Dr Weinberger asks what is loss of control? Are symptoms that need reliever medication a “full blown exacerbation”? Is the “yellow zone” simply a “procrastinator's zone”? Should we just cut to the chase and give oral corticosteroid medication any time a child has symptoms of asthma?
Is early initiation of oral corticosteroids by parents a good strategy? A clinical trial of 204 Medicaid-insured children with asthma 2 to 14 years of age in Baltimore, Maryland randomized participants to either prednisone or placebo for an attack that had not improved after a dose of the child's regular acute asthma medicine. They found a larger number of attacks resulting in ED visits in the group receiving prednisone and no difference in hospitalizations. Although the study assessments did not detect differences in side effects between the groups, it is possible that unmeasured side effects such as agitation or difficulty sleeping drove the parents to seek urgent/emergent medical attention. A clinical trial in the United Kingdom randomized 217 children 1 to 5 years with episodic wheezing associated with coryza to placebo or prednisolone for 5 days at onset of wheezing associated with coryza. There were no statistically significant differences in day or night symptom scores. Unexpectedly, the hospitalization rate was greater in the group receiving prednisolone (12% vs 3%), although the difference fell shy of the criteria for statistical significance (P = .06). Although oral corticosteroid medication has definite benefits for patients with a moderate to severe asthma exacerbation, these clinical trials suggest that for most patients, early initiation by parents is not beneficial.