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Question 6:

In the child with an asthma exacerbation in the ED, should intravenous magnesium sulfate be administered to prevent hospitalization, to decrease time in the ED, and/or to improve pulmonary function?

Asthma ED team recommendation: The Asthma ED Team recommends the administration of intravenous magnesium sulfate 50 mg/kg with a maximum of 2 grams (single dose) for the management of severe asthma. In addition, we recommend the administration of intravenous magnesium sulfate at the same dose for children with moderate asthma exacerbations who fail to respond to continued therapy after one hour. We place a high value on ameliorating symptoms and reducing the hospitalization rate for children with moderate and severe asthma exacerbations.

One meta-analysis, Rowe (2000), reported fewer hospital admissions and shorter lengths of stay in the ED. In addition, in those subjects with severe asthma exacerbations, the change in pulmonary function was significantly better with the administration of magnesium sulfate based on high quality studies. One randomized control trial, Singh (2008), was identified. However, it is a low quality study due to the small number of subjects and large drop-out rate. This study also reported improved lung function as measured by %FEV1 at 120 minutes and decrease number of admission in children treated with intravenous magnesium. This recommendation is based on consistent results from well-performed studies. The recommendation may be applied to most patients with severe asthma exacerbations, or to those with moderate asthma exacerbations that do not respond to conventional initial therapy.

Literature supporting this recommendation: Literature was searched since the publication of EPR-3. Four citations were found from the search with two citations answering the question, one of these was a Cochrane Collaborative meta-analysis (Rowe, 2000) and the other was a single study (Singh, 2008).

These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.