Contoversy about the use Corticosteroids in pediatric

Controversy about the use ofControversy about the use of
corticosteroids in pediatricscorticosteroids in pediatrics
ByBy
Mohamed Zannoun (MD)
Associated Professor of pediatric Al-Azhar University
Dameitta
09/16/16 Mohamed Zannoun

ControversyControversy

Types of Steroids
• Replacement Therapy
• glucocorticoid (hydrocortisone)
• mineralocorticoid (fludrocortisone)
• Anti-inflammatory Therapy
• Short acting: hydrocortisone
• Intermediate acting: prednisolone;
methylprednisolone; triamcinolone
• Long acting: dexamethasone

Routes of Administration
• Systemic : oral,
transrectal, IV, IM
• Local: topical,
intranasal,
intraocular,
intraarticular

Availability of International Guidelines
on Use of Steroid
• No one-for-all guideline
• Glucocorticoid Replacement Therapy : Guidelines
published by Royal College of Physicians of
London, UK ; not available from Endocrine
Society, USA.
• Systemic Use of Glucocorticoid: Guidelines
available for EULAR (European League for
Rheumatology)
• Local Use of Steroid: guidelines on individual
disease, general guidelines not available

Royal College of Physicians of London Guidelines
on Glucocorticoid Replacement Therapy
• Recommended Daily Dose for
Glucocorticoid
• Hydrocortisone (cortisol) 15-30mg
• Cortisone acetate 25-37.5mg
• Prednisolone 5-7.5mg
• Dexamethasone 0.5mg
• Recommended Daily Dose of
Mineralocorticoid
• Fludrocortisone 100-200mcg09/16/16 Mohamed Zannoun

Pediatric
emergency

HIGH ALTITUDE CEREBRAL EDEMA HACE
• . Dexamethasone should be
administered at a dose of
0.15 mg/kg per dose given
orally every 6 hr. The few
mild cases of HACE reported
in children have recovered
with dexamethasone and
descent. Nelson 2016 p557

Brain Death
• Corticosteroids should generally not be used
unless adrenal insufficiency is documented.
Nelson 2016 p512

Role of corticosteroids in management of
hereditary angioedema
• corticosteroids have no effect. Nelson 2016
p1060.09/16/16 Mohamed Zannoun

corrosive
• The use of corticosteroids or
prophylactic antibiotics is not
beneficial.
Nelson 2016p464
• The role of corticosteroids is
controversial. Nelson 2016 p1795

In human studies: Inconclusive
so far
• NEJM. 1990:
– Prospective study over an
18-year period
– No benefit
• Toxicol Rev. 2005:
– 1991-2004 in the English,
German, French, Spanish
– No benefit

hydrocarbons and hydrocarbon-
induced pneumonitis
Treatment is supportive Neither corticosteroids nor
prophylactic antibiotics have shown any clear
benefit.
Nelson 2016 p465

Burns
• Treatment is initially focused
on establishing and
maintaining a patent airway
through prompt and early
nasotracheal or orotracheal
intubation and adequate
ventilation and oxygenation.
• Wheezing is common, and β-
agonist aerosols or inhaled
corticosteroids are useful.
Nelson 2016 p574.09/16/16 Mohamed Zannoun

Generally in Pediatric emergency
• Inhaled bronchodilators, such as
albuterol, augmented by oral or IV
corticosteroids, remain the
mainstay
of therapy:-
• 1- Mild to moderate acute distress
caused by lower airway obstruction.
• 2- Children with more significant
obstruction appear dyspneic, with
tachypnea, retractions, and easily
audible wheezing. Nelson 2016 p49409/16/16 Mohamed Zannoun

Perinatal09/16/16 Mohamed Zannoun

Antenatal corticosteroids
• A single course of antenatal corticosteroids is
recommended in pregnancies 24-34 wk of gestation that
are at risk for preterm delivery. Antenatal steroids decrease
the risk of death, grades III and IV IVH, and PVL in the
neonate.
• The prophylactic administration of low-dose
indomethacin (0.1 mg/kg/day for 3 days)
to VLBW preterm infants reduces
the incidence of severe IVH.
Nelson 2016 p836-837.

Congenital Adrenal Hyperplasia
21-hydroxylase deficiency
• This suppresses secretion of
steroids by the fetal adrenal,
including secretion of
adrenal androgens. If started
by 6 wk of gestation, it
ameliorates virilization of the
external genitalia Nelson
2016 p2720

Congenital heart block
• Prenatal Dexamethasone
thearpy , Nelson 2016
p817

Post natal corticosteroids
• Long-term adverse neurodevelopmental
outcomes are also associated with high-dose
postnatal corticosteroid use in VLBW infants.
• Early postnatal exposure to dexamethasone,
within the 1st wk of life, is associated with
metabolic derangements, poor growth,
increased risk for sepsis, and an increased
risk of spontaneous bowel perforation.
Nelson 2016 p838.

