Paeds · clinical-pharmacology-and-therapeutics

Corticosteroid therapy and adverse effects

Also known as Glucocorticoid therapy in children · Prednisolone dosing and weaning · Adrenal suppression from steroids · Stress-dose hydrocortisone · Corticosteroid adverse effects

A fellowship approach to corticosteroid therapy in children covering glucocorticoid versus mineralocorticoid potency and the equivalent-dose ladder (hydrocortisone, prednisolone, methylprednisolone, dexamethasone), weight-based prednisolone and dexamethasone dosing for asthma and croup, the hypothalamic-pituitary-adrenal axis and how exogenous steroids suppress it, the recognition and emergency management of adrenal crisis with age-banded stress-dose hydrocortisone, the safe weaning of longer courses, and the full spectrum of adverse effects from growth suppression to osteopenia.

high12 referencesUpdated 17 July 202619 min readVerification in progress

Practise this topic

On this page & tools

Your progress

Saved locally on this device.

Practise this topic

Target exams

RACP General PaediatricsRACP DWERACP DCERCPCH Progress+MRCPCH TheoryMRCPCH ClinicalABP General PediatricsACGME PediatricsRCPSC Pediatrics

Red flags

A child on long-term or high-dose corticosteroids who collapses, vomits, or becomes hypoglycaemic during a febrile illness is in adrenal crisis until proven otherwiseAbrupt cessation of systemic corticosteroids after more than two to three weeks of pharmacologic dosing without a weaning planFailure to give stress-dose hydrocortisone before surgery, sepsis, or major trauma in a child with known or suspected adrenal suppressionInhaled corticosteroid escalated to a very high dose (especially fluticasone) without checking for declining growth, weight, or cortisolInterpreting a single random cortisol as reassuring during critical illness, when the axis is dynamically stressedUsing dexamethasone where mineralocorticoid activity is needed, or hydrocortisone where profound anti-inflammatory potency is needed, without understanding potency equivalence

Life stages

neonateinfanttoddlerpreschoolschool-ageadolescentyoung-adult-transition

Care settings

community-schooloutpatientwarded-acutenicupicuretrievaltelehealth

Clinical exam formats

written-only

Board mappings

General and Community PaediatricsCurrent 2026 PREP curriculum — Learning Objective: Safe prescribing and medication management in infants, children and young peopleCurrent 2026 PREP curriculum — Learning Objective 2.2.1: Recognise, prioritise and manage an acutely ill infant, child or young personRenewed curriculum for first-year trainees from 2027 — Learning goal 6: Clinical management – essential general paediatricsRenewed curriculum for first-year trainees from 2027 — Learning goal 9: Quality and safety, including medication safetyClinical ApplicationsMedical SciencesLong CasesShort Cases4. Professional skills and knowledge: Patient management7. Patient safety, including safe prescribing8. Quality improvement and patient safetyGeneral Paediatrics: Prescribes and monitors medicines safely, including corticosteroids and adrenal replacement therapyFoundation of Practice (FOP)Theory and Science (TAS)Applied Knowledge in Practice (AKP)ClinicalHistoryCommunicationGeneral Pediatrics Content Outline — Domain 10: Principles of Pharmacology and Medication ManagementGeneral Pediatrics Content Outline — Domain 4: Endocrine DisordersGeneral Pediatrics Content Outline — Universal Task 4: Management and TreatmentSystems-Based Practice 2: Medication Safety and StewardshipPatient Safety/Quality Improvement 1: Medication SafetyMedical Knowledge 2: Diagnostic and Therapeutic Decision MakingMedical ExpertPharmacistPediatrics: Core EPA #5 — Recommending and Initiating Pharmacologic Interventions

Your progress

Saved locally on this device.

