Management of Respiratory Distress Syndrome in Preterm Infants In Wales: A Full Audit Cycle of a Quality Improvement Project

Impact of Early Surfactant Administration on Ductus Arteriosus Assessed at 24 h in Preterm Neonates Less than 32 Weeks of Gestational Age

BACKGROUND AND OBJECTIVES

The purpose of this study was to investigate whether early surfactant administration affects the status of ductus arteriosus (DA) in preterm infants ≤ 32 weeks of gestational age (GA) within 24 h of birth.

MATERIALS AND METHODS

It is a prospective study conducted from 1 March 2022 to 31 December 2023 in a tertiary academic center. In-born infants ≤ 32 weeks of gestation (n = 88) were enrolled. The study group was further divided into surfactant (n = 44) and non-surfactant (n = 44) subgroups.

RESULTS

A total of 76% of the preterm infants who received surfactant therapy (RRR = 0.839) recorded an increase in Kindler score at 24 h of life (1 - RR = 1 - 0.24 = 76%). Surfactant administration was significantly associated with decreased pre-ductal diastolic pressure (29.9 mmHg vs. 34.8 mmHg, p = 0.0231), post-ductal diastolic pressure (28.7 mmHg vs. 32.2 mmHg, p = 0.0178), pre-ductal MAP (41.6 mmHg vs. 46.5 mmHg, p = 0.0210), and post-ductal MAP (41.0 mmHg vs. 45.3 mmHg, p = 0.0336). There were no significant changes in ductus arteriosus parameters at 24 h of life.

CONCLUSIONS

Early surfactant administration does not affect the status of ductus arteriosus in preterm infants ≤ 32 weeks of gestational age at 24 h of life.

Curosurf surfactant application on preterm babies with respiratory complications-health-economic benefits

Background

The implementation of surfactant for respiratory syndrome approbates the therapy as a revolutionary method in intensive neonatal therapy and respiratory resuscitation. It is important to investigate the costs of this treatment.

Objective

The aim of the study is to analyze the data by the application of the surfactant Curosurf to preterm babies with respiratory complications and describe the treatment costs, healthcare resource utilization and evaluate economic benefits of surfactant use in the treatment of neonates with respiratory distress syndrome (RDS) and hyaline-membrane disease (HDM).

Methods

A retrospective survey was performed covering 167 babies based on respiratory complications due to preterm birth and the necessity to apply a surfactant therapy. A documentary method was implemented and for each patient, an individual research protocol was filled out - a questionnaire created specifically for the purposes of the study.

Results and discussion

An analysis of the data from the application of CUROSURF was made and the obtained therapeutic results were compared to expenditures for the therapy, short-term therapeutic effect, benefits and consequences of the therapy of preterm newborns with respiratory complications. The application of CUROSURF to babies with RDS resulted in the realization of net savings due to the elimination of the necessity of conducting several diagnostic and therapeutic procedures as well as their duration reduction of hospital stay, thus defining its health-economic benefits.

Conclusions

The models of evaluation of cost effectiveness reveal that the medicinal product is expensive but effective from the aspect of short-term therapeutic results.

Global, Regional and National Trends in the Burden of Neonatal Respiratory Failure and essentials of its diagnosis and management from 1992 to 2022: a scoping review

Neonatal respiratory failure (NRF) is an emergency which has not been examined extensively. We critically synthesized the contemporary in-hospital prevalence, mortality rate, predictors, aetiologies, diagnosis and management of NRF to better formulate measures to curb its burden. We searched MEDLINE and Google Scholar from 01/01/1992 to 31/12/2022 for relevant publications. We identified 237 papers from 58 high-income and low-and middle-income countries (LMICs). NRF prevalence ranged from 0.64 to 88.4% with some heterogeneity. The prevalence was highest in Africa, the Middle East and Asia. Globally as well as in Asia and the Americas, respiratory distress syndrome (RDS) was the leading aetiology of NRF. Neonatal sepsis was first aetiology in Africa, whereas in both Europe and the Middle East it was transient tachypnoea of the newborn. Independent predictors of NRF were prematurity, male gender, ethnicity, low/high birth weight, young/advanced maternal age, primiparity/multiparity, maternal smoking, pregestational/gestational diabetes mellitus, infectious anamneses, antepartum haemorrhage, gestational hypertensive disorders, multiple pregnancy, caesarean delivery, antenatal drugs, foetal distress, APGAR score, meconium-stained amniotic fluid and poor pregnancy follow-up. The NRF-related in-hospital mortality rate was 0.21-57.3%, highest in Africa, Asia and the Middle East. This death toll was primarily due to RDS globally and in all regions. Clinical evaluation using the Silverman-Anderson score was widely used and reliable. Initial resuscitation followed by specific management was the common clinical practice.

CONCLUSION

NRF has a high burden globally, driven by RDS, especially in LIMCs where more aggressive treatment and innovations, preferably subsidized, are warranted to curb its alarming burden.

