Timing of hydrocortisone therapy in neonates with shock: a systematic review, meta-analysis, and clinical practice guideline
BackgroundThe effect of the timing of initiation of hydrocortisone in neonatal shock has not been evaluated. The objective of this systematic review was to compare the effect of earlier vs. later initiation of hydrocortisone in neonatal shock.MethodsMedline, Embase, and CENTRAL were searched from in...
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Frontiers Media S.A.
2025-03-01
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| author | Viraraghavan Vadakkencherry Ramaswamy Gunjana Kumar Abdul Kareem Pullattayil S Abhishek S. Aradhya Pradeep Suryawanshi Mohit Sahni Supreet Khurana Shiv Sajan Saini Ravishankar K Shashi Kant Dhir Deepak Chawla Praveen Kumar Kiran More |
| author_facet | Viraraghavan Vadakkencherry Ramaswamy Gunjana Kumar Abdul Kareem Pullattayil S Abhishek S. Aradhya Pradeep Suryawanshi Mohit Sahni Supreet Khurana Shiv Sajan Saini Ravishankar K Shashi Kant Dhir Deepak Chawla Praveen Kumar Kiran More |
| author_sort | Viraraghavan Vadakkencherry Ramaswamy |
| collection | DOAJ |
| description | BackgroundThe effect of the timing of initiation of hydrocortisone in neonatal shock has not been evaluated. The objective of this systematic review was to compare the effect of earlier vs. later initiation of hydrocortisone in neonatal shock.MethodsMedline, Embase, and CENTRAL were searched from inception until 15 May 2024. Randomized controlled trials (RCTs) and non-RCTs were eligible for inclusion. A random effects meta-analysis was used to synthesize the data. The evidence certainty was evaluated according to Grading of Recommendations Assessment, Development, and Evaluation (GRADE). A clinical practice guideline was formulated as recommended by the GRADE group.ResultsOf the 3,757 titles and abstracts screened, 20 studies were included: 7 RCTs and 13 non-RCTs. While clinical benefit or harm could not be ruled out for the outcome of mortality from the meta-analysis of the RCTs [early initiation risk ratio (RR): 0.46, 95% confidence interval (CI): 0.03–7.92; late initiation RR: 0.43, 95% CI: 0.12–1.47], the non-RCTs included in the narrative review suggested that late hydrocortisone initiation might be associated with increased risk of mortality. The meta-analysis indicated that early and late hydrocortisone administration may be associated with an increased response to treatment therapy (early initiation RR: 1.85, 95% CI: 1.26–2.71; late initiation RR: 2.50, 95% CI: 1.16–5.39). Late hydrocortisone initiation may increase the risk of necrotizing enterocolitis (NEC) ≥ stage 2 (RR: 2.46, 95% CI: 1.19–5.08). The evidence certainty was very low for most of the outcomes evaluated.ConclusionThe early use of hydrocortisone in neonates with shock requiring vasopressors is associated with better outcomes and no major adverse effects. Later institution of hydrocortisone therapy in neonatal shock may improve the response to therapy but may be associated with adverse outcomes including mortality and NEC. The results are to be interpreted with caution as the evidence certainty was predominantly very low.Systematic Review Registrationhttps://www.crd.york.ac.uk/PROSPERO/view/CRD42023432169, identifier: CRD42023432169. |
| format | Article |
| id | doaj-art-2bdfd7b7f34c4b579c2c796d894b6675 |
| institution | DOAJ |
| issn | 2296-2360 |
| language | English |
| publishDate | 2025-03-01 |
| publisher | Frontiers Media S.A. |
| record_format | Article |
| series | Frontiers in Pediatrics |
| spelling | doaj-art-2bdfd7b7f34c4b579c2c796d894b66752025-08-20T02:47:52ZengFrontiers Media S.A.Frontiers in Pediatrics2296-23602025-03-011310.3389/fped.2025.14919761491976Timing of hydrocortisone therapy in neonates with shock: a systematic review, meta-analysis, and clinical practice guidelineViraraghavan Vadakkencherry Ramaswamy0Gunjana Kumar1Abdul Kareem Pullattayil S2Abhishek S. Aradhya3Pradeep Suryawanshi4Mohit Sahni5Supreet Khurana6Shiv Sajan Saini7Ravishankar K8Shashi Kant Dhir9Deepak Chawla10Praveen Kumar11Kiran More12Department of Neonatology, Ankura Hospital for Women and Children, Hyderabad, IndiaDepartment of Neonatology, National Institute of Medical Sciences, Jaipur, IndiaQueen's University Library, Queen's University, Kingston, ON, CanadaDepartment of Neonatology, Ovum Women and Child Specialty Hospital, Bengaluru, IndiaDepartment of Neonatology, Bharati Vidyapeeth Medical College Hospital, Pune, IndiaDepartment of