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Letters to the Editor Indian Pediatrics 2002; 39:889-890 |
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I am thankful for the critical comments on our paper(1). The worry of long-term neuro-sequalae with the indiscriminate use of gluco-corticoids especially within first 96 hours of life is justified. However, can these recommendations be blindly followed in Indian context with constraints of hospital resources, non-availability of home oxygen support etc. Corticosteroids have many actions, which could favorably affect the outcome of preterm babies. They reduce the release of inflammatory mediators, neutrophil influx micro vascular permeability and pulmonary edema(2). All of these factors are involved in the causation of chronic lung disease(3-4). The Cochrane review meta-analysis quoted by Patole and Vijayakumar have clearly shown the beneficial effects on the immediate outcome of babies with CLD. These effects are reduction of CLD, and lower mortality at 28 days. However, the administration of corticosteroids after 2 weeks seems less harmful. The immediate adverse effects are transitory and the side effects in animal models include impaired cell multiplication of lungs and central nervous system. Dexamethasone given to rats on day 4-14 resulted in increased lung volumes, enlarged air spaces and reduced alveolar surface area(5). The adverse effects on central nervous system were decreased brain weight and DNA content reported in animal model, however the follow up of infants entered into early cortiocosteroids trials (though on small sample size) did not indicate adverse long term neurological outcome(6). Hence corticosteroids continue to be a standard protocol in the management of CLD though with a caution regarding their long-term effects. The recommendations are for using them only after two weeks of life, in infants who continue to show clear evidence of progressive pulmonary damage and remain oxygen dependant and the therapy should be for as minimum a period as possible to achieve the desired result(7). We followed these recommendations while treating our patients. The other known side effects of corticosteroids include transient hypertension, hypertrophic cardiomyopathy, increased nosocomial infections and intestinal perforation. One of the modality of reducing side effects may be the use of appropriate preparation, smallest effective dose and stopping therapy at the earliest. Appropriate timing of administration of therapy may also be an important issue worth investigating. Till such time we have better alternatives especially in Indian Context where babies must be discharged only when they do not need oxygen, we would have to continue using this modality though the optimum dosages require investigation. Anil Narang, Professor and Head, Department of Pediatrics, PGIMER, Chandigarh, India. . |
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