Budesonide Use in Neonatal Intensive Care Unit

Indications and Benefits

Inhaled budesonide is not recommended for routine use in preterm infants without respiratory symptoms, as evidence shows no significant benefit in symptom-free days, length of supplemental oxygen use, weight gain, or hospital admissions 1
The American College of Respiratory and Critical Care Medicine suggests that for infants with established respiratory symptoms, a 3-month trial of inhaled budesonide with close monitoring may be considered 2, 3
In infants with post-prematurity respiratory disease and respiratory symptoms, some studies show improvement in symptom scores with budesonide administration, with a strength of evidence considered low 1
A prospective study of children with airway obstruction showed improvement in symptom scores after 4 months of budesonide treatment, though without significant differences in spirometric measurements, based on a moderate level of evidence 2

Studies show no significant difference in length of supplemental oxygen use, weight gain, number of hospital admissions, or length of stay with budesonide use, according to the American Journal of Respiratory and Critical Care Medicine 1, 4, 3
Potential adverse effects of budesonide include oral candidiasis, sore throat, and potential growth effects, though evidence is mixed, with a low strength of evidence 3

Before starting inhaled budesonide, assess and document baseline status including severity of symptoms and pulmonary function, and plan for a 3-month trial period, as recommended by the American College of Respiratory and Critical Care Medicine 2
Monitoring during treatment should include watching for clinical improvement in respiratory symptoms and monitoring for potential side effects, with a moderate level of evidence 1, 3
Consider discontinuation of budesonide if no clinical improvement is observed, based on a low strength of evidence 2

The quality of evidence for inhaled corticosteroid use in neonates is very low, with most recommendations being conditional, according to the American College of Respiratory and Critical Care Medicine 1, 4
Cost considerations suggest that reducing inhaled corticosteroid use when not indicated could result in significant cost savings, with a moderate level of evidence 3

Budesonide should be used with caution in neonates due to potential systemic effects including adrenal suppression and growth impairment, with nebulized budesonide being the preferred formulation when indicated for specific conditions such as bronchopulmonary dysplasia (BPD) or croup, as stated by the American Thoracic Society 5

For neonates requiring nebulized budesonide, delivery requires a face mask that should fit snugly over the nose and mouth, and budesonide suspension is compatible with albuterol, ipratropium, and levalbuterol nebulizer solutions in the same nebulizer, according to the American Academy of Pediatrics 6
Only jet nebulizers should be used as ultrasonic nebulizers are ineffective for suspensions, as recommended by the American College of Chest Physicians 7
The recommended dose for nebulized administration in infants is 0.25-0.5 mg twice daily for low-dose therapy, as suggested by the National Institutes of Health 8

Uncontrolled data suggest inhaled steroids may improve lung mechanics and short-term outcomes in neonates with bronchopulmonary dysplasia (BPD), according to the European Respiratory Society 6
The American Thoracic Society states that routine use of corticosteroids is discouraged due to associated side effects and lack of long-term benefit 5