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Jenkinson AC, Kaltsogianni O, Dassios T, Greenough A. Systematic review of the long-term effects of postnatal corticosteroids. J Perinat Med 2023; 51:1120-1128. [PMID: 37606507 DOI: 10.1515/jpm-2023-0297] [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: 07/19/2023] [Accepted: 08/06/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Dexamethasone administration can reduce bronchopulmonary dysplasia, our objective was to identify long term adverse effects. CONTENT A systematic review was performed to determine the childhood and adolescent cardiopulmonary and cognitive effects of dexamethasone systemically administered to preterm infants during neonatal intensive care. Relevant studies were identified by searching two electronic health databases and the grey literature. Spirometry assessments were used as respiratory outcomes, blood pressure and echocardiography assessments as cardiovascular outcomes and cognitive and motor function as cognitive outcomes. From 1,479 articles initially identified, 18 studies (overall 1,609 patients) were included (respiratory n=8, cardiovascular n=2, cognitive n=10); all were observational cohort studies. Dexamethasone exposure was associated with worse pulmonary outcomes in children and adolescents (more abnormal FVC and FEV1:FVC z scores). Dexamethasone exposure was associated in one study with lower IQ scores compared to preterm controls (mean 78.2 [SD 15.0] vs. 84.4 [12.6], [p=0.008]) and in two others was associated with lower total and performance IQ when compared to term controls (p<0.001). SUMMARY AND OUTLOOK Postnatal dexamethasone exposure has a negative influence on pulmonary and cognitive outcomes in childhood and adolescence. Medications with a better benefit to risk profile need to be identified.
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Affiliation(s)
- Allan C Jenkinson
- Department of Women and Children, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Ourania Kaltsogianni
- Department of Women and Children, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Theodore Dassios
- Department of Women and Children, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Anne Greenough
- Department of Women and Children, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
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Szabó H, Baraldi E, Colin AA. Corticosteroids in the prevention and treatment of infants with bronchopulmonary dysplasia: Part I. systemic corticosteroids. Pediatr Pulmonol 2022; 57:600-608. [PMID: 34964559 DOI: 10.1002/ppul.25805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/21/2021] [Accepted: 12/27/2021] [Indexed: 11/06/2022]
Abstract
Bronchopulmonary dysplasia (BPD) is the most significant respiratory complication of prematurity, and its consequences last from birth into adulthood. Unfortunately, the dramatic improvements in the management of premature infants have not led to a decreased incidence of BPD, or to breakthroughs in treatments offered for this long-lasting chronic respiratory disorder. Over recent decades the pathological picture of BPD has changed from inflammation, interstitial fibrosis and emphysema attributed to volu-, barotrauma and oxygen toxicity to larger, simplified alveoli and dysmorphic vessels related to arrested alveolarization and vasculogenesis with inflammation maintaining a central role. Corticosteroids (CSs) play a key role in the development of respiratory epithelial cells and lung maturation. These potent anti-inflammatory agents have long been used for the prevention and treatment of BPD; however, the risk/benefit ratio of their use remains unresolved. CSs administered antenatally have contributed to reduce mortality and respiratory distress syndrome, no such effect on BPD reduction has been observed. Postnatal systemic CSs reduced the rate and severity of BPD, yet their long-term neurodevelopmental and respiratory consequences markedly limit routine administration. This is the first in a two-part State-of-the-Art series that reviews the latest relevant clinical trials investigating the short-term and long-term effects of CSs in the prevention and treatment of BPD.
