My 1‑year‑old child receiving systemic corticosteroids now has dyspnea, persistent fever, decreased appetite and diarrhea while being treated with Tyrol (acetaminophen); what is the appropriate management?

Immediate Evaluation and Management of a 1-Year-Old on Systemic Corticosteroids with Worsening Symptoms

This child requires urgent medical evaluation to rule out serious infection, as systemic corticosteroids significantly increase infection risk in young children, and the combination of persistent fever, dyspnea, and gastrointestinal symptoms raises concern for sepsis or pneumonia. 1

Critical First Steps: Rule Out Life-Threatening Complications

Immediate Infection Workup Required

• Obtain blood and urine cultures, and chest radiography immediately to evaluate for infectious etiologies, as children on corticosteroids have a 2.02-fold increased risk of sepsis and 2.19-fold increased risk of pneumonia within 5-30 days of steroid initiation 1
• Consider broad-spectrum antibiotics empirically if the child appears ill, particularly if neutropenic 2
• The persistent fever despite acetaminophen is a red flag—fever lasting >3 days or temperature ≥39°C for >10 hours unresponsive to acetaminophen warrants escalation of care 2

Assess for Adrenal Insufficiency

• Evaluate for signs of adrenal crisis: hypotension (systolic BP <70 + (2 × age in years) mmHg for 1-year-old = <72 mmHg), lethargy, or shock 2, 3
• Adrenal insufficiency is common (56-88%) in critically ill children with systemic inflammatory conditions requiring vasopressor support 3
• If hypotensive or in shock, consider low-dose corticosteroid supplementation with hydrocortisone after obtaining cortisol levels 3

Respiratory Assessment

Evaluate Severity of Dyspnea

• Measure oxygen saturation immediately—if SpO2 <90% on room air, this represents Grade 2 respiratory compromise requiring supplemental oxygen 2
• Assess for increased work of breathing: use of accessory muscles, tachypnea, retractions 2
• Chest radiography is essential to characterize the respiratory findings and rule out pneumonia, atelectasis, or other pathology 4

Consider Alternative Diagnoses

• In a 1-year-old with respiratory symptoms, other disorders may mimic asthma: gastroesophageal reflux, cystic fibrosis, or chronic lung disease 2
• The diagnosis of asthma cannot be reliably made at this age, and symptoms are more likely due to viral respiratory infections 2, 4

Gastrointestinal Symptoms Management

Address Decreased Appetite and Diarrhea

• Assess hydration status carefully—loose stools combined with decreased oral intake increases dehydration risk 2
• Monitor for signs of gastrointestinal bleeding, as corticosteroid bursts increase GI bleeding risk 1.41-fold within the first month 1
• Ensure adequate fluid intake; consider intravenous hydration if unable to maintain oral intake 2

Corticosteroid-Related Complications to Monitor

Systemic Adverse Effects in Young Children

• Children, especially 1-year-olds, have higher body surface area-to-volume ratio, dramatically increasing systemic corticosteroid exposure and risk of adverse effects 5
• Monitor for behavioral changes (irritability, fussiness, insomnia), which occur in up to 29% of infants with systemic corticosteroid exposure 5
• Watch for weight gain and increased appetite paradoxically, though this child has decreased appetite suggesting illness severity 5

Immunosuppression Concerns

• Increased susceptibility to infections is a major concern—the child's persistent fever may represent a serious bacterial infection masked by steroids 5, 1
• Consider opportunistic infections if immunosuppression is prolonged 5

Specific Management Algorithm

If Infection is Confirmed or Highly Suspected:

1. Start appropriate antimicrobial therapy immediately 2
2. Continue corticosteroids at current dose if already prescribed for a specific indication (do not abruptly stop) 6
3. Provide supportive care: oxygen, hydration, fever management with acetaminophen 2

If No Infection Found:

1. Re-evaluate the indication for systemic corticosteroids in this 1-year-old
2. Consider that routine corticosteroid use is discouraged in young infants due to adverse effects including decreased alveolar number, neurologic complications, and cardiac issues 4
3. If steroids must continue, use the lowest effective dose for the shortest duration 5, 7

Regarding Steroid Discontinuation:

• If steroids have been used long-term, withdraw gradually rather than abruptly to prevent adrenal insufficiency 6
• Short courses (<2 weeks) are unlikely to cause long-term side effects, but courses >2 weeks warrant specialist referral and a weaning plan 8

Critical Pitfalls to Avoid

• Do not attribute all symptoms to the underlying condition being treated with steroids—new fever and respiratory symptoms may represent serious infection 1
• Do not assume acetaminophen failure means the condition is non-infectious—bacterial infections can present with persistent fever despite antipyretics 2
• Do not abruptly discontinue corticosteroids if they have been used for more than a few days, as this risks adrenal crisis 6, 8
• Do not delay specialist consultation—a 1-year-old on systemic steroids with multiple concerning symptoms requires pediatric subspecialty evaluation 2

Immediate Disposition

This child requires same-day evaluation by a physician, with strong consideration for emergency department assessment or hospital admission given the combination of systemic corticosteroid use, persistent fever, respiratory symptoms, and gastrointestinal complaints. 2, 1