Less postnatal steroids, more bronchopulmonary dysplasia

In modern neonatology, the use of steroids for the prevention or treatment of bronchopulmonary dysplasia (BPD) or chronic lung disease (CLD) in preterm infants has had fluctuating popularity. This treatment determines an acute improvement in pulmonary mechanics, which can be appreciated already on or two days after first administration of steroids. This has been confirmed by some meta-analyses of randomised controlled trials, which suggest that postnatal administration of steroids reduces incidence and severity of BPD. However, the use of steroids has been associated with some adverse short-term and longterm effects. Many of the data on adverse effects were reported during the years 1998–2001; therefore, in 2001-2 new clinical guidelines (recommended by the European Association of Perinatal Medicine and by Committees for the Fetus and Newborn of the American Academy of Pediatrics and the Canadian Pediatric Society) suggested not to administrate steroids routinely for prevention or treatment of BPD. Since 1998, databases on very low birthweight infants (VLBWI) have reported that there has been a progressive reduction in the use of postnatal steroids. However, more research in postnatal steroid treatment is still needed.
An Israel group conducted a population-based study to evaluate trends in postnatal steroid use for BPD and to correlate the changes with the incidence of oxygen (O2) dependency at 28 days of age and at 36 weeks postmenstrual age (PMA). O2 dependency at 28 days and 36 weeks PMA was chosen as outcome variable because it is directly correlated with clinical diagnosis of RDS.
The evaluated sample was composed of 7188 infants included in Israel’s National VLBW Infant Database and born between 1997 and 2004, of gestational age 24–32 weeks. All infants required mechanical ventilation or O2 therapy.
Results show that steroid use fell significantly from 23.5% in 1997–8 to 11% in 2003–4. Statistical analysis show that O2 therapy at both 28 days and 36 weeks was significantly raised from 1997-8 to 2003-4 [odds ratio (OR) 1.75 at 28 days and OR 1.41 at 36 weeks]. The mean duration of O2 therapy increased from 25.3 days in 1997-8 to 28.0 days in 2003-4. Survival increased from 78.5% in 1997-8 to 81.6% in 2003-4.
In summary, this observational study has shown, in more than 7000 VLBWI, that the reduction in the use of postnatal steroids observed from 1997-8 to 2003-4 was associated with a 1.7-fold increase in O2 dependency at 28 days of age and a 1.4-fold increase at 36 weeks PMA, which is directly correlated with the risk of developing RDS. However, the magnitude of the increase in duration of O2 therapy was modest. Further studies are needed to identify those severely ill infants in whom the potential benefits of steroid treatment in reducing BPD and its associated neurodevelopmental impairment may exceed the risks associated with steroid treatment.

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