2 AAP Grand Rounds

Guardians of patients in the prednisolone group reported 94% compliance with administration of at least three doses. At the four-day follow-up assessment, there was no difference in the change in mean clinical asthma score between the IM dex group and oral prednisolone group. There were also no clinically mean-ingful differences in secondary outcome measures including respiratory signs at four-day follow-up, admission rates within 14 days, or unplanned physician visits within 14 days. Emesis occurred at least one time in 9/69 (13%) of patients discharged with oral prednisolone. Swelling, tenderness, and erythema at the injection site occurred in 4/62 (6%), 1/62 (2%), and 1/62 (2%) of IM dex patients, respectively.

The authors conclude that there were no differences in ef-ficacy between a single dose of IM dex and a five-day course of oral prednisolone in children with mild to moderate asthma exacerbations.

Commentary by Ronald I. Paul, MD, FAAPPediatric Emergency Medicine, University of Louisville, Louisville, KY

Dr. Paul has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

Because of their unpleasant tastes, emesis can follow oral administration of prednisone and prednisolone suspensions, potentially limiting the effectiveness of steroid therapy in chil-dren. Other investigators have reported that IM dex is an effec-tive alternative treatment for children who are unable to take oral steroid suspensions.5,6

In one of these prior studies, dexamethasone acetate was used, which has a longer duration of action (one to three weeks) than the dexamethasone phosphate preparation used in the current study (36-72 hours).5 Adrenal suppression in patients receiving IM dexamethasone acetate was not seen, although the number of patients studied was small.5 Oral dexametha-sone phosphate has also been compared to oral prednisone or prednisolone and was shown to have equal efficacy.7 However, two doses of dexamethasone were given, including one dose provided to the patient to take the next day.

The current study provides further evidence of the equal efficacy of dexamethasone phosphate to oral steroids for treat-ment of mild to moderate asthma exacerbations. Although IM injections are painful, a single dose may be considered for the child who has emesis with oral steroids or is known to have had emesis when given oral steroids during previous asthma exacerbations.

References1. http://www.nhlb.nih.gov/guidelines/asthma/index.htm2. Qureshi F, et al. J Pediatr. 2001;139:20-26.3. Scarfone RJ, et al. Pediatrics. 1993;92:513-518.4. Scarfone RJ, et al. Ann Emerg Med. 1995;26:480-486.5. Gries DM, et al. J Pediatr. 2000;136:298-303.6. Klig JE, et al. J Asthma. 1997;34:419-425.7. Qureshi F, et al. J Pediatr. 2001;139:20-26.

AAP Grand Rounds™ is published monthly by the American Academy of Pediatrics, 141 Northwest Point Blvd., Elk Grove Village, IL 60007. Copy-right © 2008 American Academy of Pediatrics. All rights reserved. Post-master: Send address changes to AAP Grand Rounds, American Academy of Pediatrics, Customer Service Center, 141 Northwest Point Blvd., Elk Grove Village, IL 60007-0198.

ISSN NumbersPrint: 1099-6605Online: 1556-362X

Customer Service and Renewals: (866) 843-2271. Email Address: grandrounds@aap.org Subscription Rates: AAP member $91/year; non-member $114/year (12 issues), including up to 18 AMA PRA Category 1 credit(s)™.

Senior Managing Editor: Kerry O’RourkeManaging Editor: Joseph PuskarzEditorial Assistant: Megan LenzProduction: Michael HayesEditorial Associates: Nancy Cochran, Seattle, WA; Nancy Moreland, Burlington, VT

In this month’s issue of AAP Grand Rounds, we introduce a new feature: the PICO question. PICO is an acronym that describes the elements of a well-formed clinical question. The structure includes:

“P” for the patient or problem “I” for the intervention of interest “C” for comparison, and “O” for outcome.

For example, a parent might ask whether a single shot of a steroid would work as well as five days of oral steroids for a young child sent home from the ER after an asthma exacerbation.

