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Melan N, Pradat P, Godbert I, Pastor-Diez B, Basson E, Picaud JC. Neurodevelopment at 24 months corrected age in extremely preterm infants treated with dexamethasone alternatives during the late postnatal period: a cohort study. Eur J Pediatr 2024; 183:677-687. [PMID: 37955745 PMCID: PMC10912127 DOI: 10.1007/s00431-023-05319-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/18/2023] [Accepted: 10/28/2023] [Indexed: 11/14/2023]
Abstract
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.
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Affiliation(s)
- Nathalie Melan
- Department of Neonatology, Hôpital de La Croix-Rousse, Hospices Civils de Lyon, 69004, Lyon, France
| | - Pierre Pradat
- Centre for Clinical Research, Hôpital de La Croix-Rousse, Hospices Civils de Lyon, 69004, Lyon, France
| | - Isabelle Godbert
- Department of Neonatology, Hôpital de La Croix-Rousse, Hospices Civils de Lyon, 69004, Lyon, France
| | - Blandine Pastor-Diez
- Department of Neonatology, Hôpital de La Croix-Rousse, Hospices Civils de Lyon, 69004, Lyon, France
| | - Eliane Basson
- Department of Neonatology, Hôpital de La Croix-Rousse, Hospices Civils de Lyon, 69004, Lyon, France
| | - Jean-Charles Picaud
- Department of Neonatology, Hôpital de La Croix-Rousse, Hospices Civils de Lyon, 69004, Lyon, France.
- CarMen Laboratory, INSERM, INRA, Université Claude Bernard Lyon 1, Pierre-Bénite, 69310, Lyon, France.
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Winter EL, Caemmerer JM, Trudel SM, deLeyer-Tiarks J, Bray MA, Dale BA, Kaufman AS. Does the Degree of Prematurity Relate to the Bayley-4 Scores Earned by Matched Samples of Infants and Toddlers across the Cognitive, Language, and Motor Domains? J Intell 2023; 11:213. [PMID: 37998712 PMCID: PMC10671985 DOI: 10.3390/jintelligence11110213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 09/30/2023] [Accepted: 11/03/2023] [Indexed: 11/25/2023] Open
Abstract
The literature on children born prematurely has consistently shown that full-term babies outperform preterm babies by about 12 IQ points, even when tested as adolescents, and this advantage for full-term infants extends to the language and motor domains as well. The results of comprehensive meta-analyses suggest that the degree of prematurity greatly influences later test performance, but these inferences are based on data from an array of separate studies with no control of potential confounding variables such as age. This study analyzed Bayley-4 data for 66 extremely premature infants and toddlers (<32 weeks), 70 moderately premature children (32-36 weeks), and 133 full-term children. All groups were carefully matched on key background variables by the test publisher during the standardization of the Bayley-4. This investigation analyzed data on the five subtests: cognitive, expressive communication, receptive communication, fine motor, and gross motor. A multivariate analysis of covariance (MANCOVA) assessed for group mean differences across the three subsamples, while controlling for the children's age. Extremely premature children scored significantly lower than moderately premature children on all subtests, and both preterm groups were significantly outscored by the full-term sample across all domains. In each set of comparisons, the cognitive and motor subtests yielded the largest differences, whereas language development, both expressive and receptive, appeared the least impacted by prematurity. A follow-up MANOVA was conducted to examine full-term versus preterm discrepancies on the five subtests for infants (2-17 months) vs. toddlers (18-42 months). For that analysis, the two preterm groups were combined into a single preterm sample, and a significant interaction between the age level and group (full-term vs. preterm) was found. Premature infants scored lower than premature toddlers on receptive communication, fine motor, and cognitive. Neither expressive communication nor gross motor produced significant discrepancies between age groups The findings of this study enrich the preterm literature on the degree of prematurity; the age-based interactions have implications for which abilities are most likely to improve as infants grow into toddlerhood.
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Affiliation(s)
- Emily L Winter
- School of Health Sciences Clinical PsyD Program, Touro University, New York, NY 10036, USA
| | | | - Sierra M Trudel
- Department of Occupational and Environmental Medicine, University of Connecticut School of Medicine, Farmington, CT 06030, USA
| | | | - Melissa A Bray
- Department of Educational Psychology, University of Connecticut, Storrs, CT 06268, USA
| | - Brittany A Dale
- Department of Special Education, Ball State University, Muncie, IN 47306, USA
| | - Alan S Kaufman
- Department of Educational Psychology, University of Connecticut, Storrs, CT 06268, USA
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Warmerdam LA, van Wezel-Meijler G, de Vries LS, Groenendaal F, Steggerda SJ. The Association of Dexamethasone and Hydrocortisone with Cerebellar Growth in Premature Infants. Neonatology 2023; 120:615-623. [PMID: 37379806 DOI: 10.1159/000531075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 04/28/2023] [Indexed: 06/30/2023]
Abstract
OBJECTIVES Corticosteroids are used to prevent or treat lung disease of prematurity. While neurological side effects have been reported, detailed effects on cerebellar growth are unknown. This study aimed to compare cerebellar growth in premature infants who received dexamethasone or hydrocortisone to premature infants who did not receive postnatal corticosteroids. STUDY DESIGN Retrospective case-control study in infants born at a gestational age of <29 weeks and admitted to two level 3 neonatal intensive care units. Exclusion criteria were severe congenital anomalies and cerebellar or severe supratentorial lesions. Infants were treated with dexamethasone (unit 1) or hydrocortisone (unit 2) for chronic lung disease. Controls (unit 1) did not receive postnatal corticosteroids. Sequential head circumference (HC) and ultrasound measurements of transcerebellar diameter (TCD), biparietal diameter (BPD), and corpus callosum-fastigium length (CCFL) were performed until 40 weeks' postmenstrual age (PMA). Growth was assessed using linear mixed models correcting for PMA at measurement, sex, HC z-score at birth, and a propensity score indicating illness severity. Group differences before treatment were assessed using linear regression. RESULTS 346 infants were included (68 dexamethasone, 37 hydrocortisone, 241 controls). Before starting corticosteroids, TCD, BPD, and HC measurements did not differ between patients and controls at a comparable PMA. After starting treatment, both types of corticosteroid had a negative association with TCD growth. BPD, CCFL, and HC growth were not negatively affected. CONCLUSION Administration of dexamethasone and hydrocortisone are both associated with impaired cerebellar growth in premature infants without evident negative associations with cerebral growth.
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Affiliation(s)
- Laura A Warmerdam
- Department of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Linda S de Vries
- Department of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, and Brain Center, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Sylke J Steggerda
- Department of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
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Onland W, van de Loo M, Offringa M, van Kaam A. Systemic corticosteroid regimens for prevention of bronchopulmonary dysplasia in preterm infants. Cochrane Database Syst Rev 2023; 3:CD010941. [PMID: 36912887 PMCID: PMC10015219 DOI: 10.1002/14651858.cd010941.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
BACKGROUND Systematic reviews showed that systemic postnatal corticosteroids reduce the risk of bronchopulmonary dysplasia (BPD) in preterm infants. However, corticosteroids have also been associated with an increased risk of neurodevelopmental impairment. It is unknown whether these beneficial and adverse effects are modulated by differences in corticosteroid treatment regimens related to type of steroid, timing of treatment initiation, duration, pulse versus continuous delivery, and cumulative dose. OBJECTIVES To assess the effects of different corticosteroid treatment regimens on mortality, pulmonary morbidity, and neurodevelopmental outcome in very low birth weight infants. SEARCH METHODS We conducted searches in September 2022 of MEDLINE, the Cochrane Library, Embase, and two trial registries, without date, language or publication- type limits. Other search methods included checking the reference lists of included studies for randomized controlled trials (RCTs) and quasi-randomized trials. SELECTION CRITERIA We included RCTs comparing two or more different treatment regimens of systemic postnatal corticosteroids in preterm infants at risk for BPD, as defined by the original trialists. The following comparisons of intervention were eligible: alternative corticosteroid (e.g. hydrocortisone) versus another corticosteroid (e.g. dexamethasone); lower (experimental arm) versus higher dosage (control arm); later (experimental arm) versus earlier (control arm) initiation of therapy; a pulse-dosage (experimental arm) versus continuous-dosage regimen (control arm); and individually-tailored regimens (experimental arm) based on the pulmonary response versus a standardized (predetermined administered to every infant) regimen (control arm). We excluded placebo-controlled and inhalation corticosteroid studies. DATA COLLECTION AND ANALYSIS Two authors independently assessed eligibility and risk of bias of trials, and extracted data on study design, participant characteristics and the relevant outcomes. We asked the original investigators to verify if data extraction was correct and, if possible, to provide any missing data. We assessed the following primary outcome: the composite outcome mortality or BPD at 36 weeks' postmenstrual age (PMA). Secondary outcomes were: the components of the composite outcome; in-hospital morbidities and pulmonary outcomes, and long-term neurodevelopmental sequelae. We analyzed data using Review Manager 5 and used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS We included 16 studies in this review; of these, 15 were included in the quantitative synthesis. Two trials investigated multiple regimens, and were therefore included in more than one comparison. Only RCTs investigating dexamethasone were identified. Eight studies enrolling a total of 306 participants investigated the cumulative dosage administered; these trials were categorized according to the cumulative dosage investigated, 'low' being < 2 mg/kg, 'moderate' being between 2 and 4 mg/kg, and 'high' > 4 mg/kg; three studies contrasted a high versus a moderate cumulative dose, and five studies a moderate versus a low cumulative dexamethasone dose. We graded the certainty of the evidence low to very low because of the small number of events, and the risk of selection, attrition and reporting bias. Overall analysis of the studies investigating a higher dose versus a lower dosage regimen showed no differences in the outcomes BPD, the composite outcome death or BPD at 36 weeks' PMA, or abnormal neurodevelopmental outcome in survivors assessed. Although there was no evidence of a subgroup difference for the higher versus lower dosage regimens comparisons (Chi2 = 2.91, df = 1 (P = 0.09), I2 = 65.7%), a larger effect was seen in the subgroup analysis of moderate-dosage regimens versus high-dosage regimens for the outcome cerebral palsy in survivors. In this subgroup analysis, there was an increased risk of cerebral palsy (RR 6.85, 95% CI 1.29 to 36.36; RD 0.23, 95% CI 0.08 to 0.37; P = 0.02; I² = 0%; NNTH 5, 95% CI 2.6 to 12.7; 2 studies, 74 infants). There was evidence of subgroup differences for higher versus lower dosage regimens comparisons for the combined outcomes death or cerebral palsy, and death and abnormal neurodevelopmental outcomes (Chi2 = 4.25, df = 1 (P = 0.04), I2 = 76.5%; and Chi2 = 7.11, df = 1 (P = 0.008), I2 = 85.9%, respectively). In the subgroup analysis comparing a high dosage regimen of dexamethasone versus a moderate cumulative-dosage regimen, there was an increased risk of death or cerebral palsy (RR 3.20, 95% CI 1.35 to 7.58; RD 0.25, 95% CI 0.09 to 0.41; P = 0.002; I² = 0%; NNTH 5, 95% CI 2.4 to 13.6; 2 studies, 84 infants; moderate-certainty evidence), and death or abnormal neurodevelopmental outcome (RR 3.41, 95% CI 1.44 to 8.07; RD 0.28, 95% CI 0.11 to 0.44; P = 0.0009; I² = 0%; NNTH 4, 95% CI 2.2 to 10.4; 2 studies, 84 infants; moderate-certainty evidence). There were no differences in outcomes between a moderate- and a low-dosage regimen. Five studies enrolling 797 infants investigated early initiation of dexamethasone therapy versus a moderately early or delayed initiation, and showed no significant differences in the overall analyses for the primary outcomes. The two RCTs investigating a continuous versus a pulse dexamethasone regimen showed an increased risk of the combined outcome death or BPD when using the pulse therapy. Finally, three trials investigating a standard regimen versus a participant-individualized course of dexamethasone showed no difference in the primary outcome and long-term neurodevelopmental outcomes. We assessed the GRADE certainty of evidence for all comparisons discussed above as moderate to very low, because the validity of all comparisons is hampered by unclear or high risk of bias, small samples of randomized infants, heterogeneity in study population and design, non-protocolized use of 'rescue' corticosteroids and lack of long-term neurodevelopmental data in most studies. AUTHORS' CONCLUSIONS The evidence is very uncertain about the effects of different corticosteroid regimens on the outcomes mortality, pulmonary morbidity, and long term neurodevelopmental impairment. Despite the fact that the studies investigating higher versus lower dosage regimens showed that higher-dosage regimens may reduce the incidence of death or neurodevelopmental impairment, we cannot conclude what the optimal type, dosage, or timing of initiation is for the prevention of BPD in preterm infants, based on current level of evidence. Further high quality trials would be needed to establish the optimal systemic postnatal corticosteroid dosage regimen.
