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Rosano K, Bery S, Marasch J, Farrell R, Mastrandrea LD, Ryan RM. Predicting iatrogenic adrenal insufficiency in neonates exposed to prolonged steroid courses: do cortisol levels help? J Perinatol 2024:10.1038/s41372-024-01996-2. [PMID: 38769337 DOI: 10.1038/s41372-024-01996-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 04/29/2024] [Accepted: 05/01/2024] [Indexed: 05/22/2024]
Abstract
OBJECTIVE To determine whether random cortisol levels obtained in neonates to assess for secondary adrenal insufficiency (AI) after prolonged steroid exposure are predictive of central AI. STUDY DESIGN Data were collected on neonates born 2017-2022 who received ≥10 consecutive days of systemic steroids and had cortisol measured thereafter. Data were then collected on whether those neonates developed signs of AI or had a failed adrenocorticotropic hormone (ACTH) stimulation test. RESULTS Of the 71 cortisol levels (in 67 neonates) that were analyzed, there was no difference in cortisol levels between neonates who developed AI (median cortisol level of 6.5 mcg/dl) and those who did not (median of 9.2 mcg/dl), or between those who failed their ACTH stimulation test or passed it, using Wilcoxon ranked sum tests. CONCLUSION These findings demonstrate that cortisol levels may not be helpful in identifying AI in neonates exposed to prolonged steroids.
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Affiliation(s)
- Kristen Rosano
- Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH, USA.
| | - Saya Bery
- Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Jaime Marasch
- Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Ryan Farrell
- Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Lucy D Mastrandrea
- Jacobs School of Medicine and Biomedical Sciences, University of Buffalo, Buffalo, NY, USA
| | - Rita M Ryan
- Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH, USA
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Watanabe H, Washio Y, Tamai K, Morimoto D, Okamura T, Yoshimoto J, Nakanishi H, Kageyama M, Uchiyama A, Tsukahara H, Kusuda S. Postnatal longitudinal analysis of serum nitric oxide and eosinophil counts in extremely preterm infants. Pediatr Neonatol 2024; 65:276-281. [PMID: 37989707 DOI: 10.1016/j.pedneo.2023.08.006] [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: 01/07/2023] [Revised: 07/24/2023] [Accepted: 08/08/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Nitric oxide (NO) may be related to the pathogenesis of several morbidities in extremely preterm infants, including late-onset adrenal insufficiency. However, eosinophilia is observed under pathological conditions with adrenal insufficiency. Therefore, this study explored postnatal changes in NO levels and eosinophil counts in extremely preterm infants with and without morbidities. METHODS Nineteen extremely preterm infants with a median gestational age of 27.0 weeks and median birth weight of 888 g were enrolled in this study. Serum levels of nitrogen oxides (NOx) and peripheral blood eosinophil counts were measured at birth and every 2 weeks thereafter. Morbidities of the study group were diagnosed using a single criterion. RESULTS Serum NOx levels (mean ± standard deviation) were 22.5 ± 14.9 μmol/L, 51.2 ± 23.7 μmol/L, 42.4 ± 15.2 μmol/L, and 33.8 ± 9.4 μmol/L at birth and 2, 4, and 6 weeks of age, respectively. The serum NOx level at 2 weeks of age was significantly higher than that at birth and 6 weeks of age. Eosinophil counts, which increase with adrenal insufficiency, were measured simultaneously and were 145 ± 199/μL, 613 ± 625/μL, 466 ± 375/μL, and 292 ± 228/μL at birth and 2, 4, and 6 weeks of age, respectively. These values showed that the eosinophil count was significantly higher at 2 weeks of age than at birth and 6 weeks of age. The serum NOx level of infants without chorioamnionitis was significantly increased at 4 weeks of age, and the eosinophil count of infants with necrotizing enterocolitis was significantly increased at 2 weeks of age. No correlation with the NOx level or eosinophil count was observed in infants with late-onset circulatory collapse. CONCLUSION The postnatal serum NOx level and eosinophil count were significantly correlated with each other and peaked at 2 weeks of age.