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Affiliation(s)
- Hajnalka Szabó
- Department of Pediatrics, Faculty of Medicine and Albert Szent-Györgyi Health Center, University of Szeged, Szeged, Hungary
| | - Eugenio Baraldi
- Neonatal Intensive Care Unit, Department of Woman's and Child's Health, Padova University Hospital, Padova, Italy
| | - Andrew A Colin
- Division of Pediatric Pulmonology, Miller School of Medicine, University of Miami, Miami, Florida, USA
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Harris C, Crichton S, Zivanovic S, Lunt A, Calvert S, Marlow N, Peacock JL, Greenough A. Effect of dexamethasone exposure on the neonatal unit on the school age lung function of children born very prematurely. PLoS One 2018; 13:e0200243. [PMID: 29985964 PMCID: PMC6037362 DOI: 10.1371/journal.pone.0200243] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 06/24/2018] [Indexed: 12/16/2022] Open
Abstract
The objective of this study was to determine the impact of postnatal dexamethasone treatment on the neonatal unit on the school age lung function of very prematurely born children. Children born prior to 29 weeks of gestational age had been entered into a randomised trial of two methods of neonatal ventilation (United Kingdom Oscillation Study). They had comprehensive lung function measurements at 11 to 14 years of age. One hundred and seventy-nine children born at a mean gestational age of 26.9 (range 23–28) weeks were assessed at 11 to 14 years; 50 had received postnatal dexamethasone. Forced expiratory flow at 75% (FEF75), 50%, 25% and 25–75% of the expired vital capacity, forced expiratory volume in one second, peak expiratory flow and forced vital capacity and lung volumes including total lung capacity and residual volume were assessed. Lung function outcomes were compared between children who had and had not been exposed to dexamethasone after adjustment for neonatal factors using linear mixed effects regression. After adjustment for confounders all the mean spirometry results were between 0.38 and 0.87 standard deviations lower in those exposed to dexamethasone compared to the unexposed. For example, the mean FEF75 z-score was 0.53 lower (95% CI 0.21 to 0.85). The mean lung function was lower as the number of courses of dexamethasone increased. In conclusion, postnatal dexamethasone exposure was associated with lower mean lung function at school age in children born extremely prematurely. Our results suggest the larger the cumulative dose the greater the adverse effect on lung function at follow-up.
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Affiliation(s)
- Christopher Harris
- MRC & Asthma UK Centre for Allergic Mechanisms in Asthma, King’s College London, London, United Kingdom
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Siobhan Crichton
- School of Population Health and Environmental Sciences, King’s College London, London, United Kingdom
| | - Sanja Zivanovic
- MRC & Asthma UK Centre for Allergic Mechanisms in Asthma, King’s College London, London, United Kingdom
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Alan Lunt
- MRC & Asthma UK Centre for Allergic Mechanisms in Asthma, King’s College London, London, United Kingdom
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Sandy Calvert
- Department of Child Health, St George's Hospital, London, United Kingdom
| | - Neil Marlow
- Neonatal Medicine, University College, London, United Kingdom
| | - Janet L. Peacock
- School of Population Health and Environmental Sciences, King’s College London, London, United Kingdom
- NIHR Biomedical Centre at Guy’s and St Thomas NHS Foundation Trust and King’s College London, London, United Kingdom
| | - Anne Greenough
- MRC & Asthma UK Centre for Allergic Mechanisms in Asthma, King’s College London, London, United Kingdom
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
- NIHR Biomedical Centre at Guy’s and St Thomas NHS Foundation Trust and King’s College London, London, United Kingdom
- * E-mail:
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Qin G, Lo JW, Marlow N, Calvert SA, Greenough A, Peacock JL. Postnatal dexamethasone, respiratory and neurodevelopmental outcomes at two years in babies born extremely preterm. PLoS One 2017; 12:e0181176. [PMID: 28723921 PMCID: PMC5517008 DOI: 10.1371/journal.pone.0181176] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 06/27/2017] [Indexed: 11/30/2022] Open
Abstract
Importance Postnatal dexamethasone is associated with reduction in bronchopulmonary dysplasia. There remains, however, concern that its short-term benefits are accompanied by long-term adverse effects e.g. poorer neurodevelopmental outcomes. Objective Our aim was to determine the effects of administration of postnatal dexamethasone on respiratory and neurodevelopmental outcome at two years of age after adjusting for neonatal and infant risk factors. Materials and methods The study included 412 infants born at 23–28 weeks of gestation, 29% had received postnatal dexamethasone. Two outcomes were examined, respiratory hospital admissions in the past 12 months and neurodevelopmental impairment. Logistic regression, adjusted for sex, birthweight z-score, gestation, maternal smoking, oxygen dependency at 36 weeks, airleak, patent ductus arteriosus, pulmonary haemorrhage, major ultrasound abnormality, mode of ventilation and age at assessment, was undertaken. Results After adjustment, postnatal dexamethasone was associated with significantly increased proportions of both respiratory hospital readmission: (0.35 vs 0.15, difference = 0.20; 95% CI: 0.08, 0.31) and neurodevelopmental impairment (0.59 vs 0.45, difference = 0.14; 95% CI: 0.02, 0.26). Conclusions Postnatal dexamethasone use in extremely preterm infants is associated with increased risks of respiratory hospital admissions and neurodevelopmental impairment. These associations were not explained by excess neonatal morbidities.
