It's well known that long-term corticosteroid use can have serious adverse effects, including Cushingoid features, gastrointestinal (GI) bleeding, infections, glaucoma, hyperglycemia, cardiovascular disease, and osteoporosis. Steroids are typically prescribed long term only when the benefits outweigh these risks. Short-term use of steroids has generally been considered harmless, as adverse effects increase with duration of exposure.

Now, however, a large-scale population study in JAMA Pediatrics of 4.5 million children has shown that even the short-term use of steroids for 14 days or less-called a corticosteroid burst-may carry serious risks.

Researchers in Taiwan used data from the National Health Insurance Program, which enrolls 99% of the population, from January 2013 to December 2017. They assessed the rates of four severe adverse events-GI bleeding, sepsis, pneumonia, and glaucoma-in children who had been prescribed a single steroid burst and in those who had never received a burst during the five-year period.

Among the 4,542,623 children younger than 18 who were eligible for inclusion, 1,064,587, or 23%, had received a single corticosteroid burst, most commonly for respiratory infections or allergic diseases. The incidence rates for the four adverse effects were higher for those who had received a steroid burst than for those who had not. Corticosteroid burst use was significantly associated with a 1.4-fold increase in GI bleeding, a 2-fold increase in sepsis, and a 2.2-fold increase in pneumonia within 30 days of starting the medication. The increased risk of glaucoma was not statistically significant.

While a handful of studies involving adults have shown increased rates of serious adverse events after short-term corticosteroid treatment, this is the first study to provide similar data in children. Corticosteroid bursts, therefore, should not be considered harmless, concluded the authors.

Corticosteroids were prescribed for one-quarter of all children in the study, typically for non-life-threatening conditions. Ninety-one percent of these children had no underlying health problems; thus the authors suggested the drugs might have been avoided without negative consequences. Clinical guidelines should indicate that benefits must clearly outweigh risks when prescribing steroid bursts, according to the authors, who also advised that careful monitoring of pediatric patients during the month following the first dose is crucial.-Joan Zolot, PA