Management of Severe Pediatric Asthma Exacerbations with Intravenous Magnesium Sulfate: A Real-World, Single-Center Experience

Background: This study described real-world patterns of intravenous magnesium sulfate (MgSO4) use among children hospitalized with asthma exacerbations, including how MgSO4 use related to markers of exacerbation severity and to hospital length of stay (LOS). Because treatment was not randomized, this design cannot isolate a causal effect of MgSO4 on LOS; groups defined by MgSO4 receipt differ systematically in baseline severity, and any LOS comparison must be interpreted as descriptive rather than causal. Methods: A retrospective cohort study was conducted on 423 pediatric patients admitted to King Abdullah Specialist Children’s Hospital, Riyadh, Saudi Arabia, between January 2021 and December 2025. Patients were categorized according to whether they received intravenous MgSO4 during hospitalization. Demographic characteristics, clinical features, treatment variables, and outcomes were analyzed. Results: The median age was 4 years, with 63.8% of patients aged ≤ 5 years, and 60.8% were male. Common clinical findings included suprasternal indrawing (57%), scalene retractions (43.7%), and wheezing (91.5%). Decreased air entry was observed in 48.2% of patients, and 64.3% required oxygen support. Of the study population, 175 patients (41.4%) received intravenous MgSO4. Administration of MgSO4 was significantly more frequent among younger patients, males, patients with respiratory distress, decreased air entry, oxygen requirement, and lower oxygen saturation levels (all p < 0.05). Patients receiving MgSO4 had a significantly longer median LOS compared with those who did not receive MgSO4 (50.57 vs. 32.30 h, p < 0.001). Conclusions: Intravenous MgSO4 administration was more commonly used among children with more severe asthma exacerbations and was accompanied by longer hospital LOS in this unmatched, non-randomized cohort. Because MgSO4 receipt and LOS are both driven by underlying severity that was only partly captured by the available covariates, this design cannot distinguish a causal effect of MgSO4 on LOS from confounding by indication, and the findings should be read as a descriptive account of real-world MgSO4 use in severe pediatric asthma rather than as evidence for or against an effect of MgSO4 on LOS.