Early dexamethasone therapy in preterm infants: a follow-up study

Postoperative encephalopathy with choreoathetosis

Since the 1980s, survival of children with CHD has increased significantly with the introduction of new surgical techniques that incorporate cardiorespiratory arrest (CRA), extracorporeal circulation (ECC), and deep hypothermia. However, an increase in survival has been associated with an increase in recognized postoperative neurological complications. Postoperative encephalopathy with choreoathetosis, also known as "postpump chorea", is one of these well-defined neurological complications and was first reported in 1961. Postpump chorea is considered one of the most devastating neurological complications following cardiac surgery. However, the exact etiology and pathophysiology of this complication is unknown. Several factors may contribute to the postoperative development of choreoathetoid movements, including deep hypothermia (core body temperature < 20ºC) with total circulatory arrest, use of cardiopulmonary bypass, and variability in blood pH and PaCO(2) resulting in fluctuations in cerebral blood flow. The length of time children are affected by choreoathetoid movements and long-term neurological outcome in these children varies and largely depends upon the form of postoperative encephalopathy that they develop, described as either mild or severe. Several groups suggest that age at time of surgery plays a role in the risk of developing postpump chorea, with a tendency for older children to develop the severe persistent form.

Glucocorticoids in the treatment of neonatal meconium aspiration syndrome

Meconium aspiration syndrome is a serious neonatal disease with complex pathophysiology. With respect to the contribution of meconium-induced lung edema, inflammation and vasoconstriction on the course of the disease, glucocorticoids are increasingly used in the treatment of MAS despite the fact that principal questions on the choice of GCs derivative, mode of delivery and dosing have not been answered yet. To bring a complex insight into the topic, this article reviews the pathomechanisms of MAS, mechanisms of action of GCs, as well as the advantages and disadvantages of GCs administration in experimental models and newborns with MAS.

Understanding developmental pharmacodynamics: importance for drug development and clinical practice

Developmental pharmacodynamics is the study of age-related maturation of the structure and function of biologic systems and how this affects response to pharmacotherapy. This may manifest as a change in the potency, efficacy, or therapeutic range of a drug. The paucity of studies exploring developmental pharmacodynamics reflects the lack of suitable juvenile animal models and the ethical and practical constraints of conducting studies in children. However, where data from animal models are available, valuable insight has been gained into how response to therapy can change through the course of development. For example, animal neurodevelopmental models have revealed that temporal differences in the maturation of norepinephrine and serotonin neurotransmitter systems may explain the lack of efficacy of some antidepressants in children. GABA(A) receptors that switch from an excitatory to inhibitory mode during early development help to explain paradoxical seizures experienced by infants after exposure to benzodiazepines. The increased sensitivity of neonates to morphine may be due to increased postnatal expression of the mu opioid receptor. An age dependency to the pharmacokinetic-pharmacodynamic relationship has also been found in some clinical studies. For example, immunosuppressive effects of ciclosporin (cyclosporine) revealed markedly enhanced sensitivity in infants compared with older children and adults. A study of sotalol in the treatment of children with supraventricular tachycardia showed that neonates exhibited a higher sensitivity towards QTc interval prolongation compared with older children. However, the data are limited and efforts to increase and establish data on developmental pharmacodynamics are necessary to achieve optimal drug therapy in children and to ensure long-term success of pediatric drug development. This requires a dual 'bottom up' (ontogeny knowledge driven) and 'top down' (pediatric pharmacokinetic-pharmacodynamic studies) approach.

Acute pathophysiological effects of intratracheal instillation of budesonide and exogenous surfactant in a neonatal surfactant-depleted piglet model

BACKGROUND

Chronic lung disease continues to be a major complication in premature infants with severe respiratory distress syndrome (RDS). This is despite having advanced ventilatory care, prenatal corticosteroids, and postnatal surfactant therapies. The combined use of intratracheal corticosteroids and surfactant may not only recruit the lungs, but also alleviate pulmonary inflammation in severe RDS.

METHODS

Fifteen newborn piglets received repeated pulmonary saline lavage to induce surfactant-depleted lungs, mimicking neonatal RDS. They were randomly divided into three groups: control group receiving no treatment; surfactant (Surf) group, treated with standard intratracheally instilled surfactant (100 mg/kg); and Budesonide plus surfactant (Bude + Surf) group, treated with intratracheally administered mixed suspension of budesonide (0.5 mg/kg) and surfactant (100 mg/kg). Blood samples were taken every 30 minutes for 4 hours. Lung tissue was examined after the experiment.

RESULTS

Significantly better oxygenation with higher PaO(2) and alveolar-arterial oxygen difference was noted in the Surf and Bude + Surf groups, compared with the control group (p < 0.05), but there were no significant differences between the Surf and Bude + Surf groups. Pulmonary histologic damage was also markedly alleviated in both the Surf and Bude + Surf groups, compared with the control group, and lung injury scores were significantly decreased in the Surf and Bude + Surf groups, compared with the control group (p < 0.05).

CONCLUSIONS

Intratracheal instillation of surfactant or surfactant plus budesonide can improve oxygenation and pulmonary histologic outcome in neonatal surfactant-depleted lungs. The additional use of budesonide does not disturb the function of the exogenous surfactant. Intratracheal administration of a corticosteroid combined with surfactant may be an effective method for alleviating local pulmonary inflammation in severe RDS.

How I treat Diamond-Blackfan anemia

Diamond-Blackfan anemia (DBA) is characterized by red cell failure, the presence of congenital anomalies, and cancer predisposition. In addition to being an inherited bone marrow failure syndrome, DBA is also categorized as a ribosomopathy as, in more than 50% of cases, the syndrome appears to result from haploinsufficiency of either a small or large subunit-associated ribosomal protein. Nonetheless, the exact mechanism by which haploinsufficiency results in erythroid failure, as well as the other clinical manifestations, remains uncertain. New knowledge regarding genetic and molecular mechanisms combined with robust clinical data from several international patient registries has provided important insights into the diagnosis of DBA and may, in the future, provide new treatments as well. Diagnostic criteria have been expanded to include patients with little or no clinical findings. Patient management is therefore centered on accurate diagnosis, appropriate use of transfusions and iron chelation, corticosteroids, hematopoietic stem cell transplantation, and a coordinated multidisciplinary approach to these complex patients.

A follow-up study of preterm infants given budesonide using surfactant as a vehicle to prevent chronic lung disease in preterm infants

OBJECTIVE

Our study of early intratracheal instillation of budesonide using surfactant as vehicle showed a significant decrease in death or chronic lung disease (CLD) in preterm infants with severe respiratory distress syndrome (RDS). We now report the long-term outcome at about 2 to 3 years of age.

STUDY DESIGN

Of the 75 potential survivors, 67 (90%) were studied (35 budesonide-treated, 32 control). All infants had birth weight <1500 g and had severe RDS requiring intermittent mechanical ventilation shortly after birth. The treated group received a mixture of budesonide and surfactant every 8 hours. The control group received only surfactant.

RESULTS

The physical growth and the neurological examinations were comparable between the groups at follow-up. Infants in the group treated with budesonide tended to have higher PDI and MDI scores than infants in the control group (79 +/- 20 vs 74 +/- 18 and 80 +/- 19 vs 75 +/- 20), but these differences were not statistically significant. The incidence of neurodevelopmental impairment was 11 (31%) in the treated group and 13 (40%) in the control group (P = .367).

CONCLUSIONS

Early intratracheal instillation of budesonide using surfactant as a vehicle significantly improved pulmonary outcome without causing long-term adverse effects.

Early (< 8 days) postnatal corticosteroids for preventing chronic lung disease in preterm infants

BACKGROUND

Chronic lung disease (CLD) remains a major problem in neonatal intensive care units. Persistent inflammation in the lungs is the most likely underlying pathogenesis. Corticosteroids have been used to either prevent or treat CLD because of their potent anti-inflammatory effects.

OBJECTIVES

To determine if postnatal corticosteroid treatment is of benefit in the prevention of chronic lung disease (CLD) in preterm infants. This review examines the outcome of trials where preterm infants at risk of CLD were given postnatal corticosteroids within the first seven days of life.

SEARCH STRATEGY

Randomised controlled trials (RCTs) of postnatal corticosteroid therapy were sought from the Cochrane Controlled Trials Register, MEDLINE (1966 - May 2008), hand searching paediatric and perinatal journals, examining previous review articles and information received from practising neonatologists. Authors of all studies were contacted, where possible, to confirm details of reported follow-up studies, or to obtain any information about long-term follow-up where none had been reported.

SELECTION CRITERIA

Randomised controlled trials of postnatal corticosteroid treatment within the first 7 days of life (early) in high risk preterm infants were selected for this review. Most studies evaluated the use of dexamethasone but we also included studies that assessed hydrocortisone, even if it was used to manage hypotension.

DATA COLLECTION AND ANALYSIS

Data regarding clinical outcomes including mortality, CLD (including late rescue with corticosteroids, and need for home oxygen therapy), death or CLD, failure to extubate, complications during the primary hospitalisation (including infection, hyperglycaemia, hypertension, pulmonary air leak, patent ductus arteriosus (PDA), severe intraventricular haemorrhage (IVH), periventricular leucomalacia (PVL), necrotising enterocolitis (NEC), gastrointestinal bleeding, intestinal perforation, severe retinopathy of prematurity (ROP), and long-term outcome (including blindness, deafness, cerebral palsy and major neurosensory disability) were abstracted and analysed using RevMan 5.

