Steroid bursts in children linked to GI bleeding, sepsis, pneumonia
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Oral corticosteroid bursts were associated with a 1.4- to 2.2-fold increased risk for gastrointestinal bleeding, sepsis and pneumonia among children within the first month after use, according to study results published in JAMA Pediatrics.
Tsung-Chieh Yao, MD, PhD, an associate professor of pediatrics at Chang Gung University in Taiwan, and colleagues assessed data from Taiwan’s National Health Insurance Research Database on children aged younger than 18 years from 2013 through 2017 in order to evaluate incidence rates for four adverse events — gastrointestinal (GI) bleeding, sepsis, pneumonia and glaucoma.
There were 4,542,623 children in the study. Of these, 1,897,858 (42%) received at least one corticosteroid burst — which is commonly used to treat acute respiratory infections and allergic diseases — during the 5-year study period.
According to the study, the incidence rate differences per 1,000 person years between children who received one corticosteroid burst vs. those who received none were 0.60 (95% CI, 0.55-0.64) for GI bleeding, 0.03 (95% CI, 0.02-0.05) for sepsis, 9.35 (95% CI, 9.19-9.51) for pneumonia and 0.01 (0.01-0.03) for glaucoma.
Those rates within 5 to 30 days after initiating corticosteroid bursts were 1.41 (95% CI, 1.27-1.57) for GI bleeding, 2.02 (95% CI, 1.55-2.64) for sepsis, 2.19 (95% CI, 2.13-2.25) for pneumonia, and 0.98 (95% CI, 0.85-1.13) for glaucoma, the researchers reported. Within the subsequent 31 to 90 days, the rates were 1.10 (95% CI, 1.02-1.19) for GI bleeding, 1.08 (95% CI, 0.88-1.32) for sepsis, 1.09 (95% CI, 1.07-1.11) for pneumonia, and 0.95 (95% CI, 0.85-1.06) for glaucoma.
“Despite the small observed incidence rate difference in sepsis between children with and children without prescriptions of corticosteroid bursts, corticosteroid bursts were associated with a twofold increased risk of sepsis during the first month after starting treatment,” Yao and colleagues wrote. “Particular caution is therefore needed when administering corticosteroid bursts to children.”
Additionally, Yao and colleagues said the findings provide evidence that corticosteroid bursts “are not innocuous but may pose potentially serious health risks, such as GI bleeding, sepsis, and pneumonia, to children. Clinicians prescribing corticosteroid bursts to children need to weigh the benefits against the risks of severe adverse events.”
Perspective
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Corticosteroids play an important role in the management of a number of childhood medical conditions, including asthma exacerbations, croup, periodic fever with aphthous ulcers, pharyngitis and adenitis and the acute management of autoinflammatory processes. However, they are also sometimes used in an effort to relieve symptoms associated with acute respiratory infections, despite evidence that they are ineffective for such conditions. In this cohort study from Taiwan, the medical records of children receiving steroid bursts of less than 14 days were examined to evaluate for adverse events. More than 1 million children received a single burst of steroids over a 5-year span, most commonly for allergic disease and acute respiratory infections; receipt of steroids increased the incidence rate ratios for GI bleeding (1.5-fold), sepsis (twofold), and pneumonia (twofold) in the 30 days after steroid use but not in the period after 30 days. Thus, corticosteroid use, even in short courses, is not without consequence.
It is understandable why we, as health care providers, are tempted to reach for steroids in the management of acute respiratory tract infections because we have very little to offer patients who do not have evidence of an acute bacterial infection. Steroids are potent antipyretics, and the absence of fever is often a parent’s primary focus when judging the well-being of their child. Second, steroids are often associated with increased appetite and energy, a secondary focus for many parents, although this double-edged sword often gives way to steroid-induced hyperphagia and hyperactivity. Third, it is logical to conclude that steroids might attenuate the inflammatory manifestations of respiratory illnesses, such as prolonged cough. Yet multiple studies, including that of Hay and colleagues, show that cough duration and severity in non-asthmatic adults are unchanged following receipt of steroids.
For this reason, I would advocate for an approach where we “call time-out to W.I.N.” Treating with corticosteroids should not be a decision made lightly. Therefore, call time out and ask the following: What am I treating — the primary disease or the symptoms of the disease? Second, is there a known indication for steroids for the particular condition? Finally, is there a bona fide need for steroid therapy? When we methodically go through these steps, I think we will find that our practice patterns will change, and we will find fewer opportunities to prescribe steroids. This well-done study would suggest that by reducing steroid prescriptions, we will also protect against the unfortunate adverse events that may occur after their use.
References:
Hay AD, et al. JAMA. 2017;doi:10.1001/jama.2017.10572.
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