Among the reported side effects of corticosteroids, growth retardation is of particular concern and specific for pediatric age. A small yet clinically significant and persistent growth retardation is possible with long-term use of inhaled corticosteroids in childhood, even at low-to-medium doses. Nevertheless, these findings should be weighed carefully against the potential for greater growth retardation that might result should frequent asthma exacerbations occur by withholding inhaled corticosteroid therapy, thus necessitating frequent oral corticosteroid bursts [11]. Indeed, the evidence for oral corticosteroids and their effects on growth is unambiguous [12–15].

Besides growth retardation, long-term use of corticosteroids in childhood and adolescence may impair the physiological process of bone mass accrual and the attainment of peak bone mass, leading to an increased risk of osteoporosis later in life. Existing data suggest that the relationship between inhaled corticosteroid use and bone mineral density in children is conflicting and confounded by numerous other variables and awaits further evaluation. On the contrary, chronic and even intermittent use of oral corticosteroids has the potential to cause a decrease in bone mineral density and increase the risk for osteoporosis and fractures in both children and adults. Therefore, clinicians should carefully weigh the potential benefit against this risk before prescribing long-term or short-term oral corticosteroid therapy [11].

Steroid administration has been proposed for several pediatric diseases, with conflicting results. In 1975, more than 25 years after their discovery, Walton and Ney wrote, “When administered for other than adrenocortical replacement, corticosteroids are not ideal therapeutic agents because at best one may hope for suppression of a disease process but rarely, if ever, a cure.” Authors have also reported that corticosteroids are relatively benign when given in large doses for a few days but are associated with severe toxic effects when administered continuously [16]. Interestingly, in 1985 Spirer and Hauser reported again that “except for the few indications for replacement steroid therapy, the rest are still controversial. Even when the use of corticosteroids in a certain disorder is widely accepted, the preferred regimen may still be debatable. Uncontrolled anecdotal data have seeded much confusion about the real indications for steroid therapy, and created fear of its effects.” They also reported that “whenever steroid therapy may be avoided or replaced by less harmful non-steroidal drugs, the latter is preferable. A local steroid preparation is preferable to systemic therapy (such as inhaled corticosteroids for asthma or intranasal steroids for allergic rhinitis). Moreover, whenever possible a ‘steroid-saving’ policy should be used by the addition of non-steroidal preparations. Indeed, in any case the benefit from therapy should outweigh the side effects, and the preparation with the best therapeutic index should be used” [8]. Table 3 presents the diseases for which corticosteroids were proposed until 1985. Despite this large number of conditions, only in a few was the evidence in favor of administering steroids sufficient to universally recommend steroid treatment. Nowadays many studies are still conducted to evaluate the efficacy of corticosteroids in the treatment of several diseases, a large number specific for pediatric age. Table 4 lists reviews published in the Cochrane Library in the period 2013–2014, confirming that the debate and the interest regarding the therapeutic role of corticosteroids is still a matter of concern [17–34]. The indication for steroid administration changed also for diseases in which it seemed revolutionary, because of the development of new drugs with more efficacy and fewer side effects. Before the introduction of corticosteroids, children with arthritis faced a lifetime of pain and disability. Whereas corticosteroids were once the mainstay of therapy, today they are largely used as bridge or adjunctive therapies [35, 36]. However, with time, corticosteroids have acquired an important role in other diseases. For example, the 2014 UK guidelines for Kawasaki disease suggested the addition of corticosteroids to intravenous immunoglobulin in severe cases with the highest risk of intravenous immunoglobulin resistance [37]. Finally, corticosteroids have been proposed for recently characterized immunological or rheumatic diseases such as the syndrome of periodic fever with aphthous stomatitis, pharyngitis, and adenitis (PFAPA) [38] or IgG4-related disease [39].