Postnatal corticosteroids to treat or prevent chronic lung disease in preterm infants

Question 1

What is chronic lung disease (previously bronchopulmonary dysplasia)?

Answer 1

Oxygen required at 36wks PMA with respiratory symptoms and compatible changes on CXR

Question 2

What percentage of surviving infants born <33 weeks GA require oxygen at 36wks PMA?

Answer 2

21%

Question 3

What are the benefits of early corticosteroids (before seven days of life)?

Answer 3

1. Earlier extubation

2. Reduced need for oxygen at 36 wks GA

Question 4

What are the adverse effects of early corticosteroids?

Answer 4

1. Hyperglycemia
2. Hypertension
3. GI hemorrhage
4. GI perforation
5. CP

Question 5

What is the overall recommendation regarding early corticosteroid therapy?

Answer 5

The benefits of early corticosteroid therapy do not appear to outweight the adverse effects

Question 6

What are the benefits of late dexamethasone (>7d of life)?

Answer 6

1. Decreased mortality at 28d
2. Reduced rate of CLD at 36wks PMA
3. Reduced combined outcome of death or CLD at 36 weks GA
4. Decreased failure to extubate within 7d
5. Decreased number of infants discharged home on oxygen

Question 7

What are the adverse effects of late corticosteroids?

Answer 7

1. Hyperglycemia
2. Hypertension
3. Hypertrophic cardiomyopathy
4. Severe ROP
5. No effect on CP or neurosensory disability

Question 8

What is the overall recommendation regarding late corticosteroid therapy?

Answer 8

Late dexamethasone appeared to have both beneficial and harmful effects, it was suggested that its use be reserved for infants who could not be weaned from mechanical ventilation

Question 9

What is the evidence for low dose dexamethasone?

Answer 9

At present, there is insufficient evidence to demonstrate the safety of routine low-dose dexamethasone use.

Question 10

What is the evidence for those at high risk of CLD?

Answer 10

If the rate of CLD was >65%, dexamethasone treatment appeared to decrease the rate of death or cerebral palsy. This suggests that dexamethasone may be beneficial to infants at very high risk of CLD but this has not yet been studied in clinical trials

Question 11

What is the evidence for hydrocortisone therapy?

Answer 11

Overall, although hydrocortisone may be a promising alternative to dexamethasone for treating babies with CLD or prolonged ventilator dependence, there is no evidence at this time to show that it is effective or safe.

Question 12

What is the evidence for inhaled corticosteroid?

Answer 12

There is currently little evidence to support the routine use of inhaled corticosteroids for the prevention or treatment of CLD. Inhaled corticosteroids do not appear to offer significant benefits over systemic corticosteroids for the treatment of infants who remain ventilator-dependent

Question 13

What is the risk of adrenal insufficiency?

Answer 13

Risk in preterm infants that have been on corticosteroids

Question 14

What are the current recommendations for use of postnatal corticosteroids in the prevention of CLD?

Answer 14

1. Using postnatal corticosteroids – dexamethasone, hydrocortisone or inhaled corticosteroids – within the first seven days of life to prevent CLD is not recommended.
2. Administering high-dose dexamethasone (0.5 mg/kg/day) to prevent or treat CLD is not recommended.
3. The routine use of low-dose dexamethasone (0.15 mg/kg/day to 0.2 mg/kg/day) for all infants who require assisted ventilation after seven days of age to prevent or treat CLD is not recommended.
4. Hydrocortisone is not recommended for treating CLD.
5. The routine use of inhaled corticosteroids to prevent CLD is not recommended.
6. It is unclear whether the benefits of late dexamethasone therapy outweigh the adverse effects for infants who are at high risk of CLD or for those with prolonged ventilator-dependence. If clinicians choose, after parental agreement, to treat an infant who is ventilator-dependent, at risk of severe CLD or who has severe CLD, low-dose dexamethasone (initial dose 0.15 mg/kg/day to 0.2 mg/ kg/day) should be used in tapering doses over a short course (seven to 10 days). Inhaled corticosteroids may be considered as an alternative to dexamethasone, but the most effective dose and duration of therapy is not known.
7. Randomized trials are needed to investigate low-dose dexamethasone treatment regimes, the treatment of infants at high risk for CLD, and the impact of inhaled corticosteroids for the management of infants with CLD. It is imperative that all trials include long-term neurodevelopmental follow-up.