Use of hydrocortisone in extremely preterm infants: emphasis on those born least mature

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Abstract
The steroid hormone cortisol plays crucial roles in innate stress response, downregulation of inflammation, and promotion of glucose homeostasis. Infants born extremely preterm may be prone to cardiovascular compromise and inflammation-mediated respiratory disease due in part to insufficient cortisol production. Current data show that hydrocortisone, the exogenous medication form of cortisol, may help prevent or treat complications associated with relative adrenal insufficiency, although the full balance of treatment risks and benefits is uncertain. Prophylactic administration of hydrocortisone beginning in the first 1–2 postnatal days in extremely preterm infants likely results in earlier initial weaning from invasive ventilation and may reduce in-hospital mortality and the composite outcome of death or bronchopulmonary dysplasia (BPD). However, such use may increase the risk of sepsis in infants born less than 26 weeks’ gestation and gastrointestinal perforation with concurrent exposure to indomethacin. Whether prophylactic hydrocortisone affects childhood neurodevelopment has not been adequately studied. Initiation of hydrocortisone after the first postnatal week in infants receiving invasive ventilation promotes successful extubation but does not affect risks of mortality, BPD, or neurodevelopmental impairment. In extremely preterm infants with hypotension, hydrocortisone can increase blood pressure, but short- and long-term safety for this indication and usefulness compared to other anti-hypotensive agents are not well established.

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