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Affiliation(s)
- Hirokazu Watanabe
- Department of Pediatrics, Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama University, Okayama, Japan
| | - Yosuke Washio
- Department of Pediatrics, Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama University, Okayama, Japan.
| | - Kei Tamai
- Department of Neonatology, Okayama Medical Center, National Hospital Organization, Okayama, Japan
| | - Daisaku Morimoto
- Department of Pediatrics, Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama University, Okayama, Japan
| | - Tomoka Okamura
- Department of Pediatrics, Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama University, Okayama, Japan
| | - Junko Yoshimoto
- Department of Pediatrics, Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama University, Okayama, Japan
| | - Hidehiko Nakanishi
- Department of Neonatology, Maternal and Perinatal Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Misao Kageyama
- Department of Neonatology, Okayama Medical Center, National Hospital Organization, Okayama, Japan
| | - Atsushi Uchiyama
- Department of Neonatology, Maternal and Perinatal Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Hirokazu Tsukahara
- Department of Pediatrics, Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama University, Okayama, Japan
| | - Satoshi Kusuda
- Department of Neonatology, Maternal and Perinatal Center, Tokyo Women's Medical University, Tokyo, Japan
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Kloosterboer S, Anolda Naber FB, Heyman H, Hoffmann-Haringsma A, Brunt TM. A Preliminary Study of Correlates of Premature Birth and Their Influence on Cortisol Levels in Young Children. Biol Res Nurs 2024; 26:240-247. [PMID: 37863478 PMCID: PMC10938487 DOI: 10.1177/10998004231209429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2023]
Abstract
OBJECTIVE The HPA-axis is programmed during early infancy, but a lot is unknown about the programming of the HPA-axis in prematurely born or small for gestational age (SGA) children. Therefore, the aim of this preliminary study was to investigate the influence of prematurity and variables associated with birth on cortisol levels in young children. METHODS Cortisol was measured in a cross-sectional design in 38 premature born participants (<37 weeks of gestation), aged between 3 - 9 years old. Correlates of prematurity (degree of prematurity and birth delivery route) were investigated in relationship with cortisol levels with regression analysis. RESULTS Corrected for sex, delivery by C-section was associated with lower cortisol levels in the children (ß = -.42, p = .028), with an explained variance of 34%. CONCLUSION Birth delivery route by C-section is associated with lowered (or flattened) cortisol levels in children born prematurely. This is clinically relevant and might have important implications, because an HPA-axis disturbance might lead to developmental problems later on in life. However, future research is necessary to investigate the underlying indications for performing a C-section, which will help to understand factors that influence the HPA-axis development in children born prematurely.
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Affiliation(s)
- Sophia Kloosterboer
- Department of Pediatrics, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | | | - Angelique Hoffmann-Haringsma
- Het Kleine Heldenhuis, Rotterdam, Netherlands
- Department of Neonatology, St Fransiscus Hospital, Rotterdam, Netherlands
| | - Tibor Markus Brunt
- Het Kleine Heldenhuis, Rotterdam, Netherlands
- Department of Psychiatry, Amsterdam University Medical Center, Amsterdam, Netherlands
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Weiss SJ, Keeton V, Richoux S, Cooper B, Niemann S. Exposure to antenatal corticosteroids and infant cortisol regulation. Psychoneuroendocrinology 2023; 147:105960. [PMID: 36327758 PMCID: PMC9968454 DOI: 10.1016/j.psyneuen.2022.105960] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 09/16/2022] [Accepted: 10/23/2022] [Indexed: 11/06/2022]
Abstract
Administration of antenatal corticosteroids (AC) is the standard of care during pregnancy for women who are at risk of early delivery. Evidence indicates that AC improve survival and reduce morbidity for preterm infants. However, research suggests that infants whose mothers receive AC have an altered hypothalamic-pituitary-axis (HPA) response to stressors in early life. Results are mixed regarding the nature of these effects, with studies showing both suppressed and augmented HPA activity. In addition, research is very limited beyond the 4th month of life. The purpose of this study was to determine if AC exposure was associated with infant cortisol levels in a resting state or in response to a stressor at 1, 6 and 12 months postnatal. We also evaluated the moderating role of preterm birth in this association. 