The clinical question in “PICO format” would be: “Among young children with acute asthma exacerbation, is a single dose of IM dexamethasone comparable to five days of oral prednisolone for resolution of asthma symptoms?”

PICO questions can help clinicians find relevant and useful information, not only from searching databases but also from their consultants.1 Having carefully structured the question, a MEDLINE search using the key words in the PICO question above would be highly likely to yield the study by Gordon. Just as a good PICO question can help a clinician find useful information, a good PICO question can guide clinical research. Many clinical research studies are designed to answer just this sort of well-structured clinical question.

Starting this month, each study that addresses a clinical question will be accompanied by the PICO question – read-ers will be able to judge how well the investigators do at answering these questions!

The PICO format works best for questions about thera-pies or other interventions (things we do to patients) but can be modified slightly to describe studies of diagnostic tests, prognosis, or studies about the possible causes of a problem.

For example, for an article about a diagnostic test, the “outcome” will be the accuracy of the test: “Among children with suspected hypercalcuria, does Ca/Cr ratio accurately reflect 24-hour urinary calcium?” and for a question about harm, the “intervention” will be an exposure: “Among children with acute otitis media due to Streptococcus pneumoniae, does exposure to PCV7 vaccine result in a greater likelihood of antimicrobial-resistant organisms?” Of course, some studies abstracted in AAP Grand Rounds do not attempt to answer a specific clinical question, but instead describe a population or discuss an important general issue (the latter is particularly likely among bioeth-ics articles). The PICO question will not be appropriate for these sorts of abstracts.

We believe the addition of PICO questions will add value for AAP Grand Rounds readers by clarifying the study ques-tion. We welcome your comments by using the “e-letters” feature at www.aapgrandrounds.org.

1. Bergus GR, et al. Arch Fam Med. 2000;9:541-547.

Weighing the Evidence: PICO Questions: What Are They, and Why Bother?By Virginia Moyer, MD, FAAP

by guest on June 4, 2018http://aapgrandrounds.aappublications.org/Downloaded from

DOI: 10.1542/gr.19-1-22008;19;2AAP Grand Rounds 

Virginia MoyerWeighing the Evidence: PICO Questions: What Are They, and Why Bother?

ServicesUpdated Information &

http://aapgrandrounds.aappublications.org/content/19/1/2including high resolution figures, can be found at:

Referenceshttp://aapgrandrounds.aappublications.org/content/19/1/2#BIBLThis article cites 1 articles, 0 of which you can access for free at:

Subspecialty Collections

ased_medicine_subhttp://classic.aapgrandrounds.aappublications.org/cgi/collection/evidence-bEvidence-Based Medicine_medicine_subhttp://classic.aapgrandrounds.aappublications.org/cgi/collection/emergencyEmergency Medicinecollection(s): This article, along with others on similar topics, appears in the following

Permissions & Licensing

mlhttp://classic.aapgrandrounds.aappublications.org/site/misc/Permissions.xhtentirety can be found online at: Information about reproducing this article in parts (figures, tables) or in its

Reprintshttp://classic.aapgrandrounds.aappublications.org/site/misc/reprints.xhtmlInformation about ordering reprints can be found online:

by guest on June 4, 2018http://aapgrandrounds.aappublications.org/Downloaded from

DOI: 10.1542/gr.19-1-22008;19;2AAP Grand Rounds 

Virginia MoyerWeighing the Evidence: PICO Questions: What Are They, and Why Bother?

http://aapgrandrounds.aappublications.org/content/19/1/2the World Wide Web at:

The online version of this article, along with updated information and services, is located on

Print ISSN: 1099-6605. Village, Illinois, 60007. Copyright © 2008 by the American Academy of Pediatrics. All rights reserved. trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grovepublication, it has been published continuously since 1999. AAP Grand Rounds is owned, published, and AAP Grand Rounds is the official journal of the American Academy of Pediatrics. A monthly

by guest on June 4, 2018http://aapgrandrounds.aappublications.org/Downloaded from