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Affiliation(s)
- Wes Onland
- Emma Children's Hospital, Amsterdam University Medical Centers, Department of Neonatology, Amsterdam, Netherlands
- Amsterdam Reproduction & Development, Amsterdam, Netherlands
| | - Moniek van de Loo
- Emma Children's Hospital, Amsterdam University Medical Centers, Department of Neonatology, Amsterdam, Netherlands
- Amsterdam Reproduction & Development, Amsterdam, Netherlands
| | - Martin Offringa
- Child Health Evaluative Sciences, Hospital for Sick Children, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Division of Neonatology, The Hospital for Sick Children, Toronto, Canada
| | - Anton van Kaam
- Emma Children's Hospital, Amsterdam University Medical Centers, Department of Neonatology, Amsterdam, Netherlands
- Amsterdam Reproduction & Development, Amsterdam, Netherlands
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Robles I, Eidsness MA, Travis KE, Feldman HM, Dubner SE. Effects of postnatal glucocorticoids on brain structure in preterm infants, a scoping review. Neurosci Biobehav Rev 2023; 145:105034. [PMID: 36608916 PMCID: PMC9898165 DOI: 10.1016/j.neubiorev.2023.105034] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 12/11/2022] [Accepted: 01/02/2023] [Indexed: 01/07/2023]
Abstract
Glucocorticoids (GC) are used in neonatal intensive care units to prevent or reduce the severity of chronic lung disease in preterm infants and have been implicated in impaired neurodevelopment. Our objective was to identify what is known about the effects of postnatal GC treatment in human preterm infants on structural brain development and to identify gaps in the literature. Following Arksey and O'Malley's scoping review methodological framework, we searched scientific literature databases for original research on human preterm infants, postnatal GCs, and brain structure. 11 studies assessed the effects of GCs on structural brain outcomes. 56 studies reported brain injury, but not structure. Dexamethasone was consistently associated with decreased total and regional brain volumes, including cerebellar volumes. Hydrocortisone was often, but not always associated with absence of brain volume differences. No studies examined the impact of inhaled GC on brain structure. Additional research on the effects of neonatal GCs after preterm birth on a variety of structural brain measures is required for understanding contributions to neurodevelopment and informing practice guidelines.
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Affiliation(s)
- Isabella Robles
- Division of Developmental-Behavioral Pediatrics, Department of Pediatrics, Stanford University School of Medicine, United States
| | - Margarita Alethea Eidsness
- Division of Developmental-Behavioral Pediatrics, Department of Pediatrics, Stanford University School of Medicine, United States
| | - Katherine E Travis
- Division of Developmental-Behavioral Pediatrics, Department of Pediatrics, Stanford University School of Medicine, United States
| | - Heidi M Feldman
- Division of Developmental-Behavioral Pediatrics, Department of Pediatrics, Stanford University School of Medicine, United States
| | - Sarah E Dubner
- Division of Developmental-Behavioral Pediatrics, Department of Pediatrics, Stanford University School of Medicine, United States.
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Di Cosmo C, De Marco G, Agretti P, Ferrarini E, Dimida A, Falcetta P, Benvenga S, Vitti P, Tonacchera M. Screening for drugs potentially interfering with MCT8-mediated T 3 transport in vitro identifies dexamethasone and some commonly used drugs as inhibitors of MCT8 activity. J Endocrinol Invest 2022; 45:803-814. [PMID: 34850364 DOI: 10.1007/s40618-021-01711-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 11/19/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Monocarboxylate transporter 8 (MCT8) is the first thyroid hormone transporter that has been linked to a human disease. Besides genetic alterations other factors might impair MCT8 activity. AIM This study aimed at investigating whether some common drugs having a structural similarity with TH and/or whose treatment is associated with thyroid function test abnormalities, or which behave as antagonists of TH action can inhibit MCT8-mediated T3 transport. METHODS [125I]T3 uptake and efflux were measured in COS-7 cells transiently transfected with hMCT8 before and after exposure to increasing concentrations of hydrocortisone, dexamethasone, prednisone, prednisolone, amiodarone, desethylamiodarone, dronedarone, buspirone, carbamazepine, valproic acid, and L-carnitine. The mode of inhibition was also determined. RESULTS Dexamethasone significantly inhibited T3 uptake at 10 μM; hydrocortisone reduced T3 uptake only at high concentrations, i.e. at 500 and 1000 μM; prednisone and prednisolone were devoid of inhibitory potential. Amiodarone caused a reduction of T3 uptake by MCT8 only at the highest concentrations used (44% at 50 μM and 68% at 100 μM), and this effect was weaker than that produced by desethylamiodarone and dronedarone; buspirone resulted a potent inhibitor, reducing T3 uptake at 0.1-10 μM. L-Carnitine inhibited T3 uptake only at 500 mM and 1 M. Kinetic experiments revealed a noncompetitive mode of inhibition for all compounds. All drugs inhibiting T3 uptake did not affect T3 release. CONCLUSION This study shows a novel effect of some common drugs, which is inhibition of T3 transport mediated by MCT8. Specifically, dexamethasone, buspirone, desethylamiodarone, and dronedarone behave as potent inhibitors of MCT8.
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Affiliation(s)
- C Di Cosmo
- Department of Clinical and Experimental Medicine, Endocrinology Unit, University of Pisa, via Paradisa 2, 56124, Pisa, Italy.
| | - G De Marco
- Department of Clinical and Experimental Medicine, Endocrinology Unit, University of Pisa, via Paradisa 2, 56124, Pisa, Italy
| | - P Agretti
- Laboratory of Chemistry and Endocrinology, University Hospital of Pisa, Pisa, Italy
| | - E Ferrarini
- Department of Clinical and Experimental Medicine, Endocrinology Unit, University of Pisa, via Paradisa 2, 56124, Pisa, Italy
| | - A Dimida
- Department of Clinical and Experimental Medicine, Endocrinology Unit, University of Pisa, via Paradisa 2, 56124, Pisa, Italy
| | - P Falcetta
- Department of Clinical and Experimental Medicine, Endocrinology Unit, University of Pisa, via Paradisa 2, 56124, Pisa, Italy
| | - S Benvenga
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - P Vitti
- Department of Clinical and Experimental Medicine, Endocrinology Unit, University of Pisa, via Paradisa 2, 56124, Pisa, Italy
| | - M Tonacchera
- Department of Clinical and Experimental Medicine, Endocrinology Unit, University of Pisa, via Paradisa 2, 56124, Pisa, Italy
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Fernandez-Gonzalez SM, Sucasas Alonso A, Ogando Martinez A, Avila-Alvarez A. Incidence, Predictors and Outcomes of Noninvasive Ventilation Failure in Very Preterm Infants. CHILDREN (BASEL, SWITZERLAND) 2022; 9:426. [PMID: 35327798 PMCID: PMC8947251 DOI: 10.3390/children9030426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/11/2022] [Accepted: 03/15/2022] [Indexed: 11/26/2022]
Abstract
Non-invasive ventilation (NIV) is now considered the first-line treatment for respiratory distress syndrome in preterm infants. We aimed to evaluate the rates of non-invasive ventilation failure rate in very preterm infants, as well as to identify its predictors and associated outcomes. We designed a single-center retrospective cohort study including infants ≤32 weeks gestational age and ≤1500 g. The NIV failure was defined as the need for intubation at <72 h of life. After applying inclusion and exclusion criteria, 154 patients were included in the study, with a mean GA of 29.7 ± two weeks. The NIV failure rate was 16.2% (n = 25) and it was associated with lower bronchopulmonary dysplasia (BPD)-free survival (OR 0.08; 95% CI 0.02−0.32) and higher incidence of intraventricular hemorrhage > II (OR 6.22; 95% CI 1.36−28.3). These infants were significantly smaller in GA and weight. Higher FiO2 during resuscitation (OR 1.14; 95% CI 1.06−1.22) and after surfactant administration (OR 1.17; 95% CI 1.05−1.31) represented independent risk factors for NIV failure. In conclusion, NIV failure is frequent and it could be predicted by a higher oxygen requirement during resuscitation and a modest response to surfactant therapy. Importantly, this NIV failure is associated with worse clinical outcomes.
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Affiliation(s)
- Sara M. Fernandez-Gonzalez
- Neonatology Department, Complexo Hospitalario Universitario A Coruña (CHUAC), 15006 A Coruña, Spain; (S.M.F.-G.); (A.S.A.); (A.O.M.)
| | - Andrea Sucasas Alonso
- Neonatology Department, Complexo Hospitalario Universitario A Coruña (CHUAC), 15006 A Coruña, Spain; (S.M.F.-G.); (A.S.A.); (A.O.M.)
| | - Alicia Ogando Martinez
- Neonatology Department, Complexo Hospitalario Universitario A Coruña (CHUAC), 15006 A Coruña, Spain; (S.M.F.-G.); (A.S.A.); (A.O.M.)
| | - Alejandro Avila-Alvarez
- Neonatology Department, Complexo Hospitalario Universitario A Coruña (CHUAC), 15006 A Coruña, Spain; (S.M.F.-G.); (A.S.A.); (A.O.M.)
- A Coruña Biomedical Research Institute (INIBIC), 15006 A Coruña, Spain
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8
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Sucasas Alonso A, Pértega Diaz S, Sáez Soto R, Avila-Alvarez A. Epidemiology and risk factors for bronchopulmonary dysplasia in preterm infants born at or less than 32 weeks of gestation. An Pediatr (Barc) 2022; 96:242-251. [DOI: 10.1016/j.anpede.2021.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 03/02/2021] [Indexed: 10/18/2022] Open
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9
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Duration of mechanical ventilation is more critical for brain growth than postnatal hydrocortisone in extremely preterm infants. Eur J Pediatr 2021; 180:3307-3315. [PMID: 33993400 DOI: 10.1007/s00431-021-04113-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/30/2021] [Accepted: 05/10/2021] [Indexed: 10/21/2022]
Abstract
Hydrocortisone is used in preterm infants. However, early disruption of growth velocities was observed in infants exposed to hydrocortisone. This retrospective study aimed to explore the postnatal brain growth of extremely preterm infants requiring hydrocortisone treatment as well as its association with perinatal factors. Extremely preterm infants exposed to hydrocortisone from 2011 to 2016 who survived up to 12 months were included. Each of them was matched with two infants not treated with hydrocortisone exhibiting similar gestational ages and nearly similar birth head circumferences. The outcome variables were brain tissue areas on MRIs performed at term-equivalent age and postnatal head circumference growth up to a corrected age of 12 months. Univariate and multiple regression analyses were performed. Infants treated with hydrocortisone (n=20) were matched with 40 infants not exposed to hydrocortisone. The infants exposed to hydrocortisone exhibited a lower birth weight (p=0.04) and a longer duration of mechanical ventilation (p<0.0001). Infants treated with hydrocortisone exhibited a smaller basal ganglia/thalamus area (p=0.04) at term-equivalent age and a smaller head circumference at a corrected age of 12 months (p=0.003). However, the basal ganglia/thalamus area and the postnatal brain growth were independently associated with the duration of mechanical ventilation and not with hydrocortisone. Interestingly, a significant interaction between hydrocortisone and sex was observed (p=0.04).Conclusion: This study supports previous data that indicated no obvious impact of hydrocortisone on brain growth and highlights the relationship between the severity of the neonatal course and postnatal brain growth in extremely preterm infants. What is Known: • Postnatal hydrocortisone disrupts transiently growth velocities including the head circumference growth. • Postnatal hydrocortisone has less impact on neurodevelopment than dexamethasone. What is New: • Hydrocortisone prescribed for infants in the most severe conditions did not show independent effect on brain growth up to the corrected age of 12 months. However, a different effect of hydrocortisone according to sex can't be excluded and needs further explorations. • Perinatal factors as birth weight and duration of mechanical ventilation were determinant for the subsequent brain growth.
