Postnatal corticosteroids to treat or prevent chronic lung disease in preterm infants

BACKGROUNDChronic lung disease (CLD), also known as bronchopulmonary dysplasia, is an important cause of mortality and morbidity in preterm infants (1,2).The incidence of CLD among surviving infants with very low birth weight ([VLBW]; birth weight less than 1500 g) in two large databases was 26% in Canada (1996/97) (1) and 23% in the United States (1995/96) (2).CLD is usually defined as oxygen dependency at 36 weeks' postmenstrual age (PMA) or 28 days' postnatal age (PNA), in conjunction with persistent clinical respiratory symptoms and compatible abnormalities on chest radiographs (3-6).Because inflammation plays an important role in the pathogenesis of CLD, corticosteroids, in particular dexamethasone, have been widely used to prevent or treat CLD (1,2,7).Postnatal corticosteroids were given to 25% of infants with VLBW in Canada (1996/97) (1) and to 19% in the United States (1995/96) (2).Corticosteroid use is higher in infants with a birth weight less than 1000 g (1,2).Numerous studies suggest that the use of systemic corticosteroids decreases the duration of ventilator dependence (8-16).However, early beneficial effects on the pulmonary system may be outweighed by an increased risk of serious short and long term adverse effects (8-24). OBJECTIVESThe objectives of this statement are to review the short and long term effects of systemic and inhaled postnatal corticosteroids for the prevention or treatment of evolving or established CLD, and to make recommendations for the use of corticosteroids in infants with VLBW.The focus of this statement is limited to the use of corticosteroids in neonates with VLBW for the prevention or treatment of CLD. LITERATURE REVIEWAn attempt was made to identify all published systematic reviews and meta-analyses on the use of corticosteroids (systemic or inhaled) for the prevention or treatment of CLD in preterm infants, using the MEDLINE, EMBASE, CINAHL and Cochrane Library electronic databases, and personal files from 1983 to April 2001.Data were also included from two trials published after the identified systematic reviews (19,25).Twelve systematic reviews published between 1992 and 2001 were identified (8-16,26-28).Nine addressed the use of systemic steroids (8-11,13-16,28), two described the use of inhaled steroids (26,27) and one addressed both (12).Numerous outcomes were evaluated.The results are presented in five sections: the first three sections report on the effects of systemic corticosteroids on the basis of age at which the infants were treated; the fourth section reports on the effects of inhaled steroids; and the fifth section describes the effects of systemic corticosteroids on neurodevelopmental outcomes. Systemic early postnatal corticosteroid therapy (less than 96 h of age)The most complete systematic reviews were published in 2001 (13,16).In addition, the meta-analysis for systemic Postnatal corticosteroids to treat or prevent chronic lung disease in preterm infants Joint statement with the American Academy of Pediatrics JOINT STATEMENT (FN 2002-01) Français en page 37 Postnatal corticosteroids to treat or prevent chronic lung disease in preterm infants.Paediatr Child Health 2002;7(1):20-28.This statement is intended for health care professionals caring for neonates and young infants.The objectives of this statement are to review the short and long term effects of systemic and inhaled postnatal corticosteroids for the prevention or treatment of evolving or established chronic lung disease, and to make recommendations for the use of corticosteroids in infants with very low birth weight.The routine use of systemic dexamethasone for the prevention or treatment of chronic lung disease in infants with very low birth weight is not recommended.