MAIN RESULTS

Twenty-eight RCTs enrolling a total of 3740 participants were eligible for inclusion in this review. A meta-analysis of these trials demonstrated significant benefits as regards earlier extubation and decreased risks of CLD at both 28 days and 36 weeks' postmenstrual age (PMA), death or CLD at 28 days and 36 weeks' PMA, PDA and ROP, including severe ROP. There were no significant differences in the rates of neonatal or subsequent mortality, infection, severe IVH, PVL, NEC or pulmonary haemorrhage. Gastrointestinal bleeding and intestinal perforation were important adverse effects and the risks of hyperglycaemia, hypertension, hypertrophic cardiomyopathy and growth failure were also increased. In the twelve trials that reported late outcomes, several adverse neurological effects were found at follow-up examinations including developmental delay (not defined), cerebral palsy and abnormal neurological examination. However, major neurosensory disability was not significantly increased, either overall in the seven studies where this outcome could be determined, or in the two individual studies where the rates of cerebral palsy or abnormal neurological examination were significantly increased. Moreover, the rates of the combined outcomes of death or cerebral palsy, or of death or major neurosensory disability were not significantly increased. Dexamethasone was the drug used in most studies (n = 20); only eight studies used hydrocortisone. In subgroup analyses by type of corticosteroid, most of the beneficial and harmful effects were attributable to dexamethasone; hydrocortisone had little effect on any outcomes except for an increase in intestinal perforation and a borderline reduction in PDA.

AUTHORS' CONCLUSIONS

The benefits of early postnatal corticosteroid treatment (</= 7 days), particularly dexamethasone, may not outweigh the known or potential adverse effects of this treatment. Although early corticosteroid treatment facilitates extubation and reduces the risk of chronic lung disease and patent ductus arteriosus, it causes short-term adverse effects including gastrointestinal bleeding, intestinal perforation, hyperglycaemia, hypertension, hypertrophic cardiomyopathy and growth failure. Long-term follow-up studies report an increased risk of abnormal neurological examination and cerebral palsy. However, the methodological quality of the studies determining long-term outcomes is limited in some cases; the surviving children have been assessed predominantly before school age, and no study has been sufficiently powered to detect important adverse long-term neurosensory outcomes. There is a compelling need for the long-term follow-up and reporting of late outcomes, especially neurological and developmental outcomes, among surviving infants who participated in all randomised trials of early postnatal corticosteroid treatment. Hydrocortisone in the doses and regimens used in the reported RCTs has few beneficial or harmful effects and cannot be recommended for prevention of CLD.

Effects of intrauterine exposure to synthetic glucocorticoids on fetal, newborn, and infant hypothalamic-pituitary-adrenal axis function in humans: a systematic review

BACKGROUND

Synthetic glucocorticoids are commonly used in reproductive medicine. Fetal organ systems are highly sensitive to changes in the intrauterine environment, including overexposure to glucocorticoids. Structural and functional alterations resulting from such changes may persist throughout life and have been associated with diverse diseases. One system that could be particularly sensitive to fetal glucocorticoid overexposure is the hypothalamic-pituitary-adrenal (hpa) axis. Many human studies have investigated this possibility, but a systematic review to identify consistent, emergent findings is lacking.

METHODS

We systematically review 49 human studies, assessing the effects of intrauterine exposure to synthetic glucocorticoids on fetal, neonate, and infant hpa function.

RESULTS

Study quality varied considerably, but the main findings held true after restricting the analyses to higher-quality studies: intrauterine exposure to synthetic glucocorticoids reduces offspring hpa activity under unstimulated conditions after pain but not pharmacological challenge. Although reduced unstimulated hpa function appears to recover within the first 2 wk postpartum, blunted hpa reactivity to pain is likely to persist throughout the first 4 months of life. There is some evidence that the magnitude of the effects is correlated with the total amount of glucocorticoids administered and varies with the time interval between glucocorticoid exposure and hpa assessment.

CONCLUSIONS

This systematic review has allowed the demonstration of the way in which intrauterine exposure to various regimens of synthetic glucocorticoids affects various forms of hpa function. As such, it guides future studies in terms of which variables need to be focused on in order to further strengthen the understanding of such therapy, whilst continuing to profit from its clinical benefits.

Drug therapies in bronchopulmonary dysplasia: debunking the myths

Bronchopulmonary dysplasia (BPD), also known as chronic lung disease (CLD), is one of the most challenging complications in premature infants. The incidence of BPD has been increasing over the past two decades in parallel with an improvement in the survival of this population. Furthermore, the clinical characteristics and the natural history of infants affected by BPD have changed considerably, and newer definitions to clarify the term 'BPD' have also evolved since its first description more than four decades ago. Several drug therapies have also evolved, either to manage these infants' respiratory distress syndrome with an aim to prevent BPD or to manage the established condition. Although there is good evidence to support the 'routine' use of some therapies, many other therapies currently used in relation to BPD remain individual- or institution-specific, depending on beliefs and myths that we have adopted. In this article, we discuss the importance of defining BPD more objectively and the support--or lack thereof--for the drug therapies used in relation to BPD.

The angiogenic factor midkine is regulated by dexamethasone and retinoic acid during alveolarization and in alveolar epithelial cells

Background

A precise balance exists between the actions of endogenous glucocorticoids (GC) and retinoids to promote normal lung development, in particular during alveolarization. The mechanisms controlling this balance are largely unknown, but recent evidence suggests that midkine (MK), a retinoic acid-regulated, pro-angiogenic growth factor, may function as a critical regulator. The purpose of this study was to examine regulation of MK by GC and RA during postnatal alveolar formation in rats.

Methods

Newborn rats were treated with dexamethasone (DEX) and/or all-trans-retinoic acid (RA) during the first two weeks of life. Lung morphology was assessed by light microscopy and radial alveolar counts. MK mRNA and protein expression in response to different treatment were determined by Northern and Western blots. In addition, MK protein expression in cultured human alveolar type 2-like cells treated with DEX and RA was also determined.

Results

Lung histology confirmed that DEX treatment inhibited and RA treatment stimulated alveolar formation, whereas concurrent administration of RA with DEX prevented the DEX effects. During normal development, MK expression was maximal during the period of alveolarization from postnatal day 5 (PN5) to PN15. DEX treatment of rat pups decreased, and RA treatment increased lung MK expression, whereas concurrent DEX+RA treatment prevented the DEX-induced decrease in MK expression. Using human alveolar type 2 (AT2)-like cells differentiated in culture, we confirmed that DEX and cAMP decreased, and RA increased MK expression.

Conclusion

We conclude that MK is expressed by AT2 cells, and is differentially regulated by corticosteroid and retinoid treatment in a manner consistent with hormonal effects on alveolarization during postnatal lung development.

The association of lung disease with cerebral white matter abnormalities in preterm infants

OBJECTIVE

Preterm infants have a high incidence of neurodevelopmental impairment associated with diffuse cerebral white matter abnormalities and also a high incidence of serious respiratory disease. However, it is unclear if lung disease and brain injury are related, and previous research has been impeded by confounding effects, including prematurity and infection. Using a new approach that permits multivariate statistical analysis, we tested the hypothesis that lung disease is associated with specific white matter abnormalities, detected as reduced fractional anisotropy (FA) in diffusion tensor imaging data.

METHODS

Fifty-three preterm infants with no evidence of focal abnormality on conventional MRI were studied at term-equivalent age by using tract-based spatial statistics, an automated observer-independent method for voxelwise analysis of major white matter pathways.

RESULTS

In several white matter tracts, FA decreased with a linear relation to the gestational age at birth. Independent of the confounding effects of prematurity and age at scan, respiratory disease was associated with specific white matter abnormalities in preterm infants; those infants receiving mechanical ventilation for >2 days in the perinatal period (n = 10) showed reduced FA in the genu of the corpus callosum, whereas subjects with chronic lung disease (n = 15) displayed a reduction in FA in the left inferior longitudinal fasciculus.

CONCLUSION

Independent of the degree of prematurity, respiratory disease is associated with cerebral white matter abnormalities.

Impact of perinatal corticosteroids on neuromotor development and outcome: review of the literature and new meta-analysis

Perinatal corticosteroids are like a double-edged sword. On the one hand, they reduce risk for major morbidity and even mortality; on the other hand, they modify growth and development of body systems, with short- and long-term consequences. The relationship between corticosteroids and neurodevelopmental outcome has been extensively studied in randomized controlled trials, cohort and case-control studies and meta-analyses. In this article we attempt accurately to reflect current clinical equipoise on this issue by reviewing the most recent literature and adding a new meta-analysis on the relationship between postnatal dexamethasone and cerebral palsy and neurodevelopmental impairment.

Long-term effects of neonatal hydrocortisone treatment for chronic lung disease on the developing brain and heart

Despite modern perinatal intensive care techniques, chronic lung disease remains a problem in preterm-born infants. The most commonly and almost exclusively prescribed drug to treat this disorder is dexamethasone. Corticosteroids improve short-term respiratory function; however, many side-effects have been reported and the adverse long-term effects of dexamethasone on neurodevelopment are particularly alarming. Hydrocortisone could be a suitable alternative for dexamethasone, if equally effective with fewer side-effects. This review evaluates the current literature on neonatal hydrocortisone treatment for chronic lung disease with regards to long-term neurodevelopmental outcome and cardiovascular effects. The neurodevelopmental studies do not show any adverse effects of hydrocortisone on neurocognitive and motor outcome, nor on incidence of brain abnormalities on magnetic resonance imaging or on long-lasting programming effects on the hypothalamus-pituitary-adrenal axis. At school age, cardiovascular stress response was the same in hydrocortisone-treated children compared with a reference group. Hydrocortisone seems a safe alternative to dexamethasone, but more double-blind randomised studies are needed.

