nature publishing group Articles Clinical Investigation Hydrocortisone vs. dexamethasone treatment for bronchopulmonary dysplasia and their effects on general movements in preterm infants Marrit M. Hitzert1, Manon J.N.L. Benders2, Annemiek M. Roescher1, Frank van Bel2, Linda S. de Vries2 and Arend F. Bos1 INTRODUCTION: Hydrocortisone (HC) and dexamethasone neurological outcome as compared to controls (6,7). A two- (DXM) are used to treat preterm infants at risk for bronchopul- center comparative study reported that HC-treated children monary dysplasia (BPD). This may, however, affect their long- had a better cognitive and motor neurodevelopmental outcome term neurological development. We aimed to determine the as compared to DXM-treated children (8). In a recent system- effect of HC and DXM therapy in preterm infants on neurologi- atic review, however, early postnatal HC therapy showed no cal functioning as assessed by the quality of general movements improvement in mortality, the rates of BPD, or in-home oxygen (GMs) until 3 months after term. dependence (9). As yet, no consensus exists regarding the most RESULTS: We found no difference in the quality of GMs between optimal therapy for preterm infants at risk for BPD. HC and DXM infants until term age. At 3 months, HC infants had The qualitative assessment of general movements (GMs) a higher median motor optimality score (MOS) than DXM infants from video recordings is a sensitive, noninvasive method to (25 vs. 21, P = 0.015). In the DXM group, MOS on the first day of investigate the integrity of the young infant’s brain (10,11). This treatment was lower than before treatment (10 vs. 11, P = 0.030). method is based on visual Gestalt perception of GM quality DISCUSSION: MOS decreased in DXM infants on the first day up to 5 months after term. Normal GMs are characterized by following treatment and at 3 months after term. This was not the complexity, variability, and fluency, whereas in abnormal GMs, case in HC infants. Our study suggests that neurological func- these are reduced (12). The quality of the fidgety general move- tioning at 3 months after term is better in infants treated with HC ments (FMs), present between 9 and 20 weeks after term and than in infants treated with DXM. defined as continuous small movements of moderate speed in METHODS: We performed a longitudinal, observational study all directions, is a particularly accurate marker for neurological including 56 preterm infants (n = 17 HC, n = 17 DXM, n = 22 outcome: most infants (96%) with normal FMs have normal controls). GM quality, videoed before and after treatment, neurological outcomes, whereas most infants (95%) in whom was assessed. In addition, a MOS was assigned to details of the FMs are absent during this period develop cerebral palsy (13). GMs. Recent studies reported that detailed aspects of GMs, expressed as a motor optimality score (MOS), also have predictive value mproved neonatal intensive care over recent decades has led for mild motor abnormalities later on (14,15). Ito significantly increased survival of preterm infants. The inci- Previously, DXM treatment was associated with the presence dence of bronchopulmonary dysplasia (BPD), however, is still of abnormal GMs, which correlated with the severity of brain approximately 30% (1). Previous studies investigating the effect lesions and the occurrence of cerebral palsy (16,17). The influ- of postnatal corticosteroid therapy showed that dexamethasone ence of HC therapy on short-term neurological outcome as (DXM) therapy facilitates extubation and reduces the rate of assessed by the quality of GMs is unknown. BPD at 28 days after birth and at 36 weeks postmenstrual age This led to our aim of determining the effects of HC and (2). Furthermore, there is a reduction in the need for late rescue DXM therapy in preterm infants on neurological functioning as with corticosteroids (3). Unfortunately, postnatal DXM therapy assessed by the quality of GMs until 3 months after term. is associated with short-term adverse effects and an increased risk of motor disorders, including cerebral palsy (3,4), particu- RESULTS larly if therapy is started within the first week of life (5). Various Patient Characteristics studies on postnatal hydrocortisone (HC) therapy reported an Table 1 shows the most important patient characteristics. equal reduction in oxygen dependency and fewer short-term The HC group differed from the DXM group in that the for- adverse effects than DXM, and no long-term adverse effects on mer infants had lower birth weights, had higher Apgar scores 1Department of Pediatrics, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; 