181 women and their infants participated in the study. Women were recruited during the 3rd trimester of pregnancy; at this time, they completed the Perceived Stress Scale and provided 8 salivary samples over a 2-day period for cortisol assay. They provided these data again at 6 and 12 months postnatal. At 1, 6, and 12 months postnatal, salivary samples were collected from infants to examine their cortisol levels before and after participation in a 'stressor protocol'. Data were extracted from the medical record on AC exposure, gestational age, maternal obstetric risk, and neonatal morbidity. Mixed effects multilevel regression modeling was used to examine the aims. Infants whose mothers received AC had significantly lower resting state (B = -2.47, CI: -3.691, -0.0484) and post-stressor (B = -2.51, CI: -4.283, -0.4276) cortisol levels across the first year of life than infants whose mothers did not receive AC. There was no moderating effect of preterm birth on the relationship between AC exposure and cortisol. Results indicate a state of dampened HPA activation and cortisol hypo-arousal that persists across the first year of life among infants who were exposed to corticosteroids in utero. Further research is needed to examine mechanisms responsible for any alterations that occur during development of the fetal HPA axis, including epigenetic and biochemical factors that control hormonal secretion, negative feedback, and glucocorticoid receptor function throughout the HPA axis. Findings warrant careful consideration by obstetric clinicians of the benefits and risks of prescribing AC.
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Affiliation(s)
- Sandra J. Weiss
- Department of Community Health Systems, University of California, San Francisco, USA,Correspondence to: Department of Community Health Systems, University of California, Box 0608, 2 Koret Way, San Francisco, CA, 94143, USA. (S.J. Weiss)
| | - Victoria Keeton
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, USA
| | - Sarah Richoux
- Department of Community Health Systems, University of California, San Francisco, USA
| | - Bruce Cooper
- Department of Community Health Systems, University of California, San Francisco, USA
| | - Sandra Niemann
- Department of Community Health Systems, University of California, San Francisco, USA
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Masumoto K, Kusuda S. Hemodynamic support of the micropreemie: Should hydrocortisone never be left out? Semin Fetal Neonatal Med 2021; 26:101222. [PMID: 33692008 DOI: 10.1016/j.siny.2021.101222] [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] [Indexed: 11/25/2022]
Abstract
Hemodynamic support for a micropreemie is critically important for preventing mortality and morbidity. An essential consideration in hemodynamic support is insufficient transition from fetal to neonatal circulation and inadequate cortisol production. The first 72 h of life are the most critical, especially when myocardial function is immature and impaired. Therefore, there is a need to determine and adjust preload, myocardial contractility, and afterload appropriately using repeated functional echocardiography. In addition, if myocardial function is not responsive to these attempts at hemodynamic management, hydrocortisone must be used to minimize the suboptimal perfusion burden. Fetal cortisol production is supported by a supply of progesterone from the placenta, and postnatally, adrenal cortisol production in the extremely preterm infant may be inadequate if the infant is placed under excessive stress. This leads to relative adrenal insufficiency which may last for up to several weeks after birth and lead to late-onset circulatory collapse, necessitating treatment with physiological doses of hydrocortisone.
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Affiliation(s)
- Kenichi Masumoto
- Department of Neonatology, Maternal and Perinatal Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Satoshi Kusuda
- Department of Pediatrics, Kyorin University, Tokyo, Japan.
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Kandel SE, Lampe JN. Inhibition of CYP3A7 DHEA-S Oxidation by Lopinavir and Ritonavir: An Alternative Mechanism for Adrenal Impairment in HIV Antiretroviral-Treated Neonates. Chem Res Toxicol 2021; 34:1150-1160. [PMID: 33821626 PMCID: PMC8058764 DOI: 10.1021/acs.chemrestox.1c00028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
![]()
Prophylactic antiretroviral
therapy (ART) in HIV infected pregnant
mothers and their newborns can dramatically reduce mother-to-child
viral transmission and seroconversion in the neonate. The ritonavir-boosted
lopinavir regimen, known as Kaletra, has been associated with premature
birth and transient adrenal insufficiency in newborns, accompanied
by increases in plasma dehydroepiandrosterone 3-sulfate (DHEA-S).
