Steroids Help Premature Infants to Survive

By Alfredo Arango - Medical Editor
this article appeared in HCA International's magazine

There have been important advances in the field of neonatology, which is the medical subspecialty that is responsible for treating premature infants. Premature infants are defined as those babies born before 37 weeks of pregnancy, while they are from 0 to 28 days old. One of major advances is this fields is the use of steroids even before these babies are born, in other words, while they are still inside the mother's womb.

"Obstetricians are doing an excellent job of prevention, preparing the mother for a premature delivery. In many of these cases, the mother is given two doses of steroids, preferably 24 hours before delivery, one dose every 12 hours. Those steroids, which are given intramuscularly, help to speed up the maturing process of the baby's lungs," says Dr. Bernardo Pimentel, pediatrician sub-specialized in neonatology and director of Neonatal Intensive Care Unit of Mercy Hospital and the Kendall Regional Medical Center Hospital, both which are in Miami.

In general, premature births cannot be predicted very far in advance, but there can certainly be enough time to use the steroids as a resource before the birth occurs. In fact, many of these births have to be performed by means of caesarean section, since the infant goes into crisis inside the mother's womb, before a normal or spontaneous birth can occur.

If a mother is admitted in preterm labor at 24 or 25 weeks into the pregnancy, with a medical condition which produces the premature birth, or which warrants speeding up the delivery, it is likely that the mother will received a type of steroid drug called corticosteroid. Mothers may be given steroids when preterm birth is likely between 24 and 34 weeks of pregnancy. Before that time, or after, the medication usually is not effective.

Research has found that giving the mother a steroid medication at least 48 hours prior to delivery greatly reduces the incidence and severity of respiratory disease in the baby. This drug helps enhance survival by enabling the lungs to mature so the baby can breathe more easily after birth. Steroid works on the pulmonary tissue in order to expand it and avoid the inflammation that could occur. They also help reduce the risk of bleeding in the brain and a serious bowel disease called necrotizing enterocolitis.

The patient does not necessarily have to sign an authorization to receive steroid therapy, as it is now considered an integral part of the standard of care and is the recommendation made by the American College of Obstetrics and Gynecologists and the American Academy of Pediatrics.

The prenatal steroids, Betamethasone and Dexamethasone, which are used in premature births complement an earlier drug used since the late 1980s known as surfactants.

Surfactant is a natural substance made in cells in the airways. It begins to be produced in the fetus at about 24-28 weeks of pregnancy. It is released to help lower surface tension, or to help make the pulmonary tissue soft, and keep the lung alveoli (air sacs) open. The surfactant helps gas exchange and oxygenation, reducing the effort of inhalation. In premature infants born with surfactant deficiency, their lungs become stiff; no matter how hard they try, they cannot expand their lungs to breathe and the alveoli collapse.

Artificial surfactant is administered in liquid form directly to the lung, through an endotracheal tube. When the infant is extremely premature, there is a possibility he/she will be intubated in the very delivery room or the operating room and is immediately given the surfactant; this is known as prophylactic (preventive). For others it is used as a "rescue" method later in the NICU if the baby is in distress. The dose of surfactant depends on the infant's weight.

Both antenatal steroids and surfactant carry little risk for the infant and are often recommended as standard treatment of preterm babies. The idea is to get the babies to react and breathe on their own, without having to resort to an artificial ventilator. The ventilator is avoided unless it is absolutely necessary, since it can have after-effects; it is an extreme recourse.

"The combination of proper prenatal care, plus the steroids and the surfactant, have provided a great increase in the survival rate of these infants," Dr. Pimentel expresses.

"These and other advances in incubators, ventilators, and monitoring systems for the premature baby have yielded great progress. In the past, babies who were born before 28 weeks of gestation had a very high mortality rate. We are now seeing babies that are born at 24 weeks gestation and are surviving without a problem," the specialist added.

According to the specialized medical journal, Journal of Perinatology, "in the US, improved perinatal care has been hailed as one of the 10 medical achievements of the 20th century (CDC). During this period in the US, infant mortality rate (IMR) dropped by 90%. In early 1900s, approximately 100 infants per 1000 live births died before reaching 1 year of life. By 1999, IMR dropped to 7/1000 live births."

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