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10
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Sucasas Alonso A, Pértega Díaz S, Sáez Soto R, Ávila-Álvarez A. [Epidemiology and risk factors for bronchopulmonary dysplasia in prematures infants born at or less than 32 weeks of gestation]. An Pediatr (Barc) 2021; 96:S1695-4033(21)00153-3. [PMID: 33814331 DOI: 10.1016/j.anpedi.2021.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/18/2021] [Accepted: 03/02/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To describe risk factors of bronchopulmonary dysplasia in very preterm infants in the first weeks of life. MATERIAL AND METHODS Retrospective cohort study of preterm infants ≤ 32 weeks of gestational age and birth weight ≤ 1500 g. A multivariate logistic regression analysis was performed to identify independent risk factors for bronchopulmonary dysplasia in the first weeks of life. RESULTS A total of 202 newborns were included in the study (mean gestational age 29.5 ± 2.1 weeks), 61.4% never received invasive mechanical ventilation. The incidence of bronchopulmonary dysplasia was 28.7%, and 10.4% of the patients were diagnosed with moderate-severe bronchopulmonary dysplasia. Bronchopulmonary dysplasia was independently associated with gestational age at birth (p < 0.001; OR = 0.44 [95% CI = 0.30-0.65]), the need for mechanical ventilation on the first day of life (p = 0.001; OR = 8.13 [95% CI = 2.41-27.42]), nosocomial sepsis (p < 0.001; OR = 9.51 [95% CI = 2.99-30.28]) and FiO2 on day 14 (p < 0.001; OR = 1.39 [95% CI = 1.16-1.66]). Receiving mechanical ventilation at the first day of life (p = 0.008; OR = 5.39 [95% CI = 1.54-18.89]) and at the third day of life (p = 0.001; OR = 9.99 [95% CI = 2.47-40.44]) and nosocomial sepsis (p = 0.001; OR = 9.87 [95% CI = 2.58-37.80]) were independent risk factors for moderate-severe bronchopulmonary dysplasia. CONCLUSIONS Gestational age at birth, mechanical ventilation in the first days of life and nosocomial sepsis are early risk factors for bronchopulmonary dysplasia. The analysis of simple and objective clinical data, allows us to select a group of patients at high risk of bronchopulmonary dysplasia in whom it could be justified to act more aggressively, and shows areas for improvement to prevent its development or reduce its severity.
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Affiliation(s)
- Andrea Sucasas Alonso
- Unidad de Neonatología, Servicio de Pediatría, Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS, A Coruña, España
| | - Sonia Pértega Díaz
- Unidad de Apoyo a la Investigación, Complexo Hospitalario Universitario A Coruña (CHUAC), SERGAS. Universidade da Coruña (UDC), A Coruña, España
| | - Rebeca Sáez Soto
- Unidad de Neonatología, Servicio de Pediatría, Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS, A Coruña, España
| | - Alejandro Ávila-Álvarez
- Unidad de Neonatología, Servicio de Pediatría, Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS, A Coruña, España; Instituto de Investigación Biomédica A Coruña (INIBIC), SERGAS, A Coruña, España.
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11
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Abstract
Several limitations and controversies surround the definition of hypotension; however, it remains one of the most common problems faced by neonates. Approximately 15% to 30% of neonates with hypotension fail to respond to volume and/or vasopressor or inotropes. They are considered to have refractory hypotension. Although it is thought to have multiple causes, absolute and relative adrenal insufficiency is considered as the main reason for refractory hypotension. This article focuses on the role of adrenal insufficiency in causing refractory hypotension in preterm and term infants, the different options of corticosteroids available, and their risk/benefit profiles.
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Affiliation(s)
- Neha Kumbhat
- Division of Neonatology, Fetal and Neonatal Institute, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Shahab Noori
- Division of Neonatology, Fetal and Neonatal Institute, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
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12
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Alison M, Tilea B, Toumazi A, Biran V, Mohamed D, Alberti C, Bourmaud A, Baud O. Prophylactic hydrocortisone in extremely preterm infants and brain MRI abnormality. Arch Dis Child Fetal Neonatal Ed 2020; 105:520-525. [PMID: 31980445 DOI: 10.1136/archdischild-2019-317720] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 12/18/2019] [Accepted: 01/02/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine whether early low-dose hydrocortisone treatment in extremely preterm infants is associated with brain damage assessed by MRI at term equivalent of age (TEA). PATIENTS AND OUTCOMES This is a predefined secondary analysis of brain abnormalities, observed by MRI at TEA, of patients randomly assigned to receive either placebo or hydrocortisone in the PREMILOC trial. Outcomes were based on brain abnormalities graded according to Kidokoro scores. RESULTS Among 412 survivors at TEA, 300 MRIs were performed and 295 were suitable for analysis. Kidokoro scoring was completed for 119/148 and 110/147 MRIs in the hydrocortisone and placebo groups, respectively. The distribution of the Kidokoro white matter (WM) subscore and other subscores was not significantly different between the two groups. There was, however, a significant association between a higher overall Kidokoro score and hydrocortisone treatment (5.84 (SD 3.51) for hydrocortisone and 4.98 (SD 2.52) for placebo; mean difference, 0.86; 95% CI 0.06 to 1.66; p=0.04). However, hydrocortisone was not statistically associated with moderate-to-severe brain lesions (Kidokoro overall score ≥6) in a multivariate logistic regression model accounting for potential confounding variables (adjusted OR (95% CI) 1.27 (0.75 to 2.14), p=0.38). Bronchopulmonary dysplasia at 36 weeks postmenstrual age significantly predicted both WM damage (adjusted OR (95% CI) 2.70 (1.03 to 7.14), p=0.04) and global brain damage (adjusted OR (95% CI) 2.18 (1.19 to 3.99), p=0.01). CONCLUSIONS Early hydrocortisone exposure in extremely preterm infants is not statistically associated with either WM brain damage or overall moderate-to-severe brain lesions when adjusted for other neonatal variables. TRIAL REGISTRATION NUMBER EudraCT number 2007-002041-20, NCT00623740.
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Affiliation(s)
- Marianne Alison
- Pediatric Radiology, Hôpital Universitaire Robert Debré, Paris, France
| | - Bogdana Tilea
- Pediatric Radiology, Hôpital Universitaire Robert Debré, Paris, France
| | - Artemis Toumazi
- Pediatric Radiology, Hôpital Universitaire Robert Debré, Paris, France
| | - Valérie Biran
- Neonatal Intensive Care Unit, Hopital Universitaire Robert Debre, Paris, Île-de-France, France.,Inserm U1141, University of Paris, Paris, France
| | - Damir Mohamed
- Centre d'Investigation Clinique-Epidémiologie Clinique, Hopital Universitaire Robert Debre, Paris, France
| | - Corinne Alberti
- Centre d'Investigation Clinique-Epidémiologie Clinique, Hopital Universitaire Robert Debre, Paris, France
| | - Aurélie Bourmaud
- Pediatric Radiology, Hôpital Universitaire Robert Debré, Paris, France
| | - Olivier Baud
- Inserm U1141, University of Paris, Paris, France .,DFEA, Hôpitaux Universitaires de Genève, Geneva, Switzerland
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13
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Clauss C, Thomas S, Khodak I, Tack V, Akerman M, Hanna N, Tiozzo C. Hydrocortisone and bronchopulmonary dysplasia: variables associated with response in premature infants. J Perinatol 2020; 40:1349-1357. [PMID: 32382114 PMCID: PMC7222054 DOI: 10.1038/s41372-020-0680-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 04/01/2020] [Accepted: 04/25/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The primary objective was to evaluate hydrocortisone's efficacy for decreasing respiratory support in premature infants with developing bronchopulmonary dysplasia (BPD). Secondary objectives included assessment of the impact of intrauterine growth restriction (IUGR), maternal history of chorioamnionitis, side effects and route of administration associated with hydrocortisone's efficacy. Dexamethasone as second-line treatment to decrease respiratory support was reviewed. METHODS Retrospective chart review of preterm infants requiring respiratory support receiving hydrocortisone. RESULTS A total of 48 patients were included. Successful extubation was achieved in 50% of intubated patients after hydrocortisone treatment with no major complications. In our small study, history of maternal chorioamnionitis, IUGR or route of administration did not affect the response. Rescue dexamethasone after hydrocortisone therapy was ineffective in the ten patients who failed extubation following hydrocortisone. CONCLUSION Hydrocortisone is effective in decreasing respiratory support in patients with developing BPD without major complications. Randomized studies are warranted to confirm our findings.
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Affiliation(s)
- Christie Clauss
- grid.240324.30000 0001 2109 4251Department of Pharmacy, NYU Winthrop Hospital, New York University Langone Medical Center, Mineola, NY USA
| | - Stacey Thomas
- grid.240324.30000 0001 2109 4251Department of Pharmacy, NYU Winthrop Hospital, New York University Langone Medical Center, Mineola, NY USA ,grid.416167.3Department of Pharmacy, The Mount Sinai Hospital, New York, NY USA
| | - Igor Khodak
- grid.240324.30000 0001 2109 4251Department of Pediatrics, NYU Winthrop Hospital, New York University Langone Medical Center, Mineola, NY USA ,grid.412750.50000 0004 1936 9166Department of Pediatrics, University of Rochester Medical Center, Rochester, NY USA
| | - Valentyna Tack
- grid.240324.30000 0001 2109 4251Department of Pediatrics, NYU Winthrop Hospital, New York University Langone Medical Center, Mineola, NY USA
| | - Meredith Akerman
- Department of Foundations of Medicine, NYU Winthrop Hospital, NYU Long Island School of Medicine, Mineola, NY USA
| | - Nazeeh Hanna
- Division of Neonatology, Department of Pediatrics, NYU Winthrop Hospital, NYU Long Island School of Medicine, Mineola, NY USA
| | - Caterina Tiozzo
- Division of Neonatology, Department of Pediatrics, NYU Winthrop Hospital, NYU Long Island School of Medicine, Mineola, NY, USA.
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14
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Lithoxopoulou M, Rallis D, Christou H, Goutsiou E, Varaklioti A, Karagianni P, Tsakalidis C, Domeyer P, Kuriakeli G, Soubasi V. Early caloric deprivation in preterm infants affects Bayley-III scales performance at 18-24 months of corrected age. RESEARCH IN DEVELOPMENTAL DISABILITIES 2019; 91:103429. [PMID: 31272067 DOI: 10.1016/j.ridd.2019.103429] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 04/13/2019] [Accepted: 06/22/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND Adequate nutrition is essential for optimal neurodevelopment to preterm infants. Our aim was to evaluate the impact of caloric deprivation on Bayley-III scales performance at 18-24 months of corrected age, in a cohort of preterm infants. METHODS We prospectively enrolled infants with gestational age <30 weeks and birth weight <1500 g. Apart from a whole cohort analysis, we performed a subgroup analysis between infants received inadequate calories (<85 Kcal/kg/day) during the first two weeks of age, compared to a standard nutrition group. All infants underwent a Bayley-III assessment at 18-24 months of corrected age. RESULTS From the 63 preterm infants analysed, 25% had caloric deprivation compared to 75% with adequate nutrition. Caloric deprived infants were of lower gestational age and birth weight, and received a lower amount of enteral feeding during the first 14 days of age. There were no differences between the two groups regarding the common neonatal co-morbidities. Caloric deprived infants had significantly lower composite index scores at 18-24 months of corrected age. Caloric deprivation, late onset sepsis, necrotizing enterocolitis, and bronchopulmonary dysplasia were significant risk factors of neurodevelopmental impairment. CONCLUSIONS Several neonatal factors affect the neurodevelopmental outcome of preterm infants, and nutrition may pose an important role.
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Affiliation(s)
- Maria Lithoxopoulou
- 2nd Department of Neonatology, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Rallis
- 2nd Department of Neonatology, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Helen Christou
- Brigham and Women's Hospital and Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Evanthia Goutsiou
- 2nd Department of Neonatology, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Agoritsa Varaklioti
- Faculty of Social Sciences, Department of Health Management, Hellenic Open University, Patras, Greece
| | - Paraskevi Karagianni
- 2nd Department of Neonatology, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christos Tsakalidis
- 2nd Department of Neonatology, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Philip Domeyer
- Faculty of Social Sciences, Department of Health Management, Hellenic Open University, Patras, Greece
| | - Georgia Kuriakeli
- 2nd Department of Neonatology, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasiliki Soubasi
- 2nd Department of Neonatology, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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15
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Pasha AB, Chen XQ, Zhou GP. Bronchopulmonary dysplasia: Pathogenesis and treatment. Exp Ther Med 2018; 16:4315-4321. [PMID: 30542380 PMCID: PMC6257511 DOI: 10.3892/etm.2018.6780] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 07/06/2018] [Indexed: 11/06/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD) is a form of chronic lung disease of infancy, which mostly affects premature infants with significant morbidity and mortality. Premature infants who require to be treated for conditions including respiratory distress syndrome have a higher risk of developing BPD. In spite of the improvement in clinical methods, the incidence of BPD has not reduced. In the present review, the pathogenesis of BPD is described along with the treatments available at present and the role of nursing in the management of BPD. Emerging preventive therapies for BPD are also discussed, including the use of recombinant human superoxide dismutase, which has been proven effective in reducing respiratory injury and its long-term effects.
