What is the role of steroids, such as dexamethasone (corticosteroid), in the treatment of pediatric pneumonia?

Steroids in Pediatric Pneumonia

Corticosteroids should not be routinely used in the treatment of pediatric pneumonia due to lack of proven benefit and potential risks. 1

Evidence Against Routine Corticosteroid Use in Pediatric Pneumonia

• Guidelines strongly recommend against the routine use of corticosteroids in non-severe community-acquired pneumonia (CAP) in adults, and suggest against routine use even in severe CAP 1
• The American Academy of Pediatrics specifically recommends against routine corticosteroid use in bronchiolitis, which shares inflammatory pathways with many pediatric pneumonias 1
• Systematic reviews and meta-analyses involving children with viral respiratory infections have not shown sufficient evidence to support the use of steroids 1
• Potential adverse effects of corticosteroids in children include:
  • Hyperglycemia and hypertension 1
  • Adrenal and hypothalamic-pituitary axis suppression 1
  • Increased risk of secondary infections 1
  • Growth impairment and developmental concerns 1
  • Cardiac complications in rare cases 1

Limited Scenarios Where Corticosteroids May Be Considered

• In severe pneumonia with respiratory failure or impending respiratory failure:

  • A Cochrane review found corticosteroids reduced early clinical failure rates in children with bacterial pneumonia (RR 0.41,95% CI 0.24 to 0.70) 2
  • However, this finding was based on only two small, clinically heterogeneous trials 2

• In specific pneumonia types:

  • Mycoplasma pneumoniae pneumonia: A retrospective cohort study found that low-dose corticosteroids may not be beneficial in pediatric inpatients and could potentially delay recovery 3
  • Pneumocystis pneumonia: Corticosteroids have a documented role in management of Pneumocystis pneumonia in immunocompromised patients 4

Administration Considerations (If Clinically Indicated)

• If corticosteroids are deemed necessary in specific severe cases:
  • For nebulized administration in infants, the recommended dose is 0.25-0.5 mg twice daily for low-dose therapy 5
  • Only jet nebulizers should be used as ultrasonic nebulizers are ineffective for suspensions 5
  • Delivery requires a face mask that fits snugly over the nose and mouth 5

Monitoring and Precautions

• If corticosteroids are used, monitor for:
  • Hyperglycemia, which is significantly more common in patients treated with corticosteroids (RR 1.72,95% CI 1.38 to 2.14) 2
  • Secondary infections, although studies show no significant differences between corticosteroid-treated patients and controls (RR 1.19,95% CI 0.73 to 1.93) 2
  • Growth effects and adrenal suppression with prolonged use 5, 6
  • Oral candidiasis, which can be prevented by rinsing the child's mouth after inhaled corticosteroid use 1

Conclusion

The preponderance of evidence suggests that routine use of corticosteroids in pediatric pneumonia should be avoided due to lack of clear benefit and potential for harm 1. While there may be specific circumstances where corticosteroids could be beneficial (severe cases with respiratory failure), these decisions should be made with careful consideration of the risk-benefit ratio, and treatment should be limited in duration 2.