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Weaning of postnatal steroids


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I would welcome comments/suggestions from my neonatology colleagues on a specific issue of weaning of postnatal steroids in chronic lung disease. We use low dose dexamethasone, 120mcg/kg/day to help babies come off the ventilator if they seem to be stuck.

In rare situations if babies respond only partially, we increase the dose to dexamethasone and try to extubate the baby e.g we will go to 250mcg/kg/day. Following the extubation, on to cpap or biphasic, if after few days baby seems to be going backwards, we sometime increase the dose of dexamethasone to prevent baby going back on the ventilator. So e.g if baby who is on 50mcg/kg/day on CPAP and FiO2 goes up significantly with no obvious reasons, we will increase to 100mcg/kg/day and then start weaning after few days when FiO2 come down. This obviously leads to baby being on steroids for weeks but wonder what else we can do! In many occasions this strategy did work and babies stayed on CPAP and then gradually weaned to be able to go home in oxygen.

I wonder if my colleagues have some other thoughts.

Thanks

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It is not clear exactly how widely dexamethasone is used. Over the past few years, three major pediatric associations in the United States, Canada and Europe — including the American Academy of Pediatrics — have recommended against using the steroid in premature babies, because of side effects that include holes in the stomach or intestine

Steroids have been proven to help these babies who are developing chronic lung disease — but tests are needed to find the lowest possible doses, and to see how these children do in the long term

there is relation between dexamethasone and low IQ,,and further lung infection

 

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Our unit uses the DART regimen (with dexamethasone sodium phosphate) when starting postnatal steroids to facilitate extubation or they are sometimes started in cases where the baby is in extremis and receiving maximal other supportive care with respect to respiratory and cardiovascular support.

This is the dosing regimen we use:

75 micrograms/kg/dose 12 hourly for 3 days*
50 micrograms/kg/dose 12 hourly for 3 days*
25 micrograms/kg/dose 12 hourly for 2 days*
10 micrograms/kg/dose 12 hourly for 2 days*
*Dose based on working weight of patient on Day 1 of regimen. Total of 10 days of steroids. Can be given IV or PO.

We do not increases or decrease the dose outside of these regimens irrespective of any change in clinical practice. We aim to extubate babies between D3 and D5 of the steroid course in order that there is still a "tail-off" period of weaning steroid cover while they are on non-invasive respiratory support. We do counsel parents prior to starting steroids about both the short-term and perceived long-term side effects of the steroid use. We very rarely do back-to-back steroid courses. If we are unable to extubate the baby on the 1st course of steroids we will generally ensure optimisation of nutrition and ensure adequate growth, treat anaemia and any associated VAP before trying another course of steroids several weeks later if they are still unable to be extubated with the above.

I hope that helps.

Kind regards

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