Restricted versus liberal water intake for preventing morbidity and mortality in preterm infants.

BACKGROUND: Most premature infants are not sufficiently mature physiologically to ingest all of their required water and nutrients orally. Therefore, premature infants rely on their caregivers to regulate their volume of water intake. Thus, the caregiver must determine the amount of water to be given each day to such infants. OBJECTIVES: The objective of this review is to examine the effects of water intake on postnatal weight loss and on the risks of dehydration, patent ductus arteriosus, necrotizing enterocolitis, bronchopulmonary dysplasia, intracranial hemorrhage, and death in premature infants. SEARCH STRATEGY: Randomized clinical trials identified in previous versions of this review were re-examined and, in each case, retained. Additional trials were sought that compared the outcomes of interest in groups of premature infants who were given different levels of water intake according to experimental protocol. Such trials were sought in a list of trials provided by the Cochrane Neonatal Review Group, with a PubMed search, and in the authors' personal files. SELECTION CRITERIA: Only randomized clinical trials of varying water intake in premature infants are included. The review was limited to trials that included infants whose water intake was provided mainly or entirely by intravascular infusion. Included studies reported at least one of the following outcomes: postnatal weight loss, dehydration, patent ductus arteriosus, necrotizing enterocolitis, bronchopulmonary dysplasia, intracranial hemorrhage, and death. DATA COLLECTION AND ANALYSIS: Standard methods of the Cochrane Collaboration were used. The studies to be included were selected by two reviewers, each of whom also assessed the methodological quality of each trial. Data were independently extracted by the reviewers, who agreed on the key details. The data were then entered into tables using RevMan 4.3.1. The adverse event rates were calculated for the restricted and liberal water intake groups for each dichotomous outcome, and the relative risk and risk difference were computed. In addition, the maximal weight loss results were recorded, and the weighted mean difference was computed. The analyses - including calculation of relative risk, risk difference, and weighted mean difference - and tests of heterogeneity were accomplished using RevMan 4.3.1 software. MAIN RESULTS: The analysis of the five studies taken together indicates that restricted water intake significantly increases postnatal weight loss and significantly reduces the risks of patent ductus arteriosus and necrotizing enterocolitis. With restricted water intake, there are trends toward increased risk of dehydration and reduced risks of bronchopulmonary dysplasia, intracranial hemorrhage, and death, but these trends are not statistically significant. AUTHORS' CONCLUSIONS: Based on this analysis, the most prudent prescription for water intake to premature infants would seem to be careful restriction of water intake so that physiological needs are met without allowing significant dehydration. This practice could be expected to decrease the risks of patent ductus arteriosus and necrotizing enterocolitis without significantly increasing the risk of adverse consequences.

Restricted versus liberal water intake for preventing morbidity and mortality in preterm infants.