Practise this topic

Target exams

RACP General PaediatricsRACP DWERACP DCERCPCH Progress+MRCPCH TheoryMRCPCH ClinicalABP General PediatricsACGME PediatricsRCPSC Pediatrics

Red flags

Life stages

neonateinfanttoddlerpreschoolschool-ageadolescentyoung-adult-transition

Care settings

community-schooloutpatientwarded-acutenicupicuretrievaltelehealth

Clinical exam formats

written-only

Board mappings

The fellowship answer

Corticosteroids are the most powerful anti-inflammatory medicines you will prescribe in paediatrics, and the price of that power is a predictable set of adverse effects and a suppressed adrenal axis. You choose the agent by matching the disease to the drug's glucocorticoid potency, its mineralocorticoid activity, and its duration of action: hydrocortisone when you need physiological replacement or mineralocorticoid cover, prednisolone for the common anti-inflammatory courses, and dexamethasone when you need maximal glucocorticoid potency with negligible salt retention. The dose is weight-based — prednisolone 1 to 2 mg/kg once daily for an asthma exacerbation, dexamethasone 0.15 mg/kg as a single oral dose for croup — [1] [3] — and any course longer than two to three weeks of pharmacologic dosing suppresses the hypothalamic-pituitary-adrenal axis and must be weaned. The danger a candidate must never miss is adrenal crisis: the steroid-dependent child who collapses, vomits, or becomes hypoglycaemic under stress needs immediate age-banded intravenous hydrocortisone — 25 mg in an infant, 50 mg in a young child, 100 mg in an adolescent — with fluid, glucose, and a search for the precipitant. [9] [12]

Overview & Definition

Picture a five-year-old gasping with an asthma exacerbation who improves within hours of a single dose of oral prednisolone, a toddler with croup whose stridor melts after dexamethasone, and a teenager on long-term prednisolone for nephrotic syndrome who arrives in the emergency department collapsed and hypoglycaemic with a fever. These three children sit on the two edges of the same medicine: its capacity to switch off inflammation, and its capacity to switch off the adrenal cortex. Corticosteroid therapy is the prescribing discipline that uses the first while defending against the second. [11] [7]

A corticosteroid earns its place when inflammation, immune activation, or hormone deficiency is the disease. Three properties decide which agent you reach for. Glucocorticoid potency measures anti-inflammatory strength relative to hydrocortisone. Mineralocorticoid activity measures the tendency to retain sodium and water and waste potassium. Duration of action measures how long the drug suppresses the hypothalamic-pituitary-adrenal (HPA) axis after a single dose — short-acting agents allow the axis to recover between doses, long-acting agents suppress it continuously. Hydrocortisone is the physiological replacement; prednisolone is the workhorse anti-inflammatory; dexamethasone is the high-potency, minimal-mineralocorticoid option. Choosing well means matching the property to the job. [7] [8]

Paediatrics Fellowship Pro

You have read the opening of this topic. The complete unit — every section and its primary-source references — is part of the Paediatrics Fellowship fellowship atlas.

References12Show ledger

[1]Paniagua N, Lopez R, Muñoz N, et al. Randomized Trial of Dexamethasone Versus Prednisone for Children with Acute Asthma Exacerbations. The Journal of pediatrics, 2017.PMID 29173304
[2]Elkharwili DA, Ibrahim OM, Elazab GA, Elrifaey SM Two regimens of dexamethasone versus prednisolone for acute exacerbations in asthmatic Egyptian children. European journal of hospital pharmacy, 2020.PMID 32419935
[3]Cetinkaya F, Tüfekçi BS, Kutluk G A comparison of nebulized budesonide, and intramuscular, and oral dexamethasone for treatment of croup. International journal of pediatric otorhinolaryngology, 2004.PMID 15013613
[4]Watterberg KL, Walsh MC, Li L, Chawla S, et al. Hydrocortisone to Improve Survival without Bronchopulmonary Dysplasia. The New England journal of medicine, 2022.PMID 35320643
[5]Patel L, Wales JK, Kibirige MS, Massarano AA, et al. Symptomatic adrenal insufficiency during inhaled corticosteroid treatment. Archives of disease in childhood, 2001.PMID 11567945
[6]Schwartz RH, Neacsu O, Ascher DP, Alpan O Moderate dose inhaled corticosteroid-induced symptomatic adrenal suppression: case report and review of the literature. Clinical pediatrics, 2012.PMID 23043135
[7]Husebye ES, Pearce SH, Krone NP, et al. Adrenal insufficiency. Lancet, 2021.PMID 33484633
[8]Hahner S, Ross RJ, Arlt W, Bancos I, et al. Adrenal insufficiency. Nature reviews. Disease primers, 2021.PMID 33707469
[9]Nowotny H, Ahmed SF, Bensing S, Beun JG, et al. Therapy options for adrenal insufficiency and recommendations for the management of adrenal crisis. Endocrine, 2021.PMID 33661460
[10]Woodcock T, Barker P, Daniel S, Fletcher S, et al. Guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency. Anaesthesia, 2020.PMID 32017012
[11]Auron M, Raissouni N Adrenal insufficiency. Pediatrics in review, 2015.PMID 25733761
[12]Lee SC, Baranowski ES, Sakremath R, Saraff V, et al. Hypoglycaemia in adrenal insufficiency. Frontiers in endocrinology, 2023.PMID 38053731

