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Early postnatal dexamethasone therapy for the prevention of chronic lung disease
Insights
Early postnatal dexamethasone did not reduce death or chronic lung disease (CLD) in premature infants. The treatment increased risks of complications and poor weight gain, outweighing potential benefits.
Area of Science:
- Neonatal Medicine
- Pediatric Critical Care
- Pharmacology
Background:
- Extremely low birth weight infants often require mechanical ventilation and are at high risk for chronic lung disease (CLD).
- Early postnatal steroid administration is explored as a strategy to mitigate CLD and mortality in these vulnerable infants.
Purpose of the Study:
- To evaluate the efficacy of early postnatal dexamethasone in reducing the incidence of death or CLD at 36 weeks postmenstrual age in ventilated premature infants.
- To assess the safety and side effects associated with early dexamethasone treatment.
Main Methods:
- A multicenter, randomized, double-blinded, controlled trial involving 542 extremely low birth weight infants (501-1000 g) requiring ventilation.
- Infants received either intravenous dexamethasone or saline placebo for 12 days, with a tapering dose schedule.
- The primary outcome was death or CLD at 36 weeks postmenstrual age; secondary outcomes included various complications and clinical parameters.
Main Results:
- No significant difference was observed in the primary outcome of CLD or death between the early dexamethasone group and the placebo group (50% vs. 53%).
- Early dexamethasone treatment was associated with a reduction in patent ductus arteriosus, indomethacin use, and late steroid treatment.
- However, the early treatment group experienced increased rates of hyperglycemia, insulin use, and a trend towards gastrointestinal issues and periventricular leukomalacia, along with poorer weight gain.
Conclusions:
- A 12-day course of early postnatal dexamethasone does not decrease the risk of death or CLD in extremely low birth weight infants.
- The observed increase in serious complications and poor weight gain suggests that the risks associated with early dexamethasone outweigh the benefits for this population.
Objective:
To test the hypothesis that early postnatal dexamethasone will reduce the incidence of death or chronic lung disease (CLD) in ventilated extremely low birth weight premature infants.
Design:
Multicenter randomized double-blinded controlled clinical trial.
Setting:
A total of 42 neonatal intensive care units in the Vermont Oxford Network.
Participants:
Infants weighing 501 to 1000 g were eligible for enrollment at 12 hours of age if they needed assisted ventilation, had received surfactant replacement therapy, were physiologically stable, had no obvious life-threatening congenital anomaly, and had blood cultures obtained and antibiotic therapy initiated.
Intervention:
Infants were randomly assigned to dexamethasone or saline placebo. Intravenous dexamethasone was administered for 12 days according to the following dosing schedule: 0.5 mg/kg/d for 3 days, 0.25 mg/kg/d for 3 days, 0.10 mg/kg/d for 3 days, 0.05 mg/kg/d for 3 days. Infants in either group could receive treatment with selective late postnatal steroids beginning on day 14 of life if they were on assisted ventilation with supplemental oxygen greater than 30%.
Outcome Measurements:
The primary outcome measure was CLD or death at 36 weeks postmenstrual age.
Results:
The study was stopped before completion of sample size goals because of concern about serious side effects in the early steroid treatment group. A total of 542 infants were enrolled (early treatment N = 273, control N = 269). The 2 groups had similar demographic characteristics. No differences were noted in the primary outcome of CLD or death at 36 weeks postmenstrual age (early treatment 50% vs control: 53%, relative risk: 0.93; 95% confidence interval [CI]: 0.79-1.09). Fewer infants who received early steroid treatment had a patent ductus arteriosus (relative risk: 0.78; 95% CI: 0.63-0.96), and fewer infants in the early steroid group received indomethacin therapy (relative risk: 0.74; 95% CI: 0.64-0.86) or late steroid treatment (relative risk: 0.69; 95% CI: 0.58-0.81). However, more infants who received early steroid treatment had complications associated with therapy including an increase in hyperglycemia (relative risk: 1.29; 95% CI: 1.13-1.46) and an increase in the use of insulin therapy (relative risk: 1.62; 95% CI: 1.36-1.94). A trend toward increased gastrointestinal hemorrhage (relative risk: 1.55; 95% CI: 0.92-2.61), gastrointestinal perforation (relative risk: 1.53; 95% CI: 0.89-2.61), and an increased systolic blood pressure (relative risk: 1.34; 95% CI: 0.97-1.85) was noted. In infants receiving cranial ultrasound examinations, a marginal increase in periventricular leukomalacia was noted in the early steroid treatment group (relative risk: 2.23; 95% CI: 0.99-5.04). Infants who received early steroid therapy had fewer days in supplemental oxygen but experienced poor weight gain.
Conclusions:
A 12-day course of early postnatal steroid therapy given to extremely low birth weight infants did not decrease the risk of CLD or death at 36 weeks postmenstrual age and was associated with an increased risk of complications and poor weight gain.