[The use of postnatal corticosteroid therapy in premature infants to prevent or treat bronchopulmonary dysplasia: current situation and recommendations]

Neurodevelopment at 24 months corrected age in extremely preterm infants treated with dexamethasone alternatives during the late postnatal period: a cohort study

The administration of dexamethasone has been associated with suboptimal neurodevelopment. We aimed to compare the development of extremely premature infants treated or not with alternatives to dexamethasone: betamethasone, hydrocortisone hemisuccinate. This retrospective cohort study included infants born before 29 weeks of gestational age, treated or not with late (day ≥ 7) postnatal steroids (betamethasone, hydrocortisone hemisuccinate). The neurodevelopment outcome was evaluated at 24 months corrected age, after adjustment on comorbidities of extreme prematurity. In order to analyse their overall development, data about growth and respiratory outcomes were collected. Among the 192 infants included, 59 (30.7%) received postnatal steroids. Suboptimal neurodevelopment concerned 37/59 (62.7%) postnatal steroid-treated and 43/133 (38.1%; p = 0.002) untreated infants. However, in multivariable analysis, only severe neonatal morbidity (p = 0.007) and male gender (p = 0.027) were associated with suboptimal neurodevelopment outcome at 24 months.  Conclusions: Betamethasone or hydrocortisone hemisuccinate treatment was not an independent risk for suboptimal neurological development, growth and respiratory outcomes assessed at 24 months corrected age in extremely premature infants.  Registration number: The study was registered on the ClinicalTrials.gov register: NCT05055193. What is Known: • Late postnatal steroids are used to treat bronchopulmonary dysplasia • Meta-analyses warned against the neurological risk of dexamethasone use during neonatal period. Early or late hydrocortisone hemisuccinate has been evaluated in multiple studies, none of which have reported an adverse effect on neurodevelopment at least to 2 years. Data about the use of betamethasone are scarce. What is New: • The risk of suboptimal neurodevelopment was higher among extremely premature infants who received postnatal steroids when compared to those who did not. • Betamethasone and hydrocortisone hemisuccinate treatment was not an independent risk factor for suboptimal neurodevelopment at 24 months corrected age.

Postnatal corticosteroid exposure in very preterm infants: A French cohort study

Background: Postnatal corticosteroids (PC) are widely used in very preterm infants. International reports and national multicenter trials describe a marked variability across countries and inter-sites, in the use of PC. Few information is available on therapeutic indications and prescription characteristics of PC.

Aim: The main objective of this study was to describe the exposure to PC in a large cohort of preterm infants born at less than 32 weeks of gestation, according to the prescription data of 41 tertiary-care NICUs in France. Secondary objectives were to describe therapeutic indications, day of life (DOL) of the first exposure, route of administration, duration, cumulative dose for each drug, and differences in exposure rates across centers.

Methods: We conducted a prospective observational cohort analysis from January 2017 to December 2021, in 41 French tertiary-care NICUs using the same computerized order-entry system.

Results: In total, 13,913 infants [birth weight 1144.8 (±365.6) g] were included. Among them, 3633 (26.1%) were exposed to PC, 21.8% by systemic and 10.1% by inhaled route. Within the study population, 1,992 infants (14.3%) received the first corticosteroid treatment in the first week of life and 1641 (11.8%) after DOL 7. The more frequent indications were prevention and/or treatment of bronchopulmonary dysplasia, and arterial hypotension. Hydrocortisone was the more often prescribed molecule. For systemic PC the first exposure occurred in mean at DOL 9.4 (±13.5), mean duration of treatment was 10.3 (±14.3) days, and the cumulative dose (expressed as the equivalent dose of hydrocortisone) was in median [IQR] 9.0 [5.5–28.8] mg/kg. For inhaled PC, the first exposure occurred in mean at DOL 34.1 (±19.7), and mean duration of treatment 28.5 (±24.4) days. The exposure rate ranged from a minimum of 5% to a maximum of 56% among centers, and significantly increased over the study period (p < 0.0001).

