Acute neonatal respiratory distress in Italy: a one-year prospective study. Italian Group of Neonatal Pneumology

Unfavorable influence of prematurity on the neonatal prognostic of small for gestational age fetuses

Vascular stress at the level of the uterus-placental unit, with chronic placental ischemia, results in intrauterine growth restriction. Expectation management can be used, when the situation allows, in cases of compensated intrauterine growth restriction. The aim of the present study was to evaluate the neonatal prognosis of preterm births with and without growth restriction and term births with growth restriction in order to improve decisional accuracy regarding the termination of pregnancy. The frequency of term birth infants with low birth weight for gestational age was ~2%. The male sex, predominated only in the group of premature infants with normal weight for the gestational age. The highest frequency of neonatal complications studied occurred in the group of preterm neonates small for gestational age (SGA) with statistical significance obtained for cardiovascular arrest acute respiratory failure, ulcer-necrotic enterocolitis, respiratory distress, cerebral edema, intraventricular hemorrhage, cerebral hemorrhage, pulmonary hemorrhage, neonatal infection, hypoglycemia, retinopathy, anemia, hemorrhagic disease, disseminated intravascular coagulation, disease of hyaline membranes, neonatal sepsis, need for intensive neonatal therapy and death. In conclusion, immediate neonatal adaptation of SGA preterm neonates is more deficient than for preterm neonates with appropriate weight for gestational age; the adaptation of preterm neonates, in turn, is more deficient than term newborns with intrauterine growth restriction. The term newborns with intrauterine growth restriction have a neonatal adaptation comparable to that of the term newborns with weight corresponding to the gestational age.

Incidence, Risk factors and Outcome of Respiratory Distress Syndrome in Term Infants at Academic Centre, Jeddah, Saudi Arabia

Introduction:

Respiratory distress syndrome (RDS) is a respiratory disorder of neonates that manifests itself within few hours after delivery. It is one of the most common causes of admission to neonatal intensive care unit (NICU) and respiratory failure in neonates.

Aim:

The aim of this study was to determine the incidence, risk factors, and the short-term outcomes of RDS in term infants born in an academic tertiary care center at King Abdul-Aziz University Hospital (KAUH), Jeddah, Saudi Arabia.

Methods:

Data of all infants admitted to the NICU at the academic center between January 1^st 2016 and December 31^st 2016 were retrospectively collected. Cases were all term infants who were admitted to NICU with the diagnosis of RDS during the study period. Controls were term infants and 1:1 matched for the date of birth (one or two days from the date of birth of the case) and received routine newborn care.

Results:

Fifty-nine term infants (59/3601, 1.64%) were admitted to the NICU with RDS and 59 control infants were matched during the study period. Infants with RDS were significantly of lower birth weight and had lower Apgar scores at one and five minutes. Although there was a higher number of cesarean section and PROM in the RDS group, but that didn’t reach statistical significance. Three infants (5.1%) died in the RDS group.

Conclusion:

Respiratory distress in term infants is still a significant cause of admission to NICU and a predisposing factor for neonatal mortality and morbidity. Preventative and anticipatory measures should be further explored to decrease the burden of this disease.

The effect of Sustained Lung Inflation on Outcomes of Acute Respiratory Distress Syndrome in Preterm Infants Born in Shahid Sadoughi Hospital during 2018

Background:Respiratory distress syndrome is the chief reason of death in infants. Sustained lung inflation (SLI) may improve respiratory outcomes and reduce the demand for mechanical ventilation (MV). Given that only few studies have been done in this field so far, the current study aimed to evaluate the effect of SLI on outcomes of acute respiratory distress syndrome in preterm infants. Materials and methods:This randomized trial was conducted on preterm infants with respiratory distress syndrome in Shahid Sadoughi Hospital, Yazd, Iran, during 2018. Data were extracted from medical records. Infants born at 25-30 weeks of gestation were randomized into two groups with an equal number of subjects (n=30) in each one. In group 1 (cases), patients received SLI (25 cm H2O for 15 seconds) and nasal continuous positive airway pressure (nCPAP) (5 cm H2O) after oropharynx and nasal suction. In group 2 (controls), patients received only nCPAP (5 cm H2O). Both nCPAP and SLI and were delivered through a T-piece ventilator and neonatal mask. Results:In the current study, no serious differences were seen between case and control groups in terms of either quantitative parameters, including MV duration, Apgar score in the first minute, duration of oxygen therapy, gestational age, birth weight, nCPAP duration, and duration of hospitalization in NICU (P>0.05), or qualitative variables, including sex, pneumothorax rate, rate of intraventricular hemorrhage, need for mechanical ventilation during the first 72 hours of life, surfactant need, and mortality rate (p>0.05), except in cases of complications (p=0.019). Conclusions:According to the results of the current study, neither nCPAP alone, nor SLI and nCPAP had any effect on the duration, or need, or type of mechanical ventilation, while the incidence of complications in the nCPAP alone group (control group) was higher than that of combined nCPAP + SLI group (case group). It is suggested that future studies should be conducted on a larger sample size.