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Affiliation(s)
- Gordon Qin
- Division of Health and Social Care Research, King’s College London, London, United Kingdom
- Queen Alexandra Hospital, Portsmouth, Hampshire, United Kingdom
| | - Jessica W. Lo
- Division of Health and Social Care Research, King’s College London, London, United Kingdom
- School of Psychiatry, UNSW Medicine, University of New South Wales, Randwick, Australia
| | - Neil Marlow
- Institute for Women’s Health, University College London, London, United Kingdom
| | - Sandy A. Calvert
- Department of Child Health, St George’s University of London, London, United Kingdom
| | - Anne Greenough
- School of Psychiatry, UNSW Medicine, University of New South Wales, Randwick, Australia
- Division of Asthma, Allergy and Lung Biology, King's College London, London, United Kingdom
| | - Janet L. Peacock
- Division of Health and Social Care Research, King’s College London, London, United Kingdom
- * E-mail:
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Hjalmarson O, Brynjarsson H, Nilsson S, Sandberg KL. Persisting hypoxaemia is an insufficient measure of adverse lung function in very immature infants. Arch Dis Child Fetal Neonatal Ed 2014; 99:F257-62. [PMID: 24356176 DOI: 10.1136/archdischild-2013-304625] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Bronchopulmonary dysplasia (BPD), defined as protracted neonatal hypoxaemia, is considered a risk factor for respiratory disease in adulthood. The relationship between this diagnosis and the actual lung injury appearing in very immature infants is, however, unknown. OBJECTIVES To compare lung function at term in very immature infants and full-term infants, and to determine how degree and duration of neonatal hypoxaemia are related to other aspects of lung function. DESIGN AND METHODS All surviving, consecutive infants with gestational age below 28 weeks from a geographically defined area were eligible. The alveolar-arterial oxygen pressure difference was assessed as a measure of oxygenation failure. At term, functional residual capacity and gas-mixing efficiency were measured by multiple-breath nitrogen washout, and compliance and conductance of the respiratory system by the occlusion method. The results were compared to those in 50 full-term controls. MAIN RESULTS Thirty-seven of 46 eligible infants were included. The preterm infants differed markedly from the full-term infants in all lung functions tested. Infants diagnosed as having BPD had more compromised lung function than those without, but the latter group differed markedly from the full-term group in functional residual capacity, compliance and gas-mixing efficiency. Only the mechanical variables were correlated to hypoxaemia at 36 weeks postmenstrual age (PMA). CONCLUSIONS Infants with gestational age below 28 weeks at birth have remarkably impaired lung function at term, regardless of whether they carry the diagnosis BPD or not. All very immature infants may be at risk of future respiratory disease and should be monitored appropriately.
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Lovering AT, Laurie SS, Elliott JE, Beasley KM, Yang X, Gust CE, Mangum TS, Goodman RD, Hawn JA, Gladstone IM. Normal pulmonary gas exchange efficiency and absence of exercise-induced arterial hypoxemia in adults with bronchopulmonary dysplasia. J Appl Physiol (1985) 2013; 115:1050-6. [DOI: 10.1152/japplphysiol.00592.2013] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Cardiopulmonary function is reduced in adults born very preterm, but it is unknown if this results in reduced pulmonary gas exchange efficiency during exercise and, consequently, leads to reduced aerobic capacity in subjects with and without bronchopulmonary dysplasia (BPD). We hypothesized that an excessively large alveolar to arterial oxygen difference (AaDO2) and resulting exercise-induced arterial hypoxemia (EIAH) would contribute to reduced aerobic fitness in adults born very preterm with and without BPD. Measurements of pulmonary function, lung volumes and diffusion capacity for carbon monoxide (DLco) were made at rest. Measurements of maximal oxygen consumption, peak workload, temperature- and tonometry-corrected arterial blood gases, and direct measure of hemoglobin saturation with oxygen (SaO2) were made preexercise and during cycle ergometer exercise in ex-preterm subjects ≤32-wk gestational age, with BPD ( n = 12), without BPD (PRE; n = 12), and full term controls (CONT; n = 12) breathing room air. Both BPD and PRE had reduced pulmonary function and reduced DLco compared with CONT. The AaDO2 was not significantly different between groups, and there was no evidence of EIAH (SaO2 < 95% and/or AaDO2 ≥ 40 Torr) in any subject group preexercise or at any workload. Arterial O2 content was not significantly different between the groups preexercise or during exercise. However, peak power output was decreased in BPD and PRE subjects compared with CONT. We conclude that EIAH in adult subjects born very preterm with and without BPD does not likely contribute to the reduction in aerobic exercise capacity observed in these subjects.