Early (< 8 days) postnatal corticosteroids for preventing chronic lung disease in preterm infants

BACKGROUND

Chronic lung disease (CLD) remains a major problem in neonatal intensive care units. Persistent inflammation in the lungs is the most likely underlying pathogenesis. Corticosteroids have been used to either prevent or treat CLD because of their potent anti-inflammatory effects.

OBJECTIVES

To determine if postnatal corticosteroid treatment is of benefit in the prevention of chronic lung disease (CLD) in preterm infants. This review examines the outcome of trials where preterm infants at risk of CLD were given postnatal corticosteroids within the first seven days of life.

SEARCH STRATEGY

Randomised controlled trials (RCTs) of postnatal corticosteroid therapy were sought from the Cochrane Controlled Trials Register, MEDLINE (1966 - May 2008), hand searching paediatric and perinatal journals, examining previous review articles and information received from practising neonatologists. Authors of all studies were contacted, where possible, to confirm details of reported follow-up studies, or to obtain any information about long-term follow-up where none had been reported.

SELECTION CRITERIA

Randomised controlled trials of postnatal corticosteroid treatment within the first 7 days of life (early) in high risk preterm infants were selected for this review. Most studies evaluated the use of dexamethasone but we also included studies that assessed hydrocortisone, even if it was used to manage hypotension.

DATA COLLECTION AND ANALYSIS

Data regarding clinical outcomes including mortality, CLD (including late rescue with corticosteroids, and need for home oxygen therapy), death or CLD, failure to extubate, complications during the primary hospitalisation (including infection, hyperglycaemia, hypertension, pulmonary air leak, patent ductus arteriosus (PDA), severe intraventricular haemorrhage (IVH), periventricular leucomalacia (PVL), necrotising enterocolitis (NEC), gastrointestinal bleeding, intestinal perforation, severe retinopathy of prematurity (ROP), and long-term outcome (including blindness, deafness, cerebral palsy and major neurosensory disability) were abstracted and analysed using RevMan 5.

MAIN RESULTS

Twenty-eight RCTs enrolling a total of 3740 participants were eligible for inclusion in this review. A meta-analysis of these trials demonstrated significant benefits as regards earlier extubation and decreased risks of CLD at both 28 days and 36 weeks' postmenstrual age (PMA), death or CLD at 28 days and 36 weeks' PMA, PDA and ROP, including severe ROP. There were no significant differences in the rates of neonatal or subsequent mortality, infection, severe IVH, PVL, NEC or pulmonary haemorrhage. Gastrointestinal bleeding and intestinal perforation were important adverse effects and the risks of hyperglycaemia, hypertension, hypertrophic cardiomyopathy and growth failure were also increased. In the twelve trials that reported late outcomes, several adverse neurological effects were found at follow-up examinations including developmental delay (not defined), cerebral palsy and abnormal neurological examination. However, major neurosensory disability was not significantly increased, either overall in the seven studies where this outcome could be determined, or in the two individual studies where the rates of cerebral palsy or abnormal neurological examination were significantly increased. Moreover, the rates of the combined outcomes of death or cerebral palsy, or of death or major neurosensory disability were not significantly increased. Dexamethasone was the drug used in most studies (n = 20); only eight studies used hydrocortisone. In subgroup analyses by type of corticosteroid, most of the beneficial and harmful effects were attributable to dexamethasone; hydrocortisone had little effect on any outcomes except for an increase in intestinal perforation and a borderline reduction in PDA.

AUTHORS' CONCLUSIONS

The benefits of early postnatal corticosteroid treatment (</= 7 days), particularly dexamethasone, may not outweigh the known or potential adverse effects of this treatment. Although early corticosteroid treatment facilitates extubation and reduces the risk of chronic lung disease and patent ductus arteriosus, it causes short-term adverse effects including gastrointestinal bleeding, intestinal perforation, hyperglycaemia, hypertension, hypertrophic cardiomyopathy and growth failure. Long-term follow-up studies report an increased risk of abnormal neurological examination and cerebral palsy. However, the methodological quality of the studies determining long-term outcomes is limited in some cases; the surviving children have been assessed predominantly before school age, and no study has been sufficiently powered to detect important adverse long-term neurosensory outcomes. There is a compelling need for the long-term follow-up and reporting of late outcomes, especially neurological and developmental outcomes, among surviving infants who participated in all randomised trials of early postnatal corticosteroid treatment. Hydrocortisone in the doses and regimens used in the reported RCTs has few beneficial or harmful effects and cannot be recommended for prevention of CLD.

Pulmonary targeting of sustained release formulation of budesonide in neonatal rats

Systemic corticosteroids are widely used for the treatment/prevention of chronic lung disease (CLD) in premature infants. The use of the inhalation route for delivering corticosteroids has been widely recognized, however so far pre-term babies continue to be treated with oral glucocorticoids, such as dexamethasone. We hypothesize that the pulmonary administration of sustained release formulations of inhaled corticosteroids to pre-term infants will result in a higher benefit/risk ratio as compared to traditional inhalation therapy. To achieve a slow release formulation budesonide particles were coated with a very thin film of polylactic acid using a pulse laser ablation technique. Coated material was characterized with respect to the dissolution behavior and particle size. Ex vivo receptor binding studies were performed to monitor the cumulative lung, liver and brain receptor occupancies after adminstration in neonatal (10-11 days old) rats after intratracheal instillation of either uncoated budesonide or poly (l-lactic acid) (PLA) coated budesonide. The mean dissolution timed for the uncoated and the polymer coated formulations were 1.2 +/- 0.5 and 4.7 +/- 0.1 h, respectively (p < 0.05). No significant differences in the respirable fraction were found between coated and uncoated formulation (p>0.05). The average receptor occupancies in the lung, liver and brain after administration of uncoated budesonide were 58.4 +/- 12.9, 56.4 +/- 6.8 and 38.3 +/- 6.7%, respectively. However, after administration of PLA coated budesonide, the average AUC estimates in the lung, liver and brain were 75.8 +/- 3.7%, 46.6 +/- 14.5 and 29 +/- 7, respectively. The results from our study suggest sustained receptor occupancy in the lungs of neonatal rats after administration of PLA coated budesonide results in lower systemic exposure (as indicated by low liver receptor occupancy). The data strongly underscore the urgent need to develop sustained release pulmonary-targeted delivery systems of corticosteroids for the treatment of CLD in pre-term infants. The administration of inhaled corticosteroids using targeted drug-delivery systems will potentially result in higher local effects and a reduction in systemic exposure.

Diagnosing and treating Diamond Blackfan anaemia: results of an international clinical consensus conference

Diamond Blackfan anaemia (DBA) is a rare, genetically and clinically heterogeneous, inherited red cell aplasia. Classical DBA affects about seven per million live births and presents during the first year of life. However, as mutated genes have been discovered in DBA, non-classical cases with less distinct phenotypes are being described in adults as well as children. In caring for these patients it is often difficult to have a clear understanding of the treatment options and their outcomes because of the lack of complete information on the natural history of the disease. The purpose of this document is to review the criteria for diagnosis, evaluate the available treatment options, including corticosteroid and transfusion therapies and stem cell transplantation, and propose a plan for optimizing patient care. Congenital anomalies, mode of inheritance, cancer predisposition, and pregnancy in DBA are also reviewed. Evidence-based conclusions will be made when possible; however, as in many rare diseases, the data are often anecdotal and the recommendations are based upon the best judgment of experienced clinicians. The recommendations regarding the diagnosis and management described in this report are the result of deliberations and discussions at an international consensus conference.

Effects of neonatal dexamethasone or methylprednisolone on rat growth and neurodevelopment

BACKGROUND

Clinical studies have demonstrated that premature infants receiving long-term dexamethasone therapy have reduced linear growth, decreased weight gain, and smaller head circumferences. The purpose of the present study was to investigate the effects of the same equivalent doses for anti-inflammatory potency of neonatal dexamethasone and methylprednisolone on rat growth and neurodevelopment.

METHODS

The pups were randomly separated into three treatment groups on postnatal day (PD) 3. At postnatal 3-5 days, tapering doses of corticosteroids or sterile saline were administered subcutaneously. Group 1 was the dexamethasone group (n = 12; PD 3, 0.5 mg/kg; PD 4, 0.25 mg/kg; PD 5, 0.125 mg/kg; PD 6, 0.05 mg/kg s.c.); group 2, methylprednisolone group (n = 12; PD 3, 2.6 mg/kg; PD 4, 1.3 mg/kg; PD 5, 0.650 mg/kg; PD 6, 0.325 mg/kg; group 3, control group (n = 12; normal saline injected). Weight was recorded on PD 3-6, 8, 14, 22, length was recorded on PD 3, 7, 14, 21 for each group. Neurological responses and physical development were tested on PD 7, 14, 21.

