Do oral corticosteroids cause side effects in pediatric patients?

Oral Steroids in Pediatrics: Side Effects Profile

Yes, oral corticosteroids cause side effects in pediatric patients, but short courses (<2 weeks) are very unlikely to cause long-term adverse effects, while multiple courses or prolonged use (>2 weeks) carry significant risks including growth suppression, behavioral changes, adrenal suppression, and increased infection susceptibility. 1

Acute Behavioral and Symptomatic Side Effects

Short-term oral steroid courses produce dose-dependent behavioral side effects that are common and clinically significant:

• Behavioral disturbances occur frequently, including anxiety (twice as common at 2 mg/kg vs 1 mg/kg), aggressive behavior (twice as common at higher doses), hyperactivity, irritability, fussiness, and insomnia affecting up to 29% of children 2, 3
• The number needed to harm is 6.1 for anxiety, 8.6 for hyperactivity, and 4.8 for aggressive behavior when comparing 2 mg/kg to 1 mg/kg daily dosing 2
• Weight gain and increased appetite are common acute effects 3
• Gastrointestinal side effects increase, particularly when combined with NSAIDs or aspirin 4

Clinical Pearl: Use 1 mg/kg daily rather than 2 mg/kg for acute asthma exacerbations, as efficacy is comparable but behavioral side effects are significantly reduced 2

Growth and Endocrine Effects

Growth suppression is the most pediatric-specific concern with oral corticosteroids:

• Growth velocity may be a more sensitive indicator of systemic corticosteroid exposure than HPA axis testing (cosyntropin stimulation, basal cortisol) 4
• Children treated with corticosteroids by any route may experience decreased growth velocity, even at low systemic doses and without laboratory evidence of HPA suppression 4
• Adrenal suppression risk increases significantly with courses >7-10 days, manifesting as hypotension, hypoglycemia, hyponatremia, and hyperkalemia 5
• The hypothalamic-pituitary-adrenal axis in children is more susceptible to suppression from exogenous corticosteroids than in adults 3

Monitoring Requirements Based on Exposure

For children requiring multiple courses of oral corticosteroids, the National Asthma Education and Prevention Program recommends:

• Ophthalmologic examination and bone density measurement should be considered in children using multiple courses of oral corticosteroids 6
• Height, weight percentile, and plots of growth velocity should be tracked systematically 6
• Blood pressure monitoring is essential, as hypertension can be dose-dependent 3
• Morning cortisol levels should be considered if prolonged use is necessary 3

Infection and Immunologic Risks

Oral corticosteroids cause clinically relevant immunosuppression in children:

• Increased susceptibility to infections due to immunosuppressive effects, including reduced B- and T-lymphocyte counts 3
• Rare cases of Pneumocystis carinii pneumonia have been reported 3
• Diminished response to toxoids and live or inactivated vaccines occurs with prolonged therapy 4
• Corticosteroids may potentiate replication of organisms in live attenuated vaccines 4
• If possible, routine vaccination should be deferred until corticosteroid therapy is discontinued 4

Cardiovascular and Metabolic Effects

Serious but rare cardiovascular complications can occur:

• Fatal cardiomyopathy and interventricular septal hypertrophy have been described in infants 3
• Hypertension is dose-dependent and requires periodic monitoring 3
• Blood glucose concentrations increase, requiring dosage adjustments of antidiabetic agents 4
• Hypokalemia risk increases when combined with potassium-depleting agents (diuretics, amphotericin-B), potentially causing arrhythmias in patients on digitalis 4

Ocular Complications

• Glaucoma and cataracts are potential adverse effects requiring monitoring with prolonged use 3
• Corticosteroids may suppress reactions to skin tests 4

Duration-Based Risk Stratification

The critical threshold for side effect risk is 2 weeks:

• Courses <2 weeks duration: Very unlikely to cause long-term side effects 1
• Courses >2 weeks duration: Warrant specialist referral and a weaning plan to reduce adrenal suppression and insufficiency 1
• Multiple short courses: Recent evidence suggests even short-term use is associated with a small but significantly increased risk of severe adverse events 6

Special Considerations for Specific Conditions

For croup management:

• A single dose of dexamethasone 0.6 mg/kg (maximum 16 mg) provides 24-72 hours of benefit with minimal side effect risk 7

For asthma exacerbations:

• Low dose and short-term (<7 days) use may be considered as clinically necessary 6
• Long-term use is not recommended due to well-known adverse effects 6
• Rebound flare is common upon discontinuation 6

Common Pitfalls to Avoid

• Do not use oral steroids for simple acute bronchitis without clear asthma risk factors, as there is no evidence of benefit and systemic steroids have significant side effects 7
• Avoid abrupt discontinuation after prolonged use (>7-10 days), as this may trigger rebound inflammation or adrenal crisis 5
• Do not combine with indomethacin or ibuprofen in infants without careful consideration, as this increases gastrointestinal perforation risk 5
• Monitor for severe weakness in myasthenia gravis patients, as anticholinesterase agents should be withdrawn at least 24 hours before initiating corticosteroid therapy 4