Steroid bursts in children linked to GI bleeding, sepsis, pneumonia

April 23, 2021

3 min read

Source / Disclosures

Disclosures:
Yao does not report relevant financial information. See the study for all relevant financial disclosures from other authors.

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Oral bursts of corticosteroids were associated with a 1.4- to 2.2-fold increased risk of gastrointestinal bleeding, sepsis and pneumonia in children within the first month of 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 reviewed data from the Taiwan National Health Insurance Research Database on children under 18 years of age from 2013 to 2017 to evaluate the incidence rates for four adverse events – gastrointestinal (GI) bleeding, sepsis, pneumonia and glaucoma.

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There were 4,542,623 children in the study. Of these, 1,897,858 (42%) received at least one burst of corticosteroids – commonly used to treat acute respiratory infections and allergic conditions – during the 5-year study period.

According to the study, the differences in incidence rate per 1000 person-years between children who received one corticosteroid burst versus those who did not receive one were 0.60 (95% CI, 0.55-0.64) for gastrointestinal 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 of initiating corticosteroid bursts were 1.41 (95% CI, 1.27-1.57) for gastrointestinal 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 gastrointestinal 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 difference in incidence in sepsis between children with and without a prescription for corticosteroid flares, corticosteroid flares were associated with a 2-fold increased risk of sepsis during the first month after initiation of treatment,” Yao and colleagues wrote. “Special caution is therefore warranted when administering bursts of corticosteroids to children.”

In addition, Yao and colleagues said the findings prove that corticosteroid bursts “are not harmless, but could pose potentially serious health risks such as gastrointestinal bleeding, sepsis and pneumonia for children. Doctors prescribing corticosteroid flares for children must weigh the benefits against the risks of serious side effects. “

Perspective

Back upstairs

C. Buddy Creech, MD, MPH

C. Buddy Creech

Corticosteroids play an important role in the treatment of a number of medical conditions in children, including asthma exacerbations, croup, periodic fever with aphthous ulcers, pharyngitis and adenitis, and the acute treatment of auto-inflammatory processes. However, they are also sometimes used to relieve the symptoms associated with acute respiratory infections, despite the evidence that they are ineffective for such conditions. In this cohort study from Taiwan, the medical records of children who had steroid bursts of less than 14 days were examined for side effects. More than 1 million children received a single dose of steroids over a 5-year period, mostly for allergic conditions and acute respiratory infections; Steroid reception increased the incidence rates for gastrointestinal bleeding (1.5-fold), sepsis (2-fold) and pneumonia (2-fold) in the 30 days after steroid use, but not in the 30-day period. The use of corticosteroids, even in short courses, is therefore not without consequences.

It is understandable why we, as health care providers, are tempted to use steroids in the treatment of acute respiratory infections because we have very little to offer patients who have no evidence of an acute bacterial infection. Steroids are powerful antipyretics, and the absence of a fever is often a parent’s primary focus when assessing their child’s well-being. 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 makes sense to conclude that steroids can soothe the inflammatory manifestations of respiratory illnesses such as prolonged coughing. Still, multiple studies, including those by Hay and colleagues, show that cough duration and severity in non-asthmatic adults remain unchanged after steroid intake.

For this reason, I would argue for an approach where we call “timeout to WIN”. Corticosteroid treatment should not be taken lightly. So call a time-out and ask the following: What am I treating – the primary disease or the symptoms of the disease? Second, there is one known indication for steroids for the specific condition? Finally, there is a bona fide need for steroid therapy? If we go through these steps methodically, I think we’ll find that our exercise patterns will change and we’ll find fewer opportunities to prescribe steroids. This well-done study would suggest that by reducing the number of steroids, we will also protect against the unfortunate side effects that can occur after using them.

References:

Hay AD, et al. JAMA. 2017; doi: 10.1001 / jama.2017.10572.

C. Buddy Creech, MD, MPH

Infectious diseases in children Member of the editorial board

Director, Vanderbilt Research Program

Associate Professor of Pediatrics

Vanderbilt University School of Medicine

Disclosures: Creech does not report any relevant disclosures.

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