Conclusion: In this French cohort of very preterm infants, around one patient out to five was exposed to PC during hospital stay in the NICU. The exposure occurred early, starting from the first week of life. Exposure rate widely varied among centers. Pharmacoepidemiology studies are useful to increase knowledge on corticosteroid utilization patterns in preterm infants.

Neurodevelopmental impairment at 2 years of age in children born before 29 weeks' gestation with bronchopulmonary dysplasia

INTRODUCTION

Very preterm children are at a high risk for neurological impairment, especially those with bronchopulmonary dysplasia (BPD). The main goal of this study was to describe the neurodevelopmental impairment (NDI) at 2 years of corrected age in children born before 29 weeks' gestation between 2010 and 2015 and affected by BPD at 28 days of life. We also searched for risk factors associated with NDI, especially postnatal steroid (PNS) administration.

MATERIAL AND METHODS

This was a retrospective study comprising a cohort of children hospitalized at the university hospital in Grenoble, born before 29 weeks' gestation between 2010 and 2015, and included in the monitoring network "Naitre et Devenir" (RND). Infants at 2 years of corrected age were classified as having NDI if they had at least one of the following outcomes: a global developmental quotient (DQ) on the revised Brunet-Lézine scale of<85, blindness, deafness, or cerebral palsy (CP) graded as level 3 or more according to the Gross Motor Function Classification System.

RESULTS

A total of 129 children were included, of whom 99 were monitored at the age of 2 years: 31.3% of the population had NDI and 4% had CP. The median DQ test result was 90 (interquartile 82-97). Factors associated with NDI in univariate analysis were low gestational age, low birth weight, a cord pH<7.2, chorioamnionitis, treatment for persistent ductus arteriosus, longer oxygen therapy, and outborn status, which almost reached statistical significance. In multivariate analysis, low gestational age and outborn status remained statistically significant, while chorioamnionitis was found to have some association with NDI. While 13.1% of the followed-up population was treated with PNS, this risk factor was not associated with NDI.

CONCLUSION

In a population of very preterm children, one third had NDI at 2 years of corrected age. Low gestational age, outborn status, and perinatal inflammation are associated with this unfavorable outcome. The frequency of sequelae confirms the importance of following up these children.

Postnatal Corticosteroids Policy for Very Preterm Infants and Bronchopulmonary Dysplasia

INTRODUCTION

Postnatal corticosteroids (PNC) are effective for reducing bronchopulmonary dysplasia (BPD) in very preterm neonates but are associated with adverse effects including an increased risk of cerebral palsy. PNC use in Europe is heterogeneous across regions. This study aimed to assess whether European neonatal intensive care units (NICUs) with a low use of PNC or an explicit policy to reduce PNC use had higher risks of mortality or BPD.

METHODS

We included 3,126 infants in 105 NICUs born between 24 + 0 and 29 + 6 weeks' gestational age in 19 regions in 11 countries in the EPICE cohort. First, we identified clusters of NICUs using hierarchical clustering based on PNC use and BPD prevalence and compared case mix and mortality between the clusters. Second, a multilevel analysis was performed to evaluate the association between a restrictive PNC policy and BPD occurrence.

RESULTS

There were 3 clusters of NICUs: 52 with low PNC use and a low BPD rate, 37 with low PNC use and a high BPD rate, and 16 with high PNC use and a medium BPD rate. Neonatal mortality did not differ between clusters (p = 0.88). A unit policy of restricted PNC use was not associated with a higher risk of BPD (odds ratio 0.68; 95% confidence interval: 0.45-1.03) after adjustment.

CONCLUSION

Up to 49% of NICUs had low PNC use and low BPD rates, without a difference in mortality. Infants hospitalized in NICUs with a stated policy of low PNC use did not have an increased risk of BPD.

The Therapeutic Potential of Stem Cells for Bronchopulmonary Dysplasia: "It's About Time" or "Not so Fast" ?