BACKGROUND: Most premature infants are not sufficiently mature physiologically to take all of their required water and nutrients orally, and so they cannot regulate their own water intake. Thus, the caregiver must determine the amount of water to be given each day to such infants. OBJECTIVES: The objective of this review is to examine the effects of water intake on postnatal weight loss and on the risks of dehydration, patent ductus arteriosus, necrotizing enterocolitis, bronchopulmonary dysplasia, intracranial hemorrhage, and death in premature infants. SEARCH STRATEGY: Randomized clinical trials were sought that compared the outcomes of interest in groups of premature infants who were given different levels of water intake according to experimental protocol. Such trials were sought in a previous review by one of the authors (Bell EF. Fluid therapy. In: Effective Care of the Newborn Infant, eds JC Sinclair, MB Bracken. Oxford: Oxford University Press, 1992: 59-72), in a list of trials provided by the Cochrane Neonatal Review Group, and in the authors' personal files. SELECTION CRITERIA: Only randomized clinical trials of varying water intake in premature infants are included. The review was limited to trials that included infants whose water intake was provided mainly or entirely by parenteral means. Studies were included regardless of outcomes examined. DATA COLLECTION AND ANALYSIS: Trials were selected by two reviewers, who also assessed the methodological quality of each trial. Data were independently extracted by the reviewers, and differences were reconciled. The data were then entered into tables using RevMan 3.1 for Windows. The adverse event rates were calculated for the restricted and liberal water intake groups for each dichotomous outcome, and the relative risk was computed. In addition, the maximal weight loss results were recorded, and the weighted mean difference was computed. The analyses (including calculation of relative risk, risk difference, and weighted mean difference) and tests of heterogeneity were accomplished with MetaView 3.1 software and a fixed effects model. No subgroup analyses were conducted. MAIN RESULTS: The analysis of the four studies taken together indicates that restricted water intake significantly increases postnatal weight loss and significantly reduces the risks of patent ductus arteriosus, necrotizing enterocolitis, and death. With restricted water intake, there are trends toward increased risk of dehydration and reduced risk of bronchopulmonary dysplasia, but these trends are not statistically significant. REVIEWER'S CONCLUSIONS: Based on this analysis, the most prudent prescription for water intake to premature infants would seem to be careful restriction of water intake so that physiological needs are met without allowing significant dehydration. This practice could be expected to decrease the risks of patent ductus arteriosus and necrotizing enterocolitis--and perhaps the overall risk of death--without significantly increased risk of adverse consequences.

VEGF induces airway epithelial cell proliferation in human fetal lung in vitro.

Vascular endothelial growth factor (VEGF) is a potent endothelial cell mitogen involved in normal and abnormal angiogenesis. VEGF mRNA and protein are abundant in distal epithelium of midtrimester human fetal lung. In the present study, we identified immunoreactivity for KDR, a major VEGF-specific receptor, in distal lung epithelial cells of human fetal lung tissue, suggesting a possible autocrine or paracrine regulatory role for VEGF in pulmonary epithelial cell growth and differentiation. Addition of exogenous VEGF to human fetal lung explants resulted in increased epithelium volume density and lumen volume density in the tissues, both morphometric parameters of tissue differentiation. Cellular proliferation demonstrated by bromodeoxyuridine uptake was prominent in distal airway epithelial cells and increased in the VEGF-treated explants. VEGF-treated explants also demonstrated increased surfactant protein (SP) A mRNA, SP-C mRNA, and SP-A protein levels compared with controls. However, SP-B mRNA levels were unaffected by VEGF treatment. [(3)H]choline incorporation into total phosphatidylcholine was increased by VEGF treatment, but incorporation into disaturated phosphatidylcholine was not affected by exogenous VEGF. Based on these observations, we conclude that VEGF may be an important autocrine growth factor for distal airway epithelial cells in the developing human lung.

Responses of fetal ovine systemic and umbilical arteries to angiotensin II.

Angiotensin II (ANG II) contracts umbilical arteries and has been hypothesized to regulate fetal blood pressure primarily by altering umbilical vascular resistance. To determine whether systemic arteries in term fetal sheep are sensitive to ANG II, isometric contraction of endothelium-intact isolated fetal renal, mesenteric, and umbilical arteries in response to ANG II was studied. ANG II (10(-7) M) elicited contractile responses in all three vessels (43 +/- 8%, 99 +/- 21%, and 105 +/- 5% of the maximal response seen with 90 mM KCl for renal, mesenteric, and umbilical arteries, respectively). The time course of the contractile responses differed among the vessels: renal and mesenteric arteries exhibited rapid transient contraction followed by relaxation, whereas umbilical artery displayed a more slowly developing but sustained contraction (1 +/- 0%, 3 +/- 1%,and 93 +/- 4% of maximal contractile response at 5 min, for renal, mesenteric, and umbilical arteries, respectively). The AT1 receptor antagonist, losartan (10(-6) M), abolished contractile responses in renal and mesenteric arteries but only slowed the contraction in umbilical artery in response to ANG II and had no effect on maximal tension. AT2 receptor blockade (PD 123319, 10(-7) M) had no significant effect on the response to ANG II in any vessel. Indomethacin (10(-6) M) significantly potentiated contraction to ANG II in renal and mesenteric but not umbilical arteries. Northern and Western blot analyses demonstrated the presence of AT1 mRNA and protein in all three vessels. Immunostaining for the AT1 receptor was present in endothelium and the tunica media. These findings demonstrate the AT1 receptor is present and functionally active in fetal systemic arteries and are consistent with previous findings that the umbilical circulation displays a greater responsiveness to ANG II than the systemic vasculature.

