Neonatal respiratory distress: potential for prevention MICHAEL J. LEwINs,* MB, CH B, MRCP; JONATHAN M. WHITFIELD,t MB, CH B, FRCP[C]; GRAHAM W. CHANCE,1 MB, FRCP, FRCP[C]
A prospective study was conducted of 100 consecutive admissions to the neonatal intensive care unit of the Hospital for Sick Children, Toronto, of infants with respiratory distress syndrome or transient tachypnea of the newborn. It was found that in l50/o of cases the illness was completely preventable, being the result of unintentionally premature termination of pregnancy. Significant intrapartum asphyxia occurred in 440/0 of the infants in whom respiratory distress syndrome developed. Factors placing the pregnancy at high risk were present antenatally in most cases, and most of the deliveries took place In hospitals without adequate facilities or staff, or both, for the requirements of the infant at and following birth. Une etude prospective a ete menee sur 100 entrees consecutives a l'unite de soins intensifs pour nouveaux-nes du Hospital for Sick Children de Toronto, pour des bebes souffrant du syndrome de detresse respiratoire et de tachypnee transitoire du nouveau-n6. II a 6t6 decouvert que dans 150/0 des cas Ia maladie aurait pu .tre entierement prevenue puisqu'elle etait le resultat d'un arr.t premature non intentionnel de Ia grossesse. Une asphyxie intrapartum significative est survenue chez 440/o des b6bes chez qui le syndrome de detresse respiratoire s'est manifest6. Des facteurs de grossesse a risque eleve etaient presents avant Ia naissance dans Ia plupart des cas, et Ia plupart des accouchements eurent lieu dans des h8pitaux ne disposant pas d'installations ou de personnel adequats pour r6pondre aux exigences de l'enfant au moment de, et apres, Ia naissance.
Respiratory distress syndrome is one of the most frequent causes of death From the division of neonatology, Hospital for Sick Children, Toronto *Present address: Alder Hey Children's Hospital, Eaton Road, Liverpool 12, England tPresent address: Newborn center, Denver Children's Hospital, 1056 E 19th Ave., Denver, CO 80218, USA IPresently coordinator, regional perinatal program, department of pediatrics, University of Western Ontario, London Reprint requests to: Dr. Graham W. Chance, War Memorial Children's Hospital, 392 South St., London, Ont. N6B 1B8
in the newborn and is the most com- retractions and grunting, requiring an mon illness of infants in the neonatal increased concentration of inspired intensive care unit of the Hospital for oxygen, usually to less than 40%, Sick Children in Toronto. Applica- and with a chest roentgenogram tion of current knowledge to routine showing good inflation and perihilar obstetric care can prevent both illness streaking). Each maternal history was oband death due to this syndrome through avoidance of such factors as tained from the transfer form filled inadvertent premature induction of out by the referring hospital as a prelabour, intrapartum asphyxia and requisite of transfer to our unit. Clarineonatal hypoxia, and cold stress. fication and completion of missing Many infants are admitted to our information were carried out by disneonatal intensive care unit with re- cussion with the physician referring spiratory distress that clearly could the infant. The following information have been prevented by the applica- was recorded: the infant's birth weight, Apgar scores and gestational tion of current knowledge. The purpose of the study described maturity (as determined by the scorin this paper was to determine the ing system developed by Dubowitz, frequency of such potentially pre- Dubowitz and Goldberg1), therapy ventable factors in the pathogenesis required in the neonatal period, the of their disease in a series of infants expected date of delivery as estimated admitted consecutively to this unit from the menstrual history, the clinical and laboratory methods used tO with respiratory distress. assess gestational maturity, the mode Patients and methods of delivery, the indications for electThe patients were drawn from all ive delivery, the risk score of the the newborn infants admitted to the pregnancy prior