RESULTS

On PD 4-6, 8, 14, 22 the weight in the dexamethasone and methylprednisolone groups was lower than in the control group, but the weight in the dexamethasone group was the lowest (P < 0.05). The length in the dexamethasone group was significantly shorter than in the methylprednisolone group on PD 14 and 21. Dexamethasone-treated animals had a reduced total neurological score compared with the methylprednisolone and control groups on PD 7, 14, 21. Although methylprednisolone-treated animals had lower total neurological score than that of the control group on PD 7 and PD 14 (P < 0.05), total neurological scores were not different in the methylprednisolone and control groups on PD 21.

CONCLUSIONS

Postnatal methylprednisolone treatment might be safer than dexamethasone treatment in newborns.

Effects of higher versus lower dexamethasone doses on pulmonary and neurodevelopmental sequelae in preterm infants at risk for chronic lung disease: a meta-analysis

OBJECTIVES

Systemic postnatal dexamethasone treatment reduces the risk of chronic lung disease in preterm infants but also may be associated with increased risk of neurodevelopmental impairment. Because it is not known whether these effects are modulated by the cumulative dexamethasone dose, we systematically reviewed the available randomized evidence on the effects of lower versus higher cumulative dexamethasone doses, in terms of death, pulmonary morbidity, and neurodevelopmental outcomes, in preterm infants.

METHODS

Randomized, controlled trials comparing higher- versus lower-dosage dexamethasone regimens in ventilated preterm infants were identified by searching the main electronic databases, references from relevant studies, and abstracts from the Societies for Pediatric Research (from 1990 onward). Eligibility and quality of trials were assessed, and data on study design, patient characteristics, and relevant outcomes were extracted.

RESULTS

Six studies that enrolled a total of 209 participants were included; 2 studies contrasted cumulative dexamethasone doses in the higher ranges (>2.7 mg/kg in the higher-dosage regimen) and 4 in the lower ranges (<or=2.7 mg/kg in the higher-dosage regimen). Meta-analysis revealed no effect of dexamethasone dose on rates of death and neurodevelopmental sequelae in these 2 subgroups. Subgroup analysis of the studies contrasting dexamethasone doses in the higher ranges showed that the higher dose of dexamethasone was more effective in reducing the occurrence of chronic lung disease than was the lower dose. Interpretation of these data was hampered by the small samples of randomly assigned children, heterogeneity of study populations and designs, use of late rescue glucocorticoids, and lack of long-term neurodevelopmental data in some studies.

CONCLUSIONS

Recommendations for optimal dexamethasone doses for preterm infants at risk for chronic lung disease cannot be based on current evidence. A well-designed, large, randomized, controlled trial is urgently needed to establish the optimal dexamethasone dosage regimen.

Early intratracheal instillation of budesonide using surfactant as a vehicle to prevent chronic lung disease in preterm infants: a pilot study

OBJECTIVE

Budesonide is an inhaled steroid with a strong topical effect but with minimal systemic effects; it has been effectively delivered to animal lungs using surfactant as a vehicle. The purposes of this study were to determine whether early intratracheal instillation of budesonide using surfactant as a vehicle would improve pulmonary status, reduce mortality, and reduce chronic lung disease morbidity.

PATIENTS AND METHODS

We conducted a prospective, randomized blind trial in 116 very low birth weight infants (< 1500 g) who had severe radiographic respiratory distress syndrome and required mechanical ventilation with fraction of inspired oxygen > or = 0.6 shortly after birth: 60 were in the treated group (intratracheal instillation of a mixture of 0.25 mg/kg of budesonide and 100.00 mg/kg of survanta, every 8 hours) and 56 were in the control group (100 mg/kg of survanta only, every 8 hours). The end point assessment was the number of infants who would die or develop chronic lung disease at 36 weeks' postconceptional age.

RESULTS

Infants in the treatment group required significantly lower mean airway pressure on day 1 and day 3 and had significantly lower oxygen index and PCO(2) during the first 3 days than infants in the control group. More infants were extubated in the treatment group than controls at 1 and 2 weeks. The combined outcome of deaths or chronic lung disease was significantly lower in the treatment group than in the control group (19 of 60 vs 34 of 56). No clinically significant adverse effects were observed during the study.

CONCLUSIONS

This pilot study indicated that early postnatal intratracheal instillation of budesonide using surfactant as vehicle significantly improved the combined outcome of death or chronic lung disease in small premature infants without causing immediate adverse effects. The results are encouraging, and a large sample multicenter trial is warranted.

Perioperative neuroprotective strategies

Long-term neurodevelopmental impairment is common in newborns and infants undergoing corrective or palliative congenital heart surgery. The etiologies of neurodevelopmental morbidity in these children are multifactorial and include prenatal, preoperative, intraoperative, and postoperative factors. Perioperative neurologic monitoring is thought to be integral to prevention or rescue from adverse neurologic events. Recent advances in perfusion techniques for congenital heart surgery now ensure adequate cerebral O(2) delivery during all phases of cardiopulmonary bypass. Periventricular leukomalacia and other serious neurologic injury can be minimized by an optimized perfusion strategy of continuous high-flow, high hematocrit cardiopulmonary bypass, minimal use of deep hypothermic circulatory arrest, antegrade cerebral perfusion during aortic arch reconstruction, pH-stat blood gas strategy, and cerebral monitoring with NIRS and trans-cranial Doppler. Because there is evidence that brain injury can also occur in the prenatal, preoperative, and postoperative periods, improved strategies to prevent injury in these arenas are much needed. Extensive further clinical investigation is warranted to identify neuroprotective management strategies for the operating room and intensive care unit to preserve neurologic function and optimize long-term neurodevelopmental outcomes in children with congenital heart disease.

Postnatal hydrocortisone treatment for chronic lung disease in the preterm newborn and long-term neurodevelopmental follow-up

The benefits versus the risks of postnatal administration of steroids in preterm-born infants are still debatable. This review examines the literature on postnatal hydrocortisone treatment for chronic lung disease (CLD) in preterm-born infants with a particular focus on the effects of such treatment on long-term neurodevelopmental outcomes. Quantitative published evidence does not point to a clear advantage of treatment with hydrocortisone over dexamethasone with regard to the impact on long-term neurological outcomes. However, in the absence of a randomised comparison, a consensus may soon have to be reached on the basis of the best available evidence whether hydrocortisone should replace dexamethasone in the treatment of CLD.

Outcomes of extremely low birth weight (<1 kg) and extremely low gestational age (<28 weeks) infants with bronchopulmonary dysplasia: effects of practice changes in 2000 to 2003

OBJECTIVE

The goal was to evaluate whether changes in neonatal intensive care have improved outcomes for children with bronchopulmonary dysplasia (oxygen dependence at corrected age of 36 weeks).

METHODS

We compared outcomes of extremely low birth weight (<1 kg) and extremely low gestational age (<28 weeks) infants with bronchopulmonary dysplasia between 2 periods (period I, 1996-1999: extremely low birth weight, n = 122; extremely low gestational age, n = 118; period II, 2000-2003: extremely low birth weight, n = 109; extremely low gestational age, n = 107).

RESULTS

For both groups, significant practice changes between period I and period II included increased prenatal and decreased postnatal steroid therapy and increased surfactant therapy, indomethacin therapy, and patent ductus arteriosus ligation. Significant morbidity changes included decreased rates of severe cranial ultrasound abnormalities and increased rates of ventilator dependence. Rates of bronchopulmonary dysplasia did not change (52% vs 53%). Follow-up evaluation revealed significantly lower rates of neurosensory abnormalities during period II (extremely low birth weight: 29% vs 16%; extremely low gestational age: 31% vs 16%). There were no changes in rates of Mental Developmental Index scores of <70 (extremely low birth weight: 42% vs 42%; extremely low gestational age: 37% vs 45%) or overall developmental impairment (extremely low birth weight: 51% vs 49%; extremely low gestational age: 50% vs 51%). For the extremely low gestational age group, predictors of neurosensory abnormalities were severe cranial ultrasound abnormality and postnatal steroid therapy. Predictors of overall impairment included severe cranial ultrasound abnormalities, ventilator dependence, postnatal steroid therapy, and patent ductus arteriosus ligation. For the extremely low birth weight group, the only predictor of neurosensory abnormalities was severe cranial ultrasound abnormality. Predictors of overall impairment included multiple birth, ventilator dependence, and severe cranial ultrasound abnormalities.

CONCLUSIONS

Neurosensory outcomes of infants with bronchopulmonary dysplasia improved during 2000 to 2003 but overall neurodevelopmental outcomes did not change.

Postnatal corticosteroids in the treatment of chronic lung disease in the preterm infant: past, present, and future

Over the past 20 years, corticosteroid use in the preterm infant has fallen in and out offavor. Steroids were introduced in the 1980s as a mode of preventing and treating chronic lung disease (CLD) in the preterm infant population. This use has been targeted toward low birth weight infants who are unable to wean off the ventilator. Dose, duration, and timing of treatment with dexamerhasone, the steroid typically used in NICUs, has varied. This article examines why the medication has fallen out of favor and whether postnatal corticosteroids still have a place in preventing and treating CLD.

Extremely low birth weight infants are at high risk for auditory neuropathy

Auditory neuropathy (AN) is a condition in which transmission of sound to the brain is abnormal. This is reflected as an electrophysiologic profile of normal otoacoustic emissions (OAE), with abnormal auditory brainstem evoked responses (ABR). Functionally speech perception is impaired and management strategies remain controversial. AN can be missed if high-risk newborns are screened for hearing loss with only OAE testing. The rate of sensorineural hearing loss (SNHL) in high-risk nursery infants is 10 times greater compared with normal term newborns. Therefore, we hypothesize that infants from the neonatal intensive care unit (NICU) are at significantly higher risk for AN than normal term infants.

