Postnatal Steroids Use for Bronchopulmonary Dysplasia in a Quaternary Care NICU

Abstract

Objective Intercenter variation and trends in postnatal steroids (PNS) use among preterm infants for prevention or treatment of bronchopulmonary dysplasia (BPD) is known. Understanding intracenter PNS use patterns facilitate implementation of center-specific change interventions to optimize outcomes.

This study aimed to (i) quantify the proportion of infants who received PNS, and describe the timing, type, trends over time, regimen used, and deviations, and (2) describe the clinical characteristics and unadjusted outcomes of infants who received PNS.

Study Design This was a cohort study in a quaternary neonatal intensive care unit including infants born at less than 33 weeks, and who received PNS for prevention or treatment of BPD between 2011 and 2021. Following data were included: proportion of babies who received PNS; type of PNS; age at initiation and duration; trends over time; deviation from published regimen; morbidity, mortality, and cointerventions.

Results One hundred and eighty four infants (8% of <33 week' infants) received PNS. The median (interquartile range [IQR]) gestational age and birth weight were 25 (24–26) weeks and 720 (625–841) grams, respectively. The median (IQR) day of initiation and duration of PNS use were 29 (19–38) and 10 (10–22) days, respectively. One hundred and fifty-seven (85%) infants received dexamethasone (DX) and 22 (12%) received hydrocortisone as the first PNS course, and 71 (39%) infants received multiple courses. The proportion of infants receiving PNS remained unchanged, but the cumulative median dose received for BPD per patient increased by 56%. Nearly one-third of cumulative PNS dose came from PNS used for non-BPD indications. Forty-six percent infants had a deviation from published regimen (±20% deviation in duration or ±10% deviation in dose). Survival, survival without major morbidity, moderate-to-severe BPD, and technology dependence at discharge were 87, 2, 91, and 67%, respectively.

Conclusion Increased variation in PNS use, deviation from published regimen, and concurrent PNS exposure from non-BPD indication offer insights into implementing interventions to improve processes.

Key Points

• In this quaternary NICU, 8% of infants born before 33 weeks were administered postnatal steroids (PNS).

• The percentage of infants given PNS remained stable; however, the cumulative dose per patient for BPD rose.

• The study identified targeted interventions to minimize clinical practice variations at the center.

Keywords

bronchopulmonary dysplasia - postnatal steroids - neonatal intensive care - variation

