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Rapid response to:

Research

Steroids and bronchodilators for acute bronchiolitis in the first two years of life: systematic review and meta-analysis

BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d1714 (Published 06 April 2011) Cite this as: BMJ 2011;342:d1714

Rapid Response:

Using evidence to inform patient care

We appreciate the opportunity to respond to the letter by Walsh et
al. and clarify some points. This was not a Cochrane review, although it
builds upon several and adds a network analysis.

To minimize bias, we used a pre-defined protocol developed with
physicians and stakeholders, with pre-defined inclusion criteria for
population, interventions, and outcomes.

A priori we decided to focus on first-time wheezers. The first
episode of wheezing may prove to be a first manifestation of a range of
phenotypes with distinct pathological, genetic, viral or environmental
determinants, and distinct prognosis.[1,2] But until valid discriminative
tools are available, we need to use simple, clinical variables to stratify
this population. We feel that it is clinically relevant, and there is a
precedence,[e.g., 3] to study separately children with first episodes of
viral infection including wheezing.[4]

We chose outcomes a priori; all studies that reported at least one of
the outcomes were included. Studies that assessed admissions after day 3
were included in the day 7 outcome.

Our critics cite one study supporting their beliefs in the
superiority of salbutamol. The study was not included in our review
because it included recurrent wheezers. It is potentially misleading to
base recommendations on a single trial without considering the totality of
evidence where other studies exist. The study compared salbutamol against
another active intervention; however, the most recent Cochrane review
found no difference in hospital admissions between salbutamol and
placebo.[5]

We were motivated by substantial new evidence since earlier reviews.
Hence, the volume of research motivated our work, not the results.

Our analysis excludes a stand-alone effect of steroids, but suggests
some additive effects when combined with adrenaline. We clearly
acknowledge the need for further research assessing combination therapy,
and that there may be a safety issue with high-dose steroids.

Substantial variation in the management of bronchiolitis throughout
the world shows that answers are not clear. We need to examine existing
evidence in an unbiased manner and conduct further rigorous research as
needed to guide the management of this complex condition.

1) Brand PL, Baraldi E, Bisgaard H, Boner AL, Castro-Rodriguez JA,
Custovic A, et al. Definition, assessment and treatment of wheezing
disorders in preschool children: an evidence-based approach. European
Respiratory Journal 2008;32:1096-110.

2) Frey U, von Mutius E. The challenge of managing wheeze in
children. N Engl J Med 2009;360:2130-2133.

3) Corneli HM, Zorc JJ, Mahajan P, Shaw KN, Holubkov R, Reeves SD,
Ruddy RM, Malik B, Nelson KA, Bregstein JS, Brown KM, Denenberg MN, Lillis
KA, Cimpello LB, Tsung JW, Borgialli DA, Baskin MN, Teshome G, Goldstein
MA, Monroe D, Dean JM, Kuppermann N; Bronchiolitis Study Group of the
Pediatric Emergency Care Applied Research Network (PECARN). A multicenter,
randomized, controlled trial of dexamethasone for bronchiolitis. N Engl J
Med. 2007 Jul 26;357(4):331-9.

4) Everard ML. Acute bronchiolitis and croup. Pediatric Clinics of NA
(2009) vol. 56 (1) pp. 119-133, x-xi.

5) Gadomski AM, Brower M. Bronchodilators for bronchiolitis. Cochrane
Database of Systematic Reviews 2010, Issue 12. Art. No.: CD001266. DOI:
10.1002/14651858.CD001266.pub3.

Competing interests: No competing interests

24 May 2011
Lisa Hartling
Assistant Professor
Ricardo Fernandes, Liza Bialy, Andrea Milne, David Johnson, Amy Plint, Terry P. Klassen, Ben Vandermeer
University of Alberta