OBJECTIVE

The objective of this study is to establish a prevalence rate and characterize risk factors for NICU graduates who demonstrate the AN electrophysiologic profile.

STUDY DESIGN

This retrospective study examined infants admitted to the NICU at Kapi'olani Medical Center for Women and Children in Honolulu, HI from 1999 through 2003. Infants were screened with automated ABR. Diagnostic testing and OAE were performed before discharge if the ABR was abnormal. Hospital courses of 24 AN, 71 SNHL and 95 gestational age (GA)-matched control infants with normal hearing were reviewed.

RESULT

With a SNHL prevalence of 16.7/1000, the rate for AN was 5.6/1000 NICU infants. Compared to infants with SNHL, infants with AN were significantly younger (GA 28.3+/-4.8 AN vs 32.9+/-5.2 weeks SNHL, P<0.0001) and smaller (BW 1318+/-894 AN vs 1968+/-1006 g SNHL). Nearly two-thirds of the AN infants were ELBW and had significantly longer hospital stays compared to SNHL infants of the same birth weight group. Exposure to furosemide, aminoglycosides, vancomycin or dexamethasone was associated with increased AN but not SNHL. Peak bilirubin level correlated with SNHL but not AN.

CONCLUSION

Low birth weight NICU infants are at significant risk for AN. ELBW infants are at significantly higher risk for both AN and SNHL. Infants admitted to the NICU should be routinely screened by automated ABR and if abnormal, further evaluation should be started before hospital discharge. Early identification of AN will result in better understanding of this disorder and lead to the development of appropriate intervention strategies.

Inhaled versus systemic corticosteroids for the treatment of chronic lung disease in ventilated very low birth weight preterm infants

BACKGROUND

Chronic lung disease (CLD) remains a serious and common problem among very low birth weight infants despite the use of antenatal steroids and postnatal surfactant therapy to decrease the incidence and severity of respiratory distress syndrome. Due to their anti-inflammatory properties, corticosteroids have been widely used to treat or prevent CLD. However, the use of systemic steroids has been associated with serious short and long-term adverse effects. Administration of corticosteroids topically through the respiratory tract might result in beneficial effects on the pulmonary system with fewer undesirable systemic side effects.

OBJECTIVES

To determine the effect of inhaled versus systemic corticosteroids administered to ventilator dependent preterm neonates with birth weight < 1500 g or gestational age < 32 weeks after two weeks of life for the treatment of evolving CLD.

SEARCH STRATEGY

Randomized and quasi-randomized trials were identified by searching the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2007), MEDLINE (1966 - June 2007), EMBASE (1980 - June 2007), CINAHL (1982 - June 2007), reference lists of published trials and abstracts published in Pediatric Research or electronically on the Pediatric Academic Societies website (1990 - April 2007).

SELECTION CRITERIA

Randomized or quasi-randomized trials comparing inhaled versus systemic corticosteroid therapy (irrespective of the dose and duration of therapy) starting after the first two weeks of life in ventilator dependent very low birth weight preterm infants.

DATA COLLECTION AND ANALYSIS

Data were extracted regarding clinical outcomes including CLD at 28 days or 36 weeks postmenstrual age (PMA), mortality, combined outcome of death or CLD at 28 days of age or 36 weeks PMA, other pulmonary outcomes and adverse effects. All data were analyzed using RevMan 4.2.10. When appropriate, meta-analysis was performed using relative risk (RR), risk difference (RD), and weighted mean difference (WMD) along with their 95% confidence intervals (CI). If RD was statistically significant, the number needed to treat (NNT) was calculated.

MAIN RESULTS

Data from one additional trial were available for inclusion in this update. Thus, five trials comparing inhaled versus systemic corticosteroids in the treatment of CLD were identified. Two trials were excluded as both included non-ventilator dependent patients and three trials qualified for inclusion in this review. Halliday et al (Halliday 2001) randomized infants at < 72 hours, while Rozycki et al (Rozycki 2003) and Suchomski et al (Suchomski 2002) randomized at 12 - 21 days. The data from the two trials of Rozycki et al and Suchmoski et al are combined using meta-analytic techniques. The data from the trial by Halliday et al are reported separately, as outcomes were measured over different time periods from the age at randomization. In none of the trials was there a statistically significant difference between the groups in the incidence of CLD at 36 weeks PMA among all randomized infants. The estimates for the trial by Halliday et al (Halliday 2001) were RR 1.10 (95% CI 0.82, 1.47), RD 0.03 (95% CI -0.08, 0.15); number of infants (n = 292). For the trials by Rozycki et al (Rozycki 2003) and Suchomski et al (Suchomski 2002) the typical RR was 1.02 (95% CI 0.83, 1.25) and the typical RD 0.01 (95% CI -0.11, 0.14); (number of infants = 139 ). There were no statistically significant differences between the groups in either trial for oxygen dependency at 28 days of age, death by 28 days or 36 weeks PMA, the combined outcome of death by or CLD at 28 days or 36 weeks PMA, duration of intubation, duration of oxygen dependence, or adverse effects. Information on the long-term neurodevelopmental outcomes was not available.

AUTHORS' CONCLUSIONS

This review found no evidence that inhaled corticosteroids confer net advantages over systemic corticosteroids in the management of ventilator dependent preterm infants. Neither inhaled steroids nor systemic steroids can be recommended as standard treatment for ventilated preterm infants. There was no evidence of difference in effectiveness or side-effect profiles for inhaled versus systemic steroids. A better delivery system guaranteeing selective delivery of inhaled steroids to the alveoli might result in beneficial clinical effects without increasing side-effects. To resolve this issue, studies are needed to identify the risk/benefit ratio of different delivery techniques and dosing schedules for the administration of these medications. The long-term effects of inhaled steroids, with particular attention to neurodevelopmental outcome, should be addressed in future studies.

Early administration of inhaled corticosteroids for preventing chronic lung disease in ventilated very low birth weight preterm neonates

BACKGROUND

Chronic lung disease remains a common complication among preterm infants. There is increasing evidence that inflammation plays an important role in the pathogenesis of CLD. Due to their strong anti-inflammatory properties, corticosteroids are an attractive intervention strategy. However, there are growing concerns regarding short and long-term effects of systemic corticosteroids. Theoretically, administration of inhaled corticosteroids may allow for beneficial effects on the pulmonary system with a lower risk of undesirable systemic side effects.

OBJECTIVES

To determine the impact of inhaled corticosteroids administered to ventilated very low birth weight preterm neonates in the first two weeks of life for the prevention of chronic lung disease (CLD).

SEARCH STRATEGY

Randomized and quasi-randomized trials were identified by searching the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2007), MEDLINE (1966 - July 2007), EMBASE (1980 - July 2007), CINAHL (1982 - July 2007), reference lists of published trials and abstracts published in Pediatric Research or electronically on the Pediatric Academic Societies web-site (1990 - April 2007).

SELECTION CRITERIA

Randomized controlled trials of inhaled corticosteroid therapy initiated within the first 2 weeks of life in ventilated preterm infants with birth weight <1500 grams were included in this review.

DATA COLLECTION AND ANALYSIS

Data regarding clinical outcomes including chronic lung disease at 28 days or 36 weeks postmenstrual age (PMA), mortality, combined outcome of death or CLD at 28 days of age and at 36 weeks PMA, the need for systemic corticosteroids, failure to extubate within 14 days and adverse effects of corticosteroids were evaluated. All data were analyzed using RevMan 4.2.10. When possible, meta-analysis was performed using relative risk (RR), risk difference (RD), along with their 95% confidence intervals (CI). If RD was significant, the number needed to treat (NNT) was calculated.

MAIN RESULTS

Three additional trials were identified for inclusion in this update. Eleven trials assessing the impact of inhaled corticosteroid for the prevention of CLD were identified. Four trials were excluded. The present review includes data analyses based on seven qualifying trials. There was no statistically significant effect of inhaled steroids on CLD either at 28 days [typical RR 1.05 (95% CI 0.84, 1.32); typical RD 0.02 (95% CO -0.07, 0.11)] or at 36 weeks PMA [typical RR 0.97 (95% CI 0.62, 1.52); typical RD 0.00 (95% CI -0.07, 0.06)], when analyzed either for all randomized infants or among survivors. No statistically significant differences were noted for mortality or for the combined outcome of mortality and CLD either at 28 days of age or at 36 weeks PMA. There were no statistically significant differences in adverse events between groups.

AUTHORS' CONCLUSIONS

Based on this updated review, there is no evidence from the trials reviewed that early administration (in the first two weeks of life) of inhaled steroids to ventilated preterm neonates was effective in reducing the incidence of CLD. Currently, use of inhaled steroids in this population cannot be recommended. Studies are needed to identify the risk/benefit ratio of different delivery techniques and dosing schedules for the administration of these medications. Studies need to address both the short-term and long-term benefits and adverse effects of inhaled steroids with particular attention to neurodevelopmental outcome.

How should we report early childhood outcomes of very low birth weight infants?

