Comparison of two dexamethasone regimens

Dexamethasone has been used to facilitate extubation in preterm infants, but higher-dose courses are associated with neurodevelopmental disability. This is a comparison of daily and cumulative dexamethasone in two different regimens.
Clinical
Published

September 16, 2025

In the 1990’s, dexamethasone regimens to facilitate extubation of preterm infants were found to be associated with worsened neurodevelopmental outcomes including cerebral palsy (; ).

Some years later, the DART trial used lower doses and a shorter duration of dexamethasone. Although underpowered, follow-up at two years did not clearly demonstrate worsened long-term morbidity (, ).

In recent years, the practice of repeated DART courses has become increasingly common.

This post is to visualize the relative daily and cumulative doses of dexamethasone administered comparing the original high-dose vs the lower-dose DART regimens. I am not aware of any evidence that follows long-term outcomes after multiple DART courses and will avoid speculation.

High-dose regimen: 42-day course

0.25 mg/kg BID for 3 days
0.15 mg/kg BID for 3 days
10% reduction every 3 days until a dose of 0.1 mg/kg given for 3 days
0.1 mg/kg QOD was continued until 42 days

From O’Shea et al. ():

DART regimen (modified): 10-day course

0.075 mg/kg BID for 3 days
0.05 mg/kg BID for 3 days
0.025 mg/kg BID for 2 days
0.025 mg/kg daily for 2 days

From Doyle et al. () and modified by local practice. In the original DART trial, the last step was 0.02 mg/kg per day for 2 doses, but local practice uses a slightly higher dose (difference of 0.01 mg/kg total cumulative dose, unlikely to be clinically significant) and will be presented here.

Daily dose

Cumulative dose

The cumulative dexamethasone dose for DART is 0.9 mg/kg, compared to 7.96 mg/kg for the high-dose regimen, for a 8.8-fold reduction.

Repeated DART courses

The current unanswered question is “How many repeated DART courses can we give, before we should be worried about unacceptably increasing risk of adverse neurodevelopmental outcome?” Until more clinical evidence is available, comfort will likely differ by provider.

References

Doyle, L.W., Davis, P.G., Morley, C.J., McPhee, A., Carlin, J.B., and DART Study Investigators (2006). Low-dose dexamethasone facilitates extubation among chronically ventilator-dependent infants: a multicenter, international, randomized, controlled trial. Pediatrics 117, 75–83. https://doi.org/10.1542/peds.2004-2843.
Doyle, L.W., Davis, P.G., Morley, C.J., McPhee, A., Carlin, J.B., and DART Study Investigators (2007). Outcome at 2 years of age of infants from the DART study: a multicenter, international, randomized, controlled trial of low-dose dexamethasone. Pediatrics 119, 716–721. https://doi.org/10.1542/peds.2006-2806.
Kothadia, J.M., O’Shea, T.M., Roberts, D., Auringer, S.T., Weaver, R.G., and Dillard, R.G. (1999). Randomized placebo-controlled trial of a 42-Day tapering course of dexamethasone to reduce the duration of ventilator dependency in very low birth weight infants. Pediatrics 104, 22–27. https://doi.org/10.1542/peds.104.1.22.
O’Shea, T.M., Kothadia, J.M., Klinepeter, K.L., Goldstein, D.J., Jackson, B.G., Weaver, R.G., and Dillard, R.G. (1999). Randomized placebo-controlled trial of a 42-day tapering course of dexamethasone to reduce the duration of ventilator dependency in very low birth weight infants: outcome of study participants at 1-year adjusted age. Pediatrics 104, 15–21. https://doi.org/10.1542/peds.104.1.15.