Level 1: Likely reliable evidence

Oral dexamethasone does not reduce the rate of hospitalization or improve respiratory status in infants with acute moderate-to-severe bronchiolitis, based on a randomized trial with 600 infants aged 2-12 months (N Engl J Med. 2007;357:331-339). Eligible infants (first wheezing episode diagnosed in the emergency department [ED] as moderate-to-severe bronchiolitis) were randomized to a single oral dose of dexamethasone 1 mg/kg (maximum 12 mg) vs. placebo.

Comparing dexamethasone vs. placebo, there were no significant differences in rates of hospital admission (39.7% vs. 41%), mean duration of hospital stay (2.55 vs. 2.27 days), rates of subsequent hospital admissions within seven days (4.2% vs. 3.8%), Respiratory Assessment Change score at four hours, or vomiting within 20 minutes (5.5% vs. 4.7%).

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These results are consistent with a Cochrane review of 13 randomized trials of systemic (oral, IM, or IV) corticosteroids in 1,198 infants and young children aged 0-30 months with acute viral bronchiolitis (Cochrane Database Syst Rev. 2004[3]:CD004878). Ten trials included inpatients evaluated within 48 hours of hospitalization, and three trials included ED patients; dosing equivalents were prednisone 0.5-10 mg/kg for two to seven days. In a meta-analysis of seven trials, corticosteroids reduced the length of hospital stay by 0.38 days, but these results were not statistically significant.

There were no significant differences in clinical score on day 3 (eight trials) (A re-analysis found that the clinical score outcome was transposed incorrectly for one trial, and repeat meta-analysis of eight trials found a modest but statistically significant reduction in clinical score with steroids [JAMA. 2007;298:430-437]), hospital admission rates (three trials), re-admission rates (six trials), respiratory rates (six trials), hemoglobin oxygen saturation (six trials), or the use of co-interventions (oxygen, supportive fluids, and bronchodilators) (13 trials).