OBJECTIVE

While the survival of extremely premature infants has improved over the past decades, the rate of complications - especially for bronchopulmonary dysplasia (BPD) - remains unacceptably high. Over the past 50 years, no safe therapy has had a substantial impact on the incidence and severity of BPD.

METHODS

This may stem from the multifactorial disease pathogenesis and the increasing lung immaturity. Mesenchymal Stromal Cells (MSCs) display pleiotropic effects and show promising results in neonatal rodents in preventing or rescuing lung injury without adverse effects. Early phase clinical trials are now underway to determine the safety and efficacy of this therapy in extremely premature infants.

RESULTS AND CONCLUSION

This review summarizes our current knowledge about MSCs, their mechanism of action and the results of preclinical studies that provide the rationale for early phase clinical trials and discuss remaining gaps in our knowledge.

[Does corticosteroid treatment during the pre and postnatal periods affect the neurodevelopmental outcome of premature newborns?]

INTRODUCTION

Glucocorticoids, widely used in the perinatal period, may be associated with adverse neurodevelopmental effects.

OBJECTIVES

To analyze neurodevelopmental outcomes in a cohort of very low birth weight newborns treated with antenatal and/or postnatal corticosteroids.

MATERIALS AND METHODS

This was a prospective cohort study in which we included all very low birth weight babies admitted to the neonatal intensive care unit of a tertiary hospital between 2008 and 2013. We compared the neurodevelopment among very low birth-weight newborns who did not receive prenatal corticosteroid therapy and those who received a complete course (two doses of 12 mg betamethasone) and an incomplete course (one dose), and between those who did not receive postnatal corticosteroid therapy and those who received it (systemic dexamethasone after the first week of life). Motor, neurosensory and cognitive functions, as well as behavior disorders during the first two years of age were evaluated.

RESULTS

A total of 225 very low birth weight newborns were analyzed; 83.6% received prenatal corticosteroid therapy (24% incomplete treatment schedule and 59.6% complete schedule). Only 13.3% received systemic dexamethasone during the postnatal period. Neurological monitoring was performed corticosteroid therapy and more neurological disorders, and no significant differences were found among those who received complete and incomplete courses of prenatal corticosteroid therapy.

CONCLUSION

These results did not demonstrate an association between perinatal corticosteroid therapy and worse neurodevelopmental outcomes in very low birth weight newborns.

Evidence-Based Neonatal Unit Practices and Determinants of Postnatal Corticosteroid-Use in Preterm Births below 30 Weeks GA in Europe. A Population-Based Cohort Study

Background

Postnatal corticosteroids (PNC) were widely used to treat and prevent bronchopulmonary dysplasia in preterm infants until studies showed increased risk of cerebral palsy and neurodevelopmental impairment. We aimed to describe PNC use in Europe and evaluate the determinants of their use, including neonatal characteristics and adherence to evidence-based practices in neonatal intensive care units (NICUs).

Methods

3917/4096 (95,6%) infants born between 24 and 29 weeks gestational age in 19 regions of 11 European countries of the EPICE cohort we included. We examined neonatal characteristics associated with PNC use. The cohort was divided by tertiles of probability of PNC use determined by logistic regression analysis. We also evaluated the impact of the neonatal unit’s reported adherence to European recommendations for respiratory management and a stated policy of reduced PNC use.

Results

PNC were prescribed for 545/3917 (13.9%) infants (regional range 3.1–49.4%) and for 29.7% of infants in the highest risk tertile (regional range 5.4–72.4%). After adjustment, independent predictors of PNC use were a low gestational age, small for gestational age, male sex, mechanical ventilation, use of non-steroidal anti-inflammatory drugs to treat persistent ductus arteriosus and region. A stated NICU policy reduced PNC use (odds ratio 0.29 [95% CI 0.17; 0.50]).

