LAUSR

The use of postnatal steroids in preterm infants at risk of bronchopulmonary dysplasia (BPD) or with BPD is frequent, despite concerns about their adverse effects and despite strong statements from the AAP discouraging their use. Vermont Oxford Network data shows increasing trend in PNS use from 8.6% in 2009 to 13% in 2020 among infants 22–29 week gestation. However, there are no published reports of practice patterns of PNS use from recent years. Specifically there are no reports about the clinical scenarios in which PNS are used, the strategy (prophylactic vs. therapeutic), the exact medications, and treatment regimens of PNS being chosen in modern practice. Therefore we conducted a web-based survey of neonatologists (members of the Section of Neonatal-Perinatal medicine in the US) in June 2020 to determine clinicians’ preference and current practice of PNS use to prevent or treat BPD in extremely preterm infants. The survey consisted of a vignette of an infant born at 25 weeks gestation requiring prolonged mechanical ventilation, with 13 questions regarding PNS use in such infants based on the age of initiation and type of steroid used. We defined PNS use based on the time of initiation [prophylactic: 1st week, treatment of evolving BPD (early: 7–14 days, moderately early: 15–21 days, moderately delayed: 22–28 days, delayed: >28 days) and treatment of established BPD at 36 weeks] and the type of steroid used [dexamethasone, hydrocortisone, prednisolone, and inhaled budesonide]. To analyze Likert scale responses, we combined the two highest and lowest responses into one category. Four hundred twenty-five neonatologists responded to the e-mail survey. Most neonatologists were working in level 3or 4 NICUs and 2/3 rd were practicing in academic centers. Only 13% of respondents used PNS prophylactically for the prevention of BPD. The percentage of respondents likely to use PNS for evolving BPD in a ventilator-dependent infant increased from 29% at 7–14 days to 85% after 28 days postnatal age [Fig. 1]. Interestingly, a significant proportion of respondents were likely to use PNS for established BPD at 36 weeks PMA [ventilator-dependent infants: 97%, on NIPPV: 71%; on CPAP: 52%; and on HFNC: 28%]. Dexamethasone was the most preferred type of PNS for inpatient management and inhaled budesonide for outpatient management. Admittedly, our low survey response (425 of ~3600 e-mail recipients) makes our results less likely to be generalizable and possibly contaminated by respondent bias. Nevertheless, ours is the only survey since the 2010 AAP statement that demonstrates the current pattern of PNS use in preterm infants in the USA. Compared to the findings of similar survey of PNS use performed before 2010, our survey reveals an increased acceptance of PNS for infants on moderate ventilator support for evolving BPD (64 vs. 13%) and for intubated infants with established BPD (97 vs. 69%) [1]. In a cohort study of 951 infants, Harmon et al. showed that PNS given in weeks 3-4 is associated with the lowest risk of severe BPD in infants at high risk of BPD [2]. Thus, our data suggest that the current practice of PNS use is consistent with current evidence and in alignment with AAP recommendations [3]. Other notable findings of our survey are: (1) the low adoption of prophylactic PNS for BPD prevention, (2) dexamethasone as the most preferred PNS in management of BPD, and (3) increasing acceptability of PNS for established BPD in non-intubated infants on moderate respiratory support. Compared to the 41% respondents using PNS in non-intubated infants with established BPD in a previous survey by Niwas et al., we observed a higher proportion of respondents (28–71% respondents, depending upon the level of non-invasive respiratory support) using PNS in non-intubated infants at 36 PMA [1]. In non-intubated infants with evolving or established BPD, PNS is likely used to prevent re-intubation or to wean off respiratory support to avoid tracheostomy, but efficacy and safety of this practice is not well studied. Costello et al. showed a statistically significant increase in the risk of NDI /death with PNS exposure after 33week PMA in a cohort of EPT infants, which raises concerns regarding the practice of delayed PNS use, especially in nonintubated infants [4]. We conclude that clinicians continue to use PNS, with a preference for dexamethasone, to treat evolving and established BPD, but not prophylactically to prevent BPD. The use of PNS after the second week for prevention and treatment of evolving BPD, consistent with current evidence and recommendation, has increased. However, a considerable percentage of neonatologists using PNS among non-intubated infants on moderate respiratory support at 36 weeks PMA, which is a non-evidence-based practice with potential for harm, warrants further research.