• Infants exposed to postnatal steroids after
the 1st wk of life have an increased risk of
cerebral palsy and developmental delay.
The risk may be increased with prolonged
steroid use (>6 wk).
• At 8 yr of age, dexamethasone-treated
children are smaller, have smaller head
circumferences, poorer motor skills and
coordination, more difficulty with visual
motor integration and lower full-scale
verbal IQ and performance IQ scores.
Nelson 2016 p838.

• It is recommended that postnatal
corticosteroid use in VLBW infants
be limited to exceptional clinical
circumstances and that parents of
infants in whom corticosteroids are
used be informed of the potential
adverse side effects, including
increased risk for developmental
delay, cerebral palsy, and impaired
growth. Nelson 2016 p838.09/16/16 Mohamed Zannoun

Prior to extubation from mechanically
ventilatted babies
• Administration of intravenous
corticosteroids (dexamethasone 0.5
mg/kg every 6 hr for 4 doses prior to
extubation) has been shown to minimize
the incidence of postextubation airway
obstruction.
• In patients in whom postextubation
airway obstruction develops, the need
for re-intubation may be obviated by
administration of nebulized racemic
epinephrine and heliox. Nelson 2016
p544.

Bronchopulmonary dysplasis BPD
• Systemic corticosteroids have
been used to treat infants with
RDS, to selectively treat infants
who continue to require
respiratory support, and to treat
those in whom BPD develops.
Mortality and/or BPD at 36 wk
decrease with moderately early
(7-14 days) administration of
corticosteroids. Nelson 2016 p854.

BPD
• Early (<96 hr) and delayed (>2 wk)
administration of systemic steroids as also
been assessed with meta-analyses, and the
results are qualitatively similar. However,
there are short-term adverse effects,
including hyperglycemia, hypertension,
gastrointestinal bleeding, gastrointestinal
perforation, hypertrophic obstructive
cardiomyopathy, poor weight gain, poor
growth of the head, and a trend toward a
higher incidence of periventricular
leukomalacia. Nelson 2016 p854.

BPD
• Routine use of systemic
corticosteroids for the
prevention or treatment of
BPD is not recommended by
the Consensus Group of the
American Academy of
Pediatrics and the Canadian
Pediatric Society. Nelson 2016
p854.

BPD
• Administration of inhaled
steroids to ventilated
preterm infants during the
1st 2 wk after birth reduced
the need for systemic
steroids and tended to
decrease rates of death
and/or BPD at 36 wk without
an increase in adverse
effects. Nelson 2016 p854.

hypotension

hypotension
• Hypotension in some infants weighing <1,000 g
does not respond to fluids or inotropic gents but
may respond to therapy with intravenous
hydrocortisone. Nelson 2016 p831.

Vascular Disorders

Treatment of Kawasaki Disease
• Corticosteroids have been trialed
as primary therapy with the first
dose of IVIG in hopes of improving
coronary outcomes. A North
American trial using a single pulse
dose of intravenous
methylprednisolone (30 mg/kg)
with IVIG as primary therapy did
not improve coronary outcomes.
Nelson 2016 p1147.

• However, a trial in Japan utilizing the
Kobayashi score to identify high-risk
children demonstrated improved
coronary outcomes with a regimen of
prednisolone (2 mg/kg) plus IVIG as
primary therapy.
• Despite these promising results,
administration of corticosteroids, as
primary therapy to all children with KD
awaits the development of a risk score
that identifies high-risk children in a
multiracial population. Nelson 2016
p1147.

