Postnatal steroids and the brain at 18 years

Abstract

Corticosteroid treatments, generally with dexamethasone, remain both controversial and effective in selected populations of very low birth weight infants at risk of developing bronchopulmonary dysplasia (BPD). The controversy is the risk of brain injury relative to the benefit of less lung disease. Adverse effects of dexamethasone on the very preterm brain are clear and diverse in animal models, and brain growth and neurofunction can be compromised for infants who receive high dose, long treatment courses with dexamethasone. However, BPD and prolonged mechanical ventilation independently can contribute to brain injury. In this issue of The Journal, Cheong et al report that preterm infants exposed to dexamethasone have focal changes and decreased selected brain volumes, as assessed by magnetic resonance imaging at 18 years of age. As pointed out in the Editorial by Watterberg, these are remarkable observations from long-term follow-up. Although we now know what we did with corticosteroids and do not want to repeat, we will have to wait a long time to know the outcomes of what we are doing now. Postnatal corticosteroid use today is primarily for very preterm ventilator-dependent infants at high risk of severe BPD. The steroid dose is lower and the duration of therapy is much shorter. The choice of steroid is also being evaluated with hydrocortisone being potentially less toxic than dexamethasone. Short-term follow-up suggests less risk for toxicity—but unfortunately only a very long time will tell—and only if we do the sort of follow-up reported by Cheong et al. Article page 737▶ Editorial page 687▶ Association between Postnatal Dexamethasone for Treatment of Bronchopulmonary Dysplasia and Brain Volumes at Adolescence in Infants Born Very PretermThe Journal of PediatricsVol. 164Issue 4PreviewTo compare brain volumes in adolescents who were born extremely preterm (<28 weeks gestation) who had received postnatal dexamethasone, and to determine if there was a postnatal dexamethasone dose–response effect on brain volumes. Full-Text PDF Open AccessDexamethasone and the Brain at Age 18 Years: Randomize the First Baby—and Follow-UpThe Journal of PediatricsVol. 164Issue 4PreviewIn this issue of The Journal, Cheong et al report magnetic resonance imaging (MRI) results at 18 years of age from a large prospective cohort study of all infants born at <28 weeks gestation in Victoria, Australia, 1991-1992.1 The authors are to be highly commended both for continuing to follow this comprehensive geographical cohort into young adulthood, and for achieving a follow-up rate of 80%, of whom 82% (146/180) had usable MRI scans. This large cohort will add valuable information to the growing literature on long-term structural and functional neurologic outcomes after extremely preterm birth. Full-Text PDF