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A new clinical respiratory distress score for surfactant therapy in preterm infants with respiratory distress

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Abstract

The guidelines for surfactant therapy are largely based on studies done in developed coun1tries wherein the facility infrastructure, patient profile, and clinical practices are different from low- and middle-income countries (LMICs). Though SRT is widely practiced in developing countries, there exists variability in clinical practice. Our objective was to identify the factors which would predict the need of surfactant administration and develop a “clinical respiratory distress (RD) score” for surfactant administration in preterm neonates with respiratory distress. A prospective observational study was conducted in 153 preterm infants (260/7 to 346/7 weeks gestation) with respiratory distress who were managed with CPAP and/or surfactant where indicated. Gestation < 32 weeks, no antenatal corticosteroid (ANS), hypothermia at admission, Apgar score < 3 at 1 minute, and Silverman score > 2 at 2 hours were found to be the significant factors in predicting surfactant requirement in multivariate regression analysis. A seven point scale was developed and categorized into two categories as < 4 and ≥ 4. The sensitivity, specificity, PPV, and NPV were 67%, 87%, 86%, and 68%, respectively, with a cutoff score ≥ 4. The positive likelihood ratio was 5.07 (95% CI 2.71–9.48), and negative likelihood ratio was 0.38 (95% CI 0.28–0.52). The observed rate of surfactant administration was found to be around 32% when the composite score was below four, and the rate increased to almost 86% when the composite score was ≥ 4. The predictive accuracy of the model was subsequently evaluated in a cohort of 56 preterm infants with respiratory distress.. Sensitivity, specificity and positive and negative predictive value during the validation phase were 97%, 73%, 85%, and 94%, respectively. With a composite score less than 4, the observed rate of surfactant administration was 6% (95% CI 1%–28%) as against the model predicted rate of 24%, while with composite score ≥ 4, the observed rate was 85% (95% CI 69%–94%) as against the model predicted rate of 90%.

Conclusion: “Clinical RD score” is a simple score, which can be utilized for decision-making for early surfactant administration for preterm infants (260/7 to 346/7 weeks gestation) with respiratory distress.

Trial Registration: NCT03273764

What is Known:

• Both CPAP and surfactant therapy are effective in management of preterm infants with RDS.

• The efficacy of surfactant replacement therapy is better when it is administered early in the course of disease.

What is New:

• Many of the known risk factors for RDS do not predict surfactant requirement.

• “Composite RD score” comprising of five independent predictors of surfactant requirement with a numeric cutoff may help decide which preterm neonates with respiratory distress need early surfactant administration in low- and middle-income countries.

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Abbreviations

ANS:

antenatal steroid

CI:

confidence interval

CPAP:

continuous positive airway pressure

RD:

respiratory distress

HMD:

hyaline membrane disease

LMIC:

low- and middle-income country

LSCS:

lower segment caesarean section

PIH:

pregnancy induced hypertension

ROC:

receiver operator characteristics

SRT:

surfactant replacement therapy

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Author information

Authors and Affiliations

  1. Department of Neonatology, Institute of Medical Sciences and SUM Hospital, Siksha O Anusandhan University, Bhubaneswar, Odisha, India

    Debasish Nanda

  2. Department of Neonatology, Lady Hardinge Medical College, Kalawati Saran Children’s Hospital and Smt. Sucheta Kriplani Hospital, New Delhi, India

    Sushma Nangia

  3. Newborn Health Knowledge Centre, WHO Collaborating Centre for Training and Research in Neonatal Care, ICMR Centre for Advanced Research in Newborn Health, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India

    Anu Thukral

  4. Epidemiology and Clinical Research Division, National Institute of Malaria Research (NIMR), Indian Council of Medical Research, New Delhi, India

    CP Yadav

Authors
  1. Debasish Nanda
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  2. Sushma Nangia
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  3. Anu Thukral
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  4. CP Yadav
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Contributions

SN conceptualized and designed the study, supervised the collection of and analysis of data, and critically revised and finalized the manuscript; AT participated in the study design and critical revision of the manuscript and helped in statistical analysis; DN participated in the study design, recruited patients, collected data, and drafted the manuscript; CP has done statistical analysis; and all authors approved the final manuscript as submitted.

Corresponding author

Correspondence to Sushma Nangia.

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The authors declare they have no conflicts of interest.

Ethical approval

The study protocol was approved by the institution’s ethics committee. Ethical approval for all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Written informed consent was obtained from the parents of participants included in the study.

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Nanda, D., Nangia, S., Thukral, A. et al. A new clinical respiratory distress score for surfactant therapy in preterm infants with respiratory distress. Eur J Pediatr 179, 603–610 (2020). https://doi.org/10.1007/s00431-019-03530-5

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  • DOI: https://doi.org/10.1007/s00431-019-03530-5

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