Usage of Steroids in Pediatric Practice

A child is not a compressed or mini man, so the method of scaling down the adult dose of a drug on the basis of body weight is not an accurate method for treating children. The pediatric pharmacology is a complex science since the drug requirements of neonates, older infants and children are quite different from adults due to difference in the absorption, biotransformation and renal excretion of drugs. Steroids are the most important drugs discovered after antibiotics. Though the steroids are not actual therapy but they provide immediate symptomatic relief. Steroids have been used both for their systemic action as well as topical actions. Steroids should not be misused and used only when indicated. Proper doses are very important for effective therapeutic effect.

In pediatric practice systemic use of steroids is indicated in many conditions. Three major dose related categories for systemic use of steroids are: (1) Replacement Therapy, (2) Therapeutic Doses (For treating hematological, renal and immunological disorders) and (3) Massive Doses (For treating hematological and renal disorders).

1) Steroids as replacement therapy:

Use of steroids as replacement therapy in congenital adrenal hyperplasia (CAH) and Addison's disease is very much indicated. The CAH is caused due to deficiency of 21-hydroxylase, so that 17-hydroxy progesterone is not converted into cortisol but is converted into adrenal androgens. Female babies with congenital adrenal hyperplasia (CAH) will be having ambiguous genitalia and male babies will show precocious puberty. The patients with CAH may also have mineralocorticoid deficiency. The other common type of CAH is represented by 11-hydroxylase deficiency and these patients are hypertensive and have masculinized looks. Both types of patients with CAH need replacement therapy with prednisolone (5mg/m² body surface area in two divided doses) or cortisone (20mg/m²body surface area in three divided doses). The dose of steroid is monitored by the estimation of 17-ketosteriod excretion, skeletal maturation and growth rate.

2) Therapeutic doses of Steroids :

Use of steroids is extremely indicated for treating hematological, renal and immunological disorders.

1. Use of Steroids in Hematological Disorders: Steroids have important role in the treatment of acute lymphatic leukemia, idiopathic thrombocytopenic purpura (ITP). Remission of acute lymphatic leukemia can be achieved with prednisolone (40mg/m² body surface area) within 4-6 weeks. However, success rate is around 80%. A success rate of around 95% is achievable if prednisolone is combined with Vincristine. In acute ITP steroids are the drug of choice to save life and are administered at a dose of 1-2mg/kg body weight for about 3 weeks or till the platelet count improves. Around 25% of patients may develop chronic ITP and may need steroid therapy (on alternate days) for about 3-6 months.
   
   


2. Use of Steroids in Renal Disorders: Treatment of nephrotic syndrome with steroids shows remarkable results. Prednisolone is given at a dose of 2mg/kg body weight daily for 4 weeks and the same dose is given at alternate days for another 4 weeks. Around 60-65% of patients show significant response in 4 weeks another 20-25% of cases will go into remission within 8 weeks of treatment. Around 8% cases may require prolonged treatment, while 3-5% may need other modes of therapy.
   
   


3. Use of Steroids in Immunological Disorders: Steroids remain the therapy of great importance in the treatment of Lupus nephritis, SLE, dermatomyositis, polyarteritis nodosa. Prednisolone is given at a dose of 2mg/kg body weight till the remission and then tapered off to minimum maintenance dose.
   
   


4. Use of Steroids in other diseases: Severe cases of asthma and status asthmaticus, where bronchodilators alone fail to control the disease; treatment with hydrocortisone and prednisolone is indicated. Steroids have been found to be useful in the treatment of ulcerative colitis. Acute cases of ulcerative colitis can be managed well with retention enema with steroids.
   
   

3) Massive Doses:

Massive doses of steroids are administered in patients affected by endotoxic shock. In these cases, steroids decrease the peripheral resistance, increase tissue perfusion and venous return. Such cases need Hydrocortisone in doses of 50-100mg/kg body weight initially and there may be need to repeat the dose 4-6 hourly for 24-48 hours. In 'rapidly progressive glomerulonephritis' (RPGN) and 'idiopathic apastic anemia' remarkable results have been achieved with higher doses of methyl prednisolone.

Hazards of Over Compliance of Drugs

There are substantial health benefits to the patients if the drug compliance by them is 100 percent. The good communication skills of the attending physician could be helpful to overcome the chances of over compliance by a considerable number of patients. Patients need to be briefed about the side effects of over doses as well as the extra doses of the drugs prescribed to them. The intake of over doses or extra doses of any prescribed drug is called over compliance. Inspite of best efforts by the prescribing doctors, about 20% patients may even take more drugs than the prescribed dose to get cured quickly and earlier, but this can be harmful and lead to serious toxicity or a variety of side effects.

Just remember, all drugs are poisonous chemicals and if taken in excess these may affect our health in many wrong ways. Even an indicative dose of an anti-allergic causes drowsiness and if taken in excess it may lead to impairment of judgment while driving. Take an example of common salt, excessive intake of it may induce vomiting and raise the blood pressure. Over use of antibiotics may disturb the normal flora of our intestine and suppress the blood formation in the bone marrow. Over compliance of steroids is known for suppressing the immune system of our body. An over dose of insulin may lead to serious hypoglycemia (low level of glucose in blood) in a diabetic patient. Overuse of some drugs may lead to serious health hazards including organ failure. Be wise and never take over dose of any drug.