Reports of outcomes for very low birth weight infants have evolved from an early focus on survival and neonatal morbidities to the comprehensive analysis and evaluation of the relationships between neonatal interventions and morbidity and neurodevelopmental status in early childhood. Post discharge findings are frequently the primary outcome for antenatal and neonatal intervention trials, and the 97 approved neonatal fellowship training programs in the United States require participation in a follow-up program. Very low birth weight survivors remain at increased risk of neurodevelopmental impairments, vision and hearing impairment, growth failure, behavior morbidities and chronic health problems. Identification of the most appropriate outcome assessment for the study objective, and the ideal timing of the assessment remains a challenge for investigators.

Long-term outcomes after repeat doses of antenatal corticosteroids

BACKGROUND

Previous trials have shown that repeat courses of antenatal corticosteroids improve some neonatal outcomes in preterm infants but reduce birth weight and increase the risk of intrauterine growth restriction. We report long-term follow-up results of children enrolled in a randomized trial comparing single and repeat courses of antenatal corticosteroids.

METHODS

Women at 23 through 31 weeks of gestation who remained pregnant 7 days after an initial course of corticosteroids were randomly assigned to weekly courses of betamethasone, consisting of 12 mg given intramuscularly and repeated once at 24 hours, or an identical-appearing placebo. We studied the children who were born after these treatments when they were between 2 and 3 years of corrected age. Prespecified outcomes included scores on the Bayley Scales of Infant Development, anthropometric measurements, and the presence of cerebral palsy.

RESULTS

A total of 556 infants were available for follow-up; 486 children (87.4%) underwent physical examination and 465 (83.6%) underwent Bayley testing at a mean (+/-SD) corrected age of 29.3+/-4.6 months. There were no significant differences in Bayley results or anthropometric measurements. Six children (2.9% of pregnancies) in the repeat-corticosteroid group had cerebral palsy as compared with one child (0.5% of pregnancies) in the placebo group (relative risk, 5.7; 95% confidence interval, 0.7 to 46.7; P=0.12).

CONCLUSIONS

Children who had been exposed to repeat as compared with single courses of antenatal corticosteroids did not differ significantly in physical or neurocognitive measures. Although the difference was not statistically significant, the higher rate of cerebral palsy among children who had been exposed to repeat doses of corticosteroids is of concern and warrants further study. (ClinicalTrials.gov number, NCT00015002 [ClinicalTrials.gov].).

Corticosteroids in perinatal medicine: how to improve outcomes without affecting the developing brain?

Antenatal glucocorticoid therapy remains one of the most striking successes in the perinatal management of complicated pregnancies that result in premature birth. The anti-inflammatory and maturative properties of fluorocorticoids are such that all women at risk of preterm delivery before 34weeks gestation should be treated. Betamethasone is preferred to dexamethasone and no more than two courses, 2weeks apart, should be given until the evidence from further controlled trials on repeated doses becomes available. In particular, the early use of postnatal dexamethasone should be avoided in preterm infants because of the deleterious effects on neurological development, including not only cerebral palsy but also cognitive function and psychiatric-related behavior. Treatment with other steroids should be restricted to the context of randomized controlled trials.

Follow-up study of a randomized controlled trial of postnatal dexamethasone therapy in very low birth weight infants: effects on pulmonary outcomes at age 8 to 11 years

OBJECTIVE

To determine whether postnatal dexamethasone (DEX) exposure affects pulmonary outcomes at school age in children born with very low birth weight (VLBW).

STUDY DESIGN

Follow-up study of 68 VLBW children who participated in a randomized controlled trial of postnatal DEX. Pulmonary function was assessed by spirometry. Current asthma status was obtained from a parent.

RESULTS

Sixty-eight percent of the placebo group had below-normal forced expiratory volume in 1 second (FEV1), compared with 40% of the DEX group (chi2 = 4.84; P = .03), with trends for lower forced vital capacity (FVC) and FEV1 values in the placebo group. Fifty percent of the placebo group and 34% of DEX group had below normal FEV1/FVC (chi2 =1.59; P =.21). Parent-reported prevalence of asthma did not differ between groups. Logistic regression analysis suggested that the positive effects of DEX on pulmonary function at follow-up were mediated in part by shortened exposure to mechanical ventilation.

CONCLUSIONS

Postnatal DEX exposure was associated with higher expiratory flow with no adverse effects on pulmonary outcomes at school age. The prevalences of asthma and impaired pulmonary function underscore the influence of neonatal illness on health at school age, and stress the importance of repeated follow-up examinations of these children.

Neonatal hydrocortisone treatment: neurodevelopmental outcome and MRI at school age in preterm-born children

OBJECTIVE

To investigate neurodevelopment at school age in preterm infants treated with hydrocortisone for bronchopulmonary dysplasia (BPD) in the neonatal period.

STUDY DESIGN

Preterm infants (n = 226; gestational age < or = 32 weeks and/or body weight < or = 1500 grams) performed subtests of the Wechsler Intelligence Scale for Children-Revised, the Visual Motor Integration test, a 15-Word Memory Test and the Movement Assessment Battery for Children at school age. Conventional MRI of the brain was obtained. Sixty-two children who received hydrocortisone for BPD (starting dose, 5 mg/kg/day; median duration, 27.5 days) were compared with 164 nontreated neonates.

RESULTS

Hydrocortisone-treated infants were younger, lighter, and sicker than their non-steroid-treated counterparts. Adjustments for gestational age, body weight, sex, mechanical ventilation, and small for gestational age were made. Adjusted mean Intelligence Quotient, Visual Motor Integration test, and memory test results were the same in the hydrocortisone-treated group and the non-steroid-treated group (99 versus 101, P = .62; 97 versus 99, P = .49, 7.9 versus 7.5, P = .42, respectively). Motor function and incidence of cerebral palsy in both groups was not different (11% versus 7%, P = .97). Occurrence of brain lesions on MRI was similar for the two groups.

CONCLUSIONS

Neonatal hydrocortisone treatment for BPD had no long-term effects on neurodevelopment.

Outcome at 2 years of age of infants from the DART study: a multicenter, international, randomized, controlled trial of low-dose dexamethasone

OBJECTIVE

Low-dose dexamethasone facilitates extubation in chronically ventilator-dependent infants with no obvious short-term complications. The objective of this study was to determine the long-term effects of low-dose dexamethasone.

METHODS

Very preterm (<28 weeks' gestation) or extremely low birth weight (birth weight <1000 g) infants who were ventilator dependent after the first week of life for whom clinicians considered corticosteroids were indicated were eligible. After informed consent, infants were randomly assigned to masked dexamethasone (0.89 mg/kg over 10 days) or saline placebo. Survivors were assessed at 2 years' corrected age by staff blinded to treatment group allocation to determine neurosensory outcome, growth, and health.

RESULTS

The trial was abandoned well short of its target sample size because of recruitment difficulties. Seventy infants were recruited from 11 centers, 35 in each group: 59 survived to 2 years of age, and 58 (98%) were assessed at follow-up, but data for cerebral palsy were available for only 56 survivors. There was little evidence for a difference in the major end point, the rate of the combined outcome of death, or major disability at 2 years of age (dexamethasone group: 46%; controls: 43%). Rates of mortality before follow-up (11% vs 20%), major disability (41% vs 31%), cerebral palsy (14% vs 22%), or of the combined outcomes of death or cerebral palsy (23% vs 37%) were not substantially different between the groups. There were no obvious effects of low-dose dexamethasone on growth or readmissions to hospital after discharge.

CONCLUSIONS

Although this trial was not able to provide definitive evidence on the long-term effects of low-dose dexamethasone after the first week of life in chronically ventilator-dependent infants, our data indicate no strong association with long-term morbidity.

A scoring system to predict chronic oxygen dependency

INTRODUCTION

Chronic oxygen dependency (COD) is a common adverse outcome of very premature birth. It is, therefore, important to develop an accurate and simple predictive test to facilitate targeting of interventions to prevent COD. Our aim was to determine if a simple score based on respiratory support requirements predicted COD development.

METHODS

A retrospective study of 136 infants, median gestation age (GA) 28 weeks (range: 23-33 weeks) and a prospective study of 75 infants, median GA 30 weeks (range: 23-32 weeks), were performed. The score was calculated by multiplying the inspired oxygen concentration by the level of respiratory support (mechanical ventilation: 2.5; continuous positive airway pressure: 1.5; nasal cannula or head box oxygen or air: 1.0). Scores were calculated on data from days 2 and 7, and their predictive ability compared to that of the maximum inspired oxygen concentration at those ages and (retrospective study) the results of lung volume measurement.

RESULTS

Infants that were oxygen dependent at 28 days and 36 weeks post-menstrual age (PMA) had higher scores on days 2 (p<0.0001, p<0.0001, respectively) and 7 (p<0.0001, p<0.0001, respectively) than the non-oxygen dependent infants in both the retrospective and prospective cohorts. Construction of receiver operator characteristic curves demonstrated the score performed better than the inspired oxygen level and lung volume measurement results. A score on day 7 >0.323 had 95% specificity and 78% sensitivity in predicting COD at 28 days, and 80% specificity and 73% sensitivity in predicting COD at 36 weeks PMA.

CONCLUSION

Chronic oxygen dependency can be predicted using a simple scoring system.

Pharmacokinetics of Intranasal and Intratracheal Pentoxifylline in Rabbits

STUDY OBJECTIVE

To evaluate the disposition of pentoxifylline and its metabolite, lisofylline, in New Zealand rabbits after two alternative routes of administration, intranasal and intratracheal.

