What are the risks of using oral steroids, such as prednisolone, in a 5-year-old child?

Risks of Oral Steroids in a 5-Year-Old Child

Short courses of oral steroids (less than two weeks) in 5-year-old children are very unlikely to cause long-term side effects, but behavioral adverse effects including anxiety, hyperactivity, and aggressive behavior are common and dose-dependent. 1, 2

Behavioral and Psychological Effects

The most immediate and clinically significant harms in young children are behavioral disturbances:

• Anxiety occurs in approximately 1 in 6 children (number needed to harm = 6.1) receiving oral steroids for acute conditions 2
• Aggressive behavior develops in approximately 1 in 5 children (number needed to harm = 4.8), with twice the incidence at higher doses (2 mg/kg/day vs 1 mg/kg/day) 2
• Hyperactivity affects approximately 1 in 9 children (number needed to harm = 8.6) during treatment 2
• These behavioral effects are transient and resolve after discontinuation, but can be distressing for families during the treatment period 2

Growth and Metabolic Effects

For short courses (5-10 days), growth suppression is not a clinically significant concern, but chronic use carries substantial risks:

• Children treated with corticosteroids by any route may experience decreased growth velocity, which can occur even at low systemic doses and without laboratory evidence of HPA axis suppression 3
• Growth velocity is a more sensitive indicator of systemic corticosteroid exposure than standard HPA axis function tests 3
• Abnormalities in glucose metabolism can develop, particularly with prolonged use 4
• Weight gain and excessive appetite are common with extended courses 3

Infectious and Immunologic Risks

• Decreased resistance to infection occurs with prolonged corticosteroid therapy 3
• Patients on prolonged therapy may exhibit diminished response to vaccines and toxoids 3
• Corticosteroids may potentiate replication of organisms in live attenuated vaccines 3
• In cystic fibrosis patients, chronic oral corticosteroid use was associated with increased colonization with Pseudomonas aeruginosa 4

Ophthalmologic Complications

• Cataracts can develop with chronic use, though this was specifically documented in cystic fibrosis patients receiving prolonged therapy 4
• Increased intraocular pressure requires monitoring in children on extended courses 3

Musculoskeletal Effects

Linear growth retardation is the most concerning long-term complication in children requiring chronic therapy:

• Growth retardation was significant enough to warrant early discontinuation in clinical trials of children with cystic fibrosis 4
• Osteoporosis risk increases with prolonged use 3
• Fractures and delayed bone healing can occur with extended courses 3

Adrenal Suppression

• Courses lasting less than 1 week do not require tapering, as there is no evidence of clinically significant HPA axis suppression 5
• Courses exceeding 10 days require gradual tapering to prevent adrenal insufficiency 5
• Children requiring courses longer than two weeks warrant specialist referral and a formal weaning plan 1

Gastrointestinal Effects

• Peptic ulcer risk increases, particularly when combined with NSAIDs 3
• Hepatomegaly and abdominal distention have been observed in children with overdosage 3

Cardiovascular Effects

• Increased blood pressure and tachycardia can occur 3
• Fluid retention is common with prolonged use 3

Context-Specific Considerations

For acute wheezing in preschool children (including 5-year-olds), oral prednisolone shows no benefit over placebo:

• A large randomized trial of 687 children aged 10-60 months with virus-induced wheezing found no significant difference in hospitalization duration, symptom scores, or albuterol use between prednisolone and placebo 6
• Similarly, children under 18 months showed no benefit from prednisolone for wheezing attacks 7
• Even in children with established wheeze, parent-initiated oral steroids conferred no benefit and showed a trend toward increased hospitalizations (p=0.058) 4

For chronic cough without airflow obstruction, there is no evidence supporting oral steroid use in children 4

Dosing Considerations to Minimize Harm

When oral steroids are indicated (such as for confirmed asthma exacerbations or specific conditions like nephrotic syndrome):

• Use 1 mg/kg/day rather than 2 mg/kg/day to reduce behavioral side effects while maintaining comparable efficacy 2
• Limit duration to the shortest effective course 1
• Monitor for behavioral changes and counsel families that these effects are temporary 2

Common Pitfalls

• Prescribing oral steroids for viral-induced wheezing in preschoolers, where evidence shows no benefit 6, 7
• Using unnecessarily high doses (2 mg/kg/day) when lower doses (1 mg/kg/day) are equally effective with fewer side effects 2
• Failing to warn families about behavioral changes, leading to unnecessary distress 2
• Tapering short courses (<10 days) when no taper is needed 5
• Continuing courses beyond 2 weeks without specialist input and a formal weaning plan 1