Adjunct Corticosteroids in Children With Community-Acquired Pneumonia Presenting to the Emergency Department: A Systematic Review and Meta-Analysis.

Community-acquired pneumonia (CAP) is a leading reason for acute pediatric presentation, and the exuberant host inflammatory response that characterizes severe disease has prompted interest in adjunct systemic corticosteroids. We systematically reviewed and, where feasible, meta-analyzed the randomized evidence in children. Following PRISMA 2020, we searched PubMed, the Excerpta Medica database (Embase), the Cochrane Library, Web of Science, and ClinicalTrials.gov for randomized controlled trials comparing adjunct systemic corticosteroids plus standard care against standard care or placebo in children (<18 years) with CAP. Risk of bias was assessed with the Cochrane Risk of Bias 2 (RoB 2) tool for randomized trials. Outcomes reported by more than one trial were pooled with random-effects models, with sensitivity analyses across alternative variance estimators; medians were converted to means using an established conversion method. Trial-specific primary outcomes were synthesized narratively. Three trials (251 children) were included. Each reported a significant benefit on its own primary outcome: shorter fever duration and fewer complications with methylprednisolone in severe CAP; shorter time to recovery with dexamethasone in parapneumonic effusion; and lower early treatment failure with dexamethasone in severe CAP. Pooled length of hospital stay favored corticosteroids (mean difference -2.10 days, 95% CI -6.79 to 2.59), with substantial heterogeneity reflecting differing clinical settings (I² = 91%). All-cause mortality did not differ between groups (risk ratio 0.74, 95% CI 0.14 to 3.85). Corticosteroids were well tolerated, with transient hyperglycemia the most common adverse effect. Across three small, clinically heterogeneous randomized trials, adjunct systemic corticosteroids improved each trial's own primary outcome and were well tolerated. Because the trials were few, diverse in population and regimen, and imprecise when pooled, the current evidence is preliminary and hypothesis-generating and is insufficient to support routine use. The consistent, favorable signal supports adequately powered, phenotype-enriched pediatric trials with harmonized outcomes.