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Early postnatal (<96 hours) corticosteroids for preventing chronic lung disease in preterm infants
1Regional Neonatal Unit, Royal Maternity Hospital, Grosvenor Road, Belfast, UK, BT12 6BB. h.halliday@qub-belfast.ac.uk
Insights
Early postnatal corticosteroids reduce chronic lung disease (CLD) and PDA in preterm infants but carry risks. Benefits may not outweigh adverse effects, necessitating reconsideration of current practices and long-term follow-up.
Area of Science:
- Neonatal Medicine
- Pediatric Pulmonology
- Pharmacology
Background:
- Chronic lung disease (CLD) is a significant neonatal intensive care unit problem, likely driven by persistent lung inflammation.
- Corticosteroids are used for CLD prevention/treatment due to potent anti-inflammatory properties.
Purpose of the Study:
- To evaluate the efficacy of early postnatal corticosteroid treatment in preventing CLD in preterm infants.
- To examine outcomes from trials using postnatal steroids within 96 hours of birth for CLD prevention.
Main Methods:
- Systematic review and meta-analysis of randomized controlled trials (RCTs) of early postnatal corticosteroids.
- Searched major databases (Oxford Database of Perinatal Trials, Cochrane, Medline) and relevant journals.
- Analyzed data on mortality, CLD, PDA, air leak, IVH, ROP, NEC, and long-term neurological outcomes.
Main Results:
- Early postnatal steroids decreased CLD rates at 28 days and 36 weeks, reduced PDA, and facilitated earlier extubation.
- No significant differences in neonatal mortality, infection, severe ROP, or NEC.
- Increased risks of gastrointestinal bleeding, intestinal perforation, hyperglycemia, and hypertension observed.
Conclusions:
- Potential benefits of early postnatal corticosteroids may be outweighed by adverse gastrointestinal and neurological effects.
- Reconsideration of current early postnatal steroid use is warranted.
- Long-term follow-up of neurological and developmental outcomes is crucial for surviving infants.
Background:
Chronic lung disease (CLD) remains a major problem in neonatal intensive care units. Persistent inflammation in the lungs is the most likely underlying pathogenesis. Corticosteroids have been used to either prevent or treat CLD because of their potent anti-inflammatory effects.
Objectives:
To determine if postnatal corticosteroid treatment is of benefit in the prevention of chronic lung disease (CLD) in the preterm infant. This review examines the outcome of trials where preterm infants at risk of CLD were given postnatal steroids within 96 hours after birth.
Search Strategy:
Randomised controlled trials of postnatal corticosteroid therapy were sought from the Oxford Database of Perinatal Trials, the Cochrane Controlled Trials Register, Medline, hand searching paediatric and perinatal journals, examining previous review articles and information received from practising neonatologists.
Selection Criteria:
Randomised controlled trials of postnatal corticosteroid treatment within 96 hours of birth (early) in high risk preterm infants were selected for this review.
Data Collection And Analysis:
Data regarding clinical outcomes including mortality, failure to extubate, pulmonary air leak, survival without chronic lung disease, CLD defined at 28 days postnatal age and 36 weeks post menstrual age, patent ductus arteriosus (PDA), severe intraventricular hemorrhage (IVH), infection, hyperglycaemia, hypertension, severe retinopathy of prematurity (ROP), necrotizing enterocolitis (NEC), gastrointestinal bleeding and longterm outcome were abstracted and analysed using Revman 4.0.4.
Main Results:
Fifteen randomised controlled trials of early postnatal corticosteroid treatment of preterm babies at risk of developing CLD were identified. A meta-analysis of these trials demonstrates benefits as regards earlier extubation, decreased risks of CLD at both 28 days and 36 weeks, death or CLD at 28 days, and PDA. There was an almost significant reduction in the risk of pulmonary air leak and in death or CLD at 36 weeks in the babies treated with early corticosteroids. There were no differences in the rates of neonatal mortality, infection, severe ROP, severe IVH, NEC and pulmonary haemorrhage. Gastrointestinal bleeding and intestinal perforation were important adverse effects and the risks of hyperglycaemia and hypertension were also increased. Several adverse neurological effects were found at follow-up examinations of survivors treated with early steroids: abnormal neurological examination, cerebral palsy and developmental delay.
Reviewer'S Conclusions:
The benefits of early postnatal corticosteroid treatment (< 96 hours) may not outweigh the known or potential adverse effects of this treatment. Gastrointestinal effects early in the neonatal period and neurological effects seen at follow-up mean that current use of early postnatal steroids needs to be reconsidered. There is a compelling need for the long term follow-up and reporting of late outcomes, especially neurologic and developmental outcomes, among surviving infants who participated in all randomized trials of early postnatal corticosteroid treatment. The role of inhaled steroids remains to be elucidated.