Incidence of neonatal necrotising enterocolitis in high-income countries: a systematic review

OBJECTIVE

To conduct a systematic review of neonatal necrotising enterocolitis (NEC) rates in high-income countries published in peer-reviewed journals.

METHODS

We searched MEDLINE, Embase and PubMed databases for observational studies published in peer-reviewed journals. We selected studies reporting national, regional or multicentre rates of NEC in 34 Organisation for Economic Co-operation and Development countries. Two investigators independently screened studies against predetermined criteria. For included studies, we extracted country, year of publication in peer-reviewed journal, study time period, study population inclusion and exclusion criteria, case definition, gestation or birth weight-specific NEC and mortality rates.

RESULTS

Of the 1888 references identified, 120 full manuscripts were reviewed, 33 studies met inclusion criteria, 14 studies with the most recent data from 12 countries were included in the final analysis. We identified an almost fourfold difference, from 2% to 7%, in the rate of NEC among babies born <32 weeks' gestation and an almost fivefold difference, from 5% to 22%, among those with a birth weight <1000 g but few studies covered the entire at-risk population. The most commonly applied definition was Bell's stage ≥2, which was used in seven studies. Other definitions included Bell's stage 1-3, definitions from the Centers for Disease Control and Prevention, International Classification for Diseases and combinations of clinical and radiological signs as specified by study authors.

CONCLUSION

The reasons for international variation in NEC incidence are an important area for future research. Reliable inferences require clarity in defining population coverage and consistency in the case definition applied. PROSPERO INTERNATIONAL PROSPECTIVE REGISTER OF SYSTEMATIC REVIEWS REGISTRATION NUMBER: CRD42015030046.

Lung ultrasonography to diagnose meconium aspiration syndrome of the newborn

Objective To investigate the diagnostic value of lung ultrasonography for neonatal meconium aspiration syndrome (MAS). Methods This prospective observational study enrolled patients diagnosed with MAS based on medical history, clinical manifestations and chest X-ray and control newborns without MAS. During ultrasonography, each lung was divided into three regions (front, lateral, and back), using anterior and posterior axillary lines as the boundary. While scanning each region of the lungs, the hand piece was perpendicular or parallel to the ribs. Results This study enrolled 117 newborns with MAS and 100 controls. The main lung ultrasonographic findings in patients with MAS were: (i) pulmonary consolidation with air bronchogram was found in all patients; (ii) pleural line anomalies and the disappearance of the A-line was found in all patients; (iii) atelectasis was found in 19 (16.2%) severe cases, who demonstrated severe massive atelectasis and visible lung pulse; (iv) pleural effusion was found in 16 patients (13.7%); and (v) alveolar-interstitial syndrome or B-line in the non-consolidation area was found in all patients with MAS. Conclusion Ultrasonography can be used routinely to diagnose MAS in an accurate, reliable, convenient, and non-invasive manner.

Common respiratory conditions of the newborn

KEY POINTS

Respiratory distress is a common presenting feature among newborn infants.Prompt investigation to ascertain the underlying diagnosis and appropriate subsequent management is important to improve outcomes.Many of the underlying causes of respiratory distress in a newborn are unique to this age group.A chest radiograph is crucial to assist in diagnosis of an underlying cause.

EDUCATIONAL AIMS

To inform readers of the common respiratory problems encountered in neonatology and the evidence-based management of these conditions.To enable readers to develop a framework for diagnosis of an infant with respiratory distress. The first hours and days of life are of crucial importance for the newborn infant as the infant adapts to the extra-uterine environment. The newborn infant is vulnerable to a range of respiratory diseases, many unique to this period of early life as the developing fluid-filled fetal lungs adapt to the extrauterine environment. The clinical signs of respiratory distress are important to recognise and further investigate, to identify the underlying cause. The epidemiology, diagnostic features and management of common neonatal respiratory conditions are covered in this review article aimed at all healthcare professionals who come into contact with newborn infants.