• Corticosteroids in varying doses
and via different routes have
also been used as secondary or
“rescue” therapy when fever
persists after the first IVIG.
However, the lack of clear data
regarding the most effective way
to administer corticosteroids as
rescue therapy has led to
significant practice variation
across centers. Nelson 2016
p1147.09/16/16 Mohamed Zannoun

Henoch-Schnlein Purpura
• Treatment for mild and self-
limited HSP is supportive, with
an emphasis on assuring
adequate hydration, nutrition,
and analgesia. Steroids are most
often used to treat significant
gastrointestinal involvement or
other life-threatening
manifestations. Nelson 2016
p121809/16/16 Mohamed Zannoun

• Prednisone (1 mg/kg/day
for 1-2 wk, followed by
taper) reduces abdominal
and joint pain but does
not alter overall prognosis
nor prevent renal disease.
Rapid tapering of
corticosteroids may lead
to a flare of HSP
symptoms. Nelson 2016
p1218

ITP
• Pulsed high-dose dexamethasone
therapy in children with chronic
idiopathic thrombocytopenic purpura
before considering splenectomy
• Dexamethasone orally or iv ??? At a
dosage of 40 mg /m2 /day maximium
40 mg /day for 4 consecutive days the
cycle repeated once monthly for six
months
• pediatric haematol oncol. 2002 Jul-
Aug 19(5):329-3509/16/16 Mohamed Zannoun

Infectious diseases09/16/16 Mohamed Zannoun

Pharyngitis
• Systemic corticosteroids are sometimes used in children
who have evidence of upper airway compromise due to
mononucleosis. Although corticosteroids are used fairly
commonly in adults with pharyngitis, large scale studies
capable of providing safety and efficacy data are lacking in
children. Corticosteroids cannot be recommended for
treatment of most pediatric pharyngitis.
• Nelson 2016 p2019.

In tonsillectomy
• The Clinical Guidelines for
Tonsillectomy include a
recommendation for
• intravenous a single dose of
intraoperative dexamethasone
(0.5 mg/kg), which decreases
postoperative nausea and
vomiting and reduces swelling.
Nelson 2016 p2026

Bronchiolitis
• Corticosteroid therapy is not
indicated except in older
children with an established
diagnosis of asthma, because
its use is associated with
prolonged virus shedding and
is of no proven clinical benefit.
Nelson 2016 p1608

Bronchiolitis
• Corticosteroids, whether
parenteral, oral, or inhaled,
have been used for bronchiolitis
despite conflicting and often
negative studies.
Corticosteroids are not
recommended in previously
healthy infants with RSV.
Nelson 2016 p2047

Bronchiolitis
• Combined therapy with nebulized
epinephrine and dexamethasone
has been used with some success,
but additional studies are needed
to confirm its efficacy and
investigate the long-term adverse
effects in infants before this
combination can be recommended.
Nelson 2016 p2048

• Croup
• The effectiveness of oral
corticosteroids in viral croup is well
established. Corticosteroids
decrease the edema in the laryngeal
mucosa through their anti-
inflammatory action. Oral steroids
are beneficial, even in mild croup, as
measured by reduced
hospitalization, shorter duration of
hospitalization, and reduced need
for subsequent interventions such as
epinephrine administration. Nelson
2016 p2034

Croup
•Most studies that demonstrated the
efficacy of oral dexamethasone used
a single dose of 0.6 mg/ kg,
•a dose as low as 0.15 mg/kg may be
just as effective intramuscular
dexamethasone and nebulized
budesonide have an equivalent
clinical effect; oral dosing of
dexamethasone is as effective as
intramuscular administration. A
single dose of oral prednisolone is less
effective. Nelson 2016 p2034

• croup
• There are no controlled studies
examining the effectiveness of
multiple doses of
corticosteroids. The only
adverse effect in the treatment
of croup with corticosteroids is
the development of Candida
albicans laryngotracheitis in a
patient who received
dexamethasone, 1 mg/ kg/24
hr, for 8 days. Nelson 2016
p2034

Epiglottitis
• Racemic epinephrine
and corticosteroids
are ineffective.
Nelson 2016 p203409/16/16 Mohamed Zannoun

Meningitis
• Some experts recommend
use of corticosteroids in
pneumococcal meningitis
early in the course of disease,
but data demonstrating clear
benefit in children is lacking.
Nelson 2016 p1325

• Data support the use of
intravenous dexamethasone,
0.15 mg/kg/ dose given every 6
hr for 2 days, in the treatment of
children older than 6 wk with
acute bacterial meningitis caused
by H. influenzae type b. lead to
reduction in sensorineural
hearing loss. Data in children
regarding benefits, if any, of
corticosteroids in the treatment
of meningitis caused by other
bacteria are inconclusive. Nelson
2016 page 294309/16/16 Mohamed Zannoun

• . Early steroid treatment of adults
with bacterial meningitis, especially
those with pneumococcal meningitis,
results in improved outcome
Corticosteroids appear to have
maximum benefit if given 1-2 hr
before antibiotics are initiated. They
also may be effective if given
concurrently with or soon after the
first dose of antibiotics.
• Nelson 2016 page 2943