WHAT IS KNOWN

• Neonatal respiratory failure is a frequent emergency associated with a significant morbidity and mortality, yet there is no comprehensive research paper summarizing its global burden. • Neonatal respiratory failure needs prompt diagnosis and treatment geared at improving neonatal survival.

WHAT IS NEW

• Neonatal respiratory failure has an alarmingly high global burden largely attributed to Respiratory distress syndrome. Low resource settings are disproportionately affected by the burden of neonatal respiratory failure. • Independent preditors of neonatal respiratory failure are several but can be classified into foetal, maternal and obstetrical factors. An illustrative pedagogical algorithm is provided to facilitate diagnosis and management of neonatal respiratory failure by healthcare providers.

Health Economic Studies of Surfactant Replacement Therapy in Neonates with Respiratory Distress Syndrome: A Systematic Literature Review

BACKGROUND

Neonatal respiratory distress syndrome (RDS) is one of the most common problems for preterm infants, and symptoms include tachypnoea, grunting, retractions and cyanosis, which occur immediately after birth. Treatment with surfactants has reduced morbidity and mortality rates associated with neonatal RDS.

OBJECTIVE

The objective of this review is to describe the treatment costs, healthcare resource utilization (HCRU) and economic evaluations of surfactant use in the treatment of neonates with RDS.

METHODS

A systematic literature review (SLR) was performed to identify available economic evaluations and costs associated with neonatal RDS. Electronic searches were conducted in Embase, MEDLINE, MEDLINE In-Process, NHS EED, DARE and HTAD to identify studies published between 2011 and 2021. Supplementary searches of reference lists, conference proceedings, websites of global health technology assessment bodies and other relevant sources were conducted. Publications were screened by two independent reviewers for inclusion and followed the population, interventions, comparators and outcomes framework eligibility criteria. Quality assessment of the identified studies was performed.

RESULTS

Eight publications included in this SLR met all eligibility criteria: three conference abstracts and five peer-reviewed original research articles. Four of these publications evaluated costs/HCRU, and five (three abstracts and two peer-reviewed articles) investigated economic evaluations (two from Russia, and one each from Italy, Spain and England). The main cost drivers and causes of increased HCRU were invasive ventilation, duration of hospitalization and RDS-associated complications. There were no significant differences in neonatal intensive care unit (NICU) length of stay or NICU total costs between infants treated with beractant (Survanta^®), calfactant (Infasurf^®) or poractant alfa (Curosurf^®). However, treatment with poractant alfa was associated with reduced total costs compared with no treatment, continuous positive airway pressure (CPAP) alone or calsurf (Kelisu^®), due to shorter duration of hospitalization and fewer complications. Early use of the surfactant after birth was more clinically effective and cost-effective than late intervention in infants with RDS. Poractant alfa was found to be cost-effective and cost-saving compared to beractant for the treatment of neonatal RDS in two Russian studies.

CONCLUSION

There were no significant differences in NICU length of stay or NICU total costs between surfactants evaluated for treating neonates with RDS. However, early use of surfactant was found to be more clinically effective and cost-effective than late treatment. Treatment with poractant alfa was found to be cost-effective versus beractant and cost-saving compared with CPAP alone or beractant or CPAP in combination with calsurf. Limitations included the small number of studies, the geographic scope of the studies and the retrospective study design of the cost-effectiveness studies.

Inhaled Budesonide in Neonatal Respiratory Distress Syndrome of Near-Term Neonates: A Randomized, Placebo-Controlled Trial

OBJECTIVE

This study evaluates the value of inhaled budesonide (BUD) administration in neonatal respiratory distress syndrome (RDS) cases especially for near-term neonates.

METHODS

A randomized controlled trial involving 120 neonates with respiratory distress, which was diagnosed as RDS, was conducted from July 2016 to March 2018. The neonates studied were divided into 2 groups: group 1 (the inhaled BUD group), consisting of 60 neonates who received BUD (2 mL, 0.25-mg/mL suspension) inhalation, twice daily for 5 days; and group 2 (the placebo group), consisting of 60 neonates with RDS who received humidified distilled sterile water inhalation (2 mL). Downes score, RDS grades, and interleukin 8 (IL-8) levels were monitored and measured on the first and fifth days of incubation.

RESULTS

Statistically significant differences (SSDs) in RDS grades, Downes score, and IL-8 levels on the fifth day of admission were observed between groups 1 and 2 (p = 0.001) and between the first and fifth days of incubation in group 1 (p = 0.001). The SSDs in the duration of hospitalization (p = 0.001) and the number of neonates receiving mechanical ventilation (p = 0.032) were found between both groups.

CONCLUSIONS

Budesonide inhalation is associated with improvements in clinical and laboratory parameters in neonates with RDS.