Corticosteroid therapy and adverse effects

Also known as Glucocorticoid therapy in children · Prednisolone dosing and weaning · Adrenal suppression from steroids · Stress-dose hydrocortisone · Corticosteroid adverse effects

high12 referencesUpdated 17 July 202619 min readVerification in progress

Practise this topic

Overview & Definition

Paediatrics Fellowship Pro

You have read the opening of this topic. The complete unit — every section and its primary-source references — is part of the Paediatrics Fellowship fellowship atlas.

References12Show ledger

[1]Paniagua N, Lopez R, Muñoz N, et al. Randomized Trial of Dexamethasone Versus Prednisone for Children with Acute Asthma Exacerbations. The Journal of pediatrics, 2017.PMID 29173304
[2]Elkharwili DA, Ibrahim OM, Elazab GA, Elrifaey SM Two regimens of dexamethasone versus prednisolone for acute exacerbations in asthmatic Egyptian children. European journal of hospital pharmacy, 2020.PMID 32419935
[3]Cetinkaya F, Tüfekçi BS, Kutluk G A comparison of nebulized budesonide, and intramuscular, and oral dexamethasone for treatment of croup. International journal of pediatric otorhinolaryngology, 2004.PMID 15013613
[4]Watterberg KL, Walsh MC, Li L, Chawla S, et al. Hydrocortisone to Improve Survival without Bronchopulmonary Dysplasia. The New England journal of medicine, 2022.PMID 35320643
[5]Patel L, Wales JK, Kibirige MS, Massarano AA, et al. Symptomatic adrenal insufficiency during inhaled corticosteroid treatment. Archives of disease in childhood, 2001.PMID 11567945
[6]Schwartz RH, Neacsu O, Ascher DP, Alpan O Moderate dose inhaled corticosteroid-induced symptomatic adrenal suppression: case report and review of the literature. Clinical pediatrics, 2012.PMID 23043135
[7]Husebye ES, Pearce SH, Krone NP, et al. Adrenal insufficiency. Lancet, 2021.PMID 33484633
[8]Hahner S, Ross RJ, Arlt W, Bancos I, et al. Adrenal insufficiency. Nature reviews. Disease primers, 2021.PMID 33707469
[9]Nowotny H, Ahmed SF, Bensing S, Beun JG, et al. Therapy options for adrenal insufficiency and recommendations for the management of adrenal crisis. Endocrine, 2021.PMID 33661460
[10]Woodcock T, Barker P, Daniel S, Fletcher S, et al. Guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency. Anaesthesia, 2020.PMID 32017012
[11]Auron M, Raissouni N Adrenal insufficiency. Pediatrics in review, 2015.PMID 25733761
[12]Lee SC, Baranowski ES, Sakremath R, Saraff V, et al. Hypoglycaemia in adrenal insufficiency. Frontiers in endocrinology, 2023.PMID 38053731