608 ‘To give or not to give – that is the question’ – The use of steroids for acute pre-school wheeze
BackgroundThere is ongoing uncertainty amongst clinicians on the use of prednisolone in acute pre-school wheeze. Some studies report that there is no positive effect by prescribing steroids for this cohort of children whilst others have shown a reduction in illness severity and duration of hospitali...
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| Published in: | Archives of disease in childhood Vol. 106; no. Suppl 1; pp. A57 - A58 |
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| Main Authors: | , , , , , |
| Format: | Journal Article |
| Language: | English |
| Published: |
London
BMJ Publishing Group Ltd and Royal College of Paediatrics and Child Health
01-10-2021
BMJ Publishing Group LTD |
| Subjects: | |
| Online Access: | Get full text |
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| Summary: | BackgroundThere is ongoing uncertainty amongst clinicians on the use of prednisolone in acute pre-school wheeze. Some studies report that there is no positive effect by prescribing steroids for this cohort of children whilst others have shown a reduction in illness severity and duration of hospitalisation.ObjectivesIn our emergency department a wheeze pathway with clinical proforma helps clinicians assess the severity of presentation (mild, moderate, severe, life-threatening) and directs them to an appropriate treatment course. For pre-school children (2–4 years) presenting with moderate severity acute wheeze, the pathway states ‘consider steroids’. This peer review examined the use of prednisolone in this group of patients.MethodsTwo paediatric registrars and two paediatric consultants independently performed a retrospective review of the notes of all pre-school children presenting with moderate severity acute wheeze over one month (n=23). In each case reviewers were asked to document whether or not they would give steroids and the justification for their decision.ResultsOf the 23 decisions made whether or not to give steroids, 9 children received steroids and 14 did not. The reviewers were in complete agreement with only 11 decisions (48%): 1 case where steroids were given, 10 when it was not. However, this value rose to 61% (14/23) where the majority of reviewers (3/4) agreed.Of the 9 who received steroids, in 4 of these cases reviewers felt steroids should not have been given. The steroids were prescribed within 15 minutes of the 1st chest assessment, and in one case steroids were even given before salbutamol. There was significant clinical improvement between 1st and 2nd chest assessments (approximately 20 mins time interval) more likely due to bronchodilator administration rather than the steroid.In the 14 children not receiving steroids, all reviewers agreed with 10 decisions (71%) not to give. In 1 instance all felt the child should have in fact received steroids due to the history of allergies and atopy, use of regular steroid inhaler, frequent admissions within the last year and poor response to bronchodilators. The remaining 3 decisions were split depending on the significance given to atopy by the reviewer and the impact of temperature on observations.Overall, the reviewers were less likely to give steroids than the clinicians who saw the patients 9% (2/23) vs 39% (9/23). Factors that impacted this discordance included timing of steroid dose (prior to reassessment after initial salbutamol), inaccurate scoring of severity, incomplete history taken and history of atopy.ConclusionsThis peer review illustrates that there is a potential overuse of steroids in acute pre-school wheeze in our emergency department. It is limited by retrospective bias contributed to by the accuracy of documentation in the medical records and any prior knowledge of the patient’s outcome by a reviewer. However, the grade of reviewer did not influence our findings. Appropriate prescribing of oral steroids in acute pre-school wheeze can be improved with ongoing education on emergency management of acute presentations. Clinical wheeze pathways should avoid vague statements and provide clearer guidance with regard to when steroids are indicated. |
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| Bibliography: | Association of Paediatric Emergency Medicine Royal College of Paediatrics and Child Health, Abstracts of the RCPCH Conference–Online, 15 June 2021–17 June 2021 |
| ISSN: | 0003-9888 1468-2044 |
| DOI: | 10.1136/archdischild-2021-rcpch.98 |