Systemic Corticosteroids in Pediatric Community-Acquired Pneumonia: Evidence, Clinical Outcomes, and Phenotype-Based Therapeutic Considerations

Background: Community-acquired pneumonia (CAP) remains a leading cause of pediatric morbidity and mortality worldwide, particularly in low-resource settings. Although antimicrobial therapy is the cornerstone of treatment, disease severity is often influenced not only by pathogen burden but also by dysregulated host inflammation. Systemic corticosteroids have therefore been investigated as adjunctive agents to reduce inflammation-mediated lung injury, but their role in children remains controversial. Methods: This narrative review summarizes current evidence on systemic corticosteroid use in pediatric pneumonia. The review focuses on biological mechanisms, clinical indications, patient selection, therapeutic regimens, timing and duration of therapy, clinical outcomes, and safety. Particular attention is given to severe CAP, Mycoplasma pneumoniae pneumonia, complicated pneumonia with parapneumonic effusion or empyema, viral pneumonia, wheezing-associated phenotypes, and immunocompromised children. Results: Available evidence suggests that corticosteroids may provide benefit in selected pediatric phenotypes characterized by severe inflammation, respiratory compromise, refractory disease, or airway hyperreactivity. Reported benefits include faster fever resolution, reduction in inflammatory markers, shorter hospital stay, more rapid clinical stabilization, and improved radiographic recovery, particularly in severe or refractory Mycoplasma pneumoniae pneumonia and selected complicated cases. However, findings are inconsistent, and treatment effects appear strongly dependent on etiology, disease severity, timing of administration, corticosteroid regimen, and patient phenotype. Routine use in uncomplicated CAP or unselected pediatric populations is not supported. Potential adverse effects include hyperglycemia, gastrointestinal and neurobehavioral symptoms, sleep disturbance, immunosuppression with an increased risk of secondary infection, delayed viral clearance in selected viral infections, and possible masking of inadequate anti-infective response or evolving complications. Conclusions: Current evidence supports a cautious, individualized, phenotype-driven approach to corticosteroid therapy in pediatric CAP. Well-designed pediatric randomized controlled trials are needed to define precise indications, optimal regimens, timing, and long-term safety.