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Meta-Analysis
. 2017 Oct 24;10(10):CD001145.
doi: 10.1002/14651858.CD001145.pub4.

Late (> 7 days) systemic postnatal corticosteroids for prevention of bronchopulmonary dysplasia in preterm infants

Lex W Doyle  1 , Jeanie L Cheong, Richard A Ehrenkranz, Henry L Halliday
Affiliations
Meta-Analysis

Late (> 7 days) systemic postnatal corticosteroids for prevention of bronchopulmonary dysplasia in preterm infants

Lex W Doyle et al. Cochrane Database Syst Rev. .

Update in

Abstract

Background: Many preterm infants who survive go on to develop bronchopulmonary dysplasia, probably as the result of persistent inflammation in the lungs. Corticosteroids have powerful anti-inflammatory effects and have been used to treat individuals with established bronchopulmonary dysplasia. However, it is unclear whether any beneficial effects outweigh the adverse effects of these drugs.

Objectives: To examine the relative benefits and adverse effects of late systemic postnatal corticosteroid treatment (> 7 days) for preterm infants with evolving or established bronchopulmonary dysplasia.

Search methods: For the 2017 update, we used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1); MEDLINE via PubMed (January 2013 to 21 February 2017); Embase (January 2013 to 21 February 2017); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; January 2013 to 21 February 2017). We also searched clinical trials databases, conference proceedings, and reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

Selection criteria: We selected for inclusion in this review randomised controlled trials (RCTs) comparing systemic postnatal corticosteroid treatment versus placebo or nothing initiated more than seven days after birth for preterm infants with evolving or established bronchopulmonary dysplasia.

Data collection and analysis: We used the GRADE approach to assess the quality of evidence.We extracted and analysed data regarding clinical outcomes including mortality, bronchopulmonary dysplasia, death or bronchopulmonary dysplasia, failure to extubate, complications during primary hospitalisation, and long-term health outcomes.

Main results: Twenty-one RCTs enrolling a total of 1424 participants were eligible for this review. All were RCTs, but methods used for random allocation were not always clear. Allocation concealment, blinding of the intervention, and blinding of outcome assessments most often were satisfactory. Late steroid treatment was associated with a reduction in neonatal mortality (at 28 days) but no reduction in mortality at 36 weeks, at discharge, or at latest reported age. Benefits of delayed steroid treatment included reductions in failure to extubate by 3, 7, or 28 days; bronchopulmonary dysplasia both at 28 days of life and at 36 weeks' postmenstrual age; need for late rescue treatment with dexamethasone; discharge on home oxygen; and death or bronchopulmonary dysplasia both at 28 days of life and at 36 weeks' postmenstrual age. Data revealed a trend towards increased risk of infection and gastrointestinal bleeding but no increase in risk of necrotising enterocolitis. Short-term adverse affects included hyperglycaemia, glycosuria, and hypertension. Investigators reported an increase in severe retinopathy of prematurity but no significant increase in blindness. Trial results showed a trend towards reduction in severe intraventricular haemorrhage, but only five studies enrolling 247 infants reported this outcome. Trends towards an increase in cerebral palsy or abnormal neurological examination findings were partly offset by a trend in the opposite direction involving death before late follow-up. The combined rate of death or cerebral palsy was not significantly different between steroid and control groups. Major neurosensory disability and the combined rate of death or major neurosensory disability were not significantly different between steroid and control groups. There were no substantial differences between groups for other outcomes in later childhood, including respiratory health or function, blood pressure, or growth, although there were fewer participants with a clinically important reduction in forced expired volume in one second (FEV1) on respiratory function testing in the dexamethasone group.GRADE findings were high for all major outcomes considered, but review authors degraded the quality of evidence by one level because we found evidence of publication bias (bronchopulmonary dysplasia at 36 weeks).

Authors' conclusions: Benefits of late corticosteroid therapy may not outweigh actual or potential adverse effects. This review of postnatal systemic corticosteroid treatment for bronchopulmonary dysplasia initiated after seven days of age suggests that late therapy may reduce neonatal mortality without significantly increasing the risk of adverse long-term neurodevelopmental outcomes. However, the methodological quality of studies determining long-term outcomes is limited in some cases (some studies assessed surviving children only before school age, when some important neurological outcomes cannot be determined with certainty), and no studies were sufficiently powered to detect increased rates of important adverse long-term neurosensory outcomes. Evidence showing both benefits and harms of treatment and limitations of available evidence suggests that it may be prudent to reserve the use of late corticosteroids for infants who cannot be weaned from mechanical ventilation, and to minimise both dose and duration for any course of treatment.

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Conflict of interest statement

Lex Doyle was Chief Investigator of the DART study, a randomised controlled trial of low‐dose, short‐course dexamethasone in ventilator‐dependent infants, funded by the National Health and Medical Research Council of Australia.

Henry Halliday (HLH) is a retired neonatologist. He is joint Editor‐in‐Chief of the journal Neonatology, and sits on many Data Monitoring and Trial Steering Committees for various neonatal/perinatal trials. He received support for co‐ordinating the OSECT study (2000), for which AstraZeneca (Sweden) supplied metered‐dose inhalers of budesonide and placebo. HLH also acts as a consultant for Chiesi Farmiceutici (Italy), a company that sells two neonatal drugs ‐ Curosurf (a surfactant to treat respiratory distress syndrome) and Peyona (a caffeine preparation to treat apnoea of prematurity).

Figures

1
1
Study flow diagram: review update.
2
2
Funnel plot of comparison: 1 Mortality, outcome: 1.4 Mortality at latest reported age.
3
3
Funnel plot of comparison: 2 Bronchopulmonary dysplasia (BPD), outcome: 2.2 BPD at 36 weeks.
4
4
Funnel plot of comparison: 3 Death or BPD, outcome: 3.2 Death or BPD at 36 weeks.
5
5
Funnel plot of comparison: 6 Long‐term follow‐up, outcome: 6.11 Death or cerebral palsy.
See this image and copyright information in PMC

Update of

References

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References to ongoing studies

NCT01353313 {unpublished data only}
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References to other published versions of this review

Doyle 2014b
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