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How to navigate in the landscape of steroids for preterm infants?

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Given recent results from placebo-controlled trials on inhaled budenoside and systemic hydrocortisone, how do you practically approach the questions on steroid use in your NICU?

As you are probably well aware, the NEUROSIS trial (inhaled budenoside) showed some reduction in BPD among survivors, but the 2y followup showed a increased nb of deaths in the budenoside group and no benefit with regards to neurodevelopment (NEJM 2015 and NEJM 2018).

The PREMILOC trial found that systemic low-dose hydrocortisone reduced the BPD risk, without a clear benefit on neurodevelopmental outcomes (Lancet 2016 and JAMA 2017). Further, a meta-analysis came out just the other week (J Ped 2018) that also concluded that survival without BPD was increased with this strategy.

With regards to clinical practise in Sweden, the latest report from our national quality register (info from 2017) presents that systemic steroids are used i ~50% of infants <25 weeks, and in ~30% of infants 25-27 weeks. The corresponding figures for inhaled steroids are ~35% and ~25%.  Yet the "national" BPD rate (oxygen need at 36w) is reported as high as ~75% in infants <25 weeks, and ~45% in infants born between 25-27 weeks. (full report here, but in Swedish)

So, what do you in practise? Do you use either, neither or both inhaled/systemic steroids to reduce BPD?
I personally feel a confused how to navigate in this landscape 🤔

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Current local practice is neither.  I think the evidence from PREMILOC is compelling and would prefer to either make it our routine or at least have a conversation with parents about this very early on, but I do not think I will be able to convince my group to do this as I am not part of our 'BPD team' and local culture is to view BPD as an acceptable outcome as long as the patient is discharged off O2 or with a low flow cannula only (and our current practices are very effective at this).

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