PURPOSE OF THE STUDY.
To determine the national incidence and presenting features of pediatric glucocorticoid-induced symptomatic adrenal suppression (AS) in Canada by using a national pediatric surveillance program.
Canadian pediatricians and pediatric subspecialists in clinical practice participated in a prospective surveillance through the Canadian Pediatric Surveillance Program, surveying for rare conditions.
Over 2500 pediatricians and pediatric subspecialists were surveyed monthly for 2 years through the Canadian Pediatric Surveillance Program either by mail or e-mail. A check-off form asked physicians whether they had identified any new cases of symptomatic adrenal suppression (AS). If a positive response was received, a case report form (CRF) was completed by the responding physician, capturing demographic and medical information. CRFs were reviewed independently by the principal investigators to ensure that there was agreement regarding confirmed cases.
During 2 years of surveillance, 80% of pediatricians participated in the surveillance program. There were 115 cases of symptomatic adrenal suppression (AS) reported, with 46 cases being confirmed. The estimated annual incidence of symptomatic AS is 0.35/100 000 children aged 0–18 years (95% CI 0.26–0.47). More than one-third of the children presented with growth failure, highlighting the importance of growth monitoring in children treated with glucocorticoids (GC). More than one-quarter had nonspecific symptoms such as fatigue, lethargy, nausea, anorexia, vomiting, abdominal pain, and myalgias. Several children exhibited features of Cushing’s syndrome. Six children presented with adrenal crisis, one of whom later died. Although GC administration by any route has the potential to result in adrenal suppression, 80% of the children with symptomatic AS were receiving GC by inhaler alone or inhaler in combination with other routes. Nearly two-thirds of the children had asthma, and another 15% had asthma plus another condition being treated with GC. Almost one-third of the children were treated with ICS alone. The most commonly used ICS was fluticasone, with most children receiving doses of ∼500 µg/day.
The estimated incidence of symptomatic AS in the pediatric population is small, but it is potentially much higher in at-risk groups (children treated with GC). The close monitoring of growth and asking about nonspecific symptoms such as fatigue, nausea, and myalgia may help with earlier detection. To reduce the risk of AS, physicians must be aware that AS can occur, evaluate GC doses frequently, and use the lowest effective dose.
This study is a good reminder that we must be aware of the risk of adrenal suppression in children treated with glucocorticoids. Although inhaled corticosteroids have dramatically improved asthma care, the close monitoring of growth and attention to nonspecific or vague symptoms suggesting AS is essential. Our goal for asthma treatment is to use the least amount possible to keep asthma in control.
- Copyright © 2017 by the American Academy of Pediatrics