsequent asthma development (12% vs 24%) and severe respiratory morbidity 6

Concurrent Bronchodilator Therapy

Steroids must always be combined with aggressive bronchodilator treatment 3:

• Nebulized salbutamol 5 mg (or 2.5 mg in very young children) via oxygen-driven nebulizer 1, 2
• Repeat every 4-6 hours initially, increasing to every 30 minutes if not improving 1, 3
• Add ipratropium 100-250 mcg nebulized every 6 hours 1
• Maintain SpO2 >92% with high-flow oxygen 1, 3

Evidence Supporting Early Steroid Use in Viral-Triggered Asthma

A landmark 1988 study demonstrated that preschool children receiving short-term prednisone (1 mg/kg) at the first symptoms of upper respiratory infection (before wheezing developed) experienced dramatic reductions compared to controls 5:

• 65% fewer wheezing days
• 56% fewer attacks
• 61% fewer emergency visits
• 90% fewer hospitalizations

This supports the principle that early corticosteroid intervention for viral-triggered asthma exacerbations significantly reduces morbidity 5.

Common Pitfalls to Avoid

Don't Withhold Steroids Due to Viral Etiology

Many deaths and unnecessary morbidity have been associated with underuse of corticosteroids in asthma, particularly when associated with viral infections 1. The presence of RSV should not be a reason to withhold appropriate asthma treatment.

Don't Confuse RSV Bronchiolitis with Asthma Exacerbation

In infants under 2 years without established asthma, recurrent wheeze with viral infections may not represent true asthma 1. However, if the child has documented asthma (family history, repeated wheeze, atopy), treat the exacerbation appropriately 1.

Ensure Proper Inhaler Technique

Before attributing treatment failure to steroid resistance, verify that the child is using proper inhaler technique with an age-appropriate spacer device 1, 2. Poor technique is a common cause of apparent treatment failure.

Post-Discharge Management

After the acute exacerbation resolves 1, 3:

• Continue inhaled corticosteroids as controller therapy
• Provide a written asthma action plan to parents
• Schedule primary care follow-up within 1 week
• Reassess within 48 hours if treated at home 3

The evidence strongly supports using systemic corticosteroids for children with asthma experiencing RSV-triggered exacerbations, following the same principles as any viral-induced asthma attack 1, 2, 3, 5.