Re: The dangers of prenatal steroids
From: art fougner, md (evsono@pipeline.com)
Tue Dec 25 07:21:29 2007
Merry Christmas.
Cochrane Review on Antenatal Steroids is available online here:
http://www.cochrane.org/reviews/CD004454.pdf
Art
At Tue, 25 Dec 2007, GIN11153@aol.com wrote:
>
>_http://www.narof.org/docs/steroids.htm_
>(http://www.narof.org/docs/steroids.htm)
>
>Preemies on Steroids: A New Iatrogenic Disaster? by Helen Harrison
>
>Published in Birth March 2001, Vol.28, No. 1, pp.57-59.At the Hot Topics in
>Neonatology conference last December, Dr. Barbara Schmidt referred to the
>year 2000 as "Annus Terribilis" for her profession.1 Large studies from the
>NICHD2 in the US and the EPICure group3 in the UK had revealed unexpectedly
>grim outcome statistics for extremely low birthweight and short gestation
>babies -- a 50% rate of disability serious enough to be diagnosed by two to three
>years of age . Because follow up at such early ages reveals only a fraction
>of the impairments diagnosed by mid to late childhood,4 the eventual toll
>in disability promises to be considerably higher.3 Premature birth, it was
>also reported, permanently disorganizes and reduces the size of the brain,
>adversely affecting cognition and behavior.5, 6 The more premature the infant,
>the smaller and more abnormal the brain.5 Adult cardiovascular disease,
>underdeveloped kidneys and diabetes were further linked to low birth weight. 7
>It had become increasingly apparent that improved survival among extremely
>preterm infants was producing greater numbers of children with permanent
>health impairments and handicaps.8 Further, some of this disability was linked
>to iatrogenic causes,2 a result of the continued haphazard use of poorly
>evaluated therapies in perinatal and neonatal care. 9, 10
>Improved survival among extremely premature infants has been credited in
>part to the use of steroid drugs 11, 12 currently administered to nearly half
>of mothers before extremely preterm delivery and to half of all extremely
>preterm infants after birth.13 In perhaps the most disturbing revelation of the
>year 2000, steroids were implicated as "neurotoxic" substances 2 that
>further reduce the size of the premature brain14 and increase rates of cerebral
>palsy,15, 16, 1 7 cognitive deficits, 2, 15 and severe retinopathy.18, 19
>Two large randomized controlled trials of postnatal steroids were halted
>prematurely because of serious short term complications such as intestinal
>perforations, growth retardation, periventricular leukomalalcia, hyperglycemia,
>hypertension, and infection. 20, 21 In addition, animal and human studies of
>steroids in the perinatal and neonatal period have suggested that steroids
>contribute to long-term cardiovascular disease, 22, 23 immune system disorders
>and autoimmune diseases such as multiple sclerosis, 24 renal calcification, 25
>abnormal lung development,26 and neurological and behavioral deficits.27, 28
>
>Prenatal steroids -- used in single two-injection doses -- have been
>accepted as safe and effective in reducing neonatal mortality and morbidity,
>however, many obstetricians treat high risk pregnant women with multiple courses
>of steroids29 on the theory that if a little bit is good, more is better. New
>research now implicates multiple doses of prenatal steroids with impaired
>head growth,30 impaired brain development and behavior problems; 31, 32
>increased mortality and lung disease; 26 gastroesophageal reflux;33 and severe
>retinopathy.34 A consensus statement from NIH, issued in August 2000, now
>discourages their use.29
>Postnatal steroids became widespread in neonatal care by the 1990s having
>been introduced into the nursery without properly conducted clinical trials
>for safety and efficacy 10 and despite warnings from researchers (beginning
>in the 1970s) of serious potential dangers.35, 36 ,37 Steroids were accepted
>enthusiastically because they produced dramatic short term improvements in the
>respiratory status of premature infants (long term benefits were less
>apparent).38 Dr. William Silverman, who has written extensively on previous
>iatrogenic mishaps in neonatology, 39,40 estimates that tens of thousands of
>infants have now been treated with these drugs, in what he suspects will be "one
>of the worst iatrogenic disasters in modern history, exceeded only by the
>DES fiasco." 41 Neonatologist Alan Jobe recently criticized his profession's
>embrace of poorly tested and potentially dangerous steroid treatment by quoting
> Tom Lehrer's bitter lyrics on the misuse of scientific technology: "Once the
> rockets are up, who cares where they come down? That's not my department
>says Wernher von Braun."38 Dr. Jobe further writes: "Adverse
>neurodevelopmental outcomes [from the use of steroids] no doubt result from the effects of
>these potent agents on the developing nervous system and should come as no
>surprise."38 Except, of course , to parents and the public.