DESIGN

Pharmacokinetics study in an animal model.

SETTING

University-affiliated animal care facility.

SUBJECTS

Twenty New Zealand white rabbits divided into four groups of five rabbits each: group 1 did not receive study drug (control group), and groups 2, 3, and 4 evaluated intravenous, intranasal, and intratracheal routes of administration, respectively.

INTERVENTION

Each rabbit in groups 2-4 received pentoxifylline as a single 20-mg/kg dose by their respective route of administration.

MEASUREMENTS AND MAIN RESULTS

Blood samples were collected over a 24-hour period and were analyzed by using high-performance liquid chromatography-tandem mass spectrometry. The pharmacokinetic parameters evaluated were area under the concentration-time curve from time zero extrapolated to infinity (AUC(0-infinity)), maximum concentration (Cmax), time to maximum concentration (Tmax), elimination rate constant (k(el)), and half-life (t1/2). Median pentoxifylline pharmacokinetic parameters after intravenous administration were AUC(0-infinity) 5420 ng x hr/ml, Cmax 16,727 ng/ml, Tmax 5 minutes, k(el) 0.036 minute(-1), and t1/2 19 minutes. Median pharmacokinetic parameters after intranasal and intratracheal administration, respectively, were AUC(0-infinity) 4224 and 6824 ng x hr/ml, Cmax 11,181 and 16,758 ng/ml, Tmax 5 and 5 minutes, k(el) 0.028 and 0.032 minute(-1), and t1/2 25 and 22 minutes. The metabolite, lisofylline, displayed a similar disposition after the three different routes of administration.

CONCLUSION

The pharmacokinetic profiles after intranasal and intratracheal administration of pentoxifylline appear similar to those after intravenous administration. These data provide support for development of pentoxifylline intranasal and intratracheal dosage formulations that would be suitable for use in premature neonates.

Lung function and exhaled nitric oxide levels in infants developing chronic lung disease

Chronic lung disease (CLD) is a common outcome of neonatal intensive care. To determine whether the results of serial exhaled nitric oxide (eNO) measurements during the perinatal period differed between infants who did and did not develop CLD. In addition, we wished to assess whether eNO results were more predictive of CLD development than lung function test results or readily available clinical data (gestational age and birthweight). The patients were 24 infants with a median gestational age of 27 (range 25-31) weeks. Measurements of eNO levels, functional residual capacity (FRC), and compliance of the respiratory system (CRS) were attempted on postnatal days 1, 3, 5, 7, 14, and 28 days. The 12 infants who developed CLD were of significantly lower birthweight and gestational age than the rest of the cohort; in addition, they had lower median FRC (P < 0.02) and CRS (P < 0.02) results, but not higher eNO levels, in the first week after birth. Construction of receiver operator characteristic (ROC) curves demonstrated that the CRS and FRC results on Day 3 were the best predictors of CLD development; the areas under the ROC curves were 0.94 and 0.91, respectively. Early lung function test results, but not eNO levels, are useful in predicting CLD development, but are not significantly better than birthweight.

Criteria supporting the study of drugs in the newborn

BACKGROUND

Profound changes in the development and the maturation of neonates' organs and organ systems over variable periods of time potentially place neonates at increased risk and/or at different risks compared with adults or older children on exposure to pharmaceutical agents. Most studies of drugs in neonates focus on pharmacokinetic and pharmacodynamic end points and include insufficient numbers of patients to permit evaluation of safety. Only one fourth to one third of approved drugs have received adequate pediatric study to permit labeling for treatment of all appropriate pediatric populations.

OBJECTIVE

The initial goal of the Newborn Drug Prioritization Group was to develop a reproducible, objective process for evaluating drugs most in need of study in the neonatal population based on a universally acceptable priority ranking. The criteria would be applicable across therapeutic classes and would identify those drugs for which immediate study was most needed.

METHODS

Because the therapeutic requirements of the neonate are unique in comparison to older infants and children, the National Institute of Child Health and Human Development and the US Food and Drug Administration (FDA) developed the Newborn Drug Development Initiative to address the limited study of off-patent drugs in newborns. In March 2003, they convened a meeting of pediatric pharmacologists and pediatric specialists from the FDA, the American Academy of Pediatrics, the National Institutes of Health, and academic institutions to discuss how to increase the study of drugs for the newborn. One of the working groups was charged to develop generic criteria for overall prioritization of drugs for study in newborns. Because resources are limited, and not all drugs identified by the 4 clinically focused working groups can receive study at the same time, a process for priority ranking is necessary.

RESULTS

The panel identified 4 general categories containing different numbers of criteria as important for ranking drugs for priority investigation: (1) the disease and indication, including elements such as the potential for adverse outcomes, frequency in newborns, and level of evidence for treatment of newborns; (2) drug characteristics, including elements such as duration of dosing, lack of age-appropriate formulation, clinically relevant drug-drug and drug-disease interactions, and drug disposition in newborns; (3) feasibility and methodology for newborn studies, including both analytical considerations and clinical end points; and (4) the ethical basis for study, including elements to address benefit or harm due to exposure to the study drug, study methodology, and benefit of the new treatment relative to established standard therapy. Based on these categories, a list of criteria to warrant study of a drug in newborns was developed.

CONCLUSION

A process for judicious use of limited resources to rectify these deficiencies remains an urgent public health need.

Less postnatal steroids, more bronchopulmonary dysplasia: a population-based study in very low birthweight infants

OBJECTIVE

To study the association between reduced use of postnatal steroids for bronchopulmonary dysplasia (BPD) in very low birthweight (VLBW) infants and oxygen (O(2))-dependency at 28 days of age and at 36 weeks postmenstrual age.

DESIGN

Large national database study.

SETTING

The Israel National VLBW Neonatal Database.

PATIENTS

The sample included infants born between 1997 and 2004, of gestational age 24-32 weeks, who required mechanical ventilation or O(2) therapy. Four time periods were compared: 1997-8 (era 1, peak use), 1999-2000 (era 2, intermediate), 2001-2 (era 3, expected reduction) and 2003-4 (era 4, lowest). The outcome variable "oxygen dependency" was based on clinical criteria. Multivariate regression models were used to account for confounding variables.

RESULTS

Steroid use fell significantly from 23.5% in 1997-8 to 11% in 2003-4 (p<0.005). After adjustment for relevant confounding variables, the odds ratio for O(2) therapy at 28 days in era 4 versus era 1 was 1.75, 95% confidence interval (CI) 1.47 to 2.09 and 1.41, 95% CI 1.15 to 1.73 at 36 weeks postmenstrual age. The mean duration of O(2) therapy increased from 25.3 days (95% CI 23.3 to 26.3) in era 1, to 28.0 days (95% CI 26.6 to 29.4) in era 4. Survival increased from 78.5% in era 1 to 81.6% in era 4 (p<0.005).

CONCLUSIONS

The use of steroids has fallen considerably since the awareness of the adverse effects of this treatment. This change has been temporally associated with increased O(2) dependency at 28 days of age and at 36 weeks postmenstrual age. The prolongation of O(2) therapy was modest in degree.

Changes in the use of postnatal steroids for bronchopulmonary dysplasia in 3 large neonatal networks

BACKGROUND

Postnatal corticosteroids were widely used in the 1990s in an attempt to reduce the incidence of bronchopulmonary dysplasia. However, high rates of short-term adverse effects and impaired neurodevelopmental outcomes were seen. In early 2002, a joint statement of the American Academy of Pediatrics and Canadian Paediatric Society called for limitation in the use of postnatal corticosteroids. The impact of this statement is not known.

OBJECTIVES

The purpose of this work was to determine the frequency of postnatal corticosteroid use and mortality and morbidities over time, particularly before and after the joint statement.

DESIGN/METHODS

We conducted a retrospective analysis of cohort data within 3 large network registries (the National Institute of Child Health and Development Neonatal Research Network [18 centers], the Vermont Oxford Network [444 centers], and the Canadian Neonatal Network [10 centers]) for the following 3 periods: prestatement (2001), statement (2002), and poststatement (2003) of very low birth-weight infants (501-1500 g). The National Institute of Child Health and Development Neonatal Research Network and the Vermont Oxford Network were also analyzed for longer-term trends from 1990 to 2003. Postnatal corticosteroid use, mortality at discharge, and neonatal morbidities (bronchopulmonary dysplasia at 36 weeks, late-onset infection >72 hours of age, necrotizing enterocolitis treated with surgery, and length of stay) between periods were compared.

RESULTS

Mean birth weight (range: 1022-1060 g), postmenstrual age (28 weeks), and gender (51% male) were similar between the networks. Race differed with more black infants in the National Institute of Child Health and Development Neonatal Research Network than the Vermont Oxford Network (38% vs 24%). Antenatal steroid use was similar (range: 61%-75%). Postnatal corticosteroid use rose from 1990 (8%-16%), peaked in 1996-1998 (24%-28%), and began to decline in 1999. Use in 2003 was significantly less than in 2001. Mortality and major morbidities were similar.

CONCLUSIONS

Postnatal corticosteroid use had decreased significantly in 3 large neonatal networks before the joint statement with further decreases after the statement with no apparent impact on mortality and short-term morbidity. Despite substantial decreases, approximately 8% of very low birth-weight infants continue to be treated with postnatal corticosteroid.

