A Steroid That Buys Time: When Doctors Should Start Hydrocortisone for a Newborn in Shock

How a 2025 review of 20 studies (Ramaswamy et al., Frontiers in Pediatrics) suggests that timing — not just the drug — may matter for babies whose blood pressure is failing

When a newborn's circulation begins to fail, doctors often add a steroid called hydrocortisone to the blood-pressure medicines already running. A 2025 review that pooled 20 studies asked a question no earlier study was designed to answer: does it matter when that steroid is started? The answer, though based on low-certainty evidence, was that starting hydrocortisone earlier — before the blood-pressure medicines are pushed to high doses — was linked to better outcomes and no major harms, while waiting until later was linked to more complications and longer recoveries.

Why This Question Matters

One of the most frightening situations in a neonatal intensive care unit (NICU) is "shock" — when a baby's blood pressure drops so low that organs may not get enough blood. The first response is fluids, then medicines called inotropes or vasopressors (drugs such as dopamine that squeeze blood vessels and strengthen the heartbeat) [1]. But these medicines don't always work, and pushing them higher and higher carries its own risks. For decades, teams have added hydrocortisone — a steroid that mimics the body's own stress hormone, cortisol — to help the other medicines do their job. Over roughly ten years, its use in the tiniest babies climbed steadily, even though survival among babies with low blood pressure did not clearly improve, a sign that doctors were reaching for it more often without solid proof of exactly how to use it [2].

How Families Used to Face This

Part of the difficulty is that experts have never fully agreed on what counts as dangerously low blood pressure in a newborn, or when to treat it — early low pressure and later low pressure have different causes and outcomes, and there was no shared rulebook [3]. So the decision to add hydrocortisone was often made case by case, based on a doctor's judgment and local habit rather than a clear standard. Families frequently heard that the team was "trying a steroid to help the blood pressure," with little way to know whether starting it sooner or later would change anything. The review by Ramaswamy and colleagues is the first attempt to turn that scattered experience into a single, evidence-based answer about timing [4].

What the Researchers Did

The team gathered every study they could find — through May 2024, in three large medical libraries — that looked at hydrocortisone plus blood-pressure medicines versus those medicines alone, in babies up to 28 days old who were in shock [1]. They found 20 studies: 7 were randomized controlled trials (the strongest kind, where babies are assigned by chance to one approach or another) and 13 were observational studies (which track what happened without assigning treatment). They then sorted the studies by timing. To measure how much blood-pressure support a baby was getting, they used a number called the vasoactive-inotropic score, or VIS — essentially a running total of all the blood-pressure medicines and their doses, a tool first invented to track support in babies recovering from heart surgery [5]. "Early" hydrocortisone meant giving it while support was still modest; "late" meant waiting until the doses were already high. Where the numbers allowed, they combined results statistically and rated how trustworthy each finding was.

Hydrocortisone helps because a stressed newborn often cannot make enough cortisol of its own — a state called relative adrenal insufficiency [6]. The steroid essentially "re-tunes" the blood vessels so that the other medicines start working again, raising blood pressure without straining the heart [7].

What They Found

The clearest differences were not about whether the steroid raised blood pressure — it did, by about 11 mm Hg, whether given early or late — but about what it cost to wait [1]. Babies given hydrocortisone early tended to need fewer additional blood-pressure medicines and came off those medicines sooner, by roughly a day and a half. Babies given it late stayed on the medicines longer — by about two and a half days — and, in one study, spent more than a month longer in the hospital [1]. An earlier carefully designed trial had already hinted at this: a "stress dose" of hydrocortisone helped preterm babies recover faster once dopamine was climbing [8].

It helps to understand what "response" means here, because it is the outcome the studies could measure most reliably. When a baby is in shock, the care team watches a cluster of signs — the blood-pressure number itself, how much urine the baby is making, the color and warmth of the skin, and the results of blood tests that show whether organs are getting enough oxygen. "Responding" to hydrocortisone means these signs start to improve and, crucially, the team can begin turning the blood-pressure medicines down rather than up. That is why the review paid so much attention to how long babies stayed on inotropes: coming off those medicines sooner is both a sign that the baby is recovering and, the researchers suspect, a reason the baby may do better, since high doses of these medicines over many hours are themselves hard on a fragile newborn [1].

The safety findings pointed the same direction. Waiting until later to start hydrocortisone was linked to a higher risk of necrotizing enterocolitis (a serious intestinal illness of premature babies), and, in some studies, more infections [1]. A reasonable way to understand this is that the longer a baby stays on high doses of the squeezing medicines, the more strain the body endures — so getting ahead of that with the steroid, rather than waiting for a crisis, may spare the baby some of that toll. The steroid's expected side effects, mainly higher blood sugar, were seen but are easily watched for with routine testing [1].