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Affiliation(s)
- Asfia Banu Pasha
- Department of Pediatrics, The First Affiliated Hospital, School of International Education, Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Xiao-Qing Chen
- Department of Pediatrics, The First Affiliated Hospital, School of International Education, Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Guo-Ping Zhou
- Department of Pediatrics, The First Affiliated Hospital, School of International Education, Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
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16
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Zhu C, Zhang S, Gu Z, Tong Y, Wei R. Caudal and intravenous dexamethasone as an adjuvant to pediatric caudal block: A systematic review and meta-analysis. Paediatr Anaesth 2018; 28:195-203. [PMID: 29436137 DOI: 10.1111/pan.13338] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2017] [Indexed: 01/25/2023]
Abstract
BACKGROUND Dexamethasone has become a popular additive for regional anesthesia. The aim of this meta-analysis was to assess the effectiveness of this additive on the duration of postoperative analgesia, postoperative vomiting, and possible adverse events in pediatrics. METHODS We searched databases, conference records, and registered trials for randomized controlled trials. The databases included the Cochrane Library, JBI Database of Systematic Reviews, PubMed, ISI Web of Knowledge, Science-Direct, and Embase. Odds ratio, weighted mean difference, and the corresponding 95% confidence intervals were calculated using the REVMAN software, version 5.3, for data synthesis and statistical analysis, which following the PRISMA statement. The main outcomes were duration of postoperative analgesia (time from the end of surgery to first administration of analgesics as evidenced by a pain score) and postoperative vomiting. RESULTS Seven studies were selected for this meta-analysis, involving 647 pediatric patients. All the patients were randomized to receive caudal or intravenous dexamethasone with caudal block (experimental group) or plain caudal block (control group). There was significantly longer duration of postoperative analgesia in the experimental group compared with control group (weighted mean difference: 238.40 minutes; 95% CI: 193.41-283.40; P < .00001). The experimental group had fewer patients who needed analgesics after surgery (odds ratio: 0.18 minutes; 95% CI: 0.05-0.66; P = .009). Additionally, the number of subjects who remained pain-free to 2, 6, 24, and 48 hours after operation was significantly greater in the experimental group than control group. Side effects in these 2 groups were comparable (odds ratio: 0.94; 95% CI: 0.34-2.56; P = .90). The incidence of postoperative vomiting was significantly decreased in the experimental group compared with control group (odds ratio: 0.29; 95% CI: 0.13-0.63; P = .002). CONCLUSION Caudal and intravenous dexamethasone could provide longer duration of postoperative analgesia and reduced the incidence of postoperative vomiting with comparable adverse effects than plain caudal block. However, any additive to the caudal space carries with it the potential for neurotoxicity and that caution should always be exercised when weighting the risks and benefits of any additive. The result was influenced by small numbers of participants and significant heterogeneity.
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Affiliation(s)
- Change Zhu
- Department of Anesthesiology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Saiji Zhang
- Department of Anesthesiology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Zhiqing Gu
- Department of Anesthesiology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yiru Tong
- Department of Anesthesiology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Rong Wei
- Department of Anesthesiology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
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17
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Abstract
The soon-to-be-delivered fetus and preterm infant have been treated with glucocorticoids to prepare for postnatal life, historically for more than 40 years. The use of glucocorticoids is as much for replacement of cortisol in the setting of a poorly functioning hypothalamic-pituitary-adrenal axis in the preterm infant, as it is for prevention of long-term lung dysfunction. Potential negative effects of glucocorticoid treatment on brain development and function have been observed more often with dexamethasone therapy than with use of other glucocorticoids. Overall, glucocorticoid treatment has improved the outcome of the preterm infant.
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Affiliation(s)
- Susan M Scott
- University of New Mexico School of Medicine, 2211 Lomas Boulevard, Albuquerque, NM 87131, USA.
| | - Susan R Rose
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, MLC 7012, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
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18
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Iwanaga K, Yamamoto A, Matsukura T, Niwa F, Kawai M. Corticotrophin-releasing hormone stimulation tests for the infants with relative adrenal insufficiency. Clin Endocrinol (Oxf) 2017; 87:660-664. [PMID: 28802067 DOI: 10.1111/cen.13446] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 07/30/2017] [Accepted: 08/10/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Very low birthweight (VLBW) infants are considered to be vulnerable to relative adrenal insufficiency (RAI); however, diagnosis is difficult in some clinical settings. Considering this background, it is necessary to establish a diagnosis of RAI in preterm infants. OBJECTIVE In this study, we attempted to clarify the difference in response to CRH stimulation tests for preterm infants with or without RAI. METHODS Between June 2009 and December 2015, we performed CRH stimulation tests for preterm infants born at a gestational age of <30 weeks at around 2 weeks of age. Retrospectively, subjects were classified into two groups: infants with RAI (n = 9) or without RAI (n = 17) based on the clinical symptoms and responsiveness to hydrocortisone. RESULTS We found no difference in base or peak serum cortisol levels related to CRH stimulation tests between the two groups; however, delta cortisol levels and responsive ratio (peak-to-base ratio) were significantly reduced in infants with RAI. 140 nmol/L for delta cortisol or 1.5 times for peak-to-base ratio may be cut-off levels in preterm infants. CONCLUSION This study provides evidence that base cortisol levels of preterm infants with RAI were not different from those without RAI; however, CRH stimulation tests may be a useful tool for the diagnosis of RAI in preterm infants.
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Affiliation(s)
- Kougoro Iwanaga
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Akane Yamamoto
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takashi Matsukura
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Fusako Niwa
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masahiko Kawai
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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19
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Rostas SE, McPherson C. Systemic Corticosteroids for the Prevention of Bronchopulmonary Dysplasia: Picking the Right Drug for the Right Baby. Neonatal Netw 2017; 35:234-9. [PMID: 27461202 DOI: 10.1891/0730-0832.35.4.234] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Bronchopulmonary dysplasia is a morbidity of prematurity with implications into adulthood on respiratory and neurologic health. Multiple risk factors contribute to the development of bronchopulmonary dysplasia leading to examination of various strategies of prevention. Systemic corticosteroids are one prevention strategy with a large body of data, creating an ongoing controversy regarding the risks and benefits of therapy. Careful consideration of the available data along with the clinical characteristics of the individual infant is required before using this powerful therapy.
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Affiliation(s)
- Sara E Rostas
- Brigham and Women's Hospital, 75 Francis Street, CWN 418, Boston, MA 02115, USA
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20
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Onland W, De Jaegere APMC, Offringa M, van Kaam A. Systemic corticosteroid regimens for prevention of bronchopulmonary dysplasia in preterm infants. Cochrane Database Syst Rev 2017; 1:CD010941. [PMID: 28141913 PMCID: PMC6464844 DOI: 10.1002/14651858.cd010941.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Cochrane systematic reviews show that systemic postnatal corticosteroids reduce the risk of bronchopulmonary dysplasia (BPD) in preterm infants. However, corticosteroids have also been associated with an increased risk of neurodevelopmental impairment. It is unknown whether these beneficial and adverse effects are modulated by differences in corticosteroid treatment regimens. OBJECTIVES To assess the effects of different corticosteroid treatment regimens on mortality, pulmonary morbidity, and neurodevelopmental outcome in very low birth weight (VLBW) infants. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 2) in the Cochrane Library (searched 21 March 2016), MEDLINE via PubMed (1966 to 21 March 2016), Embase (1980 to 21 March 2016), and CINAHL (1982 to 21 March 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials. SELECTION CRITERIA Randomized controlled trials (RCTs) comparing two or more different treatment regimens of systemic postnatal corticosteroids in preterm infants at risk for BPD, as defined by the original trialists. Studies investigating one treatment regimen of systemic corticosteroids to a placebo or studies using inhalation corticosteroids were excluded. DATA COLLECTION AND ANALYSIS Two authors independently assessed eligibility and quality of trials and extracted data on study design, participant characteristics and the relevant outcomes. We asked the original investigators to verify if data extraction was correct and, if possible, to provide any missing data. The primary outcomes to be assessed were: mortality at 36 weeks' postmenstrual age (PMA) or at hospital discharge; BPD defined as oxygen dependency at 36 weeks' PMA; long-term neurodevelopmental sequelae, including cerebral palsy, measured by the Bayley Mental Developmental Index (MDI); and blindness or poor vision. Secondary outcomes were: duration of mechanical ventilation and failure to extubate at day 3 and 7 after initiating therapy; rescue treatment with corticosteroids outside the study period; and the incidence of hypertension, sepsis and hyperglycemia during hospitalizations. Data were analyzed using Review Manager 5 (RevMan 5). We used the GRADE approach to assess the quality of evidence. MAIN RESULTS Fourteen studies were included in this review. Only RCTs investigating dexamethasone were identified. Eight studies enrolling a total of 303 participants investigated the cumulative dosage administered; three studies contrasted a high versus a moderate and five studies a moderate versus a low cumulative dexamethasone dose.Analysis of the studies investigating a moderate dexamethasone dose versus a high-dosage regimen showed an increased risk of BPD (typical risk ratio (RR) 1.50, 95% confidence interval (CI) 1.01 to 2.22; typical risk difference (RD) 0.26, 95% CI 0.03 to 0.49; number needed to treat for an additional harmful outcome (NNTH) 4, 95% CI 1.9 to 23.3; I² = 0%, 2 studies, 55 infants) as well as an increased risk of abnormal neurodevelopmental outcome (typical RR 8.33, 95% CI 1.63 to 42.48; RD 0.30, 95% CI 0.14 to 0.46; NNTH 4, 95% CI 2.2 to 7.3; I² = 68%, 2 studies, 74 infants) when using a moderate cumulative-dosage regimen. The composite outcomes of death or BPD and death or abnormal neurodevelopmental outcome showed similar results although the former only reached borderline significance.There were no differences in outcomes between a moderate- and a low-dosage regimen.Four other studies enrolling 762 infants investigated early initiation of dexamethasone therapy versus a moderately early or delayed initiation and showed no significant differences in the primary outcomes. The two RCTs investigating a continuous versus a pulse dexamethasone regimen showed an increased risk of the combined outcome death or BPD when using the pulse therapy. Finally, two trials investigating a standard regimen versus a participant-individualized course of dexamethasone showed no difference in the primary outcome and long-term neurodevelopmental outcomes.The quality of evidence for all comparisons discussed above was assessed as low or very low, because the validity of all comparisons is hampered by small samples of randomized infants, heterogeneity in study population and design, non-protocolized use of 'rescue' corticosteroids and lack of long-term neurodevelopmental data in most studies. AUTHORS' CONCLUSIONS Despite the fact that some studies reported a modulating effect of treatment regimens in favor of higher-dosage regimens on the incidence of BPD and neurodevelopmental impairment, recommendations on the optimal type of corticosteroid, the optimal dosage, or the optimal timing of initiation for the prevention of BPD in preterm infants cannot be made based on current level of evidence. A well-designed large RCT is urgently needed to establish the optimal systemic postnatal corticosteroid dosage regimen.
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Affiliation(s)
- Wes Onland
- Emma Children's Hospital AMC, University of AmsterdamDepartment of NeonatologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Anne PMC De Jaegere
- Emma Children's Hospital AMC, University of AmsterdamDepartment of NeonatologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Martin Offringa
- Hospital for Sick ChildrenChild Health Evaluative Sciences555 University AvenueTorontoONCanadaM5G 1X8
| | - Anton van Kaam
- Emma Children's Hospital AMC, University of AmsterdamDepartment of NeonatologyMeibergdreef 9AmsterdamNetherlands1105 AZ
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Abstract
Glucocorticoids are primary stress hormones produced by the adrenal cortex. The concentration of serum glucocorticoids in the fetus is low throughout most of gestation but surge in the weeks prior to birth. While their most well-known function is to stimulate differentiation and functional development of the lungs, glucocorticoids also play crucial roles in the development of several other organ systems. Mothers at risk of preterm delivery are administered glucocorticoids to accelerate fetal lung development and prevent respiratory distress. Conversely, excessive glucocorticoid signaling is detrimental for fetal development; slowing fetal and placental growth and programming the individual for disease later in adult life. This review explores the mechanisms that control glucocorticoid signaling during pregnancy and provides an overview of the impact of glucocorticoid signaling on fetal development.
