Optimal postnatal corticosteroid regimens to prevent bronchopulmonary dysplasia with minimal adverse effects.

Postnatal corticosteroids can facilitate ventilator weaning and reduce the risk of bronchopulmonary dysplasia (BPD); therefore, they are commonly used to prevent or treat BPD in preterm infants, particularly those born extremely preterm. Despite their frequent use in high-risk infants with severe BPD, no clear guidelines have been established for the optimal timing of administration, dosage, corticosteroid type, route of delivery, and indication based on the infant's baseline risk of BPD. Early systemic corticosteroid administration, particularly dexamethasone within the first week of life, appears to be associated with adverse neurodevelopmental outcomes and is generally not recommended. Dexamethasone and hydrocortisone exhibit distinct biological and clinical effects, yet evidence from direct comparative studies is limited. Dexamethasone may improve cerebral palsy-free survival of infants at high risk of BPD but poses potential harm in those at low risk, highlighting the need for individualized risk-based decision-making. Optimal dosing remains unclear: lower doses may reduce systemic side effects despite the uncertainty of their neurodevelopmental safety, whereas higher doses may be more effective in selected high-risk infants. Inhaled corticosteroids have inconclusive benefits compared with systemic therapy. The intratracheal administration of corticosteroids with surfactant improves distal airway delivery and reduces death or BPD rates; however, short- and long-term safety data remain limited. Overall, postnatal corticosteroids should be used cautiously and selectively in high-risk, ventilator-dependent infants with severe BPD. Future high-quality trials are needed to evaluate long-term survival free of neurodevelopmental impairments.