Genetic Contributions to the Development of Complications in Preterm Newborns

Aim

We aimed to identify specific polymorphisms of genes encoding for vascular endothelial growth factor A (VEGFA), endothelial nitric oxide synthase (eNOS), renin-angiotensin system (angiotensinogen gene [AGT], angiotensinogen type 1 receptor [AGTR1], angiotensin-converting enzyme [ACE]), and heme oxygenase-1 (HMOX-1) in a cohort of preterm infants and correlate their presence with the development of respiratory distress syndrome (RDS) requiring mechanical ventilation (MV), bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH) and retinopathy of prematurity (ROP).

Study Design

We carried out a retrospective study to evaluate the allele frequency and genotype distribution of polymorphisms of VEGFA, eNOS, AGT, AGTR1, ACE, and HMOX-1 in a population of preterm neonates (n=342) with a gestational age ≤28 weeks according to the presence or absence of RDS requiring MV, BPD, IVH, or ROP. Moreover, we evaluated through the haplotype reconstruction analysis whether combinations of the selected polymorphisms are related to the occurrence of RDS, BPD, IVH and ROP.

Results

In our population 157 infants developed RDS requiring MV, 71 BPD, 70 IVH, and 43 ROP. We found that TC+CC rs2070744 eNOS (41.7 vs. 25.4%, p=0.01) and GT+TT rs1799983 eNOS (51.8 vs. 35.2%, p=0.01) polymorphisms are independent risk factors for BPD. Haplotype reconstruction showed that haplotypes in VEGF and eNOS are significantly associated with different effects on RDS, BPD, IVH, and ROP in our population.

Conclusions

We found that TC+CC rs2070744 eNOS and GT+TT rs1799983 eNOS polymorphisms are independent predictors of an increased risk of developing BPD. Haplotypes of VEGFA and eNOS may be independent protective or risk markers for prematurity complications.

Risk factors and prognosis for neonatal sepsis in southeastern Mexico: analysis of a four-year historic cohort follow-up

BACKGROUND

Neonatal sepsis is a worldwide public health issue in which, depending on the studied population, marked variations concerning its risk and prognostic factors have been reported. The aim of this study was to assess risk and prognostic factors for neonatal sepsis prevailing at a medical unit in southeastern Mexico. Thus, we used a historic cohort design to assess the association between a series of neonates and their mothers, in addition to hospital evolution features and the risk and prognosis of neonatal sepsis (defined by Pediatric Sepsis Consensus [PSC] criteria) in 11,790 newborns consecutively admitted to a Neonatology Service in Mérida, Mexico, between 2004 and 2007.

RESULTS

Sepsis was found in 514 of 11,790 (4.3 %) newborns; 387 of these cases were categorized as early-onset (<72 h) (75.3 %) and 127, as late-onset (>72 h) (24.7 %). After logistic regression, risk factors for sepsis included the following: low birth weight; prematurity; abnormal amniotic fluid; premature membrane rupture (PMR) at >24 h; respiratory complications, and the requirement of assisted ventilation, O(2) Inspiration fraction (IF) >60 %, or a surgical procedure. Some of these factors were differentially associated with early- or late-onset neonatal sepsis. The overall mortality rate of sepsis was 9.5 %. A marked difference in the mortality rate was found between early- and late-onset sepsis (p >0.0001). After Cox analysis, factors associated with mortality in newborns with sepsis comprised the following: prematurity; low birth weight; low Apgar score; perinatal asphyxia, and the requirement of any invasive medical or surgical procedure.

CONCLUSIONS

The incidence of neonatal sepsis in southeastern Mexico was 4.3 %. A different risk and prognostic profile between early- and late-onset neonatal sepsis was found.

Effect of antenatal corticosteroids on respiratory morbidity in singletons after late-preterm birth

OBJECTIVE

To evaluate whether neonates born to women who previously had received antenatal corticosteroids and then delivered a late-preterm-birth neonate had less respiratory morbidity compared with those not exposed to antenatal corticosteroids.

METHODS

This is a secondary analysis from a multicenter observational study regarding mode of delivery after previous cesarean delivery. We compared women who received one course of antenatal corticosteroids with unexposed parturients and evaluated various respiratory outcomes among those having a singleton, late-preterm-birth neonate. We controlled for potential confounders including gestational age at delivery, diabetes, mode of delivery, and maternal race.