Clinical performance of an in-line point-of-care monitor in neonates.

OBJECTIVE: To evaluate the bias, precision, and blood loss characteristics of an ex vivo in-line point-of-care testing blood gas and electrolyte monitor designed for use in critically ill newborn infants. STUDY DESIGN: Study participants included consecutive neonates with an umbilical artery catheter (UAC) in use for clinical laboratory testing. The in-line monitor (VIA LVM Blood Gas and Chemistry Monitoring System, VIA Medical, San Diego, CA) was directly connected to the participant's UAC and the monitor's determinations of pH, PCO(2), PO(2), sodium, potassium, and hematocrit (Hct) were compared with those simultaneously drawn and measured with a standard bench top laboratory instrument (Radiometer 625 ABL; Radiometer America, Inc, Westlake, OH). The bias (the mean difference from the reference method) and precision (1 standard deviation of the mean difference) performance criteria of the in-line monitor were derived using standard laboratory procedures. RESULTS: Sixteen neonates monitored for a total of 37 days had a total of 229 paired blood samples available for comparison by the 2 methods. Bias and precision performance characteristics of the in-line monitor were similar to reports of other point-of-care devices (ie, pH: -.003 +/-.024; PCO(2):.35 +/- 2.84 mm Hg; PO(2):.39 +/- 7.30 mm Hg; sodium:.52 +/- 2.34 mmol/L; potassium:.17 +/-.18 mmol/L; and Hct:.61 +/- 2.80%). The range of values observed for each parameter included much of the range anticipated among critically ill neonates (ie, pH: 7.15-7.65; PCO(2): 25-75 mm Hg; PO(2): 25-275 mm Hg; sodium: 127-150 mmol/L; potassium: 2.6-5.5 mmol/L; and Hct: 32%-60%). Mean blood loss (+/- standard deviation) per sample with the in-line monitor was approximately one-tenth that of the reference method: 24 +/- 7 microL versus 250 microL, respectively. There was no evidence of hemolysis and no patient related safety issues were identified with use of the in-line monitor. CONCLUSIONS: Repeated laboratory testing of critically ill neonates using an ex vivo in-line monitor designed for use in neonates provides reliable laboratory results. The blood loss and hemolysis data obtained suggests that this monitoring device offers potential for reducing neonatal blood loss-and possibly transfusion needs-during the first weeks of life. Before this promising technology can be routinely recommended for care of critically ill neonates, greater practical experience in a variety of clinical settings is needed.

Restricted versus liberal water intake for preventing morbidity and mortality in preterm infants.

