Adrenal suppression from glucocorticoids: preventing an iatrogenic cause of morbidity and mortality in children

Adrenal suppression (AS) is an important side effect of glucocorticoids (GCs) including inhaled corticosteroids (ICS). AS can often be asymptomatic or associated with non-specific symptoms until a physiological stress such as an illness precipitates an adrenal crisis. Morbidity and death associated with adrenal crisis is preventable but continues to be reported in children. There is a lack of consensus about the management of children at risk of AS. However, healthcare professionals need to develop an awareness and approach to keep these children safe. In this article, current knowledge of the risk factors, diagnosis and management of AS are reviewed while drawing attention to knowledge gaps and areas of controversy. Possible strategies to reduce the morbidity associated with this iatrogenic condition are provided for healthcare professionals.

Despite clear evidence of the morbidity associated with AS in the paediatric population, evidence-based guidelines about screening and management of children at risk are lacking. There are few known risk factors for the development of symptomatic AS; therefore, the burden of screening for and managing asymptomatic biochemical AS needs to be balanced with the risk of severe morbidity and mortality in a subset of patients. There is a lack of consensus among paediatric endocrinologists about the approach to the management of children at risk of AS, and as a result, clinicians who are prescribing GC therapy may have limited guidance about how to keep their patients safe. Within this review article, our working group comprised of paediatric endocrinologists, paediatricians and other paediatric subspecialists who frequently prescribe GC therapy present the best available evidence about AS risk, screening, testing and management while acknowledging the controversies that exist about the management of AS. The intent of this review is to draw attention to this important entity and to allow the reader to create an informed and practical approach to the management of their patients at risk.

While relatively uncommon, symptomatic AS can be associated with significant morbidity and mortality. Symptomatic AS can be prevented by responsible GC prescribing and follow-up, recognition of signs and symptoms including poor growth, and screening and treatment of children at increased risk. Education of clinicians and at-risk patients/parents about AS is integral to reducing morbidity associated with this iatrogenic condition. Until further evidence is available, consultation with an endocrinologist should be considered when there is uncertainty about how to approach the management of a child or adolescent with possible or proven AS. Clinicians and families should not lose sight of the fact that GCs are essential for the management of many paediatric conditions and that the risk of AS should not be a barrier to their use.