Effect of IV Hydrocortisone on Mortality among Neonates with Hypotension: A Systematic Review and Meta-analysis of Randomized, Placebo-Controlled Trials.

BACKGROUND: Hypotension is common among preterm and term neonates in the neonatal intensive care unit, particularly those with very low birth weight, sepsis, or hypoxic-ischemic encephalopathy. Some remain hypotensive despite volume expansion and vasopressors, possibly due to relative adrenal insufficiency. Hydrocortisone is proposed as adjunct therapy, but its effect on mortality is uncertain. OBJECTIVE: To evaluate whether IV hydrocortisone reduces all-cause mortality in neonates with hypotension. METHODS: The MEDLINE, Embase, CENTRAL, and Scopus databases were searched up to March 30, 2025, for randomized controlled trials (RCTs) that compared IV hydrocortisone with placebo and reported mortality. Two reviewers independently screened the studies, extracted data, and assessed bias. A fixed-effects Mantel-Haenszel meta-analysis was used, based on the degree of heterogeneity. RESULTS: Five RCTs (with a total of 239 neonates) were included. Heterogeneity was low (I 2 = 0%). Hydrocortisone significantly reduced mortality (odds ratio 0.48, 95% confidence interval 0.24-0.96). CONCLUSIONS: IV hydrocortisone may reduce mortality in refractory neonatal hypotension. However, larger trials are needed to confirm this finding.