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Affiliation(s)
| | - Steven S. Laurie
- University of Oregon, Department of Human Physiology, Eugene, Oregon
| | | | - Kara M. Beasley
- University of Oregon, Department of Human Physiology, Eugene, Oregon
| | - Ximeng Yang
- University of Oregon, Department of Human Physiology, Eugene, Oregon
| | - Caitlyn E. Gust
- University of Oregon, Department of Human Physiology, Eugene, Oregon
| | - Tyler S. Mangum
- University of Oregon, Department of Human Physiology, Eugene, Oregon
| | - Randall D. Goodman
- University of Oregon, Department of Human Physiology, Eugene, Oregon
- Oregon Heart and Vascular Institute, Springfield, Oregon; and
| | - Jerold A. Hawn
- University of Oregon, Department of Human Physiology, Eugene, Oregon
- Oregon Heart and Vascular Institute, Springfield, Oregon; and
| | - Igor M. Gladstone
- University of Oregon, Department of Human Physiology, Eugene, Oregon
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
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Cazzato S, Ridolfi L, Bernardi F, Faldella G, Bertelli L. Lung function outcome at school age in very low birth weight children. Pediatr Pulmonol 2013; 48:830-7. [PMID: 23129340 DOI: 10.1002/ppul.22676] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Accepted: 07/31/2012] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of this study was to assess pulmonary function and its predictors in very low birth weight (birth weight ≤1,500 g) children (VLBWc) with or without bronchopulmonary dysplasia (BPD), born at gestational age ≤32 weeks at a single tertiary center during 1996-1999, after the introduction of surfactant therapy. METHODS Of the 120 surviving VLBW children, 48 (40%) VLBWc (22 with prior-BPD) at age 8.5 ± 1.0 years and 46 age-matched controls (8.8 ± 1.4 years) born at term, underwent lung function study. RESULTS Adjusted values (z-score) of forced vital capacity (z-FVC), forced expiratory volume in 1 sec (z-FEV1), forced expiratory flow 25-75% (z-FEF25-75), carbon monoxide lung diffusion capacity (z-DLCO), and DLCO/alveolar volume (z-DLCO/VA) were significantly lower than controls (mean difference, 95% CI: -1.35, -1.81 to -0.90, P < 0.001; -1.31, -1.73 to -0.90, P < 0.001; -0.87, -1.29 to -0.46, P < 0.001; -0.98, -1.72 to -0.23, P < 0.001; -0.70, -1.22 to -0.18, P < 0.05; respectively). Residual volume (z-RV) and RV/total lung capacity (RV/TLC) ratio (%) were significantly higher in VLBWc than controls (mean difference, 95% CI: 1.06, 0.44 to 1.68, P < 0.001; 9.54%, 5.73 to 13.3%, P < 0.001; respectively). No differences were found in lung function between VLBWc (no-BPD vs. BPD) with the exception of a significant higher RV/TLC ratio in the BPD-subgroup (mean difference, 95% CI: 7.0%, 0.4 to 13%, P = 0.03). Lung function abnormalities were found in 30 (63%) VLBWc with evidence of airway obstruction and diffusing capacity impairment. A weak relationship was observed between gestational age with z-FVC (r = 0.30, P = 0.04), birth weight with z-FEV1 (r = 0.30, P = 0.04) and RV/TLC ratio (r = -0.49, P = 0.001). The duration of oxygen treatment correlated negatively with the z-DLCO/Va (r = -0.5, P = 0.02). No differences were found in FeNO levels between VLBWc and controls. CONCLUSION VLBWc at school age showed lung function abnormalities characterized by airway obstruction, hyperinflation, and diffusion impairment. Neonatal lung damage together with preterm birth may play a role in worsening the functional respiratory outcome.
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Affiliation(s)
- Salvatore Cazzato
- Department of Pediatrics, University of Bologna, S. Orsola-Malpighi Hospital Bologna, Italy.
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