BACKGROUND: Most premature infants are not sufficiently mature physiologically to take all of their required water and nutrients orally, and so they cannot regulate their own water intake. Thus, the caregiver must determine the amount of water to be given each day to such infants. OBJECTIVES: The objective of this review is to examine the effects of water intake on postnatal weight loss and on the risks of dehydration, patent ductus arteriosus, necrotizing enterocolitis, bronchopulmonary dysplasia, intracranial hemorrhage, and death in premature infants. SEARCH STRATEGY: Randomized clinical trials were sought that compared the outcomes of interest in groups of premature infants who were given different levels of water intake according to experimental protocol. Such trials were sought in a previous review by one of the authors (Bell EF. Fluid therapy. In: Effective Care of the Newborn Infant, eds JC Sinclair, MB Bracken. Oxford: Oxford University Press, 1992: 59-72, approximately approximately Bell 1992 approximately approximately ), in a list of trials provided by the Cochrane Neonatal Review Group, and in the authors' personal files. SELECTION CRITERIA: Only randomized clinical trials of varying water intake in premature infants are included. The review was limited to trials that included infants whose water intake was provided mainly or entirely by parenteral means. Studies were included regardless of outcomes examined. DATA COLLECTION AND ANALYSIS: Trials were selected by two reviewers, who also assessed the methodological quality of each trial. Data were independently extracted by the reviewers, and differences were reconciled. The data were then entered into tables using RevMan 3.1 for Windows. The adverse event rates were calculated for the restricted and liberal water intake groups for each dichotomous outcome, and the relative risk was computed. In addition, the maximal weight loss results were recorded, and the weighted mean difference was computed. The analyses (including calculation of relative risk, risk difference, and weighted mean difference) and tests of heterogeneity were accomplished with MetaView 3.1 software and a fixed effects model. No subgroup analyses were conducted. MAIN RESULTS: The analysis of the four studies taken together indicates that restricted water intake significantly increases postnatal weight loss and significantly reduces the risks of patent ductus arteriosus, necrotizing enterocolitis, and death. With restricted water intake, there are trends toward increased risk of dehydration and reduced risk of bronchopulmonary dysplasia, but these trends are not statistically significant. REVIEWER'S CONCLUSIONS: Based on this analysis, the most prudent prescription for water intake to premature infants would seem to be careful restriction of water intake so that physiological needs are met without allowing significant dehydration. This practice could be expected to decrease the risks of patent ductus arteriosus and necrotizing enterocolitis--and perhaps the overall risk of death--without significantly increased risk of adverse consequences.

Neuregulin-1 and human epidermal growth factor receptors 2 and 3 play a role in human lung development in vitro.

The human epidermal growth factor receptor (HER) family consists of four distinct receptors: HER1 (epidermal growth factor receptor), HER2, HER3, and HER4. Their specific activating ligands are collectively known as neuregulins (NRG). We hypothesized that one member of the NRG family, NRG-1, and the HER family would play a role in fetal lung development. To test this hypothesis, we defined NRG-1 and HER gene expression in mid-trimester human fetal lung tissue. HER2 and HER3 messenger RNA and protein were detected in the fetal lung, but HER4 expression was not detected. Immunohistochemical staining of fetal lung tissue localized HER2 and HER3 protein to the developing lung epithelium. NRG-1 expression was not found in freshly isolated human fetal lung, but it was observed in fetal lung explants after 2 d of explant culture. Immunohistochemistry of cultured human fetal lung explants revealed that NRG-1 protein was also expressed in pulmonary epithelial cells. Exposing human fetal lung to recombinant NRG-1 activated the HER receptor complex as measured by approximately 4-fold increases in receptor phosphotyrosine content. In addition, NRG-1 increased explant epithelial cell volume density approximately 2-fold (P < 0. 03); increased epithelial cell proliferation approximately 2-fold, as determined by bromodeoxyuridine labeling (P = 0.002); and reduced surfactant protein-A (SP-A) levels by 53% (P < 0.05). These data are consistent with an autocrine regulatory process mediated by NRG-1 activation of HER2/HER3 heterodimers expressed on developing human fetal lung epithelial cells. Receptor activation results in increased lung epithelial cell proliferation and volume density, and decreased SP-A production, a marker of type II pneumocyte differentiation.

Vascular endothelial growth factor gene expression in human fetal lung in vitro.