Pertussis Bordetella pertussis
• No randomized, blinded
clinical trial of sufficient size
has been performed to
evaluate the usefulness of
corticosteroids in the
management of pertussis
Nelson 2016 p1380

Salmonella typhoid fever
• Although additional treatment with
dexamethasone (3 mg/kg for the
initial dose, followed by 1 mg/kg
every 6 hr for 48 hr) is recommended
for severely ill patients with shock,
stupor, or coma; corticosteroids
should be administered only under
strict controlled conditions and
supervision, because their use may
mask signs of abdominal
complications. Nelson 2016 p1392

Tuberculosis
• Corticosteroids decrease mortality rates and
long-term neurologic sequelae in some
patients with tuberculous meningitis by
reducing vasculitis, inflammation, and,
ultimately, intracranial pressure. Lowering
the intracranial pressure limits tissue damage
and favors circulation of antituberculosis
drugs through the brain and meninges..
Nelson 2016 p1459.

tuberculosis
• Short courses of corticosteroids also may be
effective for children with endobronchial
tuberculosis
• Several randomized clinical trials have
shown that corticosteroids can help relieve
symptoms and constriction associated with
acute tuberculous pericardial effusion.
Corticosteroids can cause dramatic
improvement in symptoms in some patients
with tuberculous pleural effusion and shift
of the mediastinum. However, the long-
term course of disease is probably
unaffected. Nelson 2016 p1459.09/16/16 Mohamed Zannoun

miliary tuberculosis
• in case of tuberculoma, a tumor-
like mass resulting from
aggregation of caseous tubercles
that usually manifests clinically as
a brain tumor Corticosteroids are
usually administered during the
1st few wk of treatment or in the
immediate postoperative period
to decrease cerebral edema
• Nelson 2016 p1452-53.

Miliary tuberculosis
• Some children with severe miliary
tuberculosis have dramatic improvement
with corticosteroid therapy if the
inflammatory reaction is so severe that
alveolocapillary block is present. There is
no convincing evidence to support a
specific corticosteroid preparation. The
most commonly used regimen is
prednisone, 1-2 mg/kg/day in 1-2 divided
doses orally for 4-6 wk, followed by a
taper. Nelson 2016 p1459.
• @@@@@@@@@@@@@@@@@@@

Herpes zoster
• Use of corticosteroids in
the treatment of herpes
zoster in children is not
recommended. Nelson
2016 p1585

Infectious mononucleosis
• Short courses of corticosteroids
(<2 wk) may be helpful for
selected complications of
infectious mononucleosis, but this
use has not been evaluated
critically. Some appropriate
indications include incipient
airway obstruction,
thrombocytopenia with
hemorrhaging, autoimmune
hemolytic anemia, seizures, and

Infectious mononucleosis
• A recommended regimen is prednisone
1 mg/kg/day (maximum: 60 mg/day) or
equivalent for 7 days and tapered over
another 7 days. There are no controlled
data showing efficacy of corticosteroids
in any of these conditions. In view of the
potential and unknown hazards of
immunosuppression for a virus infection
with oncogenic complications,
corticosteroids should not be used in
uncomplicated cases of infectious
mononucleosis. Nelson 2016 p1589

Sepsis and Septic shock
• Corticosteroids should
not be administered for
the treatment of sepsis
in the absence of shock.
• Nelson 2016 p525-26

Sepsis and Septic shock
• In adults if adequate fluid resuscitation
and vasopressor therapy are not able to
restore hemodynamic stability In case
we suggest intravenous hydrocortisone
alone at a dose of 200 mg per day.
Timely hydrocortisone therapy in
children with fluid refractory,
catecholamine resistant shock and
suspected or proven absolute (classic)
adrenal insufficiency. Nelson 2016
p525-2609/16/16 Mohamed Zannoun

cardiogenic shock
• Currently available pediatric
data do not demonstrate an
overall survival benefit in
patients with cardiogenic shock
treated with hydrocortisone.
Determination of baseline
cortisol levels prior to steroid
administration may be beneficial
in guiding therapy, although this
idea remains controversial.

live vaccines
• Corticosteroids can suppress the
immune system. Children
receiving corticosteroids (≥2
mg/kg/day or ≥20 mg/day of
prednisone or equivalent) for 14
or more days should not receive
live vaccines until therapy has
been discontinued for at least 1
mo. Nelson 2016 p1256

live vaccines
• Children on the same dose levels
but for <2 wk may receive live
viral vaccines as soon as therapy is
discontinued, although some
experts would wait 2 wk after
therapy has been discontinued.
Children receiving lower doses of
corticosteroids may be vaccinated
while receiving therapy. Nelson
2016 p125609/16/16 Mohamed Zannoun

wheezing infants
• Oral steroids are generally
reserved for atopic wheezing
infants thought to have asthma
that is refractory to other
medications.
• Their use in 1st-time wheezing
infants or in infants who do not
need hospitalization is
controversial. Nelson 2016
p204709/16/16 Mohamed Zannoun

