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Title: Steroid Treatment for Relative Adrenal Insufficiency Offers No Benefit in Preemies
URL: http://www.pslgroup.com/dg/22E78E.htm
Doctor's Guide
October 9, 2008

BALTIMORE, Md -- October 9, 2008 -- Treating relative adrenal insufficiency with hydrocortisone in premature babies to fight inflammation and prevent lung disease is not as effective as previously thought, according to a study published in the October issue of Pediatrics.

The study also suggests that although low cortisol levels are not necessarily harmful, high cortisol levels appear to increase the risk of dangerous bleeding in the brain and require that babies be monitored aggressively to ward off life-threatening complications.

The findings shed new light on the clinical meaning of low cortisol levels in preemies, showing that contrary to common belief, low blood concentrations of this hormone do not put extremely low-birth-weight babies (<1 kg) at higher risk for retinopathy of prematurity, inflammation, or lung disease.

Researchers also found no difference in health outcomes between babies with low cortisol levels who were treated with hydrocortisone and those given a placebo. While hydrocortisone had no adverse effects on a baby's health, it also did nothing to prevent or reduce respiratory diseases, infections, haemorrhages, or retinopathy.

"We were intrigued and somewhat surprised, but contrary to what we expected, low cortisol levels do not appear to be dangerous and may actually be the norm in premature babies," said study lead investigator Susan Aucott, MD, Johns Hopkins Children's Hospital, Baltimore, Maryland.

"What this means is we should really think twice before rushing to treatment with hydrocortisone in our effort to 'correct' these low levels."

For the study, researchers compared the cortisol levels of 311 extremely low-birth-weight preemies immediately after birth and 1 week after birth. They found that low cortisol levels did not increase the risk for adverse short-term outcomes or death.

Bronchopulmonary dysplasia occurred in 58% of infants with low cortisol levels, in 58% with midrange cortisol levels, and in 62% with moderately elevated cortisol levels. Brain haemorrhages occurred in 24% of infants with low cortisol levels, in 36% with midrange cortisol levels, and in 49% with mildly elevated cortisol levels.

Babies with moderately to severely elevated cortisol levels at birth and shortly after birth had a higher risk for life-threatening brain bleeds, dangerous gastrointestinal perforations, and severe retinopathy.

Researchers have yet to pinpoint the exact mechanism leading to these dangerous spikes in cortisol, but regardless of the trigger, the authors said neonatologists should aggressively monitor infants with elevated cortisol levels because of their vulnerability to haemorrhages and other life-threatening complications.

Elevated cortisol concentrations, especially values >31 mcg/dL at 12 to 48 hours after birth and >18 mcg/dL at 5 to 7 days after birth, appeared to make babies more prone to serious bleeding in the brain, although researchers caution a cause-effect relationship could not be established from this study because elevated cortisol concentration could be a consequence of the haemorrhage but not necessarily a trigger of it.

Very high cortisol levels, >62 mcg/dL, appeared to heighten a baby's risk for severe brain haemorrhages, gastrointestinal perforation, and death. Death occurred in 12% of infants who had low cortisol levels 48 hours after birth and in 13% with midrange levels of cortisol, but in nearly 30% of infants with severely elevated cortisol levels at 48 hours of birth. Gastrointestinal bleeds occurred in 3% of infants with low cortisol levels at 48 hours of birth, in 9% with cortisol levels in the mid-range, but in 24% with significantly elevated cortisol levels.


SOURCE: Johns Hopkins Medical Institutions

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