Neonatal respiratory function depends on the development of a well-formed pulmonary capillary bed. Vascular endothelial growth factor (VEGF) is a potent inducer of endothelial cell growth and angiogenesis. High levels of VEGF protein and messenger RNA (mRNA) have been detected in the developing lung, suggesting that VEGF plays a role in the development of the pulmonary capillary bed. To begin to understand the role of VEGF in human lung development, we explored the regulation of VEGF gene expression and the localization of VEGF protein and mRNA in a model of the developing human lung. VEGF protein and mRNA were detected in midtrimester human fetal lung tissue, and their levels increased with time in explant culture. VEGF protein and mRNA were increased by the maintenance of human fetal lung explants in 2% O2 environments compared with 20% O2 environments. VEGF mRNA levels were found to be increased by cyclic adenosine monophosphate (cAMP) in explants that were incubated in 20% O2, but not in those incubated in 2% O2. Immunostaining for VEGF protein demonstrated localization primarily in airway epithelial cells in midtrimester human fetal lung tissue. Immunostaining for VEGF increased with incubation of human fetal lung explants in 2% and 20% O2. Interestingly, VEGF protein was localized primarily in the basement membrane subjacent to airway epithelial cells after 4 d of incubation in 20% O2. Incubation of tissues in the presence of dibutyryl cAMP resulted in an increase in immunostaining for VEGF, primarily in the basement membranes of prealveolar ducts in 20% O2-treated tissues. In situ hybridization studies indicated that VEGF mRNA was present in both mesenchymal cells and airway epithelial cells. These data suggest that VEGF gene expression is regulated by both oxygen and cAMP in the developing human lung. The detection of VEGF mRNA and protein in distal airway epithelial cells and the detection of VEGF protein in the basement membrane subjacent to the airway epithelial cells suggest that translocation of VEGF protein occurs after its synthesis in the epithelium. Localization of VEGF to the basement membrane of airway epithelial cells may be important for directing capillary development in the human lung.

Carbohydrate-deficient glycoprotein syndrome type 1 with profound thrombocytopenia and normal phosphomannomutase and phosphomannose isomerase activities.

We report siblings with a variant of carbohydrate-deficient glycoprotein syndrome, type 1 (CDGS1), characterized by normal phosphomannomutase and phosphomannose isomerase activities, severe thrombocytopenia, and respiratory compromise. Each infant died after a course of intensive care, suggesting that infants with CDGS1 and normal phosphomannomutase and phosphomannose isomerase activities may have a more severe CDGS1 phenotype.

Cyclic AMP-dependent protein kinase (PKA) gene expression is developmentally regulated in fetal lung.

We characterized the ontogeny of cAMP-dependent protein kinase (PKA) enzymatic activity and PKA subunit mRNA expression in developing lung. The lungs of fetal Sprague-Dawley rat pups were removed after 16, 18, or 20 days of gestation and at term. PKA activity was greatest in the 18- and 20-day gestation lungs. Tissue cAMP levels were lowest in the 16-day lungs and increased with lung maturity. We were able to detect only low levels of mRNA for the C beta subunit of PKA by northern blot analysis of total lung RNA and we were able to detect mRNA for the RI beta and RII beta subunits only by RT-PCR. Therefore, we limited our analysis of PKA subunit mRNA levels to those for C alpha, RI alpha and RII alpha. The mRNA levels for C alpha, were highest in the 16-day lung, decreased at 18 and 20 days, were lower in the newborn and lowest in the adult lung. RI alpha mRNA levels were also highest at 16 days and lowest in the adult lung. However, RII alpha mRNA levels were similar in the 18-day, 20-day and newborn lungs. Dexamethasone treatment of fetal lung explants resulted in a small decrease in RI alpha mRNA levels but was not associated with a change in PKA activity. We conclude that PKA activity and PKA subunit mRNA expression are developmentally regulated in fetal lung. Such regulation results in optimal PKA activity at the time of type II alveolar cell differentiation, presumably in preparation for air breathing. The absence of an effect of glucocorticoid on PKA activity suggests that glucocorticoids are not responsible for the increase in PKA activity which accompanies this critical time in lung maturation.

O2 regulates surfactant protein A mRNA transcription and stability in human fetal lung in vitro.

