Corticosteroids have been shown to be effective for preterm and term infants with vasopressor-resistant hypotension or relative adrenal suppression. Following administration, studies have shown an increase blood pressure and urine output and a decrease in vasopressor dose and duration.

Little is known about the long-term effects of early hydrocortisone use in preterm and term infants but there seems to be no detrimental neurologic outcomes as seen with dexamethasone to date. Still, benefit should outweigh risk prior to using and families counseled about possible risks associated and the lowest effective dose for the shortest duration should be used.

Eligibility

• Patients receiving maximal doses of vasopressors with persistent hypotension unresponsive to conventional measures

• Baseline cortisol level < 5 mcg/dL

Dosing Recommendations

Hydrocortisone 3 mg/kg/day divided q8h for 5 days (Ng P, et al. Pediatrics; 117(2): 367-375)

Adrenal suppression has been described in the literature lasting up to one month in preterm infants following corticosteroid use. A cortisol stimulation test may be needed especially if used longer than 5 days. If less than 5 days, then hydrocortisone may be discontinued without a taper from physiologic doses. If the patient has surgery or gets septic prior to a normal cortisol stimulation test, hydrocortisone should be restarted at 3 mg/kg/day divided q8h.

Tapering may be required for some patients at 3 mg/kg/day and tapered over 3-5 days. Decrease dose daily by 0.5-1 mg/kg/day. (Example: 3 mg/kg/day, 2 mg/kg/day, 1 mg/kg/day, then off)

Monitoring

Frequent BP and blood gases with weaning of ventilator and vasopressors accordingly; glucose, triglycerides

Supplemental Interventions: Please see Systemic Steroids For Evolving CLD for further explanation – create a link

Discontinue supplemental vitamin A- Supplemental vitamin A should be held during the 8 days of hydrocortisone treatment and for 1 week following the course.

Protein intake- Protein intake should be increased to 4 g/kg/d during the 8 days of hydrocorisone treatment.

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.

Triglycerides- Postnatal steroid administration has been associated with hypertriglyceridemia. Monitor triglycerides routinely and adjust lipids accordingly.

Steroid rebound- As the systemic effects of steroids wear off, the patient may experience a rebound anticipated 1-2 days after the last dose of hydrocortisone. However, infection must still be considered in the differential diagnosis at this time.

Indomethacin- The combination of hydrocortisone and indomethacin should be avoided especially in ELBW infants. There may also be a theoretical concern for maternal use of indomethacin and use of early postnatal hydrocortisone.

References
Ng PC, Lee C, Bnur F, et al. A Double-Blind, Randomized, Controlled Study of a “Stress Dose” of Hydrocortisone for Rescue Treatment of Refractory Hypotension in Preterm Infants. Pediatrics 2006;107(2):367-375.
Noori S, Friedlich P, Wong P, et al. Hemodynamic Changes After Low-Dosage Hydrocortisone Administration in Vasopressor-Treated Preterm and Term Neonates. Pediatrics 2006;118:1456-1466
Rizvi ZB, Aniol HS, Myers TF, et al. Effects of dexamethasone on the hypothalamic-pituitary-adrenal axis in preterm infants. J Pediatr. 1992;120:961–965
Elizabeth H. Thilo, Henry J. Rozycki and Conra Backstrom Lacy C. Mammel, Robert J. Couser, Soraya Abbasi, Cynthia H. Cole, Susan W. Aucott, Kristi L. Watterberg, Michele L. Shaffer, Mary J. Mishefske, Corinne L. Leach, Mark. Hydrocortisone Treatment in Extremely Low Birth Weight Infants: Growth and Neurodevelopmental Outcomes After Early Low-Dose, DOI:  Pediatrics 2007;120;40-48, 10.1542/peds.2006-3158

Aucott, SW. Hypotension in the Newborn: Who Needs Hydrocortisone?. Journal of Perinatology (2005) 25, 77–78. doi:10.1038/sj.jp.7211225