What are the guidelines for using oral steroids, such as prednisolone (corticosteroid), in pediatric patients?

Guidelines for Oral Steroid Use in Pediatric Patients

Oral steroids should be used judiciously in pediatric patients, with careful consideration of indication, dosage, duration, and potential adverse effects, as children are particularly vulnerable to growth suppression and other side effects.

General Dosing Recommendations

• For most pediatric conditions requiring oral steroids, prednisolone or prednisone is typically administered at 1-2 mg/kg/day in single or divided doses, with the specific regimen determined by the condition being treated 1
• The initial dosage should be maintained or adjusted until a satisfactory response is noted, with subsequent gradual dose reduction to determine the lowest effective maintenance dose 1
• Short courses of oral steroids (less than two weeks) are unlikely to cause long-term side effects in children 2
• Children requiring courses longer than two weeks warrant specialist referral and a weaning plan to reduce risk of adrenal suppression 2

Condition-Specific Guidelines

Asthma Exacerbations

• For acute asthma exacerbations, the National Heart, Lung, and Blood Institute recommends 1-2 mg/kg/day of prednisone or prednisolone in single or divided doses 1
• "Burst therapy" should continue until the child achieves 80% of personal best peak expiratory flow rate or symptoms resolve (typically 3-10 days) 1
• Evidence suggests that a lower dose of 1 mg/kg/day is preferable to 2 mg/kg/day for mild persistent asthma exacerbations, as it provides comparable benefits with fewer behavioral side effects 3

Bell's Palsy

• Despite the absence of quality trials supporting steroid use in children with Bell's palsy, oral steroids may be considered given the presumed similar disease process as in adults 4
• When used, a 10-day course of oral steroids with at least 5 days at a high dose (either prednisolone 50 mg for 10 days or prednisone 60 mg for 5 days with a 5-day taper) initiated within 72 hours of symptom onset is recommended 4
• The benefit of treatment after 72 hours is less clear 4

Nephrotic Syndrome

• For initial treatment of nephrotic syndrome in children, the standard regimen is 60 mg/m²/day of prednisone or prednisolone given in three divided doses for 4 weeks, followed by 4 weeks of single-dose alternate-day therapy at 40 mg/m²/day 1
• For infrequent relapses of steroid-sensitive nephrotic syndrome, treatment with a single daily dose of prednisone 60 mg/m² or 2 mg/kg (maximum 60 mg/day) until the child has been in complete remission for at least 3 days is suggested 4
• For frequently relapsing or steroid-dependent nephrotic syndrome, daily prednisone until remission for at least 3 days, followed by alternate-day prednisone for at least 3 months is recommended 4

Inflammatory Bowel Disease (Crohn's Disease)

• For induction of remission in mild to moderate active Crohn's disease, oral prednisone is suggested when other treatments (sulfasalazine, 5-aminosalicylic acid, oral budesonide, or exclusive enteral nutrition) have failed 4
• Oral corticosteroids are NOT recommended for maintenance therapy in Crohn's disease due to lack of demonstrated efficacy and potential for negative long-term effects 4

Hidradenitis Suppurativa

• In pediatric patients with hidradenitis suppurativa who require systemic immunomodulators, prednisone is suggested for acute, widespread flares 4

Adverse Effects and Monitoring

• Children are particularly vulnerable to corticosteroid side effects, especially growth suppression, which is unique to the pediatric population 5, 6
• Behavioral side effects such as anxiety, hyperactivity, and aggressive behavior can occur and appear to be dose-dependent 3
• Systemic corticosteroids should be used with particular caution in children with linear growth delay, osteoporosis, or mental health disorders 4
• Other potential adverse effects include adrenal suppression, immunosuppression resulting in infection, weight gain, and gastrointestinal effects 2, 7
• The potency of dexamethasone and betamethasone in suppressing growth is nearly 18 times higher than that of prednisolone 5

Special Considerations

• Alternate-day therapy may help minimize growth suppression in children requiring longer courses of treatment 5
• For children requiring courses longer than two weeks, a weaning plan should be implemented to reduce the risk of adrenal suppression 2
• When discontinuing long-term therapy, gradual withdrawal rather than abrupt cessation is recommended 1
• For topical corticosteroid use in pediatric psoriasis, high-potency or ultra-high-potency formulations should be used with caution, especially in younger patients (0-6 years) and infants who are vulnerable to hypothalamic-pituitary-adrenal axis suppression due to their high body surface area-to-volume ratio 4

Contraindications and Cautions

• Oral corticosteroids are strongly not recommended for maintenance therapy in pediatric Crohn's disease 4
• Prolonged or repetitive courses of antimicrobials or steroids are strongly not recommended for otitis media with effusion 4
• Careful monitoring is required for children on long-term steroid therapy, with particular attention to growth parameters 5, 6