Hi all,

Yesterday, the Tiny Baby Collaborative held a webinar about using hydrocortisone in extremely preterm infants (under 23 weeks of gestational age), which featured Dr. Satoshi Kusuda from the Neonatal Research Network of Japan and Dr. Erik Jensen from Stanford University (the webinar will probably be available in the near future here: https://www.tinybabycollaborative.org/webinars)

I was unable to attend the entire event, but was wondering if anyone here also attended and maybe we can discuss this issue.

My understanding is that in such extremely preterm infants, adrenal insufficiency is very common (which makes sense) and with the added stress of premature delivery and adaptation, circulatory collapse is a common risk. The two experts presented several papers and reviews, but I am afraid I am not clear on the bottom line (beside the fact that we need more studies, as always).

Hydrocortisone was shown to reduce BPD and failure to extubate, as well as in-hospital death, but was shown to increase the risk for hyperglycemia. A comparison with dexamethasone was also shown, where dexamethasone was shown to have a lower risk ratio for failure to extubate (0.61 vs. 0.79 for hydrocortisone). The experts concluded that no robust data inform use of hydrocortisone for respiratory or neurodevelopmental indications in infants born before 23 weeks of gestation.

Interested to hear your thoughts about this, as well as your practices. How do YOU use hydrocortisone (or other corticosteroids) in tiny infants?

Here are some of the papers that were cited in the webinar:

Effect of Prophylaxis for Early Adrenal Insufficiency Using Low-Dose Hydrocortisone in Very Preterm Infants: An Individual Patient Data Meta-Analysis

Early (< 7 days) systemic postnatal corticosteroids for prevention of bronchopulmonary dysplasia in preterm infants

Postnatal Corticosteroids To Prevent Bronchopulmonary Dysplasia

Your answer is present in Premiloc trial.

But how well represented was the <23w population in the Premiloc trial?

(I don’t have access to that paper from here)

56 minutes ago, Stefan Johansson said:

But how well represented was the <23w population in the Premiloc trial?

(I don’t have access to that paper from here)

None! The eligiblity criteria for PREMILOC were gestation of 24+0-27+6 weeks.

My limited experience, from rotation at a Level 4 center in Sweden that uses Premiloc-dosing for all infants <28W, is that the results are generally positive. It seems to help with stabilising BP, and when maternal infection is a factor, there’s often a need for extra hydrocortisone. Side effects like hyperglycemia are usually manageable with fluid adjustments, but in some cases the infant will need supplemental insuline.

The Swedish experience was published not long ago ( https://pubmed.ncbi.nlm.nih.gov/41712209/ ), though it’s hard to reach statistical significance in the micropreemie group given the small numbers, and to correct for differences in ventilation strategies between centers, the overall outcome was positive. While my experience with these patients is very limited, I do trust my seniors who’s says it’s a solid strategy.

The only Swedish center involved in the Tiny Baby collaboration has not adapted this strategy as far as I know. I attended a course in extreme prematurity there a few years ago, and the recommendation then was that supplemental corticosteroids should be avoided.

Having seen very distressing clinical course in these less than 26 wks infants , we are leaning towards a 10d course of Hydrocortisone between 5to10 days of life and use of DART after 3 wks of life. Encouraging clinical course with this approach.

PDA management-bias towards no treatment upto 2 weeks. If a decision is made to treat PDA irrespective of the reasons or causes-Acetaminophen will br the first line 3 to 7day

Would love to hear the webinar when available

On 4/10/2026 at 7:15 PM, Rao said:

Would love to hear the webinar when available

The webinar (#14) is now available for watching in the Tiny Baby Collaborative website.