The effect of O2 on surfactant protein (SP) A mRNA transcription and half-life was determined in midtrimester human fetal lung tissue cultured in either 20 (control) or 70% O2. Incubation of tissues in 70% O2 resulted in a 133% increase in SP-A mRNA transcription rate compared with control tissues. The SP-A mRNA half-life was increased by 54% in lung tissues cultured in 70% O2 vs. control tissues. Western blot analysis indicated a threefold increase in SP-A in the 70% O2 condition, demonstrating that O2 regulation of SP-A mRNA levels results in corresponding changes in SP-A levels. Primer extension assays were performed to determine whether the observed increase in SP-A mRNA levels is secondary to the preferential expression of one of the human SP-A genes, SP-A1 or SP-A2. Transcripts of both the SP-A1 and SP-A2 genes were increased approximately 100% in tissues maintained in 70% O2 compared with control tissues. These data demonstrate that O2 regulates human SP-A mRNA levels by both transcriptional and posttranscriptional mechanisms. Furthermore, because there is no differential effect of O2 on the expression of SP-A1 vs. SP-A2 mRNA, the properties of these genes that mediate regulation by O2 must be conserved between the two genes.

Oxygen modulates surfactant protein mRNA expression and phospholipid production in human fetal lung in vitro.

We studied the effect of 20-95% O2 on mRNA levels for the surfactant-associated proteins (SP)-A, SP-B, and SP-C and [3H]choline incorporation into total phosphatidylcholine and type II cell-specific disaturated phosphatidylcholine (DPPC) in human fetal lung in culture. SP-A mRNA levels were increased by 25 and 39% in lung explants incubated in 70 and 95% O2, respectively, compared with levels in tissues incubated in 20% O2. SP-B mRNA levels were unaffected by O2, whereas SP-C mRNA levels were increased by 85, 102, and 115% in atmospheres of 35, 50, and 70% O2, respectively. [3H]choline incorporation into total phosphatidylcholine and DPPC were both increased in human fetal lung explants incubated in increased O2 concentrations compared with tissues incubated in 20% O2. Tissue levels of adenosine 3',5'-cyclic monophosphate (cAMP)-dependent protein kinase (PKA) activity were not affected by O2 concentration, implying that the changes observed in SP mRNA levels and [3H]choline incorporation may not be mediated through alterations in PKA enzyme activity. These findings demonstrate that O2 regulates SP mRNA expression and phospholipid production in human fetal lung in vitro. We speculate that surfactant composition and possibly function may be regulated by O2 in human lung.

Oxygen modulates the differentiation of human fetal lung in vitro and its responsiveness to cAMP.

Previously, it was found that lung explants from mid-trimester human abortuses differentiate spontaneously in organ culture in serum-free defined medium in an atmosphere of 95% air-5% CO2. Dibutyryl adenosine 3',5'-cyclic monophosphate (DBcAMP) treatment of human fetal lung in culture increases the rate of morphological differentiation and enhances expression of the surfactant protein A (SP-A) gene. To begin to define the factors responsible for this accelerated in vitro differentiation, we analyzed the effects of atmospheric oxygen on the morphological and biochemical development of human fetal lung in culture and on responsiveness of the cultured tissue to DBcAMP. We found that when lung explants were maintained in an atmosphere containing 1% oxygen they failed to differentiate spontaneously and no induction of SP-A gene expression was apparent. Furthermore, at 1% oxygen, DBcAMP had no effect to stimulate morphological differentiation or SP-A gene expression. When lung tissues that had been maintained for 5 days in 1% oxygen were transferred to an environment containing 20% oxygen, there was rapid morphological development and induction of SP-A gene expression. The effects on morphological development were manifest within 24 h of transfer to the 20% oxygen environment; within 72 h, a marked stimulatory effect of DBcAMP on SP-A gene expression also was observed. Our findings further suggest that the effects of oxygen on the levels of SP-A and SP-A mRNA are concentration dependent. Interestingly, the inductive effects of DBcAMP on SP-A gene expression were apparent only at oxygen concentrations > or = 10%. Morphological differentiation of the cultured human fetal lung tissue also was influenced by oxygen in a concentration-dependent manner. These findings suggest that oxygen plays an important permissive role in the spontaneous differentiation of human fetal lung in vitro.

Developmental and hormonal regulation of surfactant protein A (SP-A) gene expression in fetal lung.