In the fetus and neonates, cytochrome P450 CYP3A7 is responsible for
the metabolism of DHEA-S into 16α-hydroxy DHEA-S, which plays
a critical role in growth and development. In order to determine if
CYP3A7 inhibition could lead to the adverse outcomes associated with
Kaletra therapy, we conducted in vitro metabolic
studies to determine the extent and mechanism of CYP3A7 inhibition
by both ritonavir and lopinavir and the relative intrinsic clearance
of lopinavir with and without ritonavir in both neonatal and adult
human liver microsomes (HLMs). We identified ritonavir as a potent
inhibitor of CYP3A7 oxidation of DHEA-S (IC50 = 0.0514
μM), while lopinavir is a much weaker inhibitor (IC50 = 5.88 μM). Furthermore, ritonavir is a time-dependent inhibitor
of CYP3A7 with a KI of 0.392 μM
and a kinact of 0.119 min–1, illustrating the potential for CYP3A mediated drug–drug
interactions with Kaletra. The clearance rate of lopinavir in neonatal
HLMs was much slower and comparable to the rate observed in adult
HLMs in the presence of ritonavir, suggesting that the addition of
ritonavir in the cocktail therapy may not be necessary to maintain
effective concentrations of lopinavir in neonates. Our results suggest
that several of the observed adverse outcomes of Kaletra therapy may
be due to the direct inhibition of CYP3A7 by ritonavir and that the
necessity for the inclusion of this drug in the therapy may be obviated
by the lower rate of lopinavir clearance in the neonatal liver. These
results may lead to a reconsideration of the use of ritonavir in neonatal
antiretroviral therapy.
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Affiliation(s)
- Sylvie E Kandel
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy, University of Colorado, Aurora, Colorado 80045, United States
| | - Jed N Lampe
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy, University of Colorado, Aurora, Colorado 80045, United States
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Iijima S. Late-onset glucocorticoid-responsive circulatory collapse in premature infants. Pediatr Neonatol 2019; 60:603-610. [PMID: 31564521 DOI: 10.1016/j.pedneo.2019.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 07/16/2019] [Accepted: 09/06/2019] [Indexed: 12/20/2022] Open
Abstract
Late-onset glucocorticoid-responsive circulatory collapse (LGCC) in infants is characterized by sudden onset of hypotension and/or oliguria, which is resistant to volume expanders and inotropes but responds rapidly to intravenous glucocorticoids. LGCC occurs after the first week of life mainly in relatively stable very low birth weight (VLBW) infants. In Japan, the incidence of LGCC is reported to be 8%. Relative adrenal insufficiency (AI) is considered the most likely cause of LGCC, but its detailed pathophysiology remains unclear. Intrinsic and extrinsic factors may affect the pathophysiological mechanism. LGCC should be recognized as one of the high-risk complications in VLBW infants and managed promptly and properly, because if it is not, it may cause life-long neurological problems. To diagnose relative AI, an accurate evaluation of adrenal function is necessary; however, the interpretation of basal serum cortisol levels is difficult in preterm infants after 7 days of life. To recognize LGCC, it is recommended that blood pressure and urine volume be carefully monitored, even outside of the transitional period. If no underlying causes are documented or volume expansion and inotropic support fail, intravenous hydrocortisone should be initiated, and an additional dose of hydrocortisone is required when the response is inadequate. There are few reports to verify or characterize LGCC and this phenomenon has not been recognized worldwide to date. This review summarizes the current knowledge about LGCC in premature infants and evaluates the most significant new findings regarding its pathophysiology, treatment, and prognosis.
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Affiliation(s)
- Shigeo Iijima
- Department of Pediatrics, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, Shizuoka 431-3192, Japan.
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Jang JH, Shin J, Jung YH, Choi CW, Kim BI. Clinical Features of Late-Onset Circulatory Collapse in Preterm Infants. NEONATAL MEDICINE 2019. [DOI: 10.5385/nm.2019.26.3.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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