RESULTS

Five thousand nine hundred twenty-four patients met the inclusion criteria; 550 received steroids and 5,374 did not. In the univariable model, compared with unexposed women, those who received antenatal corticosteroids appeared more likely to have neonates who required ventilatory support (11.5% compared with 8.6%, P=.022), had respiratory distress syndrome (RDS) (17.1% compared with 12.2%, P=.001), developed transient tachypnea of the newborn (12.9% compared with 9.8%, P=.020), or required resuscitation in the delivery room (55.8% compared with 49.7%, P=.007). After controlling for confounding factors, we found no significant differences among the groups regarding all of the above outcomes with an odds ratio for RDS of 0.78 (95% confidence interval, 0.60-1.02) and ventilator support of 0.75 (95% confidence interval, 0.55-1.03).

CONCLUSION

Exposure to antenatal corticosteroids does not significantly affect respiratory outcomes among those with a subsequent late-preterm birth.

A Population-Based Study of Meconium Aspiration Syndrome in Neonates Born between 37 and 43 Weeks of Gestation

The epidemiology of meconium aspiration syndrome (MAS) in term neonates is described in a population-based retrospective study of data recorded for all births from 2000 to 2007 in a French region (Burgundy). Of the 132 884 eligible term newborns, the rate of meconium-stained amniotic fluid (MSAF) was 7.93%. The prevalence of severe MAS was 0.067% in the overall population. MAS rate was 0.11% at 37-38 weeks of gestation (WG), 0.20% at 39–41 WG, and 0.49% at 42-43 WG. Factors independently associated with severe MAS were identified by a case-control study, that is, thick meconium amniotic fluid, fetal tachycardia, Apgar score ≤3 at 1 minute, and birth in a level III facility. Our results confirm the high prevalence of MSAF after 37 WG but also show the low frequency of severe MAS in a period corresponding to the new international recommendations on the management of birth with MSAF.

Case-control study of respiratory dynamic compliance in mechanically ventilated near-term newborns in a pre-hospital setting

PURPOSE

To determine the threshold value between normal or decreased dynamic compliance (Cdyn) in ventilated near-term newborns.

METHODS

A case control study was performed during pediatric transport. Controls were newborns without pulmonary disease (group 1; n = 30) and cases were newborns with respiratory distress syndrome, the paradigm of decreased Cdyn (group 2; n = 30). All consecutive newborns of more than 34 weeks' gestation and less than 5 days of life, intubated and ventilated with Babylog 8,000 plus (Dräger, Lübeck, Germany) were included from February 2008 to June 2010. Newborns were assigned to groups 1, 2, or 3 (other patients with disease where the compliance is not easily predictable) by two physicians, using predefined criteria. Cdyn was as measured by the ventilator in spontaneous mandatory ventilation mode with less than 15% leaks.

RESULTS

One hundred and twelve newborns were included in the study. In the multivariate analysis, the groups of diseases and height were statistically associated with Cdyn (p < 0.001). The receiver operating characteristic curve of Cdyn corrected for height constructed with group 1 and 2 newborns yielded a cutoff value of 2.02 mL/mbar/m with a sensitivity of 100% (95% confidence interval [100-100%]) and a specificity of 96% (95% confidence interval [90-100%]) to differentiate between group 1 and 2 newborns.

CONCLUSION

Ventilator-measured dynamic compliance can differentiate normal and decreased compliance in near-term newborns of more than 34 weeks' gestation in the clinical setting.

Controversy: antenatal steroids

There is no controversy that women at risk of preterm delivery before 32 to 34 weeks' gestational age should be treated with antenatal steroids. Three recent meta-analyses by the Cochrane Collaboration on the benefits of antenatal steroids, the choice of steroid and dosing, and repeat doses of corticosteroids comprehensively summarize the available clinical information to about 2007. However, there are many unanswered questions about which steroid and dose to use and about their use in selected populations. This review focuses on those areas of uncertainty.

Precursors for late preterm birth in singleton gestations

OBJECTIVE

To characterize precursors for late preterm birth in singletons and incidences of neonatal morbidities and perinatal mortality by gestational age and precursor.

METHODS

Using retrospective observational data, we compared 15,136 gestations born late preterm with 170,593 deliveries between 37 0/7 and 41 6/7 weeks. We defined the following categories of precursors for late preterm delivery: "spontaneous labor," "premature rupture of the membranes (preterm PROM)," "indicated" delivery, and "unknown." Incidences of neonatal morbidities were calculated according to category of precursor stratified by gestational age at delivery. Neonatal morbidities and mortality associated with potentially avoidable deliveries (eg, "soft" precursors or elective) were compared between late preterm births and neonates born at 37-40 weeks.

