Methylprednisolone for heart surgery in pediatric patients: a meta-analysis of randomized trials

Perioperative corticosteroids, particularly methylprednisolone, have been used for decades in pediatric cardiac surgery to attenuate the systemic inflammatory response associated with cardiopulmonary bypass. This systematic review and meta-analysis evaluated the efficacy and safety of perioperative methylprednisolone in pediatric patients undergoing cardiac surgery with cardiopulmonary bypass. This systematic review and meta-analysis followed PRISMA 2020 guidelines (PROSPERO CRD420251231338). We searched PubMed/MEDLINE, Embase, Scopus, Web of Science, and CENTRAL from inception to November 2025 for randomized controlled trials comparing perioperative intravenous methylprednisolone with placebo or standard care in patients aged < 18 years undergoing cardiac surgery with cardiopulmonary bypass. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. The primary outcome was all-cause in-hospital or 30-day mortality. Secondary outcomes included mechanical ventilation duration, cardiac intensive care unit length of stay, postoperative infections, and hyperglycemia. Random-effects models with Paule-Mandel estimator and Hartung-Knapp confidence intervals were used to pool risk ratios and mean differences. We included eight randomized controlled trials (1,735 pediatric patients; 867 on methylprednisolone, 868 controls). Overall, methylprednisolone was not associated with reduced mortality compared with control (RR 0.66, 95% CI 0.35-1.25; I² = 0%; 6 trials, 1,586 patients). However, methylprednisolone reduced the duration of mechanical ventilation (MD - 0.27 days, 95% CI - 0.46 to - 0.09; I²=0%; 5 trials) but significantly increased the risk of hyperglycemia (RR 2.28, 95% CI 1.38-3.78; I²=45.0%; 6 trials). No differences were observed in infection rates (RR 1.06, 95% CI 0.68-1.66; I²=0%; 5 trials) or ICU length of stay (MD - 0.13 days, 95% CI - 0.51 to 0.25; I²=0%; 5 trials). Perioperative methylprednisolone was not associated with reduced overall mortality in pediatric cardiac surgery. Among secondary outcomes, methylprednisolone was associated with a modest reduction in mechanical ventilation duration but with a significantly increased risk of postoperative hyperglycemia. These findings indicate that any potential benefit in ventilatory outcomes should be weighed against the higher metabolic risk. Further research is required to determine whether any patient subgroups may derive net clinical benefit from its use.