Is a New Era Coming for Bronchopulmonary Dysplasia Prevention With Corticosteroids?-Reply

To the Editor We read with interest the recent network meta-analysis by Ramaswamy et al1 comparing different corticosteroid regimens for preventing bronchopulmonary dysplasia (BPD) and the accompanying editorial by Parikh.2 The main result lies in the authors’ suggestion that moderately early (8 to 14 days) medium cumulative doses (2 to 4 mg/kg) of dexamethasone may be the most appropriate regimen for preventing BPD and mortality.1 Randomized clinical trials with dexamethasone administered in the first postnatal week were excluded from analysis. As the authors said, although the evidence is still of low quality, their findings are very useful to neonatologists in clinical practice. Our attention was drawn to a core question of how to treat preterm newborns at risk of BPD. All but one of the studies including dexamethasone in their analysis concerned infants treated with mechanical ventilation. The target population of the meta-analysis was infants who were very ill from birth with early persistent pulmonary deterioration. However, most preterm infants (even those with extremely low birth weight) are currently treated with noninvasive ventilation strategies from birth or after early extubation,3 and this has become a cornerstone of BPD prevention. A sizable proportion (51%) of neonates with mild respiratory disease at birth who are treated with noninvasive respiratory support are nonetheless still at risk of needing progressively increased oxygen supply and at risk of developing BPD.4 Should preterm neonates who are treated with noninvasive ventilation and who are at risk of BPD be considered eligible for a postnatal corticosteroid regimen like the one proposed by the authors of this network meta-analysis?1