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.