>As the rockets began landing last year, the explosions occurred out of
>public and parental sight. Disturbing studies and commentaries on steroids were
>presented (quietly) in neonatal journals and conferences. However the
>media, for the most part, seems to have missed this iatrogenic
>disaster-in-the-making. Perhaps there have simply been no press releases from the medical
>journals and researchers. As neonatologist Mildred Stahlman once remarked, "We
>have allowed the media to publicize our successes widely, and have minimized
>our failures to the public"42
>I participate in several Internet listservs for parents of premature
>infants. The parents with whom I correspond uniformly report that they were never
>informed of the known and suspected risks of multiple prenatal or postnatal
>steroids. A few parents say they were told the drugs might "slow growth," but
>complications involving the brain, eyes and other organs and systems were
>never mentioned. When I give parents the studies and commentaries referenced
>in this article they become angry that they were never given this information,
>though much of it has been available to neonatologists for decades. They
>are devastated to discover that many of the illnesses and disabilities their
>children now suffer may have resulted from, or have been complicated by, the
>use of steroids. In addition, high risk pregnant women report they continue to
>be treated with multiple doses of antenatal steroids without being informed
>of the risks.
>The steroid issue is being discussed by physicians on the Internet, as
>well. A recent poll 43 of 259 neonatologists conducted by Dr. Richard Scott
>Taylor revealed that steroids are still commonly used and that neonatologists'
>practices vary widely concerning when and how they use these drugs. Less than
>10% of the respondents reported involving parents in formal informed consent
>procedures for the use of steroids. Dr. Taylor comments: "It.does not make
>sense to me that as physicians, we get informed consent for standard
>procedures with clear risk benefit balance such as immunizations and blood
>transfusions yet are not necessarily expected to get consent for PNCS [post-natal
>corticosteroids] where there is no standard for use, and significant potential for
>harm..But perhaps we should. "
>I strongly agree! Given the current widespread use of poorly evaluated
>therapies in neonatal care and the dismal outcomes (with and without steroids) I
>must also agree with neonatologist Jeffrey Maisels that care for very low
>birthweight infants is currently "a vast and uncontrolled experiment
>undertaken without informed consent and with possibly undesirable results."44
>The time has come for parents -- who, with their children, must suffer the
>outcomes -- and for the public -- who ultimately pay for this care and its
>consequences -- to be honestly informed about the "experimental" nature of
>neonatal treatment for very preterm infants and its unfortunate results. It
>is also time for parents and the public to demand that steroids and, in fact,
>all poorly evaluated neonatal treatments be used only in the context of
>formal clinical trials. Furthermore, the time has come, in the wake of this
>"annus terribilis" to assert the right of parents to give, or to withhold, their
>fully informed consent to the experimental, arduous, and dangerous treatment
>of their extremely premature infants.9
>
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>3. Wood NS, Marlow N, Costeloe K, et al. Neurologic and developmental
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>(http://www.cheo.on.ca/rtaylor/PNSteroid-r.htm)
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>Gail
--
art fougner, md
"May The Wings of Liberty Never Lose a Feather." - Jack Burton
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