In the intricate and high-stakes environment of neonatal intensive care units (NICUs), the treatment of premature and critically ill newborns often involves the administration of corticosteroids. These potent medications play a crucial role in managing inflammation and facilitating respiratory function, yet their use carries the risk of inducing adrenal insufficiency (AS), a potentially life-threatening condition. A groundbreaking study published in the Journal of Perinatology has now cast light on the variability in how neonatologists across multiple centers screen for and manage corticosteroid-induced adrenal insufficiency, revealing a concerning lack of standardized protocols in the NICU setting.
Corticosteroid-induced adrenal insufficiency arises when prolonged or high-dose corticosteroid therapy suppresses the hypothalamic-pituitary-adrenal (HPA) axis, impairing the neonate’s ability to produce endogenous cortisol. Cortisol is vital for maintaining homeostasis, particularly in physiological stress responses. In vulnerable newborns, an impaired adrenal function can precipitate critical complications, including hypotension, electrolyte disturbances, and cardiovascular collapse. Despite these risks, the approach to identifying and treating AS in neonates remains unclear and inconsistent across various healthcare institutions.
The multicenter study, spearheaded by Watson, Garg, and Constantacos, surveyed neonatologists’ practices related to screening methodologies, diagnostic criteria, and management strategies for AS in NICU patients who have received corticosteroids. Their findings lay bare a landscape characterized by divergent practices informed by institutional culture, individual clinician preference, and a notable absence of clear evidence-based guidelines. This inconsistency may compromise patient outcomes, warranting urgent attention to unify clinical approaches.
The researchers employed a comprehensive questionnaire extended to neonatologists working across diverse geographical and institutional settings. Key areas of inquiry included the criteria that prompt screening for AS, the types and timing of adrenal function tests utilized, and the therapeutic interventions employed when adrenal insufficiency is confirmed or suspected. The survey revealed a wide variability not only in the thresholds and frequency of testing but also in the choice between dynamic versus static endocrine evaluations, such as the corticotropin stimulation test compared to baseline cortisol measurement.
Adding further complexity, the treatment paradigms for managing confirmed or suspected AS diverge markedly. Some practitioners initiate hydrocortisone replacement therapy immediately after diagnosis, while others adopt a watchful waiting approach, closely monitoring clinical symptoms before intervention. The dosage regimens and duration of corticosteroid tapering differ substantially, underscoring the absence of consensus on the optimal balance between mitigating AS-related risks and avoiding potential steroid overexposure.
One compelling insight from the study highlighted the profound impact of institutional protocols—or the lack thereof—on clinical decisions. Neonatologists practicing in centers with established guidelines reported higher consistency and confidence in their approach to AS compared to those at facilities without standardized recommendations. This disparity underscores the critical role of evidence-based protocols in harmonizing care delivery and improving neonatal outcomes.
Further analytical stratification revealed that neonatologists’ experience levels also influenced screening and management tendencies. Senior clinicians with extensive NICU exposure tended to rely more heavily on clinical acumen and less on routine biochemical screening, whereas younger neonatologists leaned towards more rigorous and protocolized testing. This generational difference potentially reflects evolving training paradigms and the gradual incorporation of endocrine diagnostic tools into neonatal practice.
The study authors emphasize that while corticosteroid therapy undeniably benefits numerous neonates, the potential for life-threatening AS creates an urgent imperative to refine screening practices. They advocate for prospective longitudinal studies to elucidate the natural history of corticosteroid-induced adrenal suppression in this delicate population and to inform robust, evidence-based guidelines. Precision medicine approaches integrating pharmacokinetic and pharmacodynamic data with clinical risk stratification may ultimately pave the way for individualized AS management.
Importantly, this investigation also acknowledges the methodological and logistic hurdles inherent in studying neonatal adrenal function. Variability in cortisol-binding globulin levels, diurnal variations, and the challenges in performing dynamic testing in critically ill infants complicate both diagnosis and monitoring. These technical limitations necessitate the development and validation of novel biomarkers and non-invasive testing modalities suitable for neonatal patients.
The implications of this study extend beyond clinical care to impact healthcare policy and education. Establishing consensus-driven protocols for AS screening and management could standardize care, reduce morbidity associated with adrenal crises, and optimize resource utilization in NICUs. Training programs for neonatologists must incorporate updated endocrine principles and practical guidance on combating corticosteroid-induced complications, fostering a workforce adept at navigating these complexities.
Moreover, the study’s multicenter design strengthens its generalizability, providing a panoramic view of current real-world practices. It invites the neonatal research community to collaborate internationally in crafting unified standards, leveraging shared registries and multicenter clinical trials to accelerate progress and enhance the safety profiles of corticosteroid therapies.
As we stand on the frontier of neonatal care advancement, harnessing the full therapeutic potential of corticosteroids while guarding against their endocrine repercussions represents a vital challenge. The study by Watson and colleagues not only illuminates a critical gap but also galvanizes the medical community toward concerted efforts for innovation, education, and standardized care models centered around neonatal adrenal health.
In conclusion, the variability exposed in neonatologists’ approaches to corticosteroid-induced adrenal insufficiency screening and management is a call to action. This multifaceted issue demands a harmonized, evidence-driven response encompassing clinical practice, research priorities, and educational frameworks. Ensuring that our tiniest patients receive the safest, most effective care necessitates such bold strides forward, marking a pivotal milestone in neonatal medicine’s evolution.
Subject of Research: Variability in neonatologists’ screening and management practices of corticosteroid-induced adrenal insufficiency in the NICU.
Article Title: Neonatologists’ practices in screening and managing corticosteroid-induced adrenal insufficiency in the NICU- a multicenter study.
Article References:
Watson, S.C., Garg, P.M. & Constantacos, C. Neonatologists’ practices in screening and managing corticosteroid-induced adrenal insufficiency in the NICU- a multicenter study. J Perinatol (2026). https://doi.org/10.1038/s41372-026-02592-2
Image Credits: AI Generated
DOI: 23 February 2026