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Affiliation(s)
- Jonathan T Busada
- Molecular Endocrinology Group, Signal Transduction Laboratory, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC, United States
| | - John A Cidlowski
- Molecular Endocrinology Group, Signal Transduction Laboratory, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC, United States.
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Ng PC. Adrenocortical insufficiency and refractory hypotension in preterm infants. Arch Dis Child Fetal Neonatal Ed 2016; 101:F571-F576. [PMID: 27601464 DOI: 10.1136/archdischild-2016-311289] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 08/18/2016] [Accepted: 08/19/2016] [Indexed: 11/04/2022]
Abstract
Preterm, very low birthweight (VLBW) infants are prone to life-threatening hypotension secondary to hypothalamic-pituitary-adrenal axis immaturity, resulting in adrenocortical insufficiency. Clinical presentations of inotrope-resistant refractory hypotension are usually evident, but interpretation of serum cortisol may pose much difficulty to front-line neonatologists. This review examines the salient pathophysiology of adrenocortical insufficiency in the immediate postnatal period, characterises its endocrinological abnormalities, and describes the typical and variant clinical presentations. Based on existing evidence, a practical scheme is proposed for logical interpretation of circulating cortisol levels and management of inotrope-resistant refractory hypotension in VLBW infants.
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Affiliation(s)
- Pak Cheung Ng
- Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
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Kennedy KA, Cotten CM, Watterberg KL, Carlo WA. Prevention and management of bronchopulmonary dysplasia: Lessons learned from the neonatal research network. Semin Perinatol 2016; 40:348-355. [PMID: 27742002 PMCID: PMC5279709 DOI: 10.1053/j.semperi.2016.05.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Despite remarkable improvements in survival of extremely premature infants, the burden of BPD among survivors remains a frustrating problem for parents and caregivers. Advances, such as antenatal steroids and surfactant replacement, which have dramatically improved survival, have not reduced BPD among survivors. Other advances that have significantly improved the combined outcome of death or BPD, such as vitamin A and avoidance of mechanical ventilation, have had smaller magnitude effects on the outcome of BPD alone. Postnatal steroids have a clear beneficial effect on BPD, but the optimal preparation, dose, and timing for maximizing benefit and minimizing harm have yet to be determined. This persistent burden of BPD among the most immature survivors remains a challenge for the NRN and other researchers in neonatal medicine.
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Affiliation(s)
- Kathleen A Kennedy
- Department of Pediatrics, University of Texas Medical School at Houston, Houston, TX.
| | | | | | - Waldemar A Carlo
- Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL
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Renault A, Patkaï J, Dassieu G, El Ayoubi M, Canouï-Poitrine F, Durrmeyer X. Hydrocortisone use in ventilated extremely preterm infants decreased bronchopulmonary dysplasia with no effects on neurodevelopment after two years. Acta Paediatr 2016; 105:1047-55. [PMID: 27239054 DOI: 10.1111/apa.13487] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 04/15/2016] [Accepted: 05/27/2016] [Indexed: 11/30/2022]
Abstract
AIM We assessed the outcomes of ventilated extremely premature infants treated with late postnatal corticosteroids from 2005-2008, according to permissive or restrictive policies in two centres. METHODS This retrospective study included inborn infants below 27 weeks of gestational age who were ventilator dependent after 14 days. Centre P permitted postnatal corticosteroids but centre R restricted their use. The effects on infants were assessed in hospital and after two years using multivariable analysis. RESULTS We compared 62 infants from centre P, including 92% who received hydrocortisone, and 48 infants from centre R, including 13% who received betamethasone. Infants from both centres had comparable baseline characteristics and perinatal management, but bronchopulmonary dysplasia (BPD) rates were significantly lower in centre P (30% versus 71%, p < 0.001) and this centre was significantly associated with a younger post-conceptional age at oxygen weaning, with an adjusted hazard ratio (aHR) of 0.45 and an aHR of 0.51at discharge. At two years of corrected age, 18% of centre P infants and 30% of centre R infants showed poor neurodevelopmental outcome (p = 0.18). CONCLUSION Using hydrocortisone after 14 days on ventilated extremely preterm infants was associated with decreased BPD, with no apparent effects on neurodevelopment at two years of corrected age.
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Affiliation(s)
- Anaïs Renault
- Neonatal Intensive Care Unit; CHI Créteil; Créteil France
| | - Juliana Patkaï
- Neonatal Intensive Care Unit; AP-HP, Maternité Cochin-Port Royal; Paris France
| | - Gilles Dassieu
- Neonatal Intensive Care Unit; CHI Créteil; Créteil France
| | - Mayass El Ayoubi
- Neonatal Intensive Care Unit; AP-HP, Maternité Cochin-Port Royal; Paris France
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé); Center for Epidemiology and Statistics Sorbonne Paris Cité; DHU Risks in pregnancy; Inserm UMR 1153; Paris Descartes University; Paris France
| | - Florence Canouï-Poitrine
- CEpiA (Clinical Epidemiology And Ageing) Unit EA4393, UPEC; Université Paris-Est, A-TVB DHU; Créteil France
- Clinical Research Unit (URC Mondor); AP-HP, Hôpital Henri-Mondor; Créteil France
| | - Xavier Durrmeyer
- Neonatal Intensive Care Unit; CHI Créteil; Créteil France
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé); Center for Epidemiology and Statistics Sorbonne Paris Cité; DHU Risks in pregnancy; Inserm UMR 1153; Paris Descartes University; Paris France
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Wong HS, Santhakumaran S, Cowan FM, Modi N. Developmental Assessments in Preterm Children: A Meta-analysis. Pediatrics 2016; 138:peds.2016-0251. [PMID: 27471220 DOI: 10.1542/peds.2016-0251] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2016] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Developmental outcomes of very preterm (gestational age ≤32 weeks) or very low birth weight (<1500 g) children are commonly reported before age 3 years although the predictive validity for later outcomes are uncertain. OBJECTIVE To determine the validity of early developmental assessments in predicting school-age cognitive deficits. DATA SOURCES PubMed. STUDY SELECTION English-language studies reporting at least 2 serial developmental/cognitive assessments on the same population, 1 between ages 1 and 3 years and 1 at ≥5 years. DATA EXTRACTION For each study, we calculated the sensitivity, specificity, and positive and negative predictive values of early assessment for cognitive deficit (defined as test scores 1 SD below the population mean). Pooled meta-analytic sensitivity and specificity were estimated by using a hierarchical summary receiver operator characteristic curve. RESULTS We included 24 studies (n = 3133 children). Early assessments were conducted at 18 to 40 months and generally involved the Bayley Scales of Infant Development or the Griffiths Mental Development Scales; 11 different cognitive tests were used at school-age assessments at 5 to 18 years. Positive predictive values ranged from 20.0% to 88.9%, and negative predictive vales ranged from 47.8% to 95.5%. The pooled sensitivity (95% confidence interval) of early assessment for identifying school-age cognitive deficit was 55.0% (45.7%-63.9%) and specificity was 84.1% (77.5%-89.1%). Gestational age, birth weight, age at assessment, and time between assessments did not explain between-study heterogeneity. LIMITATIONS The accuracy of aggregated data could not be verified. Many assessment tools have been superseded by newer editions. CONCLUSIONS Early developmental assessment has poor sensitivity but good specificity and negative predictive value for school-age cognitive deficit.
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Affiliation(s)
- Hilary S Wong
- Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom; and
| | | | - Frances M Cowan
- Section of Neonatal Medicine, Imperial College London, London, United Kingdom
| | - Neena Modi
- Section of Neonatal Medicine, Imperial College London, London, United Kingdom
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Baud O, Maury L, Lebail F, Ramful D, El Moussawi F, Nicaise C, Zupan-Simunek V, Coursol A, Beuchée A, Bolot P, Andrini P, Mohamed D, Alberti C. Effect of early low-dose hydrocortisone on survival without bronchopulmonary dysplasia in extremely preterm infants (PREMILOC): a double-blind, placebo-controlled, multicentre, randomised trial. Lancet 2016; 387:1827-36. [PMID: 26916176 DOI: 10.1016/s0140-6736(16)00202-6] [Citation(s) in RCA: 207] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Bronchopulmonary dysplasia, a major complication of extreme prematurity, has few treatment options. Postnatal steroid use is controversial, but low-dose hydrocortisone might prevent the harmful effects of inflammation on the developing lung. In this study, we aimed to assess whether low-dose hydrocortisone improved survival without bronchopulmonary dysplasia in extremely preterm infants. METHODS In this double-blind, placebo-controlled, randomised trial done at 21 French tertiary-care neonatal intensive care units (NICUs), we randomly assigned (1:1), via a secure study website, extremely preterm infants inborn (born in a maternity ward at the same site as the NICU) at less than 28 weeks of gestation to receive either intravenous low-dose hydrocortisone or placebo during the first 10 postnatal days. Infants randomly assigned to the hydrocortisone group received 1 mg/kg of hydrocortisone hemisuccinate per day divided into two doses per day for 7 days, followed by one dose of 0·5 mg/kg per day for 3 days. Randomisation was stratified by gestational age and all infants were enrolled by 24 h after birth. Study investigators, parents, and patients were masked to treatment allocation. The primary outcome was survival without bronchopulmonary dysplasia at 36 weeks of postmenstrual age. We used a sequential analytical design, based on intention to treat, to avoid prolonging the trial after either efficacy or futility had been established. This trial is registered with ClinicalTrial.gov, number NCT00623740. FINDINGS 1072 neonates were screened between May 25, 2008, and Jan 31, 2014, of which 523 were randomly assigned (256 hydrocortisone, 267 placebo). 255 infants on hydrocortisone and 266 on placebo were included in analyses after parents withdrew consent for one child in each group. Of the 255 infants assigned to hydrocortisone, 153 (60%) survived without bronchopulmonary dysplasia, compared with 136 (51%) of 266 infants assigned to placebo (odds ratio [OR] adjusted for gestational age group and interim analyses 1·48, 95% CI 1·02-2·16, p=0·04). The number of patients needed to treat to gain one bronchopulmonary dysplasia-free survival was 12 (95% CI 6-200). Sepsis rate was not significantly different in the study population as a whole, but subgroup analyses showed a higher rate only in infants born at 24-25 weeks gestational age who were treated with hydrocortisone (30 [40%] of 83 vs 21 [23%] of 90 infants; sub-hazard ratio 1·87, 95% CI 1·09-3·21, p=0·02). Other potential adverse events, including notably gastrointestinal perforation, did not differ significantly between groups. INTERPRETATION In extremely preterm infants, the rate of survival without bronchopulmonary dysplasia at 36 weeks of postmenstrual age was significantly increased by prophylactic low-dose hydrocortisone. This strategy, based on a physiological rationale, could lead to substantial improvements in the management of the most premature neonates. FUNDING Assistance Publique-Hôpitaux de Paris.