to the onset of neonatal intensive care unit at our labour (retrospectively calculated achospital from Jan. 1, 1978 to Apr. cording to the scoring system of 20, 1978. Our unit is the only neo- Coopland and colleagues2) and levels natal referral centre providing ter- of the clinical facilities and staffing tiary care in metropolitan Toronto; patterns of the referring hospitals it also serves a large part of central (graded according to the recommenand northern Ontario. As such, it re- dations of the American Medical Asceives many of the seriously ill new- sociation and the American Academy born from an annual birth population of Pediatrics3). The data obtained were analysed of approximately 55 000; however, 75% of the infants referred are with the use of Student's t-test and the chi-square test. born in metropolitan Toronto. Included in a detailed prospect- Results ive study were 100 infants admitted Of the 100 infants 77 had respiraconsecutively with respiratory dis- tory distress syndrome and 23 had tress syndrome (defined as respira- transient tachypnea of the newborn; tory distress with retraction of the 15 (19%) of the former and none suprasternal notch and costal margins of the latter died. The requirement and grunting, requiring an increased for therapeutic measures is shown concentration of inspired oxygen, and in Table I. The indications for variwith a typical chest roentgenogram ous modes of therapy were the same showing a reticulogranular appear- as those described in a previous reance and air bronchograms showing port from our unit.4 volume loss) or with transient tachypnea of the newborn (defined as Inappropriate elective delivery In 15 instances elective delivery respiratory distress with tachypnea,
1076 CMA JOURNAL/MAY 5, 1979/VOL. 120
Table I-Therapy required Sr 100 Waite with respiratory distrep
Mode of therapy
**
.DiagnosIs; no. (and .6) of Infants Respiratory Transient tachypnea' (n= 7?) (en 23) 56(75), "' 0 (0)'. 17(U) .1' (4) 2, (3) 22(96)
distress syndrome
Artificial ventll*tlon to#tlnuous postlin airways pressure lncreaetdconcentratleneflpplredoxygen
of the newborn'
ThhlaiY2Memn gestetlonal age, 'birth wsltlit:and Au.r swes of infants In whom respiratory dxatresnyndrometewlopqd, according to antenetal of the pregnancy Antenatal rlsk;mosn *'1'SW Zatreme Low(ns25)IUhh(n=A&'Xn=12) 'Gestatlonal nge (wic) 32.9 *32 ' 31.7 t IS '2 *1.2 t 2.1 ,DhrVv*jlgbt(g)
,i9',**
Appraeete Mhiplwiute
0.2*2.1 4.1*2.3,
At'Ssdmtes
S *04.:
Slgnlflcante' otdlfference, Low v. high, Nt ton. extreme,
i*#W'
*Lowv.high,P
A prospective study was conducted of 100 consecutive admissions to the neonatal intensive care unit of the Hospital for Sick Children, Toronto, of infants with respiratory distress syndrome or transient tachypnea of the newborn. It was found that in l50/o of cases the illness was completely preventable, being the result of unintentionally premature termination of pregnancy. Significant intrapartum asphyxia occurred in 440/0 of the infants in whom respiratory distress syndrome developed. Factors placing the pregnancy at high risk were present antenatally in most cases, and most of the deliveries took place In hospitals without adequate facilities or staff, or both, for the requirements of the infant at and following birth. Une etude prospective a ete menee sur 100 entrees consecutives a l'unite de soins intensifs pour nouveaux-nes du Hospital for Sick Children de Toronto, pour des bebes souffrant du syndrome de detresse respiratoire et de tachypnee transitoire du nouveau-n6. II a 6t6 decouvert que dans 150/0 des cas Ia maladie aurait pu .tre entierement prevenue puisqu'elle etait le resultat d'un arr.t premature non intentionnel de Ia grossesse. Une asphyxie intrapartum significative est survenue chez 440/o des b6bes chez qui le syndrome de detresse respiratoire s'est manifest6. Des facteurs de grossesse a risque eleve etaient presents avant Ia naissance dans Ia plupart des cas, et Ia plupart des accouchements eurent lieu dans des h8pitaux ne disposant pas d'installations ou de personnel adequats pour r6pondre aux exigences de l'enfant au moment de, et apres, Ia naissance.