What This Means for Your Baby

If your baby is in shock and the team is considering hydrocortisone, this review gently favors giving it sooner — when the blood-pressure medicines are being turned up, rather than only after they have been pushed to their limit. In practice, doctors may consider adding it once dopamine reaches about 10 micrograms per kilogram each minute, a modest level of support, using a dose that is then tapered off over a couple of days as the baby improves [1].

If this happens with your baby, it is reasonable to ask the team a few questions: how much blood-pressure medicine is my baby on now, is the plan to add hydrocortisone or wait, and what signs are you watching to know if it is working? You may hear the team refer to the "VIS" number or to a specific dopamine dose — these are simply ways of describing how much support your baby needs, and they help the team decide when the steroid might help most. Because the steroid can raise blood sugar, your baby will have extra sugar checks for a day or two, and the medicine is normally lowered gradually rather than stopped all at once. Knowing the plan in advance can make an intensely stressful stretch a little more navigable, and most teams welcome these questions.

It is important to hold this alongside a few honest cautions. The evidence is described by the authors themselves as very low certainty — meaning future studies could change the picture [1]. Many of the "late" babies were simply the sickest ones to begin with, which can make late treatment look worse than it truly is. And the babies in these studies were very different from one another — some extremely premature, some full-term babies being cooled after a difficult birth, some with a birth defect of the diaphragm — so no single rule fits every baby perfectly [9]. Doctors also learned that a blood test for cortisol does not reliably predict who will respond, so waiting for lab results should not delay treatment [1]. Finally, not every low number needs aggressive treatment at all: the largest trial of dopamine for low blood pressure in premature babies had to stop early, and careful, watchful restraint remains a legitimate approach [10]. (This use of hydrocortisone for acute shock is different from its use to help prevent chronic lung disease, which is a separate decision with its own evidence.)

What Researchers Are Working On Next

The authors are clear that what the field needs now is a large, carefully designed trial that deliberately compares starting hydrocortisone early versus late, using the same blood-pressure-support threshold for every baby and following the children as they grow to see how they develop [1]. None of the studies so far tracked long-term development, which is a meaningful gap for a medicine given during such a delicate time. Even the very first randomized comparisons in this field, decades ago, showed hydrocortisone could steady a struggling baby's blood pressure — but they, too, left the timing question open [11]. For now, families can take reassurance that this common NICU medicine is being used more thoughtfully, and that the best current reading of the evidence is a hopeful one: when hydrocortisone is needed, starting it a little earlier may help a baby recover a little sooner.

References

  1. Ramaswamy VV, Kumar G, Pullattayil Abdul Kareem S, et al. Timing of hydrocortisone therapy in neonates with shock: a systematic review, meta-analysis, and clinical practice guideline. Front Pediatr. 2025;13:1491976. doi:10.3389/fped.2025.1491976 ↩
  2. Rios DR, Moffett BS, Kaiser JR. Trends in pharmacotherapy for neonatal hypotension. J Pediatr. 2014;165(4):697–701.e1. doi:10.1016/j.jpeds.2014.06.009 ↩
  3. Dempsey EM. What should we do about low blood pressure in preterm infants. Neonatology. 2017;111(4):402–407. doi:10.1159/000460603 ↩
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  5. Gaies MG, Gurney JG, Yen AH, et al. Vasoactive-inotropic score as a predictor of morbidity and mortality in infants after cardiopulmonary bypass. Pediatr Crit Care Med. 2010;11(2):234–238. doi:10.1097/PCC.0b013e3181b806fc ↩
  6. Fernandez EF, Watterberg KL. Relative adrenal insufficiency in the preterm and term infant. J Perinatol. 2009;29(Suppl 2):S44–S49. doi:10.1038/jp.2009.24 ↩
  7. Seri I, Tan R, Evans J. Cardiovascular effects of hydrocortisone in preterm infants with pressor-resistant hypotension. Pediatrics. 2001;107(5):1070–1074. doi:10.1542/peds.107.5.1070 ↩
  8. Ng PC, Lee CH, Bnur FL, et al. A double-blind, randomized, controlled study of a "stress dose" of hydrocortisone for rescue treatment of refractory hypotension in preterm infants. Pediatrics. 2006;117(2):367–375. doi:10.1542/peds.2005-0869 ↩
  9. Cummings JJ, Pramanik AK; Committee on Fetus and Newborn. Postnatal corticosteroids to prevent or treat chronic lung disease following preterm birth. Pediatrics. 2022;149(1):e2022057530. doi:10.1542/peds.2022-057530 ↩
  10. Dempsey EM, Barrington KJ, Marlow N, et al. Hypotension in Preterm Infants (HIP) randomised trial. Arch Dis Child Fetal Neonatal Ed. 2021;106(4):398–403. doi:10.1136/archdischild-2020-320241 ↩
  11. Bourchier D, Weston PJ. Randomised trial of dopamine compared with hydrocortisone for the treatment of hypotensive very low birthweight infants. Arch Dis Child Fetal Neonatal Ed. 1997;76(3):F174–F178. doi:10.1136/fn.76.3.f174 ↩