Oral Steroids

In keeping with a regular theme of this blog, let’s review patterns of use/overuse of oral steroids. (OS).  “Glucocorticosteroids” have been in use since the 1940’s; most common forms are prednisone, prednisolone, methylprednisolone, and dexamethasone.  Note that these are not “anabolic” steroids–drugs that cause muscle development and are sometimes abused by unscrupulous athletes and coaches.  Rather these steroids reduce the body’s inflammatory response, relieving a variety of medical conditions (at least in theory) like respiratory problems (croup, bronchitis, even common cold) allergic (hives, hay fever), skin (eczema, psoriasis, seborrhea), overuse orthopedic ailments (tennis elbow, back pain).

Now, for SOME of the above, with more severe exacerbations, OS can be very helpful.  But there are pitfalls that we should keep in mind. Firstly, the evidence for efficacy in several of the above is at best questionable if not actually disproven (for example, bronchiolitis in babies and back pain in all ages).  Secondly, these are powerful drugs with significant side effects so they are best used sparingly and judiciously.  Here again, 2 more points.  #1, as I say, “the punishment should fit the crime,” by which I mean that I try to limit OS use to patients who are quite sick and/or very uncomfortable. #2 given #1 there are often milder interventions (e.g, inhaled steroids for respiratory illnesses, anti-histamines or cool bathes for hives)that can address the problem at hand at lesser risk so they should be used first whenever possible.

What are some side effects of short term (< 1 wk) OS use? (long term OS use has many serious risks and are used only for chronic or potentially life threatening illnesses)  Most common are vomiting, sleep disturbance, and mild behavior change like irritability or overactivity.  Short term immune suppression with increased risk of infection is a concern.  Less common, transient, but still unsettling are weight gain, fluid retention, slight facial swelling, and elevations of BP or blood sugar.  Growth compromise and bone thinning have not been definitively established but with repeated usage are a real concern among researchers and clinicians.  Suppression of natural steroid production has sometimes been demonstrated with even short term use.   This is actually a quite alarming development, but thankfully so far it is only a short term and biochemical phenomenon and has never been shown to cause any adverse clinical event in a patient in reality.

I keep all of that close in mind when I consider using OS.  It concerns me greatly, given all of the above, to find too many instances when my patients are treated in emergency rooms or urgent care centers where I strongly feel that the providers in those locations are too quick and easy to jump to the use of OS for milder and even clinically questionable circumstances.  If your child is treated at one of these places I urge you to carry a healthy skepticism if  prescribed OS and, if you feel it is safe, please subsequently call me or even come in so we can discuss if it is the best approach for that situation.

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The Latest on Colic

We’ve spoken about colic before.  Anyone who’s raised an infant has at least some experience here.  By definition we are referring to children ❤ mo old who cry for >3 hr/day for >3day/wk.  Officially about 20% of infants fit the definition; in reality many babies will experience at least some colicky periods.  Now, there have been almost as many remedies suggested as there are doctors treating the condition: non-medical interventions are always good–swaddling, holding, gently walking with baby; heating pads to baby’s belly, specially prepared colic relieving “gentle” formulas or nursing mother dietary changes, even extra warm baby booties; crib vibrating devices.  There have been a variety of medicines tried–“gas drops” like simethicone or “gripe water”, antacids, up to powerful narcotics like paregoric.

The truth is that all of the above have proponents and all have had some level of at least anecdotal success.  With most of the medicines used there have been credible reports of some side effects–in some instances quite serious ones.  So I generally try and stay away from drugs as we are dealing with the littlest and most vulnerable people and a problem that, while upsetting and frustrating, is otherwise benign and self limited(usually by the time the baby is 3 mo old).  So, greatest caution should be the order of the day, I think.

Into the mix we can now add probiotics, specifically those containing a bacteria called Lactobacillus reuterii.  Probiotics have actually been used in Europe with good success for quite some time now.  Several new studies, as recently as last year, compared L. reuterii to placebo and found significant improvement, at least in breast fed babies.  They were 2-3x more likely to to see improvement for an average of 46 minutes per day and spit up 2-3x less frequently.  Unfortunately, there was no significant improvement demonstrated in formula fed babies.  Dosage is important–about 1,000,000 cells/dose appears to be about right.  There are numerous preparations and brands available (I avoid naming or endorsing specific products in this blog).  Very few untoward effects have ever been reported; however I should note that some gastroenterologists express  reservations about administering doses of microorganisms to young infants.  Therefore it is best if we discuss using probiotics for your fussy baby, so give me a call and let’s talk.

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