Respiratory distress syndrome is one of the most frequent causes of death From the division of neonatology, Hospital for Sick Children, Toronto *Present address: Alder Hey Children's Hospital, Eaton Road, Liverpool 12, England tPresent address: Newborn center, Denver Children's Hospital, 1056 E 19th Ave., Denver, CO 80218, USA IPresently coordinator, regional perinatal program, department of pediatrics, University of Western Ontario, London Reprint requests to: Dr. Graham W. Chance, War Memorial Children's Hospital, 392 South St., London, Ont. N6B 1B8
in the newborn and is the most com- retractions and grunting, requiring an mon illness of infants in the neonatal increased concentration of inspired intensive care unit of the Hospital for oxygen, usually to less than 40%, Sick Children in Toronto. Applica- and with a chest roentgenogram tion of current knowledge to routine showing good inflation and perihilar obstetric care can prevent both illness streaking). Each maternal history was oband death due to this syndrome through avoidance of such factors as tained from the transfer form filled inadvertent premature induction of out by the referring hospital as a prelabour, intrapartum asphyxia and requisite of transfer to our unit. Clarineonatal hypoxia, and cold stress. fication and completion of missing Many infants are admitted to our information were carried out by disneonatal intensive care unit with re- cussion with the physician referring spiratory distress that clearly could the infant. The following information have been prevented by the applica- was recorded: the infant's birth weight, Apgar scores and gestational tion of current knowledge. The purpose of the study described maturity (as determined by the scorin this paper was to determine the ing system developed by Dubowitz, frequency of such potentially pre- Dubowitz and Goldberg1), therapy ventable factors in the pathogenesis required in the neonatal period, the of their disease in a series of infants expected date of delivery as estimated admitted consecutively to this unit from the menstrual history, the clinical and laboratory methods used tO with respiratory distress. assess gestational maturity, the mode Patients and methods of delivery, the indications for electThe patients were drawn from all ive delivery, the risk score of the the newborn infants admitted to the pregnancy prior to the onset of neonatal intensive care unit at our labour (retrospectively calculated achospital from Jan. 1, 1978 to Apr. cording to the scoring system of 20, 1978. Our unit is the only neo- Coopland and colleagues2) and levels natal referral centre providing ter- of the clinical facilities and staffing tiary care in metropolitan Toronto; patterns of the referring hospitals it also serves a large part of central (graded according to the recommenand northern Ontario. As such, it re- dations of the American Medical Asceives many of the seriously ill new- sociation and the American Academy born from an annual birth population of Pediatrics3). The data obtained were analysed of approximately 55 000; however, 75% of the infants referred are with the use of Student's t-test and the chi-square test. born in metropolitan Toronto. Included in a detailed prospect- Results ive study were 100 infants admitted Of the 100 infants 77 had respiraconsecutively with respiratory dis- tory distress syndrome and 23 had tress syndrome (defined as respira- transient tachypnea of the newborn; tory distress with retraction of the 15 (19%) of the former and none suprasternal notch and costal margins of the latter died. The requirement and grunting, requiring an increased for therapeutic measures is shown concentration of inspired oxygen, and in Table I. The indications for variwith a typical chest roentgenogram ous modes of therapy were the same showing a reticulogranular appear- as those described in a previous reance and air bronchograms showing port from our unit.4 volume loss) or with transient tachypnea of the newborn (defined as Inappropriate elective delivery In 15 instances elective delivery respiratory distress with tachypnea,
1076 CMA JOURNAL/MAY 5, 1979/VOL. 120
Table I-Therapy required Sr 100 Waite with respiratory distrep
Mode of therapy
**
.DiagnosIs; no. (and .6) of Infants Respiratory Transient tachypnea' (n= 7?) (en 23) 56(75), "' 0 (0)'. 17(U) .1' (4) 2, (3) 22(96)
distress syndrome
Artificial ventll*tlon to#tlnuous postlin airways pressure lncreaetdconcentratleneflpplredoxygen
of the newborn'
ThhlaiY2Memn gestetlonal age, 'birth wsltlit:and Au.r swes of infants In whom respiratory dxatresnyndrometewlopqd, according to antenetal of the pregnancy Antenatal rlsk;mosn *'1'SW Zatreme Low(ns25)IUhh(n=A&'Xn=12) 'Gestatlonal nge (wic) 32.9 *32 ' 31.7 t IS '2 *1.2 t 2.1 ,DhrVv*jlgbt(g)
,i9',**
Appraeete Mhiplwiute
0.2*2.1 4.1*2.3,
At'Ssdmtes
S *04.:
Slgnlflcante' otdlfference, Low v. high, Nt ton. extreme,
i*#W'
*Lowv.high,P
