Association of Oral Corticosteroid Bursts With Severe Adverse Events in Children | Critical Care Medicine | JAMA Pediatrics | JAMA Network
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    1 Comment for this article
    Paul Nelson, MS, MD | Family Health Care, PC retired
    Clearly, this is an interesting study. The widespread prescribing of steroids for Taiwanese children seems, at best, unusual. This study reports that 42% of all children in Taiwan are receiving at least one burst of corticosteroids during their childhood. The association with glaucoma seems particularly alarming. Makes one wonder about the factors that might underly the
    administration of multiple episodes of corticosteroid use for too many children.
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    Original Investigation
    April 19, 2021

    Association of Oral Corticosteroid Bursts With Severe Adverse Events in Children

    Author Affiliations
    • 1Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
    • 2School of Medicine, Chang Gung University College of Medicine, Taoyuan, Taiwan
    • 3Center for Allergy and Clinical Immunology Research, College of Medicine, National Cheng Kung University, Tainan, Taiwan
    • 4Department of Pediatrics, National Cheng Kung University Hospital, Tainan, Taiwan
    • 5Department of Statistics, National Cheng Kung University, Tainan, Taiwan
    • 6Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan
    • 7Precision Medicine and Translational Research Center, Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts
    • 8Department of Pediatrics, Children’s Hospital, Boston, Massachusetts
    • 9Department of Pediatrics, New Taipei Municipal Tu Cheng Hospital, Chang Gung Memorial Hospital, New Taipei, Taiwan
    JAMA Pediatr. Published online April 19, 2021. doi:10.1001/jamapediatrics.2021.0433
    Key Points

    Question  Are there potential harms associated with oral corticosteroid bursts (defined as the use of oral corticosteroids for 14 or fewer days) in children?

    Findings  In this nationwide population-based cohort study of 1 064 587 children who received a single corticosteroid burst, a burst was associated with 1.4- to 2.2-fold increased risk of gastrointestinal bleeding, sepsis, and pneumonia within the first month after corticosteroid initiation.

    Meaning  This study suggests that clinicians should be aware of potentially severe adverse events associated with corticosteroid bursts in children.


    Importance  The adverse effects from the long-term use of oral corticosteroids are known, but, to our knowledge, few studies have reported the risk of corticosteroid bursts, particularly among children.

    Objective  To quantify the associations of corticosteroid bursts with severe adverse events, including gastrointestinal (GI) bleeding, sepsis, pneumonia, and glaucoma, in children.

    Design, Setting, and Participants  This cohort study used data derived from the National Health Insurance Research Database in Taiwan from January 1, 2013, to December 31, 2017, on children younger than 18 years of age and used a self-controlled case series design. Data were analyzed from January 1 to July 30, 2020.

    Exposure  Oral corticosteroid bursts (defined as oral corticosteroid use for ≤14 days).

    Main Outcomes and Measures  Incidence rates were calculated of 4 severe adverse events (GI bleeding, sepsis, pneumonia, and glaucoma) in children who did or did not receive corticosteroid bursts. Conditional fixed-effect Poisson regression was used to estimate incidence rate ratios (IRRs) of severe adverse events within 5 to 30 days and 31 to 90 days after initiation of corticosteroid bursts.

    Results  Among 4 542 623 children, 23% (1 064 587; 544 268 boys [51.1%]; mean [SD] age, 9.7 [5.8] years) were prescribed a single corticosteroid burst. The most common indications were acute respiratory tract infections and allergic diseases. The incidence rate differences per 1000 person-years between children administered a single corticosteroid burst and those not prescribed corticosteroids 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 (95% CI, 0.01-0.03) for glaucoma. The IRRs 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 IRRs within the subsequent 31 to 90 days 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.

    Conclusions and Relevance  This study suggests that corticosteroid bursts, which are commonly prescribed for children with respiratory and allergic conditions, are associated with a 1.4- to 2.2-fold increased risk of GI bleeding, sepsis, and pneumonia within the first month after initiation of corticosteroid therapy that is attenuated during the subsequent 31 to 90 days.