Can a 6-year-old child with asthma, presenting with wheezing and a positive COVID-19 (Coronavirus Disease 2019) test, be treated with prednisone for wheezing?

Treatment of Wheezing in a 6-Year-Old Asthmatic Child with COVID-19

Yes, prednisone should be given to this child for asthma-related wheezing, even with concurrent COVID-19 infection, at a dose of 1-2 mg/kg/day for 3-5 days. 1

Rationale for Systemic Corticosteroid Use

The concern about corticosteroids potentially impairing antiviral immunity in COVID-19 does not apply to asthmatic children experiencing bronchospasm. 2 In asthma exacerbations, the underlying type 2 inflammation actually inhibits antiviral immunity, and corticosteroids paradoxically restore protective antiviral responses by suppressing this pathologic inflammation. 2

For bronchospasm related to respiratory infection (including COVID-19), the benefits of controlling respiratory symptoms outweigh the theoretical risks of delayed viral clearance. 1

Specific Dosing Recommendations

Standard Prednisone Dosing

• Dose: 1-2 mg/kg/day for 3-5 days 1
• For a 6-year-old child (typically 20-25 kg), this translates to approximately 20-50 mg daily 1
• Use the lowest effective dose to control symptoms 1

Alternative: Dexamethasone

• Dexamethasone can be used as an effective alternative with improved compliance and palatability 3
• Meta-analysis demonstrates no superiority of prednisone over dexamethasone for mild-to-moderate exacerbations 3
• Dexamethasone offers potential benefits of shorter duration (1-2 days), less vomiting, and better compliance 3

Duration and Safety Considerations

Treatment Duration

• Limit treatment to 3-5 days for acute bronchospasm 1
• Courses under 2 weeks at this dose can be discontinued abruptly without tapering 1
• No taper is needed for short courses in this clinical scenario 1

Critical Safety Warning

• Any child receiving more than 5 mg/day prednisone equivalent for more than 1 month should be assumed to have adrenal suppression 1
• Never abruptly discontinue steroids in a child with potential adrenal suppression 1
• For this acute 3-5 day course, adrenal suppression is not a concern 1

Important Clinical Caveats

When Prednisone May NOT Be Beneficial

• One high-quality trial found that oral prednisolone was not superior to placebo in preschool children (10-60 months) with mild-to-moderate viral-induced wheezing presenting to the hospital 4
• However, this applies specifically to mild-to-moderate presentations in the emergency department setting 4
• The clinical context matters: if the child has established asthma (not just viral wheeze) and requires treatment, corticosteroids remain appropriate 1

COVID-19 Specific Considerations

• Continue glucocorticoids at the lowest effective dose to control respiratory symptoms and avoid adrenal insufficiency in children with asymptomatic or mild COVID-19 1
• The American College of Rheumatology supports continuing corticosteroids for respiratory symptom control even with concurrent COVID-19 1
• Glucocorticoids may increase risk of secondary infection, but for bronchospasm requiring treatment, symptom control takes priority 1

Practical Algorithm

Step 1: Confirm this is asthma exacerbation (established asthma diagnosis with wheezing) rather than simple viral wheeze in a child without asthma history 5

Step 2: Assess severity:

• If mild-to-moderate and first presentation to hospital: Consider that corticosteroids may not provide benefit 4
• If moderate-to-severe or established asthma with clear exacerbation: Proceed with corticosteroids 1

Step 3: Choose corticosteroid:

• Prednisone 1-2 mg/kg/day for 3-5 days (standard approach) 1
• OR Dexamethasone for 1-2 days (improved compliance) 3

Step 4: Continue inhaled bronchodilators and controller medications as indicated 1

Step 5: Discontinue abruptly after 3-5 days without taper 1