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173

REV. HOSP. CLÍN. FAC. MED. S. PAULO 54(6):173-174, 1999 NOVEMBER-DECEMBER

EDITORIAL

NEONATAL CHRONIC LUNG DISEASE

Mário Cícero Falcão*

RHCFAP-2987 FALCÃO, MC - Neonatal chronic lung disease. Rev. Hosp. Clín. Fac. Med. S. Paulo 54 (6): 173-174, 1999.

Advances in neonatal intensive care have decreased the incidence and mor-bidity of chronic lung disease. How-ever, chronic lung disease remains an important issue for clinical and public health because this illness is associated with chronic respiratory difficulties, prolonged and recurrent hospitaliza-tion, and increased incidence of neuro-logical disabilities, growth restriction, and death.

Chronic lung disease following lung injury is one of the most frustrat-ing illnesses in modern neonatal medi-cine. Despite surfactant replacement therapy and other improvements in neonatal care, there has not been a dra-matic decrease in its incidence.

The issues surrounding therapy of neonatal chronic lung disease are com-plex. Many different therapeutic mo-dalities have been investigated, and a systematic review of controlled trials in the scientific literature is needed in or-der to determine which therapies have adequate proof of efficacy.

There are numerous studies on the use of parenteral or/and inhaled corti-costeroids in the treatment of chronic lung disease. Longer and shorter cor-ticosteroid regimens have been evalu-ated. Dexamethasone usage has be-come widespread due to its immediate short-term efficacy, but data concern-ing long-term pulmonary effects should be obtained.

Non-pulmonary effects of dexam-ethasone therapy may be significant and can be divided into two categories. The first are usually transient adverse effects that are not difficult to manage clinically. These include hyperglyce-mia, hypertension, elevation of the neutrophil count, and protein catabo-lism with associated poor weight gain. The second group of adverse effects includes those which are less common, but warrant concern because of their potential to adversely effect the ultimate outcome of the infant, such as intesti-nal perforation and gastrointestiintesti-nal hem-orrhage, increased risk of severe

retin-opathy of prematurity, an elevated risk of infection, and the suppression of the hypothalamic-pituitary-adrenal axis. Observations of children treated with systemic glucocorticoids that suggest that the risk of growth suppression is decreased when the frequency of ad-ministration is reduced also point to ef-fects on the hypothalamic-pituitary-ad-renal axis. Furthermore, supporting evi-dence comes from studies in adults, which have assessed secretory profiles of cortisol during treatment with exog-enous glucocorticoids.

The risk of suppression of the hypo-thalamic-pituitary-adrenal axis depends on the timing and frequency of dosing, suggesting that systemic adverse effects of exogenous corticoids may reflect an interaction with hormonal circadian rhythms. Regarding growth-suppressive effects, the underlying pathophysiologic mechanisms are probably multifactorial, with the involvement of a combination of altered central endocrine and periph-eral end-organ responsiveness to many

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REV. HOSP. CLÍN. FAC. MED. S. PAULO 54(6):173-174, 1999 NOVEMBER-DECEMBER

physiologic regulators of the growth process.

The timing, dose, route of adminis-tration, and duration of therapy required to achieve maximal response with mini-mal adverse effects in infants with

chronic lung disease remain uncertain. The two most important ways to prevent chronic lung disease, which have been known for decades, are to delay the premature labor and to use prenatal corticosteroid therapy.

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