Is dart therapy safe for use in neonates?

DART Therapy in Neonates: Safety and Clinical Application

Direct Answer

DART (Dexamethasone: A Randomized Trial) therapy refers to a low-dose systemic dexamethasone protocol for facilitating extubation in ventilator-dependent preterm neonates, and while it can be used safely as a single course, multiple courses (two or more) are associated with significantly increased risk of cerebral palsy and ophthalmological complications at two years of corrected age. 1

Understanding DART Therapy

DART therapy is a specific low-dose dexamethasone regimen designed to help wean preterm infants from mechanical ventilation after the first week of life. 1 This is distinct from other uses of corticosteroids in neonates and should not be confused with "dart catheter" procedures for pneumothorax management. 2

Evidence on Safety and Outcomes

Single Course vs. Multiple Courses:

• A single course of DART therapy (average cumulative dose 0.819 mg/kg) can be used for extubation in ventilator-dependent preterm neonates. 1

• Two or more courses of DART therapy (average cumulative dose 1.697 mg/kg) significantly increase the risk of cerebral palsy with functional motor class 2 (OR = 6.837; 95% CI: 1.054-44.337) and ophthalmological problems requiring glasses (OR = 4.157; 95% CI: 1.026-16.837) at two years of corrected age. 1

• Infants requiring multiple DART courses typically have lower gestational age (25 vs. 26 weeks) and greater baseline morbidity. 1

Clinical Decision Algorithm

When considering DART therapy:

1. Confirm indication: Ventilator-dependent preterm infant after the first week of life who has failed conventional weaning strategies. 1

2. Assess baseline risk: Document gestational age, current morbidities, and previous steroid exposure. 1

3. If initiating first course: Use low-dose dexamethasone protocol as studied in DART trials, with cumulative dose targeting approximately 0.8 mg/kg. 1

4. If first course fails: Strongly reconsider before initiating a second course given the 6.8-fold increased risk of cerebral palsy and 4.2-fold increased risk of ophthalmological complications. 1

5. Alternative strategies before second course: Optimize ventilator settings, address underlying infections, ensure adequate nutrition, and consider non-pharmacologic interventions. 1

Critical Pitfalls to Avoid

• Do not use multiple courses of DART therapy without explicit discussion with parents about the substantially elevated neurodevelopmental risks. The increased prevalence of cerebral palsy with functional impairment represents a major quality-of-life concern that outweighs potential short-term respiratory benefits. 1

• Do not confuse DART therapy with other neonatal interventions such as dart catheter placement for pneumothorax, which is an entirely different procedure with its own complications including empyema. 2

• Recognize that preterm infants have decreased drug clearance compared to term infants, making them more vulnerable to cumulative steroid toxicity. 3

• Understand that inadequate pain management during procedures can have long-term neurodevelopmental consequences, but this is separate from DART therapy considerations. 3

Context: Other Neonatal Therapies

While the evidence provided discusses various neonatal interventions including anticoagulation for thrombosis 4, stroke management 4, 5, and pain management 4, 3, these are not directly related to DART therapy safety. The most relevant and highest-quality evidence specifically addressing DART therapy in neonates is the 2024 multicenter retrospective study demonstrating the neurodevelopmental risks of multiple courses. 1

The key clinical message: A single course of DART therapy may be reasonable for extubation of ventilator-dependent preterm neonates, but multiple courses carry unacceptable risks to long-term neurological outcomes and should be avoided whenever possible. 1