Disseminated candidiasis after steroid treatment for early neonatal hypotension
Editor—We are concerned that intravenous steroids are increasingly being used for the treatment of early neonatal hypotension without proper evaluation. We recently treated three newborn premature infants who had received a six day reducing course of intravenous hydrocortisone (starting at 12.5 mg/kg/day in divided doses) from day 1 of age for the treatment of hypotension. They were otherwise stable, apart from one infant who had a patent ductus arteriosus. All developed severe systemic candidiasis and necrotising enterocolitis by 14 days of age, with only one infant surviving.
Reported adverse effects of steroid treatment for neonatal hypotension include fungal infection,1 hyperglycaemia, septal and ventricular hypertrophy,2 and hypertension.3There are also well described short term complications of early steroid use for chronic lung disease including gastrointestinal haemorrhage and intestinal perforation.4 Long term adverse effects in these neonates include an increased risk of cerebral palsy and developmental delay.5 Any benefit of treating neonatal hypotension with intravenous steroids would have to be substantial in order to outweigh these risks.
It is not clear that steroids confer any advantage over appropriate inotropic treatment of neonatal hypotension. A number of small studies have reported increases in blood pressure when steroids are used. The largest study of 40 infants randomised to receive inotropes or hydrocortisone3 showed 81% success when hypotension was treated with hydrocortisone compared with 100% success with dopamine treatment (at rates of 5–20 μg/kg/min). Inotropes allow more accurate titration of drug dose to response and are known to be effective in maintaining blood pressure. If dopamine is insufficient, adrenaline (epinephrine) or noradrenaline (norepinephrine) should be added for further inotropic support.
Further studies are needed to understand the role of steroids in the newborn premature infant before their use for the treatment of hypotension becomes universal, and at present any advantages of steroid treatment over escalation of inotropic support are outweighed by adverse effects. This is of particular importance in the light of the increasing evidence5 that the benefits of steroid treatment of chronic lung disease in newborn premature infants may not outweigh the adverse effects. Consideration must be given to limiting the use of steroids for neonatal hypotension to situations where other proven methods of cardiovascular support have failed.