Publikationsverlauf

Eingereicht: 07. Dezember 2023

Angenommen: 12. Februar 2024

Accepted Manuscript online:
13. Februar 2024

Artikel online veröffentlicht:
04. März 2024

• References

• 1 The Canadian Neonatal Network™. Annual Report 2021. . Accessed January 1, 2023 at: https://www.canadianneonatalnetwork.org/portal/Portals/0/Annual%20Reports/2021%20CNN%20annual%20report%20final_amended.pdf
• 2 Esterman E, Goyen TA, Jani P. et al. Systemic postnatal corticosteroid use for the prevention of bronchopulmonary dysplasia and its relationship to early neurodevelopment in extremely preterm infants. World J Pediatr 2023; 19 (06) 586-594
• 3 Walsh MC, Morris BH, Wrage LA. et al; National Institutes of Child Health and Human Development Neonatal Research Network. Extremely low birthweight neonates with protracted ventilation: mortality and 18-month neurodevelopmental outcomes. J Pediatr 2005; 146 (06) 798-804
• 4 Short EJ, Kirchner HL, Asaad GR. et al. Developmental sequelae in preterm infants having a diagnosis of bronchopulmonary dysplasia: analysis using a severity-based classification system. Arch Pediatr Adolesc Med 2007; 161 (11) 1082-1087
• 5 Short EJ, Klein NK, Lewis BA. et al. Cognitive and academic consequences of bronchopulmonary dysplasia and very low birth weight: 8-year-old outcomes. Pediatrics 2003; 112 (05) e359-e359
• 6 Centers for Disease Control and Prevention (CDC). Economic costs associated with mental retardation, cerebral palsy, hearing loss, and vision impairment–United States, 2003. MMWR Morb Mortal Wkly Rep 2004; 53 (03) 57-59
• 7 Doyle LW, Davis PG, Morley CJ, McPhee A, Carlin JB. DART Study Investigators. Low-dose dexamethasone facilitates extubation among chronically ventilator-dependent infants: a multicenter, international, randomized, controlled trial. Pediatrics 2006; 117 (01) 75-83
• 8 Baud O, Maury L, Lebail F. et al; PREMILOC Trial Study Group. Effect of early low-dose hydrocortisone on survival without bronchopulmonary dysplasia in extremely preterm infants (PREMILOC): a double-blind, placebo-controlled, multicentre, randomised trial. Lancet 2016; 387 (10030): 1827-1836
• 9 Onland W, Cools F, Kroon A. et al; STOP-BPD Study Group. Effect of hydrocortisone therapy initiated 7 to 14 days after birth on mortality or bronchopulmonary dysplasia among very preterm infants receiving mechanical ventilation: a randomized clinical trial. JAMA 2019; 321 (04) 354-363
• 10 van der Heide-Jalving M, Kamphuis PJGH, van der Laan MJ. et al. Short- and long-term effects of neonatal glucocorticoid therapy: is hydrocortisone an alternative to dexamethasone?. Acta Paediatr 2003; 92 (07) 827-835
• 11 Nath S, Reynolds AM, Lakshminrusimha S, Ma C, Hudak ML, Ryan RM. Retrospective analysis of short-term respiratory outcomes of three different steroids used in clinical practice in intubated preterm infants. Am J Perinatol 2020; 37 (14) 1425-1431
• 12 Yao S, Uthaya S, Gale C, Modi N, Battersby C. UK Neonatal Collaborative (UKNC). Postnatal corticosteroid use for prevention or treatment of bronchopulmonary dysplasia in England and Wales 2012-2019: a retrospective population cohort study. BMJ Open 2022; 12 (11) e063835
• 13 Cummings JJ, Pramanik AK. Committee on Fetus and Newborn. Postnatal corticosteroids to prevent or treat chronic lung disease following preterm birth. Pediatrics 2022; 149 (06) e2022057530
• 14 Lemyre B, Dunn M, Thebaud B. Postnatal corticosteroids to prevent or treat bronchopulmonary dysplasia in preterm infants. Paediatr Child Health 2020; 25 (05) 322-331
• 15 Onland W, van de Loo M, Offringa M, van Kaam A. Systemic corticosteroid regimens for prevention of bronchopulmonary dysplasia in preterm infants. Cochrane Database Syst Rev 2023; 3 (03) CD010941
• 16 Sweet DG, Carnielli V, Greisen G. et al. European Consensus Guidelines on the Management of Respiratory Distress Syndrome - 2019 Update. Neonatology 2019; 115 (04) 432-450
• 17 Ramaswamy VV, Bandyopadhyay T, Nanda D. et al. Assessment of postnatal corticosteroids for the prevention of bronchopulmonary dysplasia in preterm neonates: a systematic review and network meta-analysis. JAMA Pediatr 2021; 175 (06) e206826
• 18 Committee on Fetus and Newborn. Postnatal corticosteroids to treat or prevent chronic lung disease in preterm infants. Pediatrics 2002; 109 (02) 330-338
• 19 Parikh S, Reichman B, Kusuda S. et al; International Network for Evaluation of Outcomes (iNeo) of neonates investigators. Trends, characteristic, and outcomes of preterm infants who received postnatal corticosteroid: a cohort study from 7 high-income countries. Neonatology 2023; 120 (04) 517-526
• 20 Kwok TC, Szatkowski L, Sharkey D. Impact of postnatal dexamethasone timing on preterm mortality and bronchopulmonary dysplasia: a propensity score analysis. Eur Respir J 2023; 62 (04) 2300825
• 21 The Canadian Neonatal Network™. Abstractor's Manual. 2021 . Accessed January 1, 2023 at: https://www.canadianneonatalnetwork.org/portal/Portals/0/CNN%20Manuals/CNN%20Manual_20210225.pdf
• 22 Htun ZT, Schulz EV, Desai RK. et al. Postnatal steroid management in preterm infants with evolving bronchopulmonary dysplasia. J Perinatol 2021; 41 (08) 1783-1796
• 23 Provost L, Murray SK. The Health Care Data Guide. 2nd ed. 2022. . Wiley. Accessed June 30, 2023 at: https://www.perlego.com/book/3526319/the-health-care-data-guide-learning-from-data-for-improvement-pdf (Original work published 2022)
• 24 Wheeler TA, Davis JT, Brilli RJ. The Aggregate Point Rule for identifying shifts on P charts and U charts. Pediatr Qual Saf 2018; 3 (05) e103
• 25 Hillman NH, Jobe AH. Preterm lung and brain responses to mechanical ventilation and corticosteroids. J Perinatol 2023; 43 (10) 1222-1229
• 26 Olsen JA. Unwarranted variations in healthcare utilization. In: Principles in Health Economics and Policy. 2nd ed. Oxford University Press; New York: 2017: 194-205
• 27 Hansen TP, Oschman A, K Pallotto E, Palmer R, Younger D, Cuna A. Using quality improvement to implement consensus guidelines for postnatal steroid treatment of preterm infants with developing bronchopulmonary dysplasia. J Perinatol 2021; 41 (04) 891-897
• 28 Watterberg KL, Walsh MC, Li L. et al; Eunice Kennedy Shriver NICHD Neonatal Research Network. Hydrocortisone to improve survival without bronchopulmonary dysplasia. N Engl J Med 2022; 386 (12) 1121-1131
• 29 Morris IP, Goel N, Chakraborty M. Efficacy and safety of systemic hydrocortisone for the prevention of bronchopulmonary dysplasia in preterm infants: a systematic review and meta-analysis. Eur J Pediatr 2019; 178 (08) 1171-1184
• 30 Greenberg RG, McDonald SA, Laughon MM. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Online clinical tool to estimate risk of bronchopulmonary dysplasia in extremely preterm infants. Arch Dis Child Fetal Neonatal Ed 2022; 107 (06) 638-643