Hydrocortisone and Neurodevelopmental Outcome

Rademaker KJ, Uiterwaal C, Groenendaal F, et al. Neonatal Hydrocortisone Treatment: Neurodevelopmental Outcome and MRI at School Age in Preterm-born Children. J Pediatr (April 2007); 150:351-7. Full Text | PDF

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 ≤32 weeks and/or body weight ≤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. 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.

Comments. Hydrocortisone (in the dosage used) appears to be safer than dexamethasone for the treatment or prevention of BPD. At least, the long-term neurodevelopmental side effects seen with dexamethasone were not found in this study. Much work remains to be done to determine the optimal drug, dosage and timing of steroid treatment for BPD. Despite these encouraging results, I doubt we will ever again be comfortable with any steroid for BPD, except in extreme cases. ABK.

Date: 10 Jun 2007
Time: 16:24:03

It is not possible to draw any conclusions about relative toxicity of hydrocortisone vs. dexamethasone with current data. In the past, dexamethasone dosage was extremely high, dosing intervals very short (especially for the apprx 48 hr biologic half-life, with likely near-complete receptor saturation), course duration was very long, and subjects were very immature. Predictably, there were major adverse effects! Who would ever dose hydrocortisone in this manner? Because of marked differences in the pharmacokinetics of these drugs, it may not even be possible to mimic this type of therapy with hydrocortisone. Often a SINGLE 0.25 mg/kg dose of dexamethasone is ALL that is needed to get an infant off a ventilator, which, in my opinion, is the only defensible indication for this drug in neonates. The effect is evident in 8-12 hrs and lasts 5-7 days. Mechanical ventilation, itself, is thought to have adverse neurodevelopmental effects. With our current evidence, we must weigh the risks and decide what to do.

UserName: Louis Heck
Institution: CentraCare Clinic
telephone:
email: louisheck@mac.com

Date: 02 Jul 2007
Time: 21:44:23

We use even lower doses of Decadron -- 0.1mg/kg/day to 0.15 mg/kg/day -- with good results on successful extubation, and taper over 5 - 7 days. We tried hydrocortisone at a dose of 5 mg/kg/day and were very disappointed in its effectiveness.

UserName: Paul Hinkes MD
Institution: Providence St. Joseph Medical Center
telephone: 818-847-6332
email: preemys@msn.com

A few years ago we have thought BPD without steroids would be a "no go". We know recognize that, if at all, only in extrem cases there is need for any steroid. Who will use steroids for a median of 27 days? At what risk? TIll all questions for "new" steroid therapies will be answered, the Europeans will have shown how to intubate, give surfacant and CPAP.

UserName: Bernhard Bungert
Institution: Kinderklinik Hanau Germany
telephone:
email: bernhard_bungert@web.de

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