Use of steroids in the perinatal period.
BACKGROUND
Corticosteroids can be used prenatally to mature the fetal lungs and postnatally to treat or prevent chronic lung disease (CLD). Randomised controlled trials have been performed to evaluate the benefits and risks of perinatal corticosteroid therapy.


METHODS
Systematic reviews of randomised controlled trials of prenatal and postnatal corticosteroids in the Cochrane Library were examined to determine the cost-benefit ratios of treatment. Outcomes are given as numbers needed to treat (NNT) or numbers needed to harm (NNH) with 95% confidence intervals (CI).


RESULTS
Prenatal corticosteroids reduce the risk of RDS (NNT 11; 95% CI 9-16), surfactant use (NNT 9; 95% CI 5-62), intraventricular haemorrhage (NNT 9; 95% CI 6-19) and neonatal mortality (NNT 23; 95% CI 16-42). There are no short-term or long-term adverse effects of a single course of prenatal betamethasone. However, repeated courses of prenatal steroids could be harmful and should be avoided outside of a randomised controlled trial. Postnatal corticosteroids can be used to prevent CLD (early use) or to treat it (late use). Beneficial effects include earlier extubation (typical NNT 5; 95% CI 4-10), reduced CLD (typical NNT 10; 95% CI 8-17) and avoidance of late steroids (NNT 7; 95% CI 6-10). However, there are significant adverse short-term effects such as hyperglycaemia (typical NNH 8; 95% CI 6-10), hypertension (typical NNH 10; 95% CI 8-14). Hy- pertrophic cardiomyopathy (typical NNH 5; 95% CI 4-11), gastrointestinal bleeding (typical NNH 17; 95% CI 11-33) and growth failure (NNH 2; 95% CI 1-2). More important are long-term adverse effects of cerebral palsy (typical NNH 8; 95% CI 6-17), developmental delay (typical NNH 7; 95% CI 4-33) and abnormal neurological examination (typical NNH 4; 95% CI 2-14). These adverse effects are more pronounced with early (<96 h) treatment but probably also occur when steroids are given later in the postnatal period.


CONCLUSIONS
A single course of prenatal betamethasone has clear benefits for the fetus who is likely to be born preterm but repeated courses may be harmful. Postnatal steroids should be avoided if at all possible. They might be indicated in very low doses for ventilator-dependent infants who might otherwise die without them.
Royal Maternity Hospital, and Department of Child Health, Queen's University of Belfast, Belfast, Northern Ireland. h.halliday@qub.ac.uk
Henry L
HL
Halliday
D000305:Adrenal Cortex Hormones / Q000627:therapeutic use*; D002908:Chronic Disease; D003362:Cost-Benefit Analysis; D005315:Fetal Diseases / Q000517:prevention & control*; D006801:Humans; D007231:Infant, Newborn; D008171:Lung Diseases / Q000517:prevention & control*; D011295:Prenatal Care; D016032:Randomized Controlled Trials as Topic
D000305:Adrenal Cortex Hormones