About Dr. Frederick Blount Expertise Pediatrician, retired. I trained at Childrens Hospital of Philadelphia some years ago and I did private practice here in Winston-Salem for 30 years until I went full time to the Wake Forest Medical School until retirement.
Pediatrics - Prednisone induced psychosis causing pain in 9 year old?
Expert: Dr. Frederick Blount - 2/9/2005
Question My nine year old daughter has had asthma all her life. Usually she presents few, if any symptoms (no retracting, few audible wheezes) when she is in respiratory distress. There have been times when I've taken her in for a routine physical and her pediatrician has admitted with a pulse ox of 87 and I had no idea she wasn't breathing well. Two weeks ago, she had an upper respiratory infection two weeks. The illness exasperated her asthma. Because she had been on prednisone twice in December, Urgent care put her on a relatively low dose of prednisone (20 mg/day for 4 days then dropping to 10mg.) Her pediatrician usually prescribes a taper starting with 60mg. The day we dropped to 10mg (a Sunday), she began havign a difficult time and was all presentation-- audibly wheezing, shortness of breath & very distressed but her sats were about 96%. Urgent care gave her 40mg, a continuous neb and sent us home because she was moving air fine. At midnight that same night, I took her to the hospital ER because she still felt, and appeared to be, distressed. I told them the pred doses she had previously had that day. They gave her 40mg more (totaling 90mg for the day), gave her a continuous neb and again sent her home. Her sats we consistantly 94-96. The following morning we saw the PA at her primary care office. Although she still appeared and felt distressed, her sats were still fine and a neb cleared most of her wheezes. I continued to neb her with albuterol every 2-3 hrs at home. At 5pm that night (monday), I had given her two back to back albuterol nebs. She was hysterical, bright red and seemed to be in extreme distress. I began another neb treatment with albuterol and atrovent and called the paramedics. Again, her sats were 96. They called a local hospital for consult and the ER attending said he would recomend she be admitted even though her sats were good, because of the difficulty she was having. I took her back to our usual hospital ER. It took them 1.5 hrs to triage her, and 7 hrs to find her a bed on the floor. Her sats remained consistant between 94-97. X-rays were clear for pneumonia, influenza was negative. Treatment was albuterol nebs Q4 (she often was asking for respiratory within 1.5 hrs. She would be diminished with both inspiratory and expiratory wheezes each time she complained). They bumped up her oral pred to 40mg every 6 hrs. Day two she began complaining of pain in both of her legs, blurry vision and headaches. I asked the RN if it could be from the prednisone, but she didn't know and didn't seem concerned about it. She was released after two nights, with instructions to neb every 3-4 hrs and continue oral pred 40mg every 12 hrs. The night of her release she had another "attack". I took her back to urgent care and again, she was diminished all over, but the treatment opened her and her sats were fine. It was suggested that we could treat her for the excessive anxiety, but the urgent care doc was leary about putting her on anti-anxiety meds with her asthma. The next morning we saw the PA at her primary care (her pediatrician was out of town all week), he added singular, zithromax (in case he missed something) and 2mg Ativan every 8 hrs. I was concerned that the Ativan dose might be too high for her (the pharmacist questioned the dose) and only gave her 1/4 tablet (.5mg) after which she had no more respiratory distressed symptoms. We saw her PA again Saturday morning for follow-up. Her asthma was in control. I was instructed to continue current meds, tapering the prednisone by 10mg every 4 days ending with 10 mg every other day for 4 days (12 day total). That saturday afternoon, the pain in her legs became excrutiating for her. The pain is bi-lateral from the tops of the thighs down to her toes, both front, back and deep. She said it feels like "glass" or "stiched being ripped out". I took her to a different hospital this time. Labs were fine (her alk phos had been elivated the previous wednesday at 463, it was down a bit by now to about 440). Her X-rays were fine. I was told that is was most likely prednisone induced psychosis. They gave her IV phentanol 10mg, 10mg then 20mg (possibly mcg?), but she had no releif from the pain. We were transferred to Children's Hospital. The attending wasn't sure if it was from the prednisone, he had never seen a reaction like this. They gave her 40 more of IV phentanol without much relief. It was determined that there was no organic cause of the pain and there was nothing they could do. She was sent home with tylenol-3, and instructed to continue her current meds (ativan, pred taper, singulair, advair 250/50, albuterol nebs Q8). The attending also felt that she needed to go to school, and continue life as normal as possible. She is down to 40mg prednisone/day. The pain continues. She will cry out for hours on end and I've been told we just have to wait it out. I'm tell her I know it hurts, but she still has to brush her hair and teeth, etc. She does okay at school. Distraction really seems to help (more than codeine). She has difficulty walking (with or without codeine). Do you think this pain might be due to the unusually high doses of prednisone? Any other suggestions? (for dosing purposes, she weighs 87 lbs). Your thoughts would be appreciated.
Answer I have not seen psychosis from prednisone so I can't comment on that aspect. Your story is so complex there is nothing I can add to it. It is good to tell her you know it hurts but I hope some one can ask, without making any kind of judgement on her answer, what she thinks about all of the illness - what are her fears? what does she think made her so sick? does she think she is going to die? It would be good to find a neutral adult with interview skills with children - a counsellor would be great - but any adult she trusts who will listen and not judge could help. In the best of all worlds it would be good to find some really fun thing for her to do. A trip to Dysney World for a few days would be great, but something like that nearby would be good also. Maybe a favorite playmate could go also if it is nearby and a parent who goes should not mention illness of any kind. I think this child needs a lot or reassurance for she has been through a lot. I would slowly withdraw any medication she is taking. Also, if you are in winter time look at all the things in the house that may keep her wheezing, anything that produces dust, lint and things she can breathe. If you haven't already, get rid of all animals, fuzzy toys, feather pillows. Cover the heating ducts so they don't blow dust at her. I hope she can clear up soon; she has had a tough time.
