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Symptomatic adrenal suppression among children in Canada
  1. Ellen B Goldbloom1,
  2. Arati Mokashi2,
  3. Elizabeth A Cummings2,
  4. Sharon Abish3,
  5. Susanne M Benseler4,
  6. Hien Q Huynh5,
  7. Wade Watson6,
  8. Alexandra Ahmet1
  1. 1Department of Pediatrics (Endocrinology), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
  2. 2Department of Pediatrics (Endocrinology), IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
  3. 3Department of Pediatrics (Hematology Oncology), Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
  4. 4Department of Pediatrics (Rheumatology), Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
  5. 5Department of Pediatrics (Gastroenterology), Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
  6. 6Department of Pediatrics (Allergy), IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
  1. Correspondence to Dr Ellen B Goldbloom, Department of Pediatrics (Endocrinology), Children's Hospital of Eastern Ontario, University of Ottawa, 401 Smyth Rd, Rm 5109, Ottawa, Ontario, Canada K1H 8L1; egoldbloom{at}cheo.on.ca

Abstract

Background Adrenal suppression (AS) is an under-recognised side effect of glucocorticoid (GC) use. AS may go undetected until a physiological stress precipitates an adrenal crisis. The incidence of AS has not been established. We sought to estimate the minimum national incidence and presenting features of paediatric symptomatic AS.

Methods Through the established methodology of the Canadian Paediatric Surveillance Program, over 2500 paediatricians were surveyed monthly for 2 years (April 2010–March 2012) to report new cases of symptomatic AS.

Results Forty-six cases of symptomatic AS were confirmed. The estimated annual incidence is 0.35/100 000 children aged 0–18 years (95% CI 0.26 to 0.47). The most common presentations were growth failure (35%), non-specific symptoms (28%) or both (13%). Adrenal crisis occurred in six cases (13%). Thirty-seven children (80%) had received inhaled corticosteroid (ICS) alone or in combination with other GC forms. Many children received high but commonly prescribed doses of ICS.

Conclusions AS is responsible for significant morbidity in children, including susceptibility to adrenal crisis. The minimal estimated incidence reported is for the entire paediatric population and would be much higher in the at-risk group (ie, children treated with GCs). Close monitoring of growth and possible symptoms of AS, which may be non-specific, are important in children on all forms of GC therapy including ICS. To reduce the risk of AS, physicians must be aware of the risk of AS, revisit GC doses frequently and use the lowest effective dose.

  • adrenal suppression
  • asthma
  • glucocorticoids
  • adrenal crisis
  • adrenal insufficiency

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Footnotes

  • Contributors EBG was a co-principal investigator. She conceptualised and designed the study, was a primary reviewer for all cases reported, coordinated and supervised data collection, analysis and interpretation, drafted the initial manuscript and approved the final manuscript as submitted. AA was a co-principal investigator. She conceptualised and designed the study, was a primary reviewer for all cases reported, contributed to the data collection, analysis and interpretation, edited early drafts of the manuscript and approved the final manuscript as submitted. AM was a co-investigator. She reviewed cases that required a third opinion, promoted the study in her own centre and specialty, contributed to interpretation of the data, edited early drafts of the manuscript and approved the final manuscript as submitted. EAC was a co-investigator. She promoted the study in her own centre and specialty, contributed to interpretation of the data, edited early drafts of the manuscript and approved the final manuscript as submitted. SA, SMB, HH and WW were co-investigators. They promoted the study in their own centres and across their specialties, and contributed to interpretation of the data. They reviewed and revised the manuscript and approved the final manuscript as submitted.

  • Funding This material is based upon work supported by a grant from The Physicians' Services Inc. Foundation and through the Canadian Paediatric Surveillance Program.

  • Competing interests AA has received honoraria for continuing education from Nycomed/Takeda and as a consultant to Reveragen. WW received honoraria from Sanofi.

  • Ethics approval Children's Hospital of Eastern Ontario Research Ethics Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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