Predicting iatrogenic adrenal insufficiency in neonates exposed to prolonged steroid courses: do cortisol levels help?

OBJECTIVE

To determine whether random cortisol levels obtained in neonates to assess for secondary adrenal insufficiency (AI) after prolonged steroid exposure are predictive of central AI.

STUDY DESIGN

Data were collected on neonates born 2017-2022 who received ≥10 consecutive days of systemic steroids and had cortisol measured thereafter. Data were then collected on whether those neonates developed signs of AI or had a failed adrenocorticotropic hormone (ACTH) stimulation test.

RESULTS

Of the 71 cortisol levels (in 67 neonates) that were analyzed, there was no difference in cortisol levels between neonates who developed AI (median cortisol level of 6.5 mcg/dl) and those who did not (median of 9.2 mcg/dl), or between those who failed their ACTH stimulation test or passed it, using Wilcoxon ranked sum tests.

CONCLUSION

These findings demonstrate that cortisol levels may not be helpful in identifying AI in neonates exposed to prolonged steroids.

Evaluation of Intravenous Immunoglobulin Administration for Hyperbilirubinemia in Newborn Infants with Hemolytic Disease

The primary objective of this research was to evaluate the use of intravenous immunoglobulin (IVIG) in infants with hemolytic disease, to assess compliance with the American Academy of Pediatrics (AAP) guideline recommendations, and to review the data on which the guidelines were based. This retrospective study evaluated all infants in the NICU (neonatal intensive care unit) who received IVIG between January 2018 and December 2020 (n = 71). Total serum bilirubin (TSB) levels surrounding the time of IVIG administration, rate of rise of bilirubin, and direct antiglobulin test (DAT) status were evaluated to determine the appropriateness of IVIG use based on the 2004 AAP recommendations that was current at the time of the study. Fifty-nine infants received IVIG for hyperbilirubinemia. Of them, 80% had an ABO mismatch, 19% had Rh mismatch, and 71% were DAT-positive. Phototherapy was started at an average of 7 h of age, and the first IVIG dose was administered at an average of 13 h of life; nearly 25% received a second IVIG dose. One infant (1.6%) met all three AAP guideline criteria of being DAT-positive, bilirubin within 3 of exchange level, and rising bilirubin despite intensive phototherapy. Twenty-five (42%) babies were DAT positive and met one of the other two criteria. Only 12% (n = 7) had a bilirubin within 3 of exchange level. Most infants who received IVIG for hyperbilirubinemia did not meet the AAP criteria, prompting us to develop an institution-specific IVIG clinical practice guideline. The 2022 AAP guideline was published after our study was completed, but it confirmed our belief that IVIG usage should be more restricted and the criteria more explicit.

Antenatal Corticosteroids: Extending the Practice for Late-Preterm and Scheduled Early-Term Deliveries?

Respiratory distress in late-preterm and early term infants generally may warrant admission to a special care nursery or an intensive care unit. In particular, respiratory distress syndrome and transient tachypnea of the newborn are the two most common respiratory morbidities. Antenatal corticosteroids (ACS) facilitate surfactant production and lung fluid resorption. The use of ACS has been proven to be beneficial for preterm infants delivered at less than 34 weeks' gestation. Literature suggests that the benefits of giving antenatal corticosteroids may extend to late-preterm and early term infants as well. This review discusses the short-term benefits of ACS administration in reducing respiratory morbidities, in addition to potential long term adverse effects. An update on the current practices of ACS use in pregnancies greater than 34 weeks' gestation and considerations of possibly extending versus restricting this practice to certain settings will also be provided.