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Affiliation(s)
- Olivier Baud
- Neonatal Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Universitaire Robert Debré, Université Paris Diderot, Sorbonne Paris Cité, INSERM U1141, Paris, France.
| | - Laure Maury
- Neonatal Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Universitaire Robert Debré, Université Paris Diderot, Sorbonne Paris Cité, INSERM U1141, Paris, France
| | - Florence Lebail
- Neonatal Intensive Care Unit, Centre Hospitalier Corbeil-Essonnes, Sud Francilien, France
| | - Duksha Ramful
- Neonatal and Pediatric Intensive Care Unit, CHR Saint-Denis, La Réunion, France
| | - Fatima El Moussawi
- Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Poissy, Poissy, France
| | - Claire Nicaise
- Neonatal Intensive Care Unit, Assistance Publique-Hôpitaux de Marseille, Centre Hospitalier Universitaire Hôpital Nord, Marseille, France
| | - Véronique Zupan-Simunek
- Neonatal Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Universitaire Antoine Béclère, Paris, France
| | - Anne Coursol
- Neonatal intensive care unit, Centre Hospitalier de Pontoise, France
| | - Alain Beuchée
- Neonatal Intensive Care Unit, Centre Hospitalier Universitaire Rennes, France
| | - Pascal Bolot
- Neonatal Intensive Care Unit, Centre Hospitalier de Saint-Denis, France
| | - Pierre Andrini
- Neonatal Intensive Care Unit, Centre Hospitalier Universitaire Grenoble, France
| | - Damir Mohamed
- Unit of Clinical Epidemiology, Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Universitaire Robert Debré, Université Paris Diderot, Sorbonne Paris-Cité, INSERM U1123 and CIC-EC 1426, Paris, France
| | - Corinne Alberti
- Unit of Clinical Epidemiology, Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Universitaire Robert Debré, Université Paris Diderot, Sorbonne Paris-Cité, INSERM U1123 and CIC-EC 1426, Paris, France
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Parikh NA, Kennedy KA, Lasky RE, Tyson JE. Neurodevelopmental Outcomes of Extremely Preterm Infants Randomized to Stress Dose Hydrocortisone. PLoS One 2015; 10:e0137051. [PMID: 26376074 PMCID: PMC4573756 DOI: 10.1371/journal.pone.0137051] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 08/11/2015] [Indexed: 12/17/2022] Open
Abstract
Objective To compare the effects of stress dose hydrocortisone therapy with placebo on survival without neurodevelopmental impairments in high-risk preterm infants. Study Design We recruited 64 extremely low birth weight (birth weight ≤1000g) infants between the ages of 10 and 21 postnatal days who were ventilator-dependent and at high-risk for bronchopulmonary dysplasia. Infants were randomized to a tapering 7-day course of stress dose hydrocortisone or saline placebo. The primary outcome at follow-up was a composite of death, cognitive or language delay, cerebral palsy, severe hearing loss, or bilateral blindness at a corrected age of 18–22 months. Secondary outcomes included continued use of respiratory therapies and somatic growth. Results Fifty-seven infants had adequate data for the primary outcome. Of the 28 infants randomized to hydrocortisone, 19 (68%) died or survived with impairment compared with 22 of the 29 infants (76%) assigned to placebo (relative risk: 0.83; 95% CI, 0.61 to 1.14). The rates of death for those in the hydrocortisone and placebo groups were 31% and 41%, respectively (P = 0.42). Randomization to hydrocortisone also did not significantly affect the frequency of supplemental oxygen use, positive airway pressure support, or need for respiratory medications. Conclusions In high-risk extremely low birth weight infants, stress dose hydrocortisone therapy after 10 days of age had no statistically significant effect on the incidence of death or neurodevelopmental impairment at 18–22 months. These results may inform the design and conduct of future clinical trials. Trial Registration ClinicalTrials.gov NCT00167544
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Affiliation(s)
- Nehal A. Parikh
- Department of Pediatrics, University of Texas Medical School at Houston, Houston, TX, United States of America
- Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, United States of America
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States of America
- Division of Neonatology, Nationwide Children’s Hospital, Columbus, OH, United States of America
- * E-mail:
| | - Kathleen A. Kennedy
- Center for Clinical Research and Evidence-Based Medicine, University of Texas Medical School at Houston, Houston, TX, United States of America
| | - Robert E. Lasky
- Center for Clinical Research and Evidence-Based Medicine, University of Texas Medical School at Houston, Houston, TX, United States of America
| | - Jon E. Tyson
- Center for Clinical Research and Evidence-Based Medicine, University of Texas Medical School at Houston, Houston, TX, United States of America
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28
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Takayanagi T, Matsuo K, Egashira T, Mizukami T. Neonatal hydrocortisone therapy does not have a serious suppressive effect on the later function of the hypothalamus-pituitary-adrenal axis. Acta Paediatr 2015; 104:e195-9. [PMID: 25605127 DOI: 10.1111/apa.12926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 11/19/2014] [Accepted: 01/09/2015] [Indexed: 11/26/2022]
Abstract
AIM This study investigated whether providing extremely low birthweight (ELBW) infants with a large amount of hydrocortisone had a serious suppressive effect on the later function of the hypothalamus-pituitary-adrenal (HPA) axis. METHODS We evaluated the function of the HPA axis in 58 ELBW infants receiving 9.0 ± 7.2 mg/kg of intravenous and 68.1 ± 34.1 mg/kg of oral hydrocortisone using a human corticotropin-releasing hormone stimulation test. The mean age at investigation was 12.0 ± 5.2 months. The response was judged to be normal when the maximum to minimum ratio of the plasma adrenocorticotropic hormone (ACTH) concentration was >2, the peak value of the serum cortisol concentration was >552 nmol/L, or the increment was >193 nmol/L than baseline concentration. RESULTS Of the 58 infants studied, 51 (88%) displayed a normal response to both the ACTH and cortisol secretion and seven infants (12%) who were judged to be poor responders exhibited a peak cortisol value of >386 nmol/L without any episode of adrenal insufficiency. CONCLUSION Providing ELBW infants with a daily low dose of long-term hydrocortisone therapy should not lead to a serious suppressive effect on the later function of the HPA axis, regardless of the administration method.
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Affiliation(s)
- Toshimitsu Takayanagi
- Department of Pediatrics; National Hospital Organization; Saga National Hospital; Saga Japan
| | - Koji Matsuo
- Department of Pediatrics; National Hospital Organization; Saga National Hospital; Saga Japan
| | - Tomoko Egashira
- Department of Pediatrics; National Hospital Organization; Saga National Hospital; Saga Japan
| | - Tomoko Mizukami
- Department of Pediatrics; National Hospital Organization; Saga National Hospital; Saga Japan
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29
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Neunhoeffer F, Renk H, Hofbeck M, Grenz C, Haller C, Heimberg E, Gerbig I, Schlensak C, Kumpf M. Safety, efficacy and response to a hydrocortisone rescue therapy protocol in children with refractory hypotension after cardiopulmonal bypass. Pediatr Cardiol 2015; 36:640-5. [PMID: 25380964 DOI: 10.1007/s00246-014-1059-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 10/31/2014] [Indexed: 11/25/2022]
Abstract
Little is known about which paediatric patients respond to hydrocortisone rescue therapy (HRT) with improvement of haemodynamic stability in refractory hypotension after cardiopulmonal bypass. Data were gathered retrospectively from children who received HRT in refractory hypotension after cardiopulmonary bypass in the period from 2000 to 2010. One hundred and sixty-six out of 1,273 children, 150 <1 year and 16 >1 year were enrolled. HRT improved haemodynamics significantly, increased blood pressure, decreased the vasoactive-inotropic score and plasma lactate concentrations in all children >1 year and in 82 % (123 out of 150) of the infants <1 year. Non-responders <1 year were significantly younger, lighter, mostly male infants and had longer cardiopulmonary bypass support time. Serum lactate and paediatric risk of mortality score were significantly higher in non-responders at time of initiation of HRT. Mortality was significantly higher in non-responders versus responders (2.44 vs. 13.5 %; p = 0.0008). HRT caused no adverse effects like electrolyte disturbances or hyperglycaemia. HRT in refractory hypotension after paediatric cardiac surgery is safe but not all infants <1 year show haemodynamic response to HRT. Non-response to HRT is associated with significantly higher mortality.
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Affiliation(s)
- F Neunhoeffer
- Department of Paediatric Cardiology, Pulmology and Paediatric Intensive Care Medicine, University Children's Hospital, Hoppe-Seyler-Str. 1, 72076, Tübingen, Germany,
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30
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Patra K, Greene MM, Silvestri JM. Neurodevelopmental impact of hydrocortisone exposure in extremely low birth weight infants: outcomes at 1 and 2 years. J Perinatol 2015; 35:77-81. [PMID: 25078865 DOI: 10.1038/jp.2014.133] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Revised: 05/19/2014] [Accepted: 06/16/2014] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Postnatal steroids are used in neonatal intensive care units despite known side effects. Hydrocortisone (HC) use persists as it is believed to have less deleterious effects on neurodevelopmental (ND) outcome compared to other steroids. The literature is sparse with respect to the ND impact of HC use in recent years. Hence, we sought to examine the effect of HC use on ND outcome in a contemporary cohort of extremely low birth weight (ELBW) infants. STUDY DESIGN A total of 175 ELBW infants (86 HC exposed, 89 steroid naive) born in 2008 to 2010 were compared for mortality, morbidity and ND outcome at 8 and 20 months corrected age. Outcome measures included neurologic exam and results of the Bayley Scales of Infant and Toddler Development-III (BSITD-III). Multiple regression analyses adjusted for the effect of other risk factors on outcome. RESULT Overall, 65 (75%) of the HC and 74 (83%) of the no-HC groups survived to discharge. HC infants were smaller (mean birth weight (BW) 719 ± 127 g vs 837 ± 99 g) and of lower gestational age (GA) (mean GA 26.0 ± 1.7 weeks vs 27.5 ± 1.8 weeks) compared to the no-HC group. Patients in the HC group were more likely to be a multiple, have a severely abnormal head ultrasound, bronchopulmonary dysplasia, retinopathy of prematurity, necrotizing enterocolitis and receive treatment for patent ductus arteriosus and hypotension than those in the no-HC group. Of the HC group, the mean age at treatment was 20 ± 19 days, mean duration of treatment 49 ± 37 days. At 8 months, the HC group had lower mean motor (87 ± 18 vs 95 ± 15, P = 0.028) and fine motor (9 ± 2.9 vs 10.5 ± 2.6, P = 0.005) and higher rate of subnormal motor (44 vs 15%, P = 0.002) and fine motor scores (24 vs 6.5%, P = 0.017). In regression analyses, HC exposure >7 days was significantly related to worse outcome on fine motor scores at 8 months while cumulative days of HC exposure was a predictor of worse outcome on language at 8 months and motor outcome at 20 months. Each additional day of HC exposure increased the odds of subnormal receptive and expressive language in the first year of life by 4 and 2%, respectively, and increased odds of subnormal motor function by 2% in the 2nd year of life. CONCLUSION HC exposure for >7 days is associated with worse performance in fine motor skills in the first year of life, while cumulative HC exposure negatively impacts receptive and expressive language skills in the first year and motor skills in the second year of life after adjusting for neonatal and social risk factors.
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Affiliation(s)
- K Patra
- Rush University Medical Center, Department of Pediatrics, Chicago, IL, USA
| | - M M Greene
- Rush University Medical Center, Department of Pediatrics, Chicago, IL, USA
| | - J M Silvestri
- Rush University Medical Center, Department of Pediatrics, Chicago, IL, USA
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Noguchi KK. Glucocorticoid Induced Cerebellar Toxicity in the Developing Neonate: Implications for Glucocorticoid Therapy during Bronchopulmonary Dysplasia. Cells 2014; 3:36-52. [PMID: 24501683 PMCID: PMC3910303 DOI: 10.3390/cells3010036] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Prematurely born infants commonly suffer respiratory dysfunction due to the immature state of their lungs. As a result, clinicians often administer glucocorticoid (GC) therapy to accelerate lung maturation and reduce inflammation. Unfortunately, several studies have found GC therapy can also produce neuromotor/cognitive deficits and selectively stunt the cerebellum. However, despite its continued use, relatively little is known about how exposure to this hormone might produce neurodevelopmental deficits. In this review, we use rodent and human research to provide evidence that GC therapy may disrupt cerebellar development through the rapid induction of apoptosis in the cerebellar external granule layer (EGL). The EGL is a transient proliferative region responsible for the production of over 90% of the neurons in the cerebellum. During normal development, endogenous GC stimulation is thought to selectively signal the elimination of the EGL once production of new neurons is complete. As a result, GC therapy may precociously eliminate the EGL before it can produce enough neurons for normal cerebellar function. It is hoped that this review may provide information for future clinical research in addition to translational guidance for the safer use of GC therapy.
