Letters to the Editor

Indian Pediatrics 2002; 39:888

Postnatal Glucocorticosteroids for Chronic Lung Disease in Preterm Neonates: A Definite No

We refer to the recent report on neonatal chronic lung disease (CLD) as an emerging problem in India(1). The long-term hazards related to postnatal glucocorticosteroid therapy for CLD in preterm neonates can not be overemphasized at this stage as the absolute number of neonatal survivors with CLD is expected to rise following improving standards of neonatal intensive care. In this report, most (94.7%) neonates with CLD received dexamethasone which was started between 15-26 days of life and continued for 21-28 days. Additionally, 8 of the 19 neonates with CLD were born at < 28 weeks gestation(1). A recent meta-analysis of randomized controlled trials of postnatal steroid therapy for CLD in preterm neonates has indicated that the typical relative risk for the development of cerebral palsy and neurodevelopmental disability was 2.86 (95% CI: 1.95, 4.19) and 1.66 (95% CI: 1.26, 2,19) respectively(2). From this subgroup of studies, the number of preterm neonates who need to be treated to have one more infant with cerebral palsy, or neurodevelopmental impairment (number needed to harm: NNH) were 7, and 11 respectively. The study concluded that the use of postnatal steroids for prevention or treatment of CLD should be abandoned in view of the associated dramatic increase in neurodevelopmental impairment especially when there is no clear evidence for a long-term benefit(2). Given this evidence, the continued use of glucocorticoids as the necessary evil in the management of CLD for lack of a better alternative is thus strongly discouraged(2-5). A "Well informed" consent for such therapy is necessary under ethically complex and hopefully rare circumstances when a parent may opt for survival with neurodevelopmental handicaps rather than neonatal death, unknowingly testing the basic principle of medicine-first, do no harm(6).

.

References

1. Narang A, Kumar P, Kumar R. Chronic lung disease in neonates: Emerging problem in India. Indian Pediatr 2002; 39: 158-161.

2. Barrington KJ. The adverse neuro-developmental effects of postnatal steroids in the preterm infant: a systematic review of RCTs. BMC Pediatr 2001; 1: 1.

3. Halliday HL, Ehrenkranz RA. Early postnatal (<96 hours) corticosteroids for preventing chronic lung disease in preterm infants. Cochrane Database Syst Rev 2000; 2: CD001146.

4. Halliday HL, Ehrenkranz RA. Moderately early (7-14 days) postnatal corticosteroids for preventing chronic lung disease in preterm infants. Cochrane Database Syst Rev 2000; 2: CD001144.

5. Halliday HL, Ehrenkranz RA. Delayed (>3 weeks) postnatal corticosteroids for chronic lung disease in preterm infants. Cochrane Database Syst Rev 2000; 2: CD001145.

6. Barrington KJ. Hazards of systemic steroids for ventilator dependent preterm infants: What would a parent want? CMAJ 2001; 165-33-34.