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To compare the clinical efficacy of single-dose intramuscular (IM) dexamethasone phosphate to a 5-day course of oral prednisolone for the treatment of moderate asthma exacerbations in young children discharged from the emergency department (ED).We performed a prospective, randomized trial in children aged 18 months to less than 7 years with asthma who presented to the ED with a clinical asthma score of 3 to 7 on a 9-point scale. Children were randomized to 1 dose of IM dexamethasone (0.6 mg/kg, maximum 15 mg) or oral prednisolone (2 mg/kg, maximum 50 mg) once daily for 5 days. The primary outcome, measured only for patients discharged from the ED, was change in asthma score from ED presentation to 4-day follow-up examination, as assessed by a physician masked to group assignment. We assessed secondary clinical course outcomes by a structured interview at 4 and 14 days.Eighty-eight patients were appropriately randomized to dexamethasone and 93 to prednisolone. Group characteristics were similar at baseline. Among those discharged from the ED, 62 (90%) of 69 and 64 (90%) of 74 patients in the dexamethasone and prednisolone groups, respectively, were reassessed at 4 days for the primary outcome. The mean change in total asthma score at 4-day follow-up was 3.6 in the dexamethasone group and 3.4 in the prednisolone group (difference, 0.2; 95% confidence interval, −0.4 to 0.7). Of patients initially discharged, 5.9% of dexamethasone patients and 4.1% of prednisolone patients were admitted before the 2-week follow-up (difference, 1.8%; 95% confidence interval, −5.4% to 9.0%).A single dose of IM dexamethasone showed no clinically meaningful difference in outcomes compared with a 5-day course of oral prednisolone for the treatment of moderate acute asthma exacerbations in young children who are discharged from the ED.