This document discusses the appropriate use of corticosteroids in pediatric infections. It notes that corticosteroids can be beneficial when used properly for a limited duration and correct indication, but cause catastrophic issues at the wrong dosage or duration or after abrupt withdrawal from prolonged therapy. It provides guidance on indications for corticosteroid use in specific infections like croup, COVID-19, bacterial meningitis, and tuberculosis. It also outlines potential risks of immunosuppression, masking of symptoms, and various side effects from corticosteroid use. Tapering of steroids is recommended after prolonged use to avoid adrenal insufficiency.

1. Steroids in Pediatric Infections

2. Proper Dosage
Limited duration
Proper Indication
Beneficial
Wrong Dosage
Wrong duration
Abrupt withdrawl after Prolonged
Therapy
Catastrophic

3. “Corticosteroids are bad during acute infectious episodes “
Is This A Paranoia ?

5. Decrease of
swelling and/
or edema
Better
perfusion
facilitates
drainage
Reduction in pain, and
Improved healing
Dampen Inflammatory responses
Exogenous Steroids

6.  The potential for masking the clinical course :
Patients taking glucocorticoids may not manifest common signs and symptoms of infection
 The risk of immunosuppression -
Delay the clearance of pathogens.
Prolong the pathogen-related illnesses.
Risk of new infections

7. Hypertension Electrolyte
disturbances
Drug induced
myopathy
Cushing Syndrome Diabetes Pyschological disorders
Immunosuppression Metabolic syndrome GERD
Adrenal Insufficiency Osteopenia,
osteoporosis
Glaucoma, cataracts Obesity

8.  Respiratory – Croup , Severe Covid 19, Pneumocystis
pneumonia
 Acute Bacterial Meningitis
 Tuberculoisis – certain forms
 Severe Enteric fever
 Infectious mon0neucleosis - only in Impending airway
obstruction

9. Croup ( Acute Laryngo tracheitis ):
 Reduces laryngeal mucosal edema
 Reduces need for nebulised adrenaline
 Decreases hospitalisation rates
 Useful in all viral croup including Covid 19
 https://www.uptodate.com/contents/management-of-croup/
 -Pei Lee, Chun-Ting Mu, Chen-Wei Yen, Shao-Hsuan Hsia, Jainn-Jim Lin, Oi-Wa Chan, Chun-Che Chiu, Shen-Hao Lai, Wen-Chieh Yang, Chun-Yu Chen,
YaTing Su, Han-Ping Wu,Predictors of disease severity and outcomes in pediatric patients with croup and COVID-19 in the pediatric emergency
department,The American Journal of Emergency MedicineVolume 72,2023,
Pages 20-26,

12.  Dexamethasone 0.15mg/kg to 0.6 mg/kg oral / IM
 A single dose of oral prednisolone is less effective.
 “3 days Prednisolone Vs 1 dose Dexamethasone “
Similar efficacy
 “Nebulised BudesonideVs IM Dexamethasone “
Similar efficacy
-
 Possibility of Candida albicans laryngotracheitis on prolonged use. (
1mg/kg/day for 8 days)
NelsonText Book of Pediatrics 21st edition

13. • The Recovery trial :
Reduction in mortality with steroid use in patients requiring
supplemental oxygen, non invasive or invasive mechanical ventilation
• The NIH COVID-19 guidelines :
Consider corticosteroids in all children requiring NIV or MV
Corticosteroids for CAP, influenza andCOVID-19: when, how and benefits or harm? Ignacio Martin-
Loeches, AntoniTorres European Respiratory
review Mar2021, 30 (159) 200346; DOI: 10.1183/16000617.0346-202

14.  Asymptomatic and mild COVID-19 : No steroids
 Moderate and severe disease :
with increasing oxygen demand - Steroids
In children on HFNC, NIV, InvasiveVentilation or ECMO – Steroids
 Start steroids only 3–5 days after onset of disease as early use prolongs viral
shedding.
 Dexamethasone 0.15 mg/kg, maximum dose 6 mg once a day (or )
Methylprednisolone 0.75 mg/kg, max dose - 30 mg once a day
Acute COVID-19 Infection in Children- IAP standard treatment guldelines 2022

16.  HIV infection and severe Pneumocystis pneumonia :
Steroids are Indicated
 Pneumocystis pneumonia without HIV infection :
Steroids are not recommended .
 Prednisolone for 3 wks

17. Adjunct Steroid usage in
 CAP Patients on Beta agonists –
Shorter Hospital stay
 CAP with acute wheezing only benefit
from adjunct systemic corticosteroid
therapy.
Weiss AK, Hall M, Lee GE, Kronman MP, Sheffler-Collins S, Shah SS. Adjunct corticosteroids
in children hospitalized with community-acquired pneumonia. Pediatrics. 2011
Feb;127(2):e255-63.
Adjunct Steroid Usage in
 CAP without Beta agonists –
Longer stay & Higher risk of
readmission.
The Evidence - No recommendation for Steroids in CAP.

