I would like to thank the authors of Physician and parent barriers to the use of oral corticosteroids for the prevention of paediatric URTI-induced acute asthma exacerbations at home, published in the July 2017 issue for their contribution in our efforts to understand and improve translational medicine; their opinions are valuable and welcome. Unfortunately, they have directed their talents to study barriers preventing physicians and parents from adopting a treatment strategy that is controversial at best and widely rejected at worst. The authors studied 27 children (52% of which were preschoolers) and report on barriers to the use of parent-initiated oral corticosteroids (OCS) at the onset of a upper respiratory tract infection (URTI) to prevent acute asthma exacerbations—a strategy which they describe as ‘effective in the management of acute asthma’ and its use as a ‘key message to paediatricians’ (1). To support this contention, they cite a 10-year-old American Guideline (2) from the National Heart Lung and Blood Institute; a recommendation that has remained unchanged from an even earlier 1997 version of this Guidleine (3)—despite 20 years of published research to inform a more contemporary view. In addition, the authors further cite two Cochrane reviews (4,5) as evidence that administering oral steroids at the onset of URTI symptoms can improve asthma-related outcomes. These Cochrane Reports, however, examined the rapid benefits of the addition of OCS to reduce asthma-related symptoms in patients receiving standard asthma therapy in an Emergency Department (ED). Although it may be tempting to extrapolate these findings to support the strategy of parent-initiated OCS at the onset of all URTIs at home, that was not the objective of those reviews and should not be generalized to support that approach when other, more direct evidence is available. Beigelman et al. (6) recently summarized the available clinical trials on this topic and highlight the paucity of evidence to support the widespread use of OCS in this age group in general, and the lack of evidence supporting parent-initiated OCS use at the onset of a URTI in particular. In addition, the short-term treatment with OCS in young children is not without risk and should not be considered lightly (7). The use of OCS to treat severe, acute viral-triggered wheezing remains an important option in current Canadian Asthma Guidelines (8,9) but the routine prophylactic use of parent-initiated OCS at the onset of a URTI does not. In our hands, standard asthma care using these Canadian Guidelines reduces asthma-related paediatric ED visits and admissions by approximately 60% and 80%, respectively (10). In this scenario, we view the need for OCS during viral-triggered asthma exacerbations as a management failure, not a component of routine care. Research in translational medicine is a crucial component of evidence-based medicine. We welcome future publications from the authors to help reduce the barriers preventing greater adoption of our national guidelines.

ObjectivesAdministration of oral corticosteroids at the onset of an upper respiratory tract infection (URTI) can be effective in the management of acute asthma exacerbations in children. This study was designed to identify barriers to parent-initiated implementation of clinical practice guideline-recommended use of oral corticosteroids for prophylaxis against severe asthma exacerbations in children.MethodsTwenty-seven children who presented to BC Children's Hospital with URTI-induced asthma exacerbations were recruited. Parents received a filled prescription for a course of oral corticosteroids to be used at the earliest onset of their child's next URTI. Each family was contacted monthly over a 1-year period to inquire about URTI events, asthma symptoms, medication use and health care utilization. Focus groups were held with family physicians, paediatricians and parents; transcripts were analyzed qualitatively to identify key themes.ResultsIncidence of URTI events among participants was high (85%). Uptake of study medication was low; 44% used the medication as directed at their first URTI event. Eleven per cent of the patients who used the study medication also visited the emergency department for an exacerbation. Focus groups identified four main barriers to the effective use of parent-initiated oral corticosteroids: physician resistance and conflicting messages from providers; parent uncertainty about oral corticosteroids; multiple caregivers and relative ease of access to an emergency department.ConclusionWe have identified key barriers to the effective use of parent-administered oral corticosteroids as an asthma management strategy and gained important insights regarding the research that is required to enhance the applicability of the strategy.