Conclusion

PNC are frequently used in Europe, but with wide regional variation that was unexplained by neonatal characteristics. Even for infants at highest risk for PNC use, some regions only rarely prescribed PNC. A stated policy of reduced PNC use was associated with observed practice and is recommended.

Bronchopulmonary Dysplasia: Chronic Lung Disease of Infancy and Long-Term Pulmonary Outcomes

Bronchopulmonary dysplasia (BPD) is a chronic lung disease most commonly seen in premature infants who required mechanical ventilation and oxygen therapy for acute respiratory distress. While advances in neonatal care have resulted in improved survival rates of premature infants, limited progress has been made in reducing rates of BPD. Lack of progress may in part be attributed to the limited therapeutic options available for prevention and treatment of BPD. Several lung-protective strategies have been shown to reduce risks, including use of non-invasive support, as well as early extubation and volume ventilation when intubation is required. These approaches, along with optimal nutrition and medical therapy, decrease risk of BPD; however, impacts on long-term outcomes are poorly defined. Characterization of late outcomes remain a challenge as rapid advances in medical management result in current adult BPD survivors representing outdated neonatal care. While pulmonary disease improves with growth, long-term follow-up studies raise concerns for persistent pulmonary dysfunction; asthma-like symptoms and exercise intolerance in young adults after BPD. Abnormal ventilatory responses and pulmonary hypertension can further complicate disease. These pulmonary morbidities, combined with environmental and infectious exposures, may result in significant long-term pulmonary sequalae and represent a growing burden on health systems. Additional longitudinal studies are needed to determine outcomes beyond the second decade, and define risk factors and optimal treatment for late sequalae of disease.

Availability and Quality of Emergency Obstetric and Newborn Care in Bangladesh

Bangladesh's maternal mortality and neonatal mortality remain unacceptably high. We assessed the availability and quality of emergency obstetric care (EmOC) and emergency newborn care (EmNC) services at health facilities in Bangladesh. We randomly sampled 50 rural villages and 50 urban neighborhoods throughout Bangladesh and interviewed the director of eight and nine health facilities nearest to each sampled area. We categorized health facilities into different quality levels (high, moderate, low, and substandard) based on staffing, availability of a phone or ambulance, and signal functions (six categories for EmOC and four categories for EmNC). We interviewed the directors of 875 health facilities. Approximately 28% of health facilities did not have a skilled birth attendant on call 24 hours per day. The least commonly performed EmOC signal function was administration of anticonvulsants (67%). The quality of EmOC services was high in 33% and moderate in 52% of the health facilities. The least common EmNC signal function was kangaroo mother care (7%). The quality of EmNC was high in 2% and moderate in 33% of the health facilities. Approximately one-third of health facilities lack 24-hour availability of skilled birth attendants, increasing the risk of peripartum complications. Most health facilities offered moderate to high quality services for EmOC and low to substandard quality for EmNC.

