To the Editor: Steroid psychosis is quite well-described in older children and adolescents, but its recognition in infants and young children is a tough task due to non-specific symptoms and a lack of awareness of the entity in the said age group. Steroids are increasingly used in a multitude of conditions in children as a pulse therapy or for a longer duration. While acute toxicity in the form of hyperglycemia and hypertension, and chronic toxicity such as cushingoid features, cataract, and hyperlipidemia are commonly sought for, subtle neuro-behavioral changes are not often looked for and hence, missed.

We had a 9-mo-old male baby, who presented with epileptic spasms. Oral prednisolone was started at 4 mg/kg/d. On day two of starting steroids, he had excessive irritability, inconsolable cry, reduced sleep, and continued to have a few clusters of spasms. Blood pressure and serum glucose levels were within normal limits. While we did consider that this could be due to spasms or an early marker of cerebral palsy, the temporality of events gave us a clue that steroid toxicity was a possibility. On stopping steroids and starting vigabatrin for the spasms, irritability reduced over one week and he was discharged.

High-dose steroids are commonly used in the management of epileptic spasms in infants. Six percent of adults on steroids are reported to have steroid-induced psychosis, however, the incidence in children is not known. To the best of our knowledge, the youngest reported case of steroid toxicity has been that of a 2-y-old boy with asthma [1]. The mechanism could be due to a dose-dependent change in the neurotransmitters such as dopamine, and serotonin leading to psychosis [2]. At times, low dose risperidone or olanzapine may have to be used to treat this. Pediatricians should be aware of this and counsel parents before starting steroids to avoid unnecessary anxiety.