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Affiliation(s)
- Kevin K Noguchi
- Department of Psychiatry, School of Medicine, Washington University in St. Louis, 660 South Euclid, Box #8134, St. Louis, MO 63110, USA; Tel.: +1-314-362-7007
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Chang YP. Evidence for adverse effect of perinatal glucocorticoid use on the developing brain. KOREAN JOURNAL OF PEDIATRICS 2014; 57:101-9. [PMID: 24778691 PMCID: PMC4000755 DOI: 10.3345/kjp.2014.57.3.101] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 02/04/2014] [Indexed: 11/27/2022]
Abstract
The use of glucocorticoids (GCs) in the perinatal period is suspected of being associated with adverse effects on long-term neurodevelopmental outcomes for preterm infants. Repeated administration of antenatal GCs to mothers at risk of preterm birth may adversely affect fetal growth and head circumference. Fetal exposure to excess GCs during critical periods of brain development may profoundly modify the limbic system (primarily the hippocampus), resulting in long-term effects on cognition, behavior, memory, co-ordination of the autonomic nervous system, and regulation of the endocrine system later in adult life. Postnatal GC treatment for chronic lung disease in premature infants, particularly involving the use of dexamethasone, has been shown to induce neurodevelopmental impairment and increases the risk of cerebral palsy. In contrast to studies involving postnatal dexamethasone, long-term follow-up studies for hydrocortisone therapy have not revealed adverse effects on neurodevelopmental outcomes. In experimental studies on animals, GCs has been shown to impair neurogenesis, and induce neuronal apoptosis in the immature brains of newborn animals. A recent study has demonstrated that dexamethasone-induced hypomyelination may result from the apoptotic degeneration of oligodendrocyte progenitors in the immature brain. Thus, based on clinical and experimental studies, there is enough evidence to advice caution regarding the use of GCs in the perinatal period; and moreover, the potential long-term effects of GCs on brain development need to be determined.
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Affiliation(s)
- Young Pyo Chang
- Department of Pediatrics, Dankook University College of Medicine, Cheonan, Korea
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33
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Moreira RS, Magalhães LC, Alves CR. Effect of preterm birth on motor development, behavior, and school performance of school-age children: a systematic review. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2014. [DOI: 10.1016/j.jpedp.2013.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Moreira RS, Magalhães LC, Alves CRL. Effect of preterm birth on motor development, behavior, and school performance of school-age children: a systematic review. J Pediatr (Rio J) 2014; 90:119-34. [PMID: 24370176 DOI: 10.1016/j.jped.2013.05.010] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 05/25/2013] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES to examine and synthesize the available knowledge in the literature about the effects of preterm birth on the development of school-age children. SOURCES this was a systematic review of studies published in the past ten years indexed in MEDLINE/Pubmed, MEDLINE/BVS; LILACS/BVS; IBECS/BVS; Cochrane/BVS, CINAHL, Web of Science, Scopus, and PsycNET in three languages (Portuguese, Spanish, and English). Observational and experimental studies that assessed motor development and/or behavior and/or academic performance and whose target-population consisted of preterm children aged 8 to 10 years were included. Article quality was assessed by the Strengthening the reporting of observational studies in epidemiology (STROBE) and Physiotherapy Evidence Database (PEDro) scales; articles that did not achieve a score of 80% or more were excluded. SUMMARY OF FINDINGS the electronic search identified 3,153 articles, of which 33 were included based on the eligibility criteria. Only four studies found no effect of prematurity on the outcomes (two articles on behavior, one on motor performance and one on academic performance). Among the outcomes of interest, behavior was the most searched (20 articles, 61%), followed by academic performance (16 articles, 48%) and motor impairment (11 articles, 33%). CONCLUSION premature infants are more susceptible to motor development, behavior and academic performance impairment when compared to term infants. These types of impairments, whose effects are manifested in the long term, can be prevented through early parental guidance, monitoring by specialized professionals, and interventions.
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Affiliation(s)
- Rafaela S Moreira
- Program in Health Sciences: Child and Adolescent Health, School of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil; Departament of Physical Therapy, Universidade Federal de Santa Catarina (UFSC), Araranguá, SC, Brazil.
| | - Lívia C Magalhães
- Department of Occupational Therapy, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Claudia R L Alves
- Departament of Pediatrics, Faculty of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
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Kersbergen KJ, de Vries LS, van Kooij BJM, Išgum I, Rademaker KJ, van Bel F, Hüppi PS, Dubois J, Groenendaal F, Benders MJNL. Hydrocortisone treatment for bronchopulmonary dysplasia and brain volumes in preterm infants. J Pediatr 2013; 163:666-71.e1. [PMID: 23706359 DOI: 10.1016/j.jpeds.2013.04.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2012] [Revised: 03/11/2013] [Accepted: 04/04/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess whether there was an adverse effect on brain growth after hydrocortisone (HC) treatment for bronchopulmonary dysplasia (BPD) in a large cohort of infants without dexamethasone exposure. STUDY DESIGN Infants who received HC for BPD between 2005 and 2011 and underwent magnetic resonance imaging at term-equivalent age were included. Control infants born in Geneva (2005-2006) and Utrecht (2007-2011) were matched to the infants treated with HC according to segmentation method, sex, and gestational age. Infants with overt parenchymal pathology were excluded. Multivariable analysis was used to determine if there was a difference in brain volumes between the 2 groups. RESULTS Seventy-three infants treated with HC and 73 matched controls were included. Mean gestational age was 26.7 weeks, and mean birth weight was 906 g. After correction for gestational age, postmenstrual age at time of scanning, the presence of intraventricular hemorrhage, and birth weight z-score, no differences were found between infants treated with HC and controls in total brain tissue or cerebellar volumes. CONCLUSIONS In the absence of associated parenchymal brain injury, no reduction in brain tissue or cerebellar volumes could be found at term-equivalent age between infants with or without treatment with HC for BPD.
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Affiliation(s)
- Karina J Kersbergen
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
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Ben Said M, Hays S, Loys CM, Coletto L, Godbert I, Picaud JC. Postnatal steroids in extremely low birth weight infants: betamethasone or hydrocortisone? Acta Paediatr 2013; 102:689-94. [PMID: 23551291 DOI: 10.1111/apa.12255] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2012] [Revised: 03/14/2013] [Accepted: 03/27/2013] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
| | | | | | | | - Isabelle Godbert
- Neonatology; University Hospital Croix Rousse; Hospices Civils de Lyon; Lyon; France
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Sanches E, Arteni N, Nicola F, Boisserand L, Willborn S, Netto C. Early hypoxia–ischemia causes hemisphere and sex-dependent cognitive impairment and histological damage. Neuroscience 2013; 237:208-15. [DOI: 10.1016/j.neuroscience.2013.01.066] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Revised: 01/29/2013] [Accepted: 01/29/2013] [Indexed: 02/05/2023]
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Parikh NA, Kennedy KA, Lasky RE, McDavid GE, Tyson JE. Pilot randomized trial of hydrocortisone in ventilator-dependent extremely preterm infants: effects on regional brain volumes. J Pediatr 2013; 162:685-690.e1. [PMID: 23140612 PMCID: PMC3609889 DOI: 10.1016/j.jpeds.2012.09.054] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Revised: 09/20/2012] [Accepted: 09/27/2012] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To test the hypothesis that high-risk ventilator-dependent extremely low birth weight (birth weight ≤1000 g) infants treated with 7 days of hydrocortisone will have larger total brain tissue volumes than placebo treated infants. STUDY DESIGN A predetermined sample size of 64 extremely low birth weight infants, between 10-21 days old and ventilator-dependent with a respiratory index score ≥2, were randomized to systemic hydrocortisone (17 mg/kg cumulative dose) or saline placebo. Primary outcome was total brain tissue volume. Volumetric magnetic resonance imaging was performed at 38 weeks postmenstrual age; brain tissue regions were segmented and quantified automatically with a high degree of accuracy and 9 structures were segmented manually. All analyses of regional brain volumes were adjusted by postmenstrual age at magnetic resonance imaging scan. RESULTS The study groups were similar at baseline and 8 infants died in each arm. Unadjusted total brain tissue volume (mean ± SD) in the hydrocortisone (N = 23) and placebo treated infants (N = 21) was 272 ± 40.3 cm(3) and 277.8 ± 59.1 cm(3), respectively (adjusted mean difference: 6.35 cm(3) (95% CI: (-20.8, 32.5); P = .64). Three of the 31 hydrocortisone treated infants and 5 of the 33 placebo treated infants survived without severe bronchopulmonary dysplasia (relative risk 0.62, 95% CI: 0.13, 2.66; P = .49). No significant differences were noted in prespecified secondary outcomes of regional structural volumes or days on respiratory support. No adverse effects of hydrocortisone were observed. CONCLUSIONS Low dose hydrocortisone in high-risk ventilator-dependent infants after a week of age had no discernible effect on regional brain volumes or pulmonary outcomes prior to neonatal intensive care unit discharge.
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Affiliation(s)
- Nehal A Parikh
- Department of Pediatrics, Neonatal-Perinatal Medicine, University of Texas Medical School at Houston, Houston, TX, USA.
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Inder TE, Benders M. Postnatal steroids in the preterm infant-the good, the ugly, and the unknown. J Pediatr 2013; 162:667-70. [PMID: 23527840 DOI: 10.1016/j.jpeds.2012.12.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 12/13/2012] [Indexed: 12/26/2022]
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Azhan A, Wong FY. Challenges in understanding the impact of blood pressure management on cerebral oxygenation in the preterm brain. Front Physiol 2012; 3:471. [PMID: 23264765 PMCID: PMC3524455 DOI: 10.3389/fphys.2012.00471] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 11/30/2012] [Indexed: 02/01/2023] Open
Abstract
Systemic hypotension in preterm infants has been related to increased mortality, cerebrovascular lesions, and neurodevelopmental morbidity. Treatment of hypotension with inotropic medications aims at preservation of end organ perfusion and oxygen delivery, especially the brain. The common inotropic medications in preterm infants include dopamine, dobutamine, adrenaline, with adjunctive use of corticosteroids in cases of refractory hypotension. Whether maintenance of mean arterial blood pressure (MAP) by use of inotropic medication is neuroprotective or not remains unclear. This review explores the different inotropic agents and their effects on perfusion and oxygenation in the preterm brain, in clinical studies as well as in animal models. Dopamine and adrenalin, because of their α-adrenergic vasoconstrictor actions, have raised concerns of reduction in cerebral blood flow (CBF). Several studies in hypotensive preterm infants have shown that dopamine elevates CBF together with increased MAP, in keeping with limited cerebro-autoregulation. Adrenaline is also effective in raising cerebral perfusion together with MAP in preterm infants. Experimental studies in immature animals show no cerebro-vasoconstrictive effects of dopamine or adrenaline, but demonstrate the consistent findings of increased cerebral perfusion and oxygenation with the use of dopamine, dobutamine, and adrenaline, alongside with raised MAP. Both clinical and animal studies report the transitory effects of adrenaline in increasing plasma lactate, and blood glucose, which might render its use as a 2nd line therapy. To investigate the cerebral effects of inotropic agents in long-term outcome in hypotensive preterm infants, carefully designed prospective research possibly including preterm infants with permissive hypotension is required. Preterm animal models would be useful in investigating the relationship between the physiological effects of inotropes and histopathology outcomes in the developing brain.
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Affiliation(s)
- Aminath Azhan
- The Ritchie Centre, Monash UniversityMelbourne, VIC, Australia
| | - Flora Y. Wong
- The Ritchie Centre, Monash UniversityMelbourne, VIC, Australia
- Monash Newborn, Monash Medical CentreMelbourne, VIC, Australia
- Department of Pediatrics, Monash UniversityMelbourne, VIC, Australia
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Tam EWY, Chau V, Ferriero DM, Barkovich AJ, Poskitt KJ, Studholme C, Fok EDY, Grunau RE, Glidden DV, Miller SP. Preterm cerebellar growth impairment after postnatal exposure to glucocorticoids. Sci Transl Med 2012; 3:105ra105. [PMID: 22013125 DOI: 10.1126/scitranslmed.3002884] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
As survival rates of preterm newborns improve as a result of better medical management, these children increasingly show impaired cognition. These adverse cognitive outcomes are associated with decreases in the volume of the cerebellum. Because animals exhibit reduced preterm cerebellar growth after perinatal exposure to glucocorticoids, we sought to determine whether glucocorticoid exposure and other modifiable factors increased the risk for these adverse outcomes in human neonates. We studied 172 preterm neonatal infants from two medical centers, the University of British Columbia and the University of California, San Francisco, by performing serial magnetic resonance imaging examinations near birth and again near term-equivalent age. After we adjusted for associated clinical factors, antenatal betamethasone was not associated with changes in cerebellar volume. Postnatal exposure to clinically routine doses of hydrocortisone or dexamethasone was associated with impaired cerebellar, but not cerebral, growth. Alterations in treatment after preterm birth, particularly glucocorticoid exposure, may help to decrease risk for adverse neurological outcome after preterm birth.
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Affiliation(s)
- Emily W Y Tam
- Departments of Neurology and Pediatrics, University of California, San Francisco, San Francisco, CA 94143, USA.
