Corticosteroid Use in Management of Pediatric Emergency Conditions

Table of Contents

 

Although corticosteroids have been used for over half a century, their use for management of many pediatric conditions is controversial. In this issue, you will learn:

The mechanisms of corticosteroid effects

Which corticosteroids are used to treat pediatric conditions, their associated properties, and recommended pediatric dosing

Evidence-based recommendations for whether or not to use corticosteroids in the management of pediatric patients with an asthma exacerbation, croup, acute pharyngitis, anaphylaxis, acute spinal injury, or bacterial meningitis

Preferred routes, dosages, and corticosteroids, as well as alternate choices

Which adverse effects have been shown to be associated with corticosteroid use

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Mechanisms of Corticosteroid Effects
6. Prehospital Care
7. Corticosteroids for the Management of Pediatric Conditions
   1. Asthma
      1. Management of Asthma
      2. Summary
   2. Croup
      1. Management of Croup
      2. Summary
   3. Acute Pharyngitis
      1. Management of Acute Pharyngitis in Children
      2. Summary
   4. Anaphylaxis
      1. Management of Anaphylaxis
      2. Summary
   5. Acute Spinal Cord Injury
      1. Management of Acute Spinal Cord Injury
      2. Summary
   6. Bacterial Meningitis
      1. Management of Bacterial Meningitis
      2. Summary
8. Adverse Effects
   1. No Adverse Effects
   2. Cerebral Thrombosis
   3. Gastrointestinal Bleeding
   4. Growth Restriction
   5. Bacterial Tracheitis
   6. Behavioral Changes
9. Controversies
10. Special Populations
11. Summary
12. Risk Management Pitfalls for Using Corticosteroids to Manage Pediatric Conditions
13. Time- and Cost-Effective Strategies
14. Case Conclusions
15. Tables
    1. Table 1. Types of Corticosteroids Used to Treat Pediatric Conditions, Their Associated Properties, and Recommended Pediatric Dosing
    2. Table 2. Comparison of Studies Evaluating the Use of Corticosteroids for Management of Acute Pharyngitis
    3. Table 3. Comparison of Studies Evaluating the Use of Corticosteroids for Management of Bacterial Meningitis
16. References

Abstract

Corticosteroids have been used for over half a century to treat various inflammatory disorders; however, their use in many pediatric conditions remains controversial. This issue reviews evidence on corticosteroid treatment in acute asthma exacerbations, croup, acute pharyngitis, anaphylaxis, acute spinal injury, and bacterial meningitis. While corticosteroids are clearly indicated for management of asthma exacerbations and croup, they are not universally recommended for potential spinal cord injury. Due to insufficient data or conflicting data, corticosteroids may be considered in children with acute pharyngitis, anaphylaxis, and bacterial meningitis.

Case Presentations

An otherwise-healthy 3-year-old boy presents to the ED after awakening in the middle of the night with a barky cough, gasping for air. His mother denies other symptoms and states that foreign body aspiration is unlikely. Upon arrival to the ED via ambulance, the boy continues to have a barky cough and inspiratory stridor with agitation, but no stridor at rest. His physical examination is otherwise unremarkable and his airway is patent, without any evidence of compromise. What are the next steps in the management of this patient? Are corticosteroids indicated in this situation? If so, which one should you prescribe, and at what dosage?

A 13-year-old adolescent girl with a past history of recurrent tonsillitis presents because of progressively worsening pain, increasing dysphagia, decreased oral intake, muffled voice, and unremitting fevers, despite being on an appropriate oral antibiotic. The girl states the illness began with a sore throat, headache, fever, and abdominal pain 4 days ago. On physical examination, she has 4+ right tonsillar enlargement with exudate. Her rapid strep test is positive. A CT scan was ordered to rule out deep space infection, and it showed no sign of phlegmon or abscess. The girl's airway is patent. You begin to consider how you should manage this patient. You decide to consult ENT, and they recommend changing the antibiotic and administering a dose of corticosteroids. Do you agree that corticosteroids are warranted? If so, which corticosteroid should you prescribe, and at what dosage?

A 15-year-old adolescent boy presents with a stiff neck and worsening severe, persistent headaches; altered mental status; and fevers for a week. He has been previously healthy, but is unimmunized. He has no nausea or vomiting, and no vision or hearing concerns. His physical examination is positive for meningismus, Kernig and Brudzinski signs, and altered mentation. Although the patient is altered, he is able to control his own airway. Lumbar puncture analysis is suggestive of bacterial meningitis. Should you consider a dose of corticosteroids? If so, which one should you prescribe, and at what dosage?

Introduction

The corticosteroid class of drugs provides some of the most important synthetic glucocorticoids, and have been used in many types of treatment since the 1950s.¹ Despite the half-century of corticosteroid usage, there is still much debate about their use in many pediatric diseases. This issue of Pediatric Emergency Medicine Practice reviews the mechanisms of corticosteroids and the evidence-based role of corticosteroid treatment in a variety of pediatric conditions.

Critical Appraisal of the Literature

A review of the literature was conducted using PubMed and the Cochrane Database of Systematic Reviews. The search was performed using the terms asthma, wheezing, croup, pharyngitis, acute spinal injury, anaphylaxis, allergic reaction, meningitis, corticosteroids, dexamethasone, prednisone, prednisolone, fluticasone, hydrocortisone, budesonide, cerebral thrombosis, gastrointestinal bleed, bacterial tracheitis, and growth restriction. Over 150 articles were reviewed, 93 of which were chosen for inclusion, including a number of case reports, clinical reviews, and retrospective and prospective controlled studies.

Risk Management Pitfalls for Using Corticosteroids to Manage Pediatric Conditions

1. “My patient had only mild croup, so I did not treat him with corticosteroids. He came back the next day with worsening symptoms and stridor.”

Patients with mild croup can progress and develop stridor, in addition to hoarseness and a barky cough. Once the child has stridor, corticosteroids should be given. The adjuvant use of corticosteroids will allow the patient to have additional therapeutic coverage for up to 72 hours (if using dexamethasone) and will decrease the incidence of return visits, the need for further treatment, or admission.

5. “The patient had severe pharyngitis. I felt that corticosteroids were necessary for pain relief.”

The efficacy of corticosteroids for pharyngitis pain relief has not been demonstrated uniformly, and there is currently insufficient evidence to endorse routine use.

7. “I treat patients with suspected acute spinal cord injury with corticosteroids—regardless of the time from injury—because it provides significant symptomatic relief.”

Corticosteroid use for acute spinal cord injury is no longer recommended. The only evidence of benefit was found if corticosteroids were given in the first 8 hours after injury.

Tables

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. The most informative references cited in this paper, as determined by the author, are noted by an asterisk (*) next to the number of the reference.

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38. Roy M, Bailey B, Amre DK, et al. Dexamethasone for the treatment of sore throat in children with suspected infectious mononucleosis: a randomized, double-blind, placebo-controlled, clinical trial. Arch Pediatr Adolesc Med. 2004;158(3):250-254. (Randomized controlled trial; 40 patients)
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