18.  Meta analysis - A total of 15 studies (6427 patients)
 Corticosteroid therapy –
Significantly higher mortality &
Three times higher incidence of nosocomial infections –
(Acinetobacter baumannii , S. pneumoniae, Pseudomonas aeruginosa &
Staphylococcus aureus & Invasive pulmonary Apergillosis).
No Role
Corticosteroids for CAP, influenza and COVID-19: when, how and benefits or harm? Ignacio Martin-Loeches, AntoniTorres European
Respiratory review Mar2021, 30 (159) 200346; DOI: 10.1183/16000617.0346-202

19.  Acute Bronchiolitis - No role .
 Retropharyngeal / Parapharyngeal abcess – No role
Subhranshu Sekhar Dhal, Hiremath Sagar1 Department of Paediatrics, Mazumdar Shaw Medical Centre, Managing
Bronchiolitis in Pediatric Patients2022 Indian Journal of Respiratory Care | Published by Wolters Kluwer - Medknow

20.  Severe Enteric fever with Coma ,shock &Obtundation –
Reduction in mortality
 Inj Dexamethasone – 3mg/kg followed by 1mg/kg 6th hourly for 48 hrs
NelsonText Book of Pediatrics 21st edition

21.  No recommendation for use of steroids.
 HLH in a Dengue patient -
Treatment with IVIg and/or corticosteroids - Improved outcomes .
 Tayal A, Kabra SK, Lodha R. Management of Dengue: An Updated Review. Indian J Pediatr. 2023
Feb;90(2):168-177. doi: 10.1007/s12098-022-04394-8. Epub 2022 Dec 27. PMID: 36574088; PMCID:
PMC9793358.

22.  Improves outcome by reducing inflammatory response
to bacterial products and neutrophil activation products.
 Lower CSF protien and Lactate levels
 Reduction in incidence of Sensory neural hearing loss.
www.thelancet.comVol 399 Febraury 19, 2022

23. H. Influenza meningitis - Dexamethasone – 0.15 mg/kg
every 6 hours - for 4 days Reduced Hearing loss
Contraindicated : Neonatal age & Listeria Monocytogenes.

25.  TB Meningitis
Decrease Mortality &Prevent Hydrocephalus and vasculitis
 Pericarditis
 Addison’s Disease –Tuberculous adrenalitis
 MiliaryTB with alveolocapillary block
 TB uveitis

26.  Tuberculosis accounts for about 20–30% of cases of Addison’s disease in
developing world.
 The clinical features of AI are manifested only after more than 90% of the
adrenal gland has been destroyed.
 lifelong replacement therapy is needed
 Increase the dose of glucocorticoid during stress, and shift to injectable
steroids in emergencies

27.  Endo bronchialTB
 Bronchial Compression
 Mediastinal Compression
 Pleurisy with severe distress
 LaryngealTB
 TB Immune Reconstituting Inflammatory Syndrome

28.  Prednisolone 1-2 mg/kg/day
or
 Dexamethasone 0.6 mg/kg/day or its equivalent
for 2-4 weeks
& tapered over the next 4 weeks.

29.  Viable parenchymal neurocysticercosis (NCC)
 Cysticercal encephalitis with diffuse cerebral edema
Steroid therapy has been associated with fewer seizures.
 Calcified parenchymal NCC with or without perilesional edema –
Corticosteroid therapy is not routinely recommended.
 Dexamethasone 0.15 mg /kg or Prednisolone 1-2 mg/kg /day –
Before the Ist dose of Antiparasitic drug & continue for 2 wks.
NelsonText Book of Pediatrics 21st edition

30. Front. Cell. Infect. Microbiol., 23 November 2020 Sec. Bacteria and HostVolume 10 - 2020 | https://doi.org/10.3389/fcimb.2020.592017
Although corticosteroid adjunctive therapy must be studied further as a treatment for HSE,
adjunctive corticosteroids are used in practice for patients with increased intracranial pressure
and cerebral edema to reduce inflammation.

32. Equivalent
dose in mg
Anti-inflammatory
potency compared to
hydrocortisone
Duration of action in
hours
Hydrocortisone 20 1 8-12
Perdnisone 5 4 12-36
Prednisolone 5 4 12-36
Dexamethasone 0.75 30 36-54
Betamethasone 0.6 30 36-54

33.  Abrupt cessation of chronic glucocorticoid therapy can be dangerous as
there is a risk of HPA axis suppression.
 Withdrawal of glucocorticoid therapy needs tapering.
 Steroid therapy for less than 14 to 21 days –
No need for any tapering regime .
 Therapy more than 21 days –
Tapering is needed (e.g., over two months).
Yasir M, Goyal A, Sonthalia S. Corticosteroid Adverse Effects. [Updated 2023 Jul 3]. In: StatPearls [Internet].Treasure
Island (FL): StatPearls Publishing; 2023 Jan-.

34. • Certain forms ofTuberculoisis
• Severe Enteric fever
• Neuro cystcercosis
• IMN with Impending airway
obstruction
• Croup
• Severe Covid 19
• Acute Bacterial Meningitis
• Septic Shock
Key Points
Adjunct steroids Indications

35.  Use adjunct steroids in Pediatric infections Judiciously
 Weight the benefits with the potential risks
 Right dose , Right Duration Crucial
 If Duration is > 3 wks – slow tapering
 Long term replacement dose – Don’t forget to give stress dose during
emergencies.
 Monitor carefully for side effects.
Key Points