Single nucleotide vitamin D receptor polymorphisms (FokI, BsmI, ApaI, and TaqI) in the pathogenesis of prematurity complications

The vitamin D receptor (VDR), coded by the VDR gene, plays a pivotal role in executing cellular functions when bound by the active form of vitamin D. Gene polymorphisms in this receptor have been increasingly associated with a heightened state of vulnerability to certain diseases. However, limited data is available concerning the role of VDR gene polymorphisms in preterm infant complications. In 114 premature infants (< 32 weeks gestation) we analyze four single nucleotide VDR polymorphisms (rs2228570 (FokI), rs1544410 (BsmI), rs797532 (ApaI), rs731236 (TaqI)) for their association with respiratory distress syndrome (RDS), intraventricular hemorrhage (IVH), bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC) and retinopathy of prematurity (ROP). The results show that BPD was almost four times more likely in infants with the genotype CC of ApaI (rs7975232) (OR 3.845; p = 0.038). While both BPD and NEC were 2.1 times more likely to occur in preterm infants with the allele C of ApaI (rs7975232) (respectively: OR 2.111 and OR 2.129, p < 0.05). The ApaI VDR polymorphism appears to influence incidence of BPD and NEC in preterm infants. Considering VDR polymorphisms in future genetic investigations, in preterm complications, may prove clinically relevant.

Assessment and comparison of mortality and short-term outcomes among premature infants before and after 32-week gestation: A cross-sectional analysis

BACKGROUND

Prematurity is a major cause of neonatal morbidity and mortality. The aim of this study is to assess the rate of prematurity and determine the mortality rate and short-term outcomes among premature infants admitted at King Abdullah University Hospital (KAUH) in Jordan.

MATERIALS AND METHODS

A retrospective cross-sectional review of all premature infants admitted at KAUH between August 2016 and August 2018 was conducted. Collected data include characteristics, medical interventions, morbidities, mortality, and discharge outcomes. Included infants were divided into two groups: less than 32-week gestation (group 1) and ≥32-week gestation (group 2). The outcomes were compared between both groups and reported accordingly.

RESULTS

Out of 7020 newborns, 1102 were delivered before 37-week gestation, representing a prematurity rate of 15.7%. The mean gestational age and birth weight were 33.8 weeks and 2116 grams respectively. Group 1 comprised 13%. Late preterm infants (gestational age 34 to 36 6/7 weeks) accounted for 74%. The mortality rate was 4.6%. More infants died from group 1 (29% vs. 1.5%, p < 0.05). Group 1 infants had higher rates of respiratory distress syndrome (92% vs. 30%), bronchopulmonary dysplasia (28.4% vs. 1.1%), severe intraventricular hemorrhage (5.9% vs. 0.1%), high-stage retinopathy of prematurity (6.6% vs. 0.2%), necrotizing enterocolitis (9.2% vs. 0%), and sepsis (18.4% vs. 2.1%). At discharge, there was a significant difference in the length of stay, corrected gestational age, and weight in favor of group 2 (p < 0.05).

CONCLUSIONS

Although high rate of prematurity was observed, the majority were late preterm with reassuring outcomes. Compared with >32-week infants, the mortality and short-term complications were more frequent among those born before 32 weeks. Still, the overall mortality rate and risk of morbidities were reasonable. Population-based analysis of the risk factors among the more vulnerable very preterm and extremely premature infants is recommended to better understand the outcomes.

Indications and Clinical Profile of Neonatal Admissions: A Cross-Sectional Descriptive Analysis from a Single Academic Center in Jordan

PURPOSE

To review the indications and clinical profile of neonatal admissions at King Abdullah University Hospital in Jordan.

MATERIALS AND METHODS

We conducted a cross-sectional review of all neonates admitted to the neonatal intensive care unit between September 2016 and September 2018. Collected data include demographic characteristics, indications for admission, morbidities and mortality, and discharge outcomes. Findings were reported among term and preterm infants.

RESULTS

A total of 1444 infants were admitted during the study period of whom 1332 (92.2%) were inborn and 612 (42.4%) were term neonates. Of the 832 preterm infants, 545 were late preterm (34-36 6/7 gestation) and 125 had very low birth weight (˂ 1500 grams); 925 (64%) were born by cesarean section. Respiratory failure of the newborn (41.2%) and prematurity (33.3%) were the main indications for admission among the whole cohort. Maternal prolonged premature rupture of membranes (PROM) was observed in nearly half the admissions of term infants. Hypoxic ischemic encephalopathy (3.2% vs 0.7%, p 0.01) and congenital anomalies (5% vs 1.2%, p 0.03) were more common in term infants. The rate of bronchopulmonary dysplasia was 39% among <28-week and 28% among <32-week premature infants. Sepsis was encountered in 59 infants. The overall mortality rate was 3.8%. Prematurity was the main predisposing factor for mortality (Adjusted OR: 9.9, 95% CI: 3.5, 27.6).

CONCLUSION

The majority of neonatal admissions at our institution are term and late preterm infants delivered by cesarean section. Prematurity, respiratory failure of the newborn, and suspected sepsis due to maternal PROM are the leading causes of admission. The mortality rate is within WHO target to achieve Sustainable Development Goal 3. Population-based studies are needed to make better conclusions that represent the whole Jordanian population. A revisit for the indications of cesarean deliveries may help to improve the neonatal outcomes.