Psychiatric adverse effects of pediatric corticosteroid use

Corticosteroids, highly effective drugs for myriad disease states, have considerable neuropsychiatric adverse effects that can manifest in cognitive disorders, behavioral changes, and frank psychiatric disease. Recent reviews have summarized these effects in adults, but a comprehensive review on corticosteroid effects in children has not been published since 2005. Here, we systematically review articles published since then that, we find, naturally divide into 3 main areas: (1) chronic effects of acute prenatal and neonatal exposure associated with prematurity and congenital conditions; (2) immediate behavioral effects of acute exposure via oncological protocols; and (3) acute behavioral effects of sporadic use in children and adolescents with other conditions. PsycInfo, MEDLINE, Embase, and Scopus were queried to identify articles reporting psychiatric adverse effects of corticosteroids in pediatric patients. Search terms included corticosteroids, adrenal cortex hormones, steroid psychosis, substance-induced psychoses, glucocorticoids, dexamethasone, hydrocortisone, prednisone, adverse effects, mood disorders, mental disorders, psychosis, psychotic, psychoses, side effect, chemically induced, emotions, affective symptoms, toxicity, behavior, behavioral symptoms, infant, child, adolescent, pediatric, paediatric, neonatal, children, teen, and teenager. Following guidelines for systematic reviews from the Potsdam Consultation on Meta-Analysis, we have found it difficult to draw specific conclusions that are more than general impressions owing to the quality of the available studies. We find a mixed picture with neonates exposed to dexamethasone, with some articles reporting eventual deficits in neuropsychiatric functioning and others reporting no effect. In pediatric patients with acute lymphoblastic leukemia, corticosteroid use appears to correlate with negative psychiatric and behavioral effects. In children treated with corticosteroids for noncancer conditions, adverse effects have been observed both during treatment and after cessation, although the data from article to article are not consistent enough to establish dose relationships. By and large, inhaled corticosteroids are considered safe and free of severe neuropsychiatric effects. Although both antipsychotic medications and benzodiazepines have been used to treat corticosteroid-induced mania and psychosis, no unified management strategy has emerged. Large-scale standardized investigations are needed to clarify the psychiatric effect of corticosteroids on children in all these conditions. Meanwhile, there is general agreement that patients as well as caregivers should be warned of the potential for behavioral adverse effects when patients receive these drugs.

Efficacy of betamethasone on the fetal motion and biophysical profile and amniotic fluid index in preterm fetuses

The term ofpreterm birth is used to define the premature neonates considering pregnancy age. In less than 34 week pregnancies, corticosteroids are prescribed to promote embryos' lung maturity. The presents study aimed at evaluating effects of betamethasone injection on feeling embryo motion by mother and index and biophysical profile in preterm pregnancies. In a descriptive-analytical study, 40 pregnant women with the pregnancy age of 30-34 weeks were evaluated. Embryo motion and index and biophysical profile of the amniotic fluid were checked before prescription of double dosage of muscular betamethasone (12 mg) at a 24 h time interval. The injection was repeated for 24 and 48 h after the first injection. The resulted outcomes were compared with those results related to before betamethasone injection. In this study, there was statistically meaningful relationship between embryo motions before injection of betamethasone and 12 h after its injection (p = 0.03). Also, there was a significant relationship between embryo motions 24 and 48 h after injection of betamethasone (p = 0.001). In other words, the embryo motions decreased 12 h after injection of betamethasone. They were improved 48 h after betamethasone injection. But, index and biophysical profile results of amniotic fluid were left unchanged. Application of betamethasone leads to evident but transient decrease in embryo motions. Although motion element of index and biophysical profile of amniotic fluid which is one of the tests used in evaluating the embryo health is fixed and normal, it can be concluded that injection of betamethasone may not affect embryo health.

Postnatal steroids in extremely low birth weight infants: betamethasone or hydrocortisone?

AIM

To compare the efficacy and tolerance of betamethasone (BTM) and hydrocortisone (HC) in weaning extremely low birth weight (ELBW) infants with bronchopulmonary dysplasia (BPD) from the ventilator.

METHODS

Monocentric, retrospective, cohort analysis based on prospective, standardized collection of data between 2005 and 2011 in ELBW receiving postnatal steroids (PS) after the second week of life. We used BTM for the first 4 years, and thereafter HC. We compared extubation rates, growth, glycaemia and blood pressure.

RESULTS

Sixty-seven infants received PS: 35 BTM and 32 HC. Most infants (83% BTM vs. 72% HC) were extubated during treatment (p = 0.281). During PS, the need for insulin was similar. Mean arterial blood pressure was similar at day 3 of PS, but was significantly lower in infants treated by BTM 30 days after the end of treatment. The z-scores for body weight and head circumference indicated significantly greater loss in BTM than HC group. This persisted only for body weight after adjustment for differences in energy intake and corticosteroid dose.

CONCLUSION

Our study suggests that HC may be as efficient as BTM in facilitating the extubation of ELBW infants, without short-term adverse effects. Blood pressure monitoring and investigation of long-term neurodevelopment are nevertheless needed.