Table 2.
| Period | Steroid/dosing | When to use | Cautions/recommendations |
|---|---|---|---|
| Prophylaxis (“Early”; <7 days) |
Hydrocortisone 10-day course: 1 mg/kg/day div BID ×7 days, 0.5 mg/kg/day QD ×3 days (PREMILOC) [34] |
Consider if unit rate of BPD is high (e.g., ≥ 50th or 75th percentile in infants 24–27 6/7 weeks) |
• Do not use with NSAIDs due to risk of intestinal perforation • NDI improved for infants 24–25 wga • NO ADRENAL SUPPRESSION if exact PREMILOC regimen is used |
| Early evolving BPD (7–28 days) |
Dexamethasone 10-day course: 0.15 mg/kg/day ×3 days, 0.10 mg/kg/day ×3 days, 0.05 mg/kg/day ×2 days, 0.02 mg/kg/day ×2 days (DART) [41] Hydrocortisone 22-day course: 5 mg/kg/day div Q6 h ×7 days, 3.75 mg/kg/day div Q8 h ×5 days, 2.5 mg/kg/day div Q12 ×5 days, 1.25 mg/kg/day QD ×5 days (STOP-BPD) [44] |
Infants <28 weeks’ GA and on invasive ventilation >7 days, consider dexamethasone at ~21 days of age Hydrocortisone might be preferred if given between 7 and 21 days of age bDART was started at mean 23 days (no upper limit noted) and STOP-BPD initiation ended at 14 days |
• Preference for hydrocortisone if given <21 days of age since hydrocortisone may be safer for the brain in general • Either can improve short-term respiratory outcomes but no difference for death or BPD at 36 weeks' PMA • DART showed no increased risk for CP or major disability, although trial had small sample size • Pending follow up from STOP-BPD • High risk for adrenal suppression if >14 days course • Research Gap—Head-to-head study of hydrocortisone vs. dexamethasone will be helpful |
| Later evolving BPD (>28 days up to 36 weeks' PMA) |
Limited data Dexamethasone 9-day course: 0.2 mg/kg/day div q12 h ×3 days 0.1 mg/kg/day div q12 h ×3 days 0.05 mg/kg/day q12 h ×3 days Modifieda DART protocol |
• No long-term data • Dexamethasone slightly better in decreasing resp support [53] • Might be best to start <50 days of age for reducing severe BPD [74] |
• At risk for adrenal suppression • Research Gap—limited data exist for giving steroids to infants with evolving lung disease who are over 1 month of age • Placebo-controlled RCT or even descriptive, anecdotal data targeted to a specific question will be useful |
| Established BPD >36 weeks' PMA |
Prednisolone 14-day course: 2 mg/kg/day div BID ×5 days 1 mg/kg/day QD ×3 days 1 mg/kg/day QoD ×3 doses Bhandari et al. [54] Prednisolone 28+ day course: 2 mg/kg/day ×7 days, 1 mg/kg/day QD ×7 days, 0.5 mg/kg/day QD ×7 days, 0.5 mg/kg 3×/week ×7 days Linafelter et al.* [55] |
• Recommend the Bhandari course, use for NICU babies on vent, CPAP or high-flow support (more than 2L NC) Consider longer course if escalation of respiratory support warranted when tapering steroid • Only go back to previous dose ONCE, then continue wean |
• Both regimens decrease pulmonary acuity score • 14-day course: facilitates ability to wean off supplemental oxygen • 28-day course: decreases respiratory support within 1 week • bActual dosing duration use in study is much longer than 28 days • At risk for adrenal suppression • Research gap—placebo-controlled RCT—difficult since these infants are on high settings/support—need mortality, NDFU endpoints |
BID twice a day, dex dexamethasone, div divided, HC hydrocortisone, NFDU neurodevelopmental follow-up, PMA postmenstrual age, QD daily, QOD every other day, RCT randomized controlled trial.
aProtocol developed before DART paper in Buffalo in 2000’s based on Pediatric Academic Societies lecture by Alan Jobe; used consistently since 2008 [53].
bStarting dose and weaning strategy at discretion of attending neonatologist; general dosing strategy described.