In a preterm infant <32 weeks gestation with established bronchopulmonary dysplasia after mechanical ventilation and supplemental oxygen, when is steroid therapy indicated and what low‑dose systemic dexamethasone regimen is recommended?

Steroid Use in Bronchopulmonary Dysplasia

When to Initiate Systemic Steroids

Systemic dexamethasone should be reserved for preterm infants <32 weeks gestation with established BPD who remain ventilator-dependent after 7-14 days of life and are on maximal ventilatory and oxygen support. 1

Timing Framework

• Do NOT initiate steroids in the first week of life (≤7 days) – early dexamethasone is associated with severe neurodevelopmental harm including cerebral palsy, neuromotor dysfunction, and impaired brain growth 2, 1

• Optimal window is 7-14 days postnatal age for infants with severe, persistent respiratory failure who cannot be weaned from mechanical ventilation 1

• After 3 weeks of age, low-dose dexamethasone may facilitate extubation in ventilator-dependent infants with established BPD 1, 3

• The 7-14 day window allows identification of infants with persistent severe respiratory failure most likely to benefit while minimizing neurodevelopmental risks 1

Recommended Low-Dose Dexamethasone Regimen

The recommended regimen is dexamethasone 0.15-0.2 mg/kg/day tapered over 7-14 days, with cumulative doses not exceeding what is necessary for extubation. 1

Dosing Details

• Start at 0.15-0.2 mg/kg/day divided into doses 1

• Taper over 7-14 days to the minimum effective duration 1

• Never exceed 0.5 mg/kg/day – high-dose regimens (≥0.5 mg/kg/day, equivalent to 15-20 mg/kg/day hydrocortisone) cause hippocampal neuronal degeneration, decreased hippocampal volume, and poor neurodevelopmental outcomes 1, 4

• Use the lowest cumulative dose necessary to achieve extubation 1

Why Low-Dose is Critical

Low-dose dexamethasone (<0.2 mg/kg/day) achieves successful extubation without the severe adverse effects seen with historical high-dose protocols 1, 4. High-dose dexamethasone does not confer additional therapeutic benefit over lower doses and is explicitly not recommended 2.

Alternative: Hydrocortisone

Hydrocortisone demonstrates a more favorable neurodevelopmental safety profile than dexamethasone and should be considered as an alternative, particularly in younger infants. 1

Hydrocortisone Regimen

• Dose: 0.5 mg/kg every 12 hours for 9-10 days, then taper to 0.25 mg/kg every 12 hours for 3 days 1

• Hydrocortisone shows no adverse effects on functional or structural neurologic outcomes in multicenter trials 1

• Never exceed 25 mg/kg/day cumulative dose 1

Critical Hydrocortisone Precautions

• Absolutely avoid concomitant use with indomethacin or ibuprofen – this combination markedly increases the risk of spontaneous gastrointestinal perforation, especially when given in the first 48 hours of life 1

• Do not give early hydrocortisone (<48 hours) due to perforation risk 1

Mandatory Informed Consent

Before initiating any systemic steroid, obtain detailed informed consent from parents that clearly outlines both the risks of untreated BPD and the potential neurodevelopmental risks of corticosteroid therapy. 2, 1

This discussion must balance:

• The high risk of death or severe BPD without treatment
• The documented neurodevelopmental risks of steroids (cerebral palsy, cognitive impairment, growth restriction)
• The individual infant's clinical trajectory and severity of respiratory failure 2

What Does NOT Work or Is Not Recommended

• Routine prophylactic steroids – not indicated 2

• Steroids for extubated infants on nasal ventilation or oxygen alone – not indicated 5

• Inhaled corticosteroids – despite reducing BPD rates, they were associated with higher mortality and cannot be recommended 6, 7

• High-dose dexamethasone (≥0.5 mg/kg/day) – causes harm without additional benefit 2, 1, 4

Clinical Decision Algorithm

1. Assess timing: Is the infant >7 days old? If <7 days, defer steroids 1

2. Assess severity: Is the infant on maximal ventilatory support with severe, persistent respiratory failure? If not ventilator-dependent, steroids are not indicated 2, 1

3. Assess trajectory: Has the infant failed to wean over 7-14 days despite optimal management? 1

4. Choose agent: Consider hydrocortisone first for better neurodevelopmental safety, especially in younger infants; use low-dose dexamethasone if hydrocortisone unavailable or after 3 weeks 1

5. Obtain consent: Document detailed discussion of risks and benefits with parents 2, 1

6. Monitor closely: Watch for hyperglycemia, hypertension, gastrointestinal bleeding, infection, and growth suppression 5

7. Use shortest duration: Taper as soon as extubation is achieved 1, 8

Common Pitfalls to Avoid

• Starting too early (<7 days) causes irreversible neurodevelopmental harm 2, 1

• Using high doses (≥0.5 mg/kg/day) provides no additional benefit and increases toxicity 2, 1, 4

• Combining hydrocortisone with indomethacin causes intestinal perforation 1

• Prolonging treatment beyond what is necessary for extubation increases adverse effects without benefit 1, 8

• Using steroids in non-ventilated infants – no indication 5