2Department of Pediatrics, Wilhelmina Children’s Hospital Utrecht, University Medical Centre Utrecht, University of Utrecht, Utrecht, The Netherlands.Correspondence: Marrit M. Hitzert ([email protected]) Received 15 April 2011; accepted 3 August 2011. doi:10.1038/pr.2011.15 100 Pediatric RESEArCH Volume 71 | Number 1 | January 2012 Copyright © 2012 International Pediatric Research Foundation, Inc. General movements after corticosteroids Articles at 5 min, and received lower mean and cumulative equivalent between the HC group and the controls nor between the HC doses of cortisol. Although not significantly different, HC group and the DXM group. At 3 months after term, 18 control infants were treated more often with sedative, anticonvulsant, infants showed normal FMs and in one infant, FMs were absent. or muscle-relaxant drugs during corticosteroid treatment than In the DXM group, the quality of FMs was abnormal in more the DXM group (94% and 67%, respectively). infants as compared to the controls (P = 0.013). Again, we found Brain ultrasound scans of three DXM infants deteriorated no differences in the quality of FMs between the HC group and after initiating DXM treatment. In one infant, the density of the controls, and between the HC and DXM groups. periventricular white matter increased, which was followed by a leukomalacia grade III. Two infants in whom periventricular MOSs in HC- and DXM-Treated Infants echodensities had normalized before DXM therapy developed In the first week after treatment had commenced, the median ventriculomegaly. All three of these infants had abnormal GMs MOS was higher in controls as compared to infants treated before therapy. At 2 years of age, six of the DXM-treated chil- with corticosteroids (Figure 2a). This difference was significant dren had developed cerebral palsy vs. none of the HC-treated between the DXM group and control infants (median 10 vs. 14, infants (P = 0.018). P = 0.010) only on day 1. We found no differences between Data on neurodevelopmental outcome at 2 years are pre- the two treatment groups, except for MOS at 3 months after sented in Table 2. In each group, test results of three infants term (Figure 2b). MOS of controls (median 24) was higher were missing either due to loss of follow-up or an insufficiently as compared to the DXM group (median 21, P = 0.010), and cooperating infant. it was higher for the infants in the HC group (median 25) as compared to the infants in the DXM group (P = 0.015). Quality of GMs In addition, we analyzed the change in MOS from day 0 to The results on the quality of GMs are shown in Figure 1. In the day 1, with each infant serving as his or her own control. Hypo- control group, nine infants showed normal GMs on day 0 and 13 kinetic infants were given 8 points, i.e., the lowest MOS. In the showed abnormal GMs. We found no difference in the quality HC group, two infants were hypokinetic before treatment. One of GMs between the HC and DXM groups and the controls on of these infants showed poor-repertoire GMs on day 1 whereas day 0. On day 7 after therapy had commenced, we found more for the other infant, no recording was available for day 1. None infants in the DXM group in whom the quality of GMs was of the infants in the DXM group was hypokinetic before corti- abnormal as compared to the controls. This finding just reached costeroid administration, whereas two infants became hypoki- statistical significance (P = 0.017). We found differences neither netic on day 1. As shown in Figure 3, we found the median MOS Table 1. Patient characteristics Hydrocortisone (n = 17) Dexamethasone (n = 17) Controls (n = 22) P value Boys/girls 11/6 13/4 12/10 NS Twins or triplets 4/17 8/17 9/22 NS Birth weight (g) 800 (630−1,700) 970 (700−1,800) 930 (595−1,290) 0.047* Gestational age (wk) 27.1 (24.9−31) 27.9 (26−30.3) 27.2 (26−29.6) NS NBRS-revised 6 (3−8) 6 (3−13) 4 (1−12) 0.036§ Apgar score at 5 min 8 (4−10) 5 (1−10) 9 (4−10) 0.009* § Mean equivalent cortisol dose (mg/d) 3.1 ± 0.8 9.8 ± 5.1 — <0.001* Cumulative equivalent cortisol dose (mg/kg) 108 ± 70 170 ± 69 — 0.006* Treatment duration (d) 22 (13−84) 24 (7−69) — NS Postnatal day of start therapy (d) 16 (7−44) 16 (4−25) 17 (9−30) NS Grade III−IV IVH 1/16 1/17 3/22 NS Grade III−IV PVL 0/17 0/17 0/22 NS Sedative or anticonvulsant drugs 16/17 12/18 6/22 <0.001†,§ Sepsis (positive blood culture) 3/17 4/16 9/22 NS Seizures (confirmed by EEG) 1/17 3/17 1/22 NS Corticosteroids mother 15/17 12/17 17/22 NS BPD 16/17 16/17 8/22 <0.001†,§ Cerebral palsy 0/17 6/17 0/22 0.001*,§ Variables represent frequencies (n/total), median (range), or mean (± SD).