Follow-up of a randomized, placebo-controlled trial of postnatal dexamethasone: blood pressure and anthropometric measurements at school age

OBJECTIVE

The purpose of this work was to evaluate the effects of a 42-day tapering course of dexamethasone on blood pressure and anthropometric measurements in school-age children who were born with very low birth weight.

METHODS

Sixty-eight children, who as neonates participated in a randomized placebo-controlled trial of a 42-day tapering course of dexamethasone (n = 38, dexamethasone; n = 30, placebo) to facilitate weaning from the ventilator, were seen at a median of 9 years of age. Participants underwent measurements of systolic blood pressure, diastolic blood pressure, mid-arm circumference, triceps skinfold thickness, height, and weight. Mann-Whitney U tests were used to compare groups, and Spearman coefficients were used to examine correlations between variables.

RESULTS

Comparing dexamethasone- and placebo-treated children, we found no differences in systolic blood pressure, mid-arm circumference, triceps skinfold thickness, height, weight, or body mass index. Twenty-nine percent of all subjects had systolic blood pressure and/or diastolic blood pressure > or = 90th percentile for age and gender. Thirty percent of all subjects had body mass index > or = 85th percentile for age and gender.

CONCLUSIONS

In a group of preterm very low birth-weight infants at high risk for chronic lung disease, we found no effects of dexamethasone on blood pressure or anthropometric measurements at 8 to 11 years of age. Of concern is that a high proportion in this sample had blood pressure > or = 90th percentile and/or body mass index > or = 85th percentile.

Dexamethasone dosing, mechanical ventilation and the risk of cerebral palsy

OBJECTIVE

Risk factors for cerebral palsy (CP) in premature infants include duration of mechanical ventilation and exposure to postnatal dexamethasone (DEX). Since DEX can reduce the duration of mechanical ventilation, limited DEX exposure could be beneficial.

METHODS

This was a retrospective, cohort study of infants of less than 1500 g birth weight surviving to discharge between 1 January 1996 and 30 June 2001 who received postnatal dexamethasone. DEX administration was based only on the need for O2 and/or mechanical ventilation. CP was diagnosed at over 10 months post-conceptional age. Univariate and multivariate analyses were used to determine significant risk factors and the relative contribution of these factors to overall risk of CP.

RESULTS

Of 218 eligible infants 162 were followed-up (74%). The CP rate was 27.3%. Significant risk factors for CP included gestational age, ventilator duration, DEX dose, presence of periventricular leukomalacia (PVL), seizures, diagnosis of retinopathy of prematurity (ROP) and use of vasopressors. By multiple logistic regression, ventilator duration, PVL, grade III/IV intraventricular hemorrhage (IVH) and DEX dose were significantly related to CP. By stepwise multiple regression, grade III/IV IVH and ventilator duration were the strongest risk factors, but DEX dose continued to be a significant risk factor.

CONCLUSIONS

The risk of CP was significantly related to the total cumulative dose of DEX. This could be due to a smaller exposure to DEX or to a reduced need for mechanical ventilation.

Neurodevelopmental outcome of bronchopulmonary dysplasia

Children born very preterm are vulnerable for long-term cognitive, educational, and behavioral impairments; bronchopulmonary dysplasia (BPD) is an additional risk factor which exacerbates these problems. As a population, children with BPD exhibit low average IQ, academic difficulties, delayed speech and language development, visual-motor integration impairments, and behavior problems. Neuropsychological studies are sparse, but there is some evidence that children with BPD also display attention problems, memory and learning deficits, and executive dysfunction. BPD does not appear to be associated with a specific neuropsychological impairment but rather a global impairment.

Effects of neonatal dexamethasone treatment on hippocampal synaptic function

OBJECTIVE

Synthetic glucocorticoid dexamethasone (DEX) is frequently used as a therapeutic agent to lessen the morbidity of chronic lung disease in premature infants. Surprisingly, little is known about the long-term neurodevelopmental outcomes of this therapy.

METHODS

Using a schedule of tapering doses of DEX similar to that used in premature infants, we examined the consequences of neonatal DEX treatment on hippocampal synaptic plasticity of infants and associative memory later in their lives.

RESULTS

Neonatal DEX treatment changed the direction of synaptic plasticity, favoring low-frequency, stimulation-induced, long-term depression and opposing the induction of long-term potentiation by high-frequency stimulation in adolescent (5-week-old) rats, but these alterations disappeared in young adult (8-week-old) rats. The effects of DEX on long-term depression and long-term potentiation were found to correlate with an increase in the autophosphorylation of Ca(2+)/calmodulin-dependent protein kinase II and a decrease in the protein phosphatase 1 activity. Neonatal DEX treatment also disrupted memory retention in 5-week-old (but not 8-week-old) rats subjected to passive avoidance learning tasks.

INTERPRETATION

These results suggest that neonatal DEX treatment alters hippocampal synaptic plasticity and contextual fear memory formation in later life, but these impairments apparently are not permanent.

Neurodevelopmental and respiratory follow-up results at 7 years for children from the United Kingdom and Ireland enrolled in a randomized trial of early and late postnatal corticosteroid treatment, systemic and inhaled (the Open Study of Early Corticosteroid Treatment)

OBJECTIVES

The goals were to compare early school-age neurodevelopmental and respiratory outcomes for children who were treated with either early (<3 days) or delayed selective (>15 days) postnatal corticosteroid therapy and to compare systemic dexamethasone treatment with inhaled budesonide treatment.

METHODS

One hundred twenty-seven (84%) of 152 survivors from the United Kingdom and Ireland who were recruited to the Open Study of Early Corticosteroid Treatment, a randomized trial of inhaled and systemic corticosteroid therapy to prevent chronic lung disease, were traced and assessed at a median age of 7 years. Outcome measures were level of disability, presence of cerebral palsy, cognitive ability, behavioral difficulties and competencies, growth, and respiratory symptoms. Results were adjusted for potential confounding variables (gestational age, birth weight, gender, prenatal steroid therapy, method of delivery, Apgar score at 5 minutes, and Clinical Risk Index for Babies score).

RESULTS

There were no significant differences among the treatment groups in cognitive ability, behavioral competencies or difficulties, overall disability rates, cerebral palsy, combined outcomes of death or cerebral palsy and death or moderate/severe disability, growth, respiratory morbidity, or diastolic blood pressure. Those assigned to dexamethasone were more likely to have high systolic blood pressure and to have a diagnosis of asthma than were those assigned to budesonide.

CONCLUSIONS

Although postnatal steroid therapy has been associated with poor long-term outcomes, this study failed to show significant differences in cognitive function between dexamethasone- and budesonide-allocated groups. There may be increased systolic blood pressure and a greater likelihood of developing asthma in childhood after postnatal dexamethasone treatment.

Lung disease and brain development

With the technical progress made in fetal and neonatal intensive care, perinatal mortality has decreased by 25% over the last decade and has expanded the surviving premature population. Prematurity drastically changes the environment of the developing organism. Striking evidence from a number of disciplines has focused attention on the interplay between the developing organism and the circumstances in which it finds itself. The environmental event during a sensitive period in development, induces injury and/or biological adaptations that lead to altered differentiation of tissues. The organism can express specific adaptive responses to its environment which include short-term changes in physiology as well as long-term adjustments. This review addresses these short-term as well as longer-term changes occurring in lung and brain tissue and illustrates how these changes can be studied using advanced imaging techniques such as magnetic resonance imaging

Growth in the neonatal intensive care unit influences neurodevelopmental and growth outcomes of extremely low birth weight infants

OBJECTIVES

The objectives of this study were to assess whether (1) in-hospital growth velocity is predictive of neurodevelopmental and growth outcomes at 18 to 22 months' corrected age among extremely low birth weight (ELBW) infants and (2) in-hospital growth velocity contributes to these outcomes after controlling for confounding demographic and clinical variables.

METHODS

Infants 501 to 1000 g birth weight from a multicenter cohort study were divided into quartiles of in-hospital growth velocity rates. Variables considered for the logistic-regression models included gender, race, gestational age, small for gestational age, mother's education, severe intraventricular hemorrhage, periventricular leukomalacia, age at regaining birth weight, necrotizing enterocolitis, late-onset infection, bronchopulmonary dysplasia, postnatal steroid therapy for pulmonary disease, and center.

RESULTS

Of the 600 discharged infants, 495 (83%) were evaluated at 18 to 22 months' corrected age. As the rate of weight gain increased between quartile 1 and quartile 4, from 12.0 to 21.2 g/kg per day, the incidence of cerebral palsy, Bayley II Mental Developmental Index (MDI) <70 and Psychomotor Developmental Index (PDI) <70, abnormal neurologic examination, neurodevelopmental impairment, and need for rehospitalization fell significantly. Similar findings were observed as the rate of head circumference growth increased. The in-hospital rate of growth was associated with the likelihood of anthropometric measurements at 18 months' corrected age below the 10th percentile values of the Centers for Disease Control and Prevention 2000 growth curve. Logistic-regression analyses, controlling for potential demographic or clinical cofounders, and adjusted for center, identified a significant relationship between growth velocity and the likelihood of cerebral palsy, MDI and PDI scores of <70, and neurodevelopmental impairment.

CONCLUSIONS

These analyses suggest that growth velocity during an ELBW infant's NICU hospitalization exerts a significant, and possibly independent, effect on neurodevelopmental and growth outcomes at 18 to 22 months' corrected age.