Neonatology, Nirmal Hospital, Surat, IndiaDepartment of Neonatology, Government Medical College and Hospital, Chandigarh, IndiaDepartment of Neonatology and Head, Postgraduate Institute of Medical Education and Research, Chandigarh, IndiaDepartment of Neonatology, Sowmya Children’s Hospital, Hyderabad, India0Department of Pediatrics, Guru Gobind Medical College, Faridkot, IndiaDepartment of Neonatology, Government Medical College and Hospital, Chandigarh, IndiaDepartment of Neonatology and Head, Postgraduate Institute of Medical Education and Research, Chandigarh, India1Division of Neonatology, MRR Children’s Hospital, Mumbai, IndiaBackgroundThe effect of the timing of initiation of hydrocortisone in neonatal shock has not been evaluated. The objective of this systematic review was to compare the effect of earlier vs. later initiation of hydrocortisone in neonatal shock.MethodsMedline, Embase, and CENTRAL were searched from inception until 15 May 2024. Randomized controlled trials (RCTs) and non-RCTs were eligible for inclusion. A random effects meta-analysis was used to synthesize the data. The evidence certainty was evaluated according to Grading of Recommendations Assessment, Development, and Evaluation (GRADE). A clinical practice guideline was formulated as recommended by the GRADE group.ResultsOf the 3,757 titles and abstracts screened, 20 studies were included: 7 RCTs and 13 non-RCTs. While clinical benefit or harm could not be ruled out for the outcome of mortality from the meta-analysis of the RCTs [early initiation risk ratio (RR): 0.46, 95% confidence interval (CI): 0.03–7.92; late initiation RR: 0.43, 95% CI: 0.12–1.47], the non-RCTs included in the narrative review suggested that late hydrocortisone initiation might be associated with increased risk of mortality. The meta-analysis indicated that early and late hydrocortisone administration may be associated with an increased response to treatment therapy (early initiation RR: 1.85, 95% CI: 1.26–2.71; late initiation RR: 2.50, 95% CI: 1.16–5.39). Late hydrocortisone initiation may increase the risk of necrotizing enterocolitis (NEC) ≥ stage 2 (RR: 2.46, 95% CI: 1.19–5.08). The evidence certainty was very low for most of the outcomes evaluated.ConclusionThe early use of hydrocortisone in neonates with shock requiring vasopressors is associated with better outcomes and no major adverse effects. Later institution of hydrocortisone therapy in neonatal shock may improve the response to therapy but may be associated with adverse outcomes including mortality and NEC. The results are to be interpreted with caution as the evidence certainty was predominantly very low.Systematic Review Registrationhttps://www.crd.york.ac.uk/PROSPERO/view/CRD42023432169, identifier: CRD42023432169.https://www.frontiersin.org/articles/10.3389/fped.2025.1491976/fullneonateshydrocortisoneshockclinical practical guidelinesmeta-analysissystematic review |
| spellingShingle | Viraraghavan Vadakkencherry Ramaswamy Gunjana Kumar Abdul Kareem Pullattayil S Abhishek S. Aradhya Pradeep Suryawanshi Mohit Sahni Supreet Khurana Shiv Sajan Saini Ravishankar K Shashi Kant Dhir Deepak Chawla Praveen Kumar Kiran More Timing of hydrocortisone therapy in neonates with shock: a systematic review, meta-analysis, and clinical practice guideline Frontiers in Pediatrics neonates hydrocortisone shock clinical practical guidelines meta-analysis systematic review |
| title | Timing of hydrocortisone therapy in neonates with shock: a systematic review, meta-analysis, and clinical practice guideline |
| title_full | Timing of hydrocortisone therapy in neonates with shock: a systematic review, meta-analysis, and clinical practice guideline |
| title_fullStr | Timing of hydrocortisone therapy in neonates with shock: a systematic review, meta-analysis, and clinical practice guideline |
| title_full_unstemmed | Timing of hydrocortisone therapy in neonates with shock: a systematic review, meta-analysis, and clinical practice guideline |
| title_short | Timing of hydrocortisone therapy in neonates with shock: a systematic review, meta-analysis, and clinical practice guideline |
| title_sort | timing of hydrocortisone therapy in neonates with shock a systematic review meta analysis and clinical practice guideline |
| topic | neonates hydrocortisone shock clinical practical guidelines meta-analysis systematic review |
| url | https://www.frontiersin.org/articles/10.3389/fped.2025.1491976/full |
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