Can steroids be used in neonatal respiratory distress syndrome (NRDS)?

Steroids in Neonatal Respiratory Distress Syndrome

Yes, steroids should be given in neonatal respiratory distress syndrome, but the timing, route, and type of steroid are critical—antenatal corticosteroids (betamethasone or dexamethasone) given to mothers before delivery are highly effective and strongly recommended, while postnatal systemic steroids (particularly high-dose dexamethasone) are generally discouraged due to adverse neurodevelopmental outcomes.

Antenatal Corticosteroids: The Gold Standard

Antenatal corticosteroids are the most effective steroid intervention for preventing and reducing the severity of neonatal RDS and should be administered to all pregnant women at risk of preterm delivery before 37 weeks of gestation. 1

Benefits of Antenatal Steroids

• Antenatal steroids decrease mortality, the severity of RDS, surfactant use, and intraventricular hemorrhage in infants born at less than 34 weeks' gestation. 2

• The combination of antenatal steroids and postnatal surfactant independently and additively reduces mortality, severity of RDS, and air leaks in preterm infants—this synergistic effect is superior to either treatment alone. 2

• In singleton pregnancies between 28-32 weeks' gestation, the combination of antenatal dexamethasone and surfactant significantly reduces both the incidence and severity of RDS compared to surfactant alone. 3

Recommended Regimen

• The standard regimen is 2 doses of 12 mg intramuscular betamethasone given 24 hours apart, with betamethasone being the preferred agent. 1

• Alternative dosing with dexamethasone (5-6 mg every 12 hours for 4 doses) has also shown efficacy, with recent evidence suggesting 5 mg may be noninferior to 6 mg in late preterm births. 4, 5

Important Contraindications and Cautions

• Antenatal corticosteroids should NOT be administered to women with pregestational diabetes mellitus due to the risk of worsening neonatal hypoglycemia. 1

• Avoid in women with low likelihood of delivery before 37 weeks, as unnecessary exposure carries uncertain long-term risks. 1

• Use caution in multiple gestations reduced to singleton, pregnancies with fetal anomalies, and women expected to deliver in <12 hours. 1

Postnatal Corticosteroids: Use with Extreme Caution

Postnatal systemic corticosteroids, particularly high-dose dexamethasone, are associated with adverse neurodevelopmental outcomes including cerebral palsy, developmental delay, and abnormal neurologic examinations, and routine use is discouraged. 2, 1

When Postnatal Steroids May Be Considered

• Postnatal dexamethasone may facilitate weaning from mechanical ventilation and extubation in infants with evolving or established bronchopulmonary dysplasia (BPD), but this must be weighed against significant risks. 2

• High daily doses of dexamethasone have been most frequently linked to adverse neurodevelopmental outcomes and should be avoided. 2

• Low-dose dexamethasone to facilitate extubation warrants further study, as increased adverse outcomes have not been consistently reported with lower doses. 2

Hydrocortisone as an Alternative

• Early hydrocortisone therapy (within first weeks of life) may improve survival without BPD in extremely preterm infants, particularly those exposed to prenatal inflammation, without the adverse neurodevelopmental effects seen with dexamethasone. 2

• Neurodevelopmental outcomes at 18-22 months showed no adverse effects of hydrocortisone treatment in multiple trials. 2

Clinical Algorithm

For prevention of RDS:

1. Identify pregnant women at risk of preterm delivery <37 weeks
2. Administer antenatal betamethasone (2 doses of 12 mg IM, 24 hours apart) unless contraindicated 1
3. Ensure delivery occurs ideally 24 hours to 7 days after first dose for maximum benefit 1
4. Plan for postnatal surfactant therapy as needed, recognizing the additive benefit with antenatal steroids 2

For established RDS/BPD requiring postnatal steroids:

1. Prioritize non-steroid interventions (surfactant, CPAP, optimal ventilation strategies) 2
2. If postnatal steroids necessary for ventilator weaning, consider hydrocortisone over dexamethasone 2
3. If dexamethasone used, employ lowest effective dose and shortest duration 2
4. Counsel families about neurodevelopmental risks 2, 1

Critical Pitfalls to Avoid

• Never withhold antenatal steroids from eligible mothers based on planned surfactant availability—the benefits are additive, not redundant. 2

• Do not routinely use early postnatal dexamethasone (<96 hours) for BPD prevention—this has been associated with increased adverse outcomes including intestinal perforation, hypertension, and poor growth. 2

• Counsel all patients that long-term risks of antenatal corticosteroid exposure remain uncertain, though current evidence supports their use given the substantial short-term benefits. 1