Steroids for kids with asthma and flu

[Socrates25]

Had an interesting case discussion the other day that triggered some disagreement among our physician group.

Case scenario: 6 year old female with h/o moderate asthma (uses flovent bid, albuterol once per week) comes in with fevers up to 104 x 24 hours, cough, wheezing. She is well appearing on exam, no retractions, no increased WOB, slight wheezing with good air entry in all lung fields. Rapid flu test is positive for influenza A.

Pediatrician decides to start tamiflu 45mg bid x 5 days and prednisone 1mg/kg (approx 30mg) once daily x 5 days, advises family to do albuterol 5mg every 4-6 hours for the next couple of days, followed by prn thereafter.

Clinical question: For asthma patients who have flu, do you guys give systemic steroids?

---

Members don't see this ad.

 

[Siverhideo1985]

Lowly med student here so this may be an obsolete comment, but...if you take out the + flu test of this scenario, would you consider treating this child with systemic corticosteroids? If there is no significant resp compromise and just some mild wheezing that resolves with albuterol, why not avoid the steroids and treat with more frequent inhaler treatments until the kid gets over the hump of the URI or flu?

In other words - would you consider putting a kid on systemic steroid burst if they came in with a URI and mild wheezing w/o resp compromise?

 

[SB100]

Was she using her albuterol anymore frequently and still wheezing and coughing as much during those 24 hours?

 

[Stitch]

Not a lot of evidence to guide us here, so it's difficult to say. My feeling is that it's probably reasonable if the kid comes in pretty tight and wheezy, but I probably wouldn't have done so for the patient you described. I'd advise to keep going with the controller meds and count on using albuterol as much as necessary. Have a low threshold to get help if she starts wheezing. Definitely agree with Tamiflu though.

 

[ifailedmcat]

In our clinic, we give Tamiflu for any high-risk patient (asthmatic, pregnant mother, < age of 2). We also use our own discretion with select cases.

Personally, I give all my asthmatics who are flu+ systemic steroids. The initial clinic visit is only a small snapshot in time. Asthma is notorious for causing significant respiratory distress at night with oftentimes symptoms completely relieved by the morning. Many times in clinic (especially during the day) kids will appear well with a normal lung exam after having had a long night of significant distress. If a kid is wheezing with some respiratory distress in the office, I'll order a neb treatment in the office. The decision to start steroids depends on either a lung exam with significant findings or a strong history of respiratory distress. I only need 1 or both criteria to decide to start steroids.

Another dilemma is that Tamiflu must be started within 48 hours for any clinical efficacy and most asthma exacerbations are either post-viral or occur well into the illness. Some flu+ patients will present with minimal symptoms initially. For these patients, I give a rx of orapred to fill only if the patient develops worsening symptoms.