Bronchial Asthma
• Corticosteroids are the most
potent and most effective
medications used to treat
both the acute (administered
systemically) and chronic
(administered by inhalation)
manifestations of asthma.
They are available in inhaled,
oral, and parenteral forms
Nelson 2016 p1107.09/16/16 Mohamed Zannoun

Oral vs IV
• Short-course systemic corticosteroid
therapy is recommended for use in
moderate to severe asthma
exacerbations to hasten recovery and
prevent recurrence of symptoms.
Corticosteroids are effective as single
doses administered in the emergency
department, short courses in the clinic
setting, and both oral and intravenous
formulations in hospitalized
children. Nelson 2016 p1114.09/16/16 Mohamed Zannoun

Oral vs IV
• Studies in children hospitalized with
acute asthma have found
corticosteroids administered orally to
be as effective as intravenous
corticosteroids. Accordingly, oral
corticosteroid therapy can often be
used, although children with sustained
respiratory distress who are unable to
tolerate oral preparations or liquids
are obvious candidates
for intravenous corticosteroid therapy.
Nelson 2016 p1114

• Systemic corticosteroids are
rarely indicated in the
treatment of chronic AD.
The dramatic clinical
improvement that may
occur with systemic
corticosteroids is frequently
associated with a severe
rebound flare of AD after
therapy discontinuation..
Nelson 2016 p1119.
Systemic CS in Atopic Dermatitis
AD (Atopic Eczema)

• Short courses of oral
corticosteroids may
be appropriate for an
acute exacerbation of
AD while other
treatment measures
are being instituted in
parallel. Nelson 2016
p1119.

Urticaria
• In Chronic urticaria If hives
persist after maximal H1-
and/or H2-receptor blockade
has been achieved, a brief
course of oral corticosteroids
may be considered, but long-
term steroid use is best
avoided. Nelson 2016 p1130.

Stevens-Johnson Syndrome SJS and Toxic
Epidermal Necrolysis TEN
• Adverse Reactions to Drugs
• Corticosteroids are
contraindicated because they
can significantly increase the
risk of infection. Nelson 2016
p1147.

DIAPER DERMATITIS
• A common practice is to presumptively treat
any diaper rash that has been present for
longer than 3 days with topical antifungal
therapy such as nystatin, clotrimazole, or
miconazole. If significant inflammation is
present, the addition of hydrocortisone 1%
may be useful for the 1st 1-2 days, but
topical corticosteroids should be used
cautiously in infants because the relatively
potent topical corticosteroid can lead to
adverse effects. Frequent diaper changes
and short periods without diapers are
important adjunctive treatments. Nelson
2016 p151709/16/16 Mohamed Zannoun

Eosinophilic Esophagitis
corticosteroids have been
used successfully for
nonresponders and for
nonallergic (“primary”) EoE,
with symptomatic and
histologic remission rates
reaching 90%. Nelson 2016
p1791

Eosinophilic Gastroenteritis
• A majority of patients
require treatment with
systemic corticosteroids,
which are often
effective. Nelson 2016
p1831

GIT disorders09/16/16 Mohamed Zannoun

Ulcerative colitis
• Children with moderate to severe
pancolitis or colitis that is
unresponsive to 5-aminosalicylate 5-
ASA therapy should be treated with
corticosteroids, most commonly,
prednisone. The usual starting dose of
prednisone is 1-2 mg/kg/24 hr (40-60
mg maximum dose). This medication
can be given once daily. With severe
colitis, the dose can be divided twice
daily and can be given intravenously.

Ulcerative colitis
Steroids are considered
an effective medication
for acute flares, but they
are not appropriate
maintenance medications
because of loss of effect
and side effects, Nelson
2016 p1824

Crohn disease
• Corticosteroids are utilized for
acute exacerbations of pediatric
Crohn disease because they
effectively suppress acute
inflammation, rapidly relieving
symptoms (prednisone, 1-2
mg/kg/day, maximum 40-60
mg). The goal is to taper dosing
as soon as the disease becomes
quiescent. Nelson 2016 p183009/16/16 Mohamed Zannoun

Contoversy about the use Corticosteroids in pediatric

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