It's a tough decision, one that comes up periodically in the NICU. Very premature babies often develop bronchopulmonary dysplasia (BPD), a progressive disease of the lungs that interferes with their ability to take in oxygen and get rid of carbon dioxide. In many children it peaks in severity at a few weeks of age and then gradually improves. It's a bad disease; many premature babies are on a ventilator for several weeks with it, and some die from it.
In the late 1980's and early 1990's studies showed improvement in BPD in babies treated with dexamethasone, a type of steroid. (Don't confuse this with the kind of steroids baseball players use. Rather than bulking you up, dexamethasone makes it harder for a baby to grow.) NICU's all over the country started using steroids liberally to treat BPD. Unfortunately, by the late 1990's, follow up studies had shown that babies treated with steroids had a higher risk of developing cerebral palsy than those not treated with them, and steroid use for BPD plummeted. In 2002 the Fetus and Newborn Committee of the American Academy of Pediatrics recommended that steroids be used for BPD only in "exceptional circumstances", although the committee did not define those circumstances. In our NICU, we use steroids for BPD very sparingly, reserving them for babies we think will likely die of BPD if not treated with steroids. Before giving steroids, we discuss them at length with the parents, telling them the risks and benefits, and asking their permission before using them.
Tonight when I came to work my partner was discussing steroid use with a 19 year old mother of a baby with severe BPD. After my partner signed out to me, I sat down with her and again explained it, trying to make sure mother understood. It's a pretty big decision for a 19 year old, and I feel a little sorry for her. Shortly after my arrival tonight I had seen her on my way to the cafeteria, flirting with a security guard, a pretty normal activity for a woman her age (although it seemed a little paradoxical, since she had just given birth three weeks ago.) A few minutes later we were talking about her baby's chances of death and cerebral palsy.
I'll have to live with the results of the steroid decision until the baby goes home; she'll have to live with it all her life.
P.S. A very creative new Grand Rounds is up at Urostream.