RESULTS

Late preterm birth comprised 7.8% of all births and 65.7% of preterm births. Percentages of precursors were 29.8% spontaneous labor, 32.3% preterm PROM, 31.8% "indicated" (obstetric, maternal, or fetal condition), and 6.1% unknown. Different precursors for delivery were associated with varying incidences of neonatal morbidity. One in 15 neonates delivered late preterm for "soft" or elective precursors, and neonatal morbidity and mortality were increased compared with delivery at or after 37 weeks for these same indications.

CONCLUSION

A significant number of late preterm births were potentially avoidable. Elective deliveries should be postponed until 39 weeks of gestation.

LEVEL OF EVIDENCE

II.

Respiratory morbidity in late preterm births

CONTEXT

Late preterm births (340/7-366/7 weeks) account for an increasing proportion of prematurity-associated short-term morbidities, particularly respiratory, that require specialized care and prolonged neonatal hospital stays.

OBJECTIVE

To assess short-term respiratory morbidity in late preterm births compared with term births in a contemporary cohort of deliveries in the United States.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective collection of electronic data from 12 institutions (19 hospitals) across the United States on 233,844 deliveries between 2002 and 2008. Charts were abstracted for all neonates with respiratory compromise admitted to a neonatal intensive care unit (NICU), and late preterm births were compared with term births in regard to resuscitation, respiratory support, and respiratory diagnoses. A multivariate logistic regression analysis compared infants at each gestational week, controlling for factors that influence respiratory outcomes.

MAIN OUTCOME MEASURES

Respiratory distress syndrome, transient tachypnea of the newborn, pneumonia, respiratory failure, and standard and oscillatory ventilator support.

RESULTS

Of 19,334 late preterm births, 7055 (36.5%) were admitted to a NICU and 2032 had respiratory compromise. Of 165,993 term infants, 11,980 (7.2%) were admitted to a NICU, 1874 with respiratory morbidity. The incidence of respiratory distress syndrome was 10.5% (390/3700) for infants born at 34 weeks' gestation vs 0.3% (140/41,764) at 38 weeks. Similarly, incidence of transient tachypnea of the newborn was 6.4% (n = 236) for those born at 34 weeks vs 0.4% (n = 155) at 38 weeks, pneumonia was 1.5% (n = 55) vs 0.1% (n = 62), and respiratory failure was 1.6% (n = 61) vs 0.2% (n = 63). Standard and oscillatory ventilator support had similar patterns. Odds of respiratory distress syndrome decreased with each advancing week of gestation until 38 weeks compared with 39 to 40 weeks (adjusted odds ratio [OR] at 34 weeks, 40.1; 95% confidence interval [CI], 32.0-50.3 and at 38 weeks, 1.1; 95% CI, 0.9-1.4). At 37 weeks, odds of respiratory distress syndrome were greater than at 39 to 40 weeks (adjusted OR, 3.1; 95% CI, 2.5-3.7), but the odds at 38 weeks did not differ from 39 to 40 weeks. Similar patterns were noted for transient tachypnea of the newborn (adjusted OR at 34 weeks, 14.7; 95% CI, 11.7-18.4 and at 38 weeks, 1.0; 95% CI, 0.8-1.2), pneumonia (adjusted OR at 34 weeks, 7.6; 95% CI, 5.2-11.2 and at 38 weeks, 0.9; 95% CI, 0.6-1.2), and respiratory failure (adjusted OR at 34 weeks, 10.5; 95% CI, 6.9-16.1 and at 38 weeks, 1.4; 95% CI, 1.0-1.9).

CONCLUSION

In a contemporary cohort, late preterm birth, compared with term delivery, was associated with increased risk of respiratory distress syndrome and other respiratory morbidity.

Caesarean route of delivery and hyaline membrane disease: a hospital-based case-control study in Greater Beirut

A hospital-based case-control study was conducted to examine the relationship between hyaline membrane disease (HMD) and caesarean route of delivery, in light of sociodemographic, obstetric and perinatal confounders and risk modifying factors. The study population consisted of 78 HMD cases and a control group of 803 infants delivered at 25-36 weeks' gestation and admitted over a 16-month period to nine hospitals in Greater Beirut, Lebanon. The likelihood of delivery by caesarean section was nearly twice as high among newborn infants diagnosed with HMD as compared with the non-HMD control group (OR = 2.02, [95% CI 1.04, 3.92], after adjusting for fetal growth ratio, one-minute Apgar score, maternal age, antenatal steroid administration and pregnancy-related complications. The impact of caesarean section on HMD was considerably more important in infants delivered < or = 32 weeks' gestation (OR = 2.10, [95% CI 0.79, 5.52]) as compared with those delivered afterwards (OR = 1.13, [95% CI 0.40, 3.21]).