Pulmonary surfactant is a developmentally-regulated lipoprotein synthesized and secreted by the type II cells of the pulmonary alveolus where surfactant glycerophospholipids and proteins act to reduce surface tension at the alveolar air-liquid interface. Surfactant protein A (SP-A), the major surfactant-associated protein, appears to serve an important role in surfactant function and reutilization by type II cells. SP-A synthesis and gene expression are initiated in fetal lung tissue in concert with the developmental induction of surfactant glycerophospholipid synthesis. In studies using midtrimester human fetal lung explants maintained in organ culture, we have observed that cyclic AMP and glucocorticoids have pronounced effects on morphologic development and on the levels of SP-A gene expression. Cyclic AMP analogues act primarily to induce SP-A gene transcription; whereas, glucocorticoids have complex effects at both the transcriptional and posttranscriptional levels. We also have found that human fetal lung in vitro secretes into the culture medium relatively large amounts of prostaglandins (PG) PGE2 and PGF2 alpha and the PGI2 and thromboxane A2 metabolites, 6-keto-PGF1 alpha and TxB2, respectively. The prostaglandin synthesis inhibitor, indomethacin, markedly inhibits SP-A gene expression and cyclic AMP formation by human fetal lung in culture; the inhibitory effect of indomethacin on SP-A gene expression can be prevented by simultaneous incubation with either Bt2cAMP or PGE2. These findings are suggestive that prostaglandins acting through cyclic AMP also may serve an important role in the regulation of SP-A gene expression in human fetal lung tissue.

Prostaglandins regulate surfactant protein A (SP-A) gene expression in human fetal lung in vitro.

We previously have observed that dexamethasone has a biphasic effect on surfactant protein A (SP-A) mRNA levels in human fetal lung in vitro. At concentrations of 10(-10)-10(-9) M, dexamethasone increases the levels of SP-A mRNA, whereas, at concentrations greater than 10(-8) M, the steroid is markedly inhibitory. In studies to define the molecular mechanisms for these effects, we observed that dexamethasone causes a dose-dependent stimulation of SP-A gene transcription, but paradoxically causes a dose-dependent inhibition of SP-A mRNA stability. In light of the well-characterized inhibitory effect of glucocorticoids on prostaglandin (PG) synthesis in a number of tissues, it was our objective in the present study to investigate the role of PGs on SP-A gene expression in human fetal lung in vitro and to determine whether the action of dexamethasone (greater than 10(-8) M) to reduce SP-A mRNA levels could be mediated by its effect to inhibit PG synthesis. We found that dexamethasone 10(-7) M) caused a marked decrease in the secreted levels of the PGE2 and PGF2 alpha, the prostacyclin metabolite, 6-keto-PGF1 alpha, and the thromboxane A2 metabolite, thromboxane B2. Indomethacin, which also caused a pronounced reduction in the levels of these secreted prostanoids, had a marked effect to reduce SP-A mRNA levels in human fetal lung in vitro. The inhibitory effects of indomethacin were associated with an 73% reduction in cAMP formation by the fetal lung in culture, and were prevented by simultaneous incubation with dibutyryl cAMP or with PGE2. PGE2 markedly increased cAMP formation by the human fetal lung tissue incubated in the absence or presence of indomethacin. Inhibitory effects of dexamethasone and indomethacin also were observed on two morphological indices of lung differentiation, alveolar lumenal volume density, and lamellar body volume density. PGE2 significantly increased lumenal volume density of the human fetal lung explants. The finding that the inhibitory action of dexamethasone (10(-7) M) on SP-A mRNA levels could not be prevented by simultaneous incubation with either PGE2 or dibutyryl cAMP and that dexamethasone had no apparent effect on cAMP formation by the fetal lung in vitro is suggestive that the action of dexamethasone (greater than or equal to 10(-8) M) to reduce SP-A mRNA levels is mediated at least in part by actions alternative to its inhibitory effects on PG synthesis.(ABSTRACT TRUNCATED AT 400 WORDS)