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Lee HJ, Kim BI, Choi ES, Choi CW, Kim EK, Kim HS, Choi JH. Effects of postnatal dexamethasone or hydrocortisone in a rat model of antenatal lipopolysaccharide and neonatal hyperoxia exposure. J Korean Med Sci 2012; 27:395-401. [PMID: 22468103 PMCID: PMC3314852 DOI: 10.3346/jkms.2012.27.4.395] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Accepted: 01/26/2012] [Indexed: 12/03/2022] Open
Abstract
The aim of our study was to investigate the differential effects of dexamethasone (DXM) and hydrocortisone (HCS) on somatic growth and postnatal lung development in a rat model of bronchopulmonary dysplasia (BPD). A rat model of BPD was induced by administering intra-amniotic lipopolysaccharide (LPS) and postnatal hyperoxia. The rats were treated with a 6-day (D1-D6) tapering course of DXM (starting dose 0.5 mg/kg/day), HCS (starting dose 2 mg/kg/day), or an equivalent volume of normal saline. DXM treatment in a rat model of BPD induced by LPS and hyperoxia was also associated with a more profound weight loss compared to control and LPS + O(2) groups not exposed to corticosteroid, whereas HCS treatment affected body weight only slightly. Examination of lung morphology showed worse mean cord length in both LPS + O(2) + DXM and LPS + O(2) + HCS groups as compared to the LPS + O(2) alone group, and the LPS + O(2) + DXM group had thicker alveolar walls than the LPS + O(2) group at day 14. The HCS treatment was not significantly associated with aberrant alveolar wall thickening and retarded somatic growth. The use of postnatal DXM or HCS in a rat model of BPD induced by intra-amniotic LPS and postnatal hyperoxia appeared detrimental to lung growth, but there was less effect in the case of HCS. These findings suggest that effect of HCS on somatic growth and pulmonary outcome may be better tolerated in neonates for preventing and/or treating BPD.
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Affiliation(s)
- Hyun Ju Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Beyong Il Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Eung Sang Choi
- Department of Pediatrics, Chung-Ang University College of Medicine, Seoul, Korea
| | - Chang Won Choi
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ee-Kyung Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Jung-Hwan Choi
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
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Abstract
There is significant uncertainty regarding the optimal circulatory management of preterm infants, with research in the field limited by the paucity of safe, reproducible biomarkers of circulatory function. This review discusses the physiology and pathophysiology of circulatory function in preterm infants, describes the mode of action and evidence for and against commonly used and recently trialled inotropic therapies and provides recommendations for managing circulatory dysfunction in the transitional period and in the context of sepsis/necrotizing enterocolitis. We recommend a pragmatic approach of assessing multiple aspects of circulatory function (blood pressure alone correlates weakly with volume of flow) in each infant, tailoring therapy on the basis of the change in function desired and frequently reassessing response to intervention.
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Affiliation(s)
- David J Cox
- Centre for the Developing Brain, Imperial College London and MRC Clinical Sciences Centre, London, UK
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Abstract
Corticosteroids are used in the neonatal intensive care unit primarily to treat two conditions: bronchopulmonary dysplasia (BPD) and hypotension (cardiovascular insufficiency). Historically, high-dose dexamethasone was used for BPD, but its use was later associated with adverse neurodevelopmental outcomes and decreased substantially. Data from randomized controlled trials regarding efficacy and safety of lower-dose dexamethasone therapy are insufficient to recommend its use. Hydrocortisone may be an alternative to dexamethasone, but again data are insufficient to support use. Hydrocortisone therapy is increasingly used to treat hypotension in critically ill newborns; however, the outcomes of this therapy must be evaluated in randomized trials.
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Affiliation(s)
- Kristi Watterberg
- Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM 87131-0001, USA.
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Pulmonary effects of neonatal hydrocortisone treatment in ventilator-dependent preterm infants. Int J Pediatr 2011; 2011:783893. [PMID: 22229038 PMCID: PMC3250043 DOI: 10.1155/2011/783893] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2011] [Accepted: 09/21/2011] [Indexed: 11/24/2022] Open
Abstract
Background/Objective. Hydrocortisone, administered to ventilated preterm neonates to facilitate extubation, has no adverse long-term effects, but short-term pulmonary effects have not been described previously. In the present study, we analyzed effects of hydrocortisone on ventilator settings and FiO2 in ventilator-dependent preterm infants. Patients and Methods. Fifty-five preterm children were included in this retrospective cohort study. Hydrocortisone was administered at a postnatal age of > 7 days to treat chronic lung disease (CLD). Ventilator settings before and after hydrocortisone administration were recorded as well as FiO2 at 36 weeks' gestational age. Presence of cerebral palsy was assessed at a mean corrected age of 24.1 months. Results. Hydrocortisone administered at a median postnatal age of 14 days significantly reduced FiO2 from a median of 0.39 to 0.30, mean airway pressure (MAP) from a median of 10.0 cm H2O to 7.6 cm H2O, and PaCO2 from a median of 53.5 mmHg to 47 mmHg. Extubation was achieved in all patients. CLD at 36 weeks was present in 11 of the 52 patients (21.1%). None developed cerebral palsy. Conclusions. Hydrocortisone was effective in reducing the FiO2, MAP, and PaCO2 and facilitated extubation. Hydrocortisone was not associated with cerebral palsy.
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Onland W, Offringa M, Cools F, De Jaegere AP, Rademaker K, Blom H, Cavatorta E, Debeer A, Dijk PH, van Heijst AF, Kramer BW, Kroon AA, Mohns T, van Straaten HL, te Pas AB, Theyskens C, van Weissenbruch MM, van Kaam AH. Systemic Hydrocortisone To Prevent Bronchopulmonary Dysplasia in preterm infants (the SToP-BPD study); a multicenter randomized placebo controlled trial. BMC Pediatr 2011; 11:102. [PMID: 22070744 PMCID: PMC3245429 DOI: 10.1186/1471-2431-11-102] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Accepted: 11/09/2011] [Indexed: 12/05/2022] Open
Abstract
Background Randomized controlled trials have shown that treatment of chronically ventilated preterm infants after the first week of life with dexamethasone reduces the incidence of the combined outcome death or bronchopulmonary dysplasia (BPD). However, there are concerns that dexamethasone may increase the risk of adverse neurodevelopmental outcome. Hydrocortisone has been suggested as an alternative therapy. So far no randomized controlled trial has investigated its efficacy when administered after the first week of life to ventilated preterm infants. Methods/Design The SToP-BPD trial is a randomized double blind placebo controlled multicenter study including 400 very low birth weight infants (gestational age < 30 weeks and/or birth weight < 1250 grams), who are ventilator dependent at a postnatal age of 7 - 14 days. Hydrocortisone (cumulative dose 72.5 mg/kg) or placebo is administered during a 22 day tapering schedule. Primary outcome measure is the combined outcome mortality or BPD at 36 weeks postmenstrual age. Secondary outcomes are short term effects on the pulmonary condition, adverse effects during hospitalization, and long-term neurodevelopmental sequelae assessed at 2 years corrected gestational age. Analysis will be on an intention to treat basis. Discussion This trial will determine the efficacy and safety of postnatal hydrocortisone administration at a moderately early postnatal onset compared to placebo for the reduction of the combined outcome mortality and BPD at 36 weeks postmenstrual age in ventilator dependent preterm infants. Trial registration number Netherlands Trial Register (NTR): NTR2768
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Affiliation(s)
- Wes Onland
- Department of Neonatology, Emma Children's Hospital, Academic Medical Center, Amsterdam, the Netherlands
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Karalis F, Soubasi V, Georgiou T, Nakas CT, Simeonidou C, Guiba-Tziampiri O, Spandou E. Resveratrol ameliorates hypoxia/ischemia-induced behavioral deficits and brain injury in the neonatal rat brain. Brain Res 2011; 1425:98-110. [DOI: 10.1016/j.brainres.2011.09.044] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Revised: 09/20/2011] [Accepted: 09/22/2011] [Indexed: 10/17/2022]
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Damsted SK, Born AP, Paulson OB, Uldall P. Exogenous glucocorticoids and adverse cerebral effects in children. Eur J Paediatr Neurol 2011; 15:465-77. [PMID: 21632268 DOI: 10.1016/j.ejpn.2011.05.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2010] [Revised: 04/15/2011] [Accepted: 05/06/2011] [Indexed: 10/18/2022]
Abstract
Glucocorticoids are commonly used in treatment of paediatric diseases, but evidence of associated adverse cerebral effects is accumulating. The various pharmacokinetic profiles of the exogenous glucocorticoids and the changes in pharmacodynamics during childhood, result in different exposure of nervous tissue to exogenous glucocorticoids. Glucocorticoids activate two types of intracellular receptors, the mineralocorticoid receptor and the glucocorticoid receptor. The two receptors differ in cerebral distribution, affinity and effects. Exogenous glucocorticoids favor activation of the glucocorticoid receptor, which is associated with unfavorable cellular outcomes. Prenatal treatment with glucocorticoids can compromise brain growth and is associated with periventricular leukomalacia, attentions deficits and poorer cognitive performance. In the neonatal period exposure to glucocorticoids reduces neurogenesis and cerebral volume, impairs memory and increases the incidence of cerebral palsy. Cerebral effects of glucocorticoids in later childhood have been less thoroughly studied, but apparent brain atrophy, reduced size of limbic structures and neuropsychiatric symptoms have been reported. Glucocortioids affect several cellular structures and functions, which may explain the observed adverse effects. Glucocorticoids can impair neuronal glucose uptake, decrease excitability, cause atrophy of dendrites, compromise development of myelin-producing oligodendrocytes and disturb important cellular structures involved in axonal transport, long-term potentiation and neuronal plasticity. Significant maturation of the brain continues throughout childhood and we hypothesize that exposure to exogenous glucocorticoids during preschool and school age causes adverse cerebral effects. It is our opinion that studies of associations between exposure to glucocorticoids during childhood and impaired neurodevelopment are highly relevant.
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Affiliation(s)
- Sara K Damsted
- Department of Paediatrics, Copenhagen University Hospital, Rigshospitalet, Juliane Marie Center, Blegdamsvej 9, DK-2100 Copenhagen, Denmark.
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Postnatal corticosteroids for prevention and treatment of chronic lung disease in the preterm newborn. Int J Pediatr 2011; 2012:315642. [PMID: 22007245 PMCID: PMC3189570 DOI: 10.1155/2012/315642] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Accepted: 07/25/2011] [Indexed: 11/22/2022] Open
Abstract
Despite significant progress in the treatment of preterm neonates, bronchopulmonary dysplasia (BPD) continues to be a major cause of neonatal morbidity. Affected infants suffered from long-term pulmonary and nonpulmonary sequel. The pulmonary sequels include reactive airway disease and asthma during childhood and adolescence. Nonpulmonary sequels include poor coordination and muscle tone, difficulty in walking, vision and hearing problems, delayed cognitive development, and poor academic achievement. As inflammation seems to be a primary mediator of injury in pathogenesis of BPD, role of steroids as antiinflammatory agent has been extensively studied and proven to be efficacious in management. However, evidence is insufficient to make a recommendation regarding other glucocorticoid doses and preparations. Numerous studies have been performed to investigate the effects of steroid. The purpose of this paper is to evaluate these studies in order to elucidate the beneficial and harmful effects of steroid on the prevention and treatment of BPD.
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Abstract
PURPOSE OF REVIEW Bronchopulmonary dysplasia (BPD) is a chronic lung disease of infancy affecting mostly premature infants with significant morbidity and mortality. Improved survival of very immature infants has led to increased numbers of infants with this disorder. Acute and chronic lung injury and impaired postnatal lung growth are thought to be responsible for the development of BPD. Whereas changes in clinical practice have improved the clinical course and outcomes for infants with BPD, over the past decade, the overall incidence of BPD has not changed. This review will describe the prenatal and postnatal factors that contribute to the pathogenesis of BPD as well as current and experimental therapies for treatment of BPD. RECENT FINDINGS The factors that contribute to the pathogenesis of BPD are well described; however, recent studies have better defined how these factors modulate lung growth. Inflammation, proinflammatory cytokines and altered angiogenic gene signaling contribute to lung injury and impair prenatal and postnatal lung growth resulting in BPD; however, to date no therapy has been identified that potently and consistently prevents or reverses their effects on lung growth. We will discuss the cell signaling pathways affected in BPD and current therapies available for modulating these pathways. SUMMARY Despite current advances in neonatal care, BPD remains a heavy burden on healthcare resources. New treatments directed at either reducing lung injury or improving lung growth are under study.
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