Routine corticosteroid use after emergency department (ED) discharge for mild to moderate pediatric anaphylaxis offered no significant benefit in preventing return visits within 7 days, according to recent findings published in the journal Medicine.1
The researchers found that 4.4% of children who received dexamethasone revisited a healthcare facility compared with 6.7% of those who received placebo, yielding an absolute risk reduction of just 2.3% (95% CI, –5.8 to 8.3%) and an estimated number needed to treat (NNT) of 44 (95% CI, 12 to ∞; P =.70).1
Corticosteroids remain a common adjunct to epinephrine and antihistamines in the treatment of anaphylaxis, particularly in hospitalized patients, study authors wrote. Observational studies have suggested that steroids may shorten hospital stay for severe cases, but evidence for their role after ED discharge has been lacking. They pointed out that clinical practice guidelines from both US and European professional organizations recommend corticosteroids as optional therapy for children following an ED stay for anaphylaxis.
Previous research, specifically a large 2015 retrospective cohort study including 5052 children discharged from an ED following anaphylaxis, found that fully two-thirds (66%) received corticosteroids.2 Within 3 days, the study authors emphasized, 5% of both steroid-treated and untreated children returned to the ED, punctuating the question of whether or not steroids offer meaningful protection against post-discharge symptom recurrence.2
“To our knowledge, this is the first randomized clinical trial to test the effect of steroids in decreasing anaphylactoid reaction in pediatric patients treated for mild-moderate anaphylaxis,” study investigators Rafah Al Sayyed, MD, from Hamad Medical Corporation, and Khalid Alansari, MD, FRCPC, FAAP, from Weill Cornell Medical College and Qatar University Medical College,” wrote.1
They conducted the randomized, blinded pilot trial at the Pediatric Emergency Center of Hamad General Hospital in Qatar between June 2018 and February 2024. Eligible participants were aged 3 months to 14 years who presented with mild to moderate anaphylaxis, defined as acute allergic reactions involving at least 2 systems. Children with severe anaphylaxis, moderate to severe asthma, immunological disease, or current corticosteroid treatment were excluded.
Participants received standard acute therapy with epinephrine and H1-antihistamines. Before discharge, 152 of the original 352 children assessed were randomly assigned to receive either oral dexamethasone syrup (0.3 mg/kg, maximum 10 mg; n=68) or a matched placebo (n=75). All were prescribed a 5-day course of cetirizine and received daily follow-up calls for a week. The primary endpoint was revisit or readmission to any healthcare facility within 7 days.
Contrary to original projections, Alansari et al reported a far lower revisit rate among participants treated with placebo (6.7% vs the expected 35%). Just 3 of the 68 dexamethasone-treated children and 5 of 75 placebo-treated participants returned to the ED within 7 days. The calculated relative risk reduction of 33.8% did not meet statistical significance, according to the findings.
The absolute risk reduction of 2.3% corresponded to an NNT of 44. Subgroup analyses by severity, cause, or systems involved showed no significant differences. Secondary outcomes—including readmission and need for hospital admission—were also not statistically significant. No serious drug-related adverse events were reported.
“Uncommon recurrence and a high number needed to treat after ED anaphylaxis treatment suggests against routine ED predischarge corticosteroid without a clinical rationale,” the team wrote
Among the study’s limitations the authors acknowledged that the trial was underpowered as a result of CVOID-19-related recruitment suspension and an overestimation of the revisit rates. They did note that the actual 6.7% rate is consistent with other study results.
Unnecessary use of corticosteroids should be avoided, Alansari and colleagues wrote. Repeated exposure without express clinical need carries potential risks, particularly for youth. Even short courses have been associated with vomiting, behavioral changes, and sleep disturbances.3 Longer-term or repeated use carries more serious risks, including growth suppression, reduced bone mineral density, increased susceptibility to infection, and Cushingoid features.4
“We conclude that dexamethasone treatment of ED-discharged anaphylaxis children aged 3 months to 14 years should not be routine, but rather restricted to those patients for whom there is a sound clinical rationale, because the proportion of patients likely to be spared return within 7 days if all are treated is quite small,” they concluded.
References
- Al Aayyed R, Alansari K. Randomized blinded pilot trial of corticosteroid after mild-moderate anaphylaxis to prevent recurrence. Medicine. 2025;104(31):p e43600. doi: 10.1097/MD.0000000000043600
- Michelson KA, Monuteaux MC, Neuman MI. Glucocorticoids and hospital length of stay for children with anaphylaxis. a restrospective study. J Pediatr. 2015;167(3):719-24.e243. doi:10.1016/j.jpeds.2015.05.033
- Aljebab F, Choonara I, Conroy S. Systematic review of the toxicity of short-course oral corticosteroids in children. Arch Dis Child. 2016 Apr;101(4):365-70. doi: 10.1136/archdischild-2015-309522
- Aljebab F, Choonara I, Conroy S. Systematic review of the toxicity of long-course oral corticosteroids in children. PLoS One. 2017;26;12(1):e0170259. doi:10.1371/journal.pone.0170259