Corticosteroids for the management of pediatric parapneumonic effusions
In a randomized controlled trial conducted in Spain and including 60 children hospitalized with community acquired pneumonia and pleural effusion, the use of dexamethasone (0.25mg/kg/ 6 hours for 48 hours)versus placebo reduced the time to recovery by almost 3 days with no apparent increase in serious adverse events. In that study, more patients receiving placebo than receiving dexamethasone needed eventual pleural drainage (16% versus 5%), but the study was underpowered to determine statistical significance for this analysis22.
To date, no other studies have assessed the role of corticosteroids in the management of parapneumonic effusion in children. However, this question makes sense, especially when the inflammatory response is clinically evident. Indeed, the anti-inflammatory properties of corticosteroids no longer need to be demonstrated 23. Beneficial effects of corticosteroids have been observed in several infectious processes where inflammation may play a key role, including respiratory diseases: in patients hospitalized with community-acquired pneumonia, the use of (methyl)prednisone reduces treatment failure and improves recovery, and meta-analysis of the few available randomized trials suggest that corticosteroids are associated with a reduction in mortality, in need for mechanical ventilation and in hospital length of stay; moreover, the use of dexamethasone in patients hospitalized with coronavirus disease 2019 (COVID-19) recently resulted in lower 28-day mortality among those receiving respiratory support13,24-26. But corticosteroids have also potential drawbacks, as they can cause systemic immunosuppression27. Corticosteroid treatment in influenza is associated with increased mortality and hospital-acquired infection, even though the evidence relates mainly to high corticosteroid doses and is of low quality with a high potential for confounding by indication28.
Considering the lack of evidence, our approach is rather cautious and conservative: we use corticosteroids as a rescue therapy when antibiotics and pleural drainage are considered a failure, only after a few days of intravenous antibiotics and only if no lung abscess has been found on chest tomodensitometry. With this strategy, no children underwent surgery in our cohort for failure of the medical management.