At what age can steroids be initiated in pediatric patients?

Age for Initiating Steroids in Pediatric Patients

The appropriate age to initiate steroids in pediatric patients depends entirely on the clinical indication, with no universal minimum age—neonates can receive steroids for specific conditions like bronchopulmonary dysplasia (BPD), while other conditions like Duchenne muscular dystrophy (DMD) should not be treated before age 2 years, and asthma management can begin in infancy when clinically indicated.

Condition-Specific Age Guidelines

Bronchopulmonary Dysplasia (BPD) in Neonates

• Systemic corticosteroids can be initiated in the first weeks of life for ventilator-dependent preterm infants at high risk of developing BPD, though timing remains controversial 1.
• The American Academy of Pediatrics recommends low-dose dexamethasone therapy (<0.2 mg/kg per day) to facilitate extubation in infants with BPD, with very low birth weight infants who remain on mechanical ventilation after 1-2 weeks of age being appropriate candidates 2.
• Early therapy (within first 96 hours of life) or moderately early therapy (7-14 days of age) facilitates weaning from ventilator and decreases BPD incidence, though it carries risks including hyperglycemia, hypertension, gastrointestinal bleeding, and growth suppression 1.
• Late therapy (after 3 weeks of age) facilitates extubation but is associated with hypertension and poor growth 1.

Critical caveat: Routine use of early postnatal dexamethasone is discouraged due to adverse neurologic outcomes including cerebral palsy and developmental delay 1, 3. Low-dose hydrocortisone (1 mg/kg per day) given early may be safer, particularly for infants with prenatal inflammation exposure 2.

Duchenne Muscular Dystrophy (DMD)

• Glucocorticoid treatment is NOT recommended for children under 2 years of age who are still gaining motor skills 1.
• Optimal initiation age is 4-8 years, specifically when the plateau phase is clearly identified—when there is no longer progress in motor skills but prior to decline 1.
• Boys with DMD typically continue making motor progress until approximately age 4-6 years, so treatment should be deferred until this natural progression plateaus 1.
• Before initiating steroids, ensure the recommended national immunization schedule is complete and varicella immunity is established 1.

Asthma

• Inhaled steroids can be used in very young children (0-2 years) when clinically indicated for recurrent wheeze and cough, though diagnosis in this age group relies almost entirely on symptoms rather than objective testing 1.
• Inhaled steroids begun before 2 weeks of age in ventilator-dependent preterm infants can reduce need for mechanical ventilation, though they have not been shown to reduce BPD incidence 1.
• For established asthma, there is no absolute minimum age restriction for inhaled corticosteroids when appropriately indicated 1.
• Oral corticosteroids for acute exacerbations can be used in children as young as 2 years of age at doses of 1 mg/kg/day, which provides comparable benefits to higher doses with fewer behavioral side effects 4.

Important consideration: Inhaled steroids at doses greater than 400 µg/day have shown short-term reductions in tibial growth rate, though long-term effects remain uncertain 1.

Safety Considerations for Infants 6-12 Months

• A 12-week study in infants 6-12 months of age with budesonide inhalation suspension showed dose-dependent effects on growth, with the 1 mg group experiencing 0.6 cm less growth compared to placebo 5.
• Seven patients (6 on budesonide, 1 on placebo) experienced shifts from normal to subnormal stimulated cortisol levels, indicating potential adrenal suppression even in this young age group 5.
• Pneumonia was observed more frequently in budesonide-treated infants compared to placebo 5.

General Principles Across All Ages

• Short courses of oral steroids (less than 2 weeks) are very unlikely to cause long-term side effects in children of any age 6.
• Courses exceeding 2 weeks duration warrant specialist referral and a weaning plan to reduce adrenal suppression and insufficiency 6.
• Growth monitoring is essential for all pediatric patients receiving inhaled corticosteroids, as growth velocity is a more sensitive indicator of systemic corticosteroid exposure than HPA-axis function tests 5, 7.
• Each patient should be titrated to the lowest effective dose to minimize systemic effects 5.

Common Pitfalls to Avoid

• Never initiate steroids in DMD patients under age 2 years or those still making motor progress, as there is no evidence of benefit and significant risk of side effects 1.
• Avoid routine early postnatal dexamethasone (<96 hours) for BPD prevention due to increased adverse outcomes including intestinal perforation 3.
• Do not use high-dose systemic corticosteroids long-term in any pediatric population due to severe neurodevelopmental consequences 8.
• Avoid concomitant use of indomethacin with hydrocortisone in neonates due to increased risk of isolated intestinal perforation 2.