Author: Laurie Barclay,MD
March 9, 2009 — Infants and preschoolers with recurrent wheezing or asthma had fewer episodes of wheezing or asthma exacerbations, reduced symptoms, and improved lung function during treatment with inhaled corticosteroids, according to the results of a systematic review with meta-analysis reported in the March issue of Pediatrics.
"Trying to find the best treatment for a preschooler with wheeze is a common and troublesome clinical challenge," write Jose A. Castro-Rodriguez, MD, PhD, from Pontificia Universidad Católica de Chile, Santiago, and Gustavo J. Rodrigo, MD, from Central de las Fuerzas Armadas, Montevideo and Facultad de Medicina Claeh, Prado y Salt Lake, Punta del Este, Maldonado, Uruguay. "The most recent international guidelines recommend the use of low-dose inhaled corticosteroids (ICSs) as the preferred controller therapy, with leukotriene modifiers as an alternative, for the management of persistent asthma in children under the age of 5. The treatment of those children with intermittent, viral-induced wheezing or low/intermediate probability of asthma remains controversial."
The goal of this meta-analysis was to compare the efficacy of inhaled corticosteroids vs placebo in infants and preschoolers with recurrent wheezing or asthma. The investigators searched MEDLINE, EMBASE, and Central databases for randomized, prospective, controlled trials published from January 1996 to March 2008 in which treatment for at least 4 weeks with inhaled corticosteroids was compared vs placebo. Wheezing/asthma exacerbations were the main endpoint, and secondary endpoints were withdrawal caused by wheezing/asthma exacerbations, changes in symptoms score, pulmonary function (peak expiratory flow and forced expiratory volume in 1 second [FEV1]), or use of albuterol.
Inclusion criteria were met by 89 studies enrolling a total of 3592 subjects. Compared with patients receiving placebo, those receiving inhaled corticosteroids had significantly less wheezing/asthma exacerbations (18.0% vs 32.1%). This effect was stronger for patients diagnosed with asthma vs those with wheeze, according to post hoc subgroup analysis. However, this effect was independent of age (infants vs preschoolers), atopic condition, type of inhaled corticosteroid (budesonide metered-dose inhaler vs fluticasone metered-dose inhaler), mode of delivery (metered-dose inhaler vs nebulizer), and study quality (Jadad score: <>
The investigators concluded that infants and preschoolers with recurrent wheezing or asthma had less wheezing/asthma exacerbations, reduction in their symptoms, and improvement in lung function during treatment with inhaled corticosteroids. They also suggest that these results support the current recommendations of most international asthma guidelines to use inhaled corticosteroids in infants and preschoolers with recurrent episodes of wheeze of appropriate severity.
Pearls for Practice:
A meta-analysis showed that infants and preschoolers with recurrent wheezing or asthma had less wheezing/asthma exacerbations, reduction in their symptoms, and improvement in lung function during treatment with inhaled corticosteroids. These findings support the current recommendations of most international asthma guidelines to use inhaled corticosteroids in infants/preschoolers with recurrent episodes of wheeze of appropriate severity. The effect of inhaled corticosteroids vs placebo on wheezing/asthma exacerbations was stronger for patients diagnosed with asthma vs patients with wheeze, according to post hoc subgroup analysis. However, this effect was independent of age, atopic condition, type of inhaled corticosteroid used, mode of delivery, and study quality and duration
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