Systemic Steroids for Evolving Severe CLD

Pharmacologic doses of steroids have been shown to effect acute improvements in respiratory status in babies with severe inflammatory chronic lung changes. Acutely steroids improve pulmonary mechanics and gas exchange often leading to a reduction in requirements for assisted ventilation. (Halliday and Ehrenkrantz. Cochrane Database of Systematic Reviews. 2000) Long-term decreases in mortality or BPD have not been substantiated.

However, accumulating evidence suggests that pharmacologic doses of steroids given to premature infants may have significant long-term adverse effects on neurodevelopment. Particularly, the incidence of cerebral palsy is increased in former preterm infants who received postnatal steroids. A recent systematic review suggests that 1 in 7 to 11 infants treated with postnatal steroids will suffer a subsequent neurodevelopmental disability (Barrington. Pediatrics 2001;107:1425-6.)

Therefore, postnatal steroid use should be limited to only the most severely ill infants who are most likely to benefit from their use. Only the lowest doses possible and shortest courses should be employed. Vanderbilt’s dexamethasone protocol is designed to target only those infants with evolving severe CLD who have a 80% risk of mortality from CLD without the use of postnatal steroids.

Given the current controversy surrounding dexamethasone usage, parents should be informed of the risks and benefits of and indications for postnatal steroid usage before dexamethasone is prescribed.

Patient criteria

• Birth-weight < 1300g

• Estimated gestational age at birth < 31 weeks

• Appropriate growth for gestational age

• Postnatal age > 10 days

• Diagnosis of severe CLD

  • Clinical respiratory distress

  • Characteristic chest X-ray

  • Fraction of inspired oxygen (FiO2) > 0.8

  • Mean airway pressure (PAW) > 8 cm H2O

Exclusion criteria

• Airway infection and/or sepsis

• Systemic hypertension

• Hyperglycemia

Dexamethasone course

Each daily dose of dexamethasone should be administered in two divided doses at 12 hour intervals by bolus intravenous infusion.

Other Interventions During Postnatal Steroid Therapy:

Supplemental Vitamin A- Supplemental vitamin A should be held during the 8 days of systemic steroid treatment and for 1 week following the dexamethasone course. This precautionary withholding of supplemental vitamin A is based on the observation that postnatal dexamethasone treatment is associated with an increase in plasma vitamin A concentrations in VLBW neonates (Shenai. Pediatrics 2000;106:547) and may therefore predispose these infants to the potential risk of vitamin A toxicity.

Protein Intake- Protein intake should be increased to 4 g/kg/d during the 8 days of dexamethasone treatment. This measure is intended to counteract the catabolic effect of dexamethasone treatment on protein metabolism (Brownlee, et al. Arch Dis Child 1992;67:1). BUN should be monitored closely during this time.

Famotidine (Pepcid) Treatment- Famotidine should be administered at a dose of 1 mg/kg/dose q 12 hours by IV or OG administration. Alternatively, famotidine may be added to the TPN solution to provide a dose of 2 mg/kg/day. This measure is intended to prevent gastrointestinal complications resulting from dexamethasone treatment. (Kelly et al. Arch Dis Child 1993;69:37). Unless contraindicated based on clinical findings, continuation or initiation of low-volume OG feeds may be desirable during dexamethasone treatment.

Triglycerides- Postnatal steroid administration has been associated with hypertriglyceridemia. Serum triglyceride levels should therefore be monitored during dexamethasone treatment and Intralipid administration decreased accordingly, if necessary.

Monitoring- Sequential monitoring of blood gases is indicated to allow for maximal and rapid weaning from mechanical ventilation and supplemental oxygen during dexamethasone treatment. This should prevent barotrauma with sudden improvements in compliance and lung function. Sequential monitoring of blood pressure and blood glucose concentration is also indicated during dexamethasone treatment to detect acute side-effects of systemic hypertension and hyperglycemia. The anti-inflammatory actions of dexamethasone result in immunosuppression, and therefore close surveillance for symptoms of sepsis is warranted.

Steroid Rebound- As the systemic effects of steroids wear off, the patient often experiences a deterioration in respiratory function. This set-back should be anticipated 3-4 days after the last dose of dexamethasone. However, infection must still be considered in the differential diagnosis at this time.

Indomethacin- an alarmingly frequent incidence of spontaneous GI perforation (11-13%) has been reported in <1000g infants receiving simultaneous postnatal dexamethasone and indomethacin. (Stark et al. Pediatrics 1999;104:739A.) This combination of medications should be avoided in this population.