June 5, 2025
Lydia Furman MD, FAAP, Associate Editor, Pediatrics
Content License: FreeView
Article type: Pediatrics Blog
In an article being early released this week in Pediatrics, Drs. Sriram Ramgopal and Kenneth Michelson of Lurie Children’s Hospital of Chicago study a straightforward and interesting question: Has the choice of dexamethasone surpassed that of prednisolone/prednisone for treatment of asthma exacerbations among children discharged from pediatric emergency departments? (10.1542/peds.2024-070153)
Traditionally, prednisone has been an evidence-based treatment of choice for asthma exacerbations. However, compared to prednisone, dexamethasone is more potent (0.75 mg of dexamethasone = 5 mg of prednisone) and has a longer half-life (36–72 hours versus 3–4 hours), permitting just two smaller volume doses, or even a single dose, in comparison to multiple day dosing for prednisone. Dexamethasone also tastes better, all factors that may improve compliance and hence outcomes.
In 2014, Pediatrics published a meta-analysis comparing the use of dexamethasone as compared to prednisone or prednisolone for treatment of asthma exacerbations; the authors concluded that there was no clinically meaningful difference in risk of asthma exacerbation relapse, that those treated with dexamethasone were less likely to have vomiting, and “practitioners should consider single or 2-dose regimens of dexamethasone as a viable alternative to a 5-day course of prednisone/prednisolone.”
Has clinical practice changed since this information became available? Drs. Ramgopal and Michelson conducted a retrospective cross-sectional analysis of practices at 28 children’s hospitals (2010–2024) using the PHIS (Pediatric Health Information System) database, an administrative database with encounter-level demographic data, to examine this question.
They included 491,576 eligible children >2 through <18 years with a diagnosis of asthma or wheezing who received either (not both) dexamethasone or prednisone/prednisolone in addition to albuterol (and as indicated, ipratropium bromide and magnesium sulfate) and additionally compared return visits within 7 days.
Practice changed over time! In fact, during the first study year, 91.1% received prednisone/prednisolone (and 8.9% received dexamethasone) and during the last study year, 95.3% of children received dexamethasone (and 4.7% received prednisone/prednisolone). The authors also identified a “breakpoint” during which change accelerated notably (September 2013 and December 2015). See the article for information regarding those readmissions.
Did it really take us over a decade to implement an evidence-based change? While this might seem a long time, it is aligned with the documented time course for translation of research into practice of 17 years. Shortened timelines are an aspirational goal for future research. For now, I feel satisfied that dexamethasone has gained ascendancy in the care of asthma exacerbations, and hope you enjoy reading about this fascinating change in practice as much as I did.
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