Real-world use of hydrocortisone and dexamethasone in the prevention and treatment of bronchopulmonary dysplasia in preterm infants <32 weeks: a nine-year cohort study.

Objectives: To describe real-world patterns of postnatal corticosteroid use and evaluate associations with respiratory outcomes in preterm infants <32 weeks' gestation. Methods: This retrospective cohort study included infants <32 weeks admitted to a tertiary neonatal intensive care unit at King Abdulaziz Medical City, Riyadh, Saudi Arabia, between January 2017 and December 2025. Postnatal steroid exposure was categorized as hydrocortisone, dexamethasone, both, or none. Primary outcomes were bronchopulmonary dysplasia (BPD) severity at 36 weeks' postmenstrual age, death before 36 weeks, and a composite of BPD or death. Multivariable regression models adjusted for baseline clinical factors, and propensity score weighting was used to address confounding by indication. Results: Among 1,228 infants, 326 (26.5%) received postnatal steroids (hydrocortisone 9.5%, dexamethasone 15.2%, both 1.8%). Steroid use increased with decreasing gestational age (54.4% at <26 weeks vs. 7.0% at 30-31 weeks, Conclusions: Postnatal corticosteroids were primarily used in infants with severe respiratory disease and were associated with higher observed respiratory morbidity rates in this higher-risk population. These findings reflect real-world corticosteroid use in higher-risk infants and should be interpreted as associations within a selected population rather than causal treatment effects.