Neonatal Distress Research Articles

The relationship between providing neonatal palliative care and nurses' moral distress: an integrative review.

Moral distress has been identified in multiple clinical settings especially in critical care areas. The neonatal intensive care unit (NICU) has frequent situations in which moral distress may occur including providing palliative care. The purpose of this integrative review was to determine the relationship between the provision of palliative care in a NICU and nurses' moral distress. The evidence reviewed supports that moral distress does occur with the provision of neonatal palliative care. An interdisciplinary care team, an established protocol, and educational interventions may decrease moral distress in nurses providing end-of-life care to infants in the NICU.

Huge Neck Masses Causing Respiratory Distress in Neonates: Two Cases of Congenital Cervical Teratoma

Congenital cervical teratomas are rare and usually large enough to cause respiratory distress in the neonatal period. We present two cases of congenital huge cystic neck masses in which distinguishing cervical cystic hygroma and congenital cystic teratoma was not possible through radiologic imaging techniques. Experience with the first case, which was initially diagnosed and treated as cystic hygroma by injection sclerotherapy, led to early suspicion and surgery in the second case. The masses were excised completely and histopathologic diagnoses were congenital teratoma in both patients. Our aim is to review congenital huge neck masses causing respiratory distress in early neonatal life to highlight this dilemma briefly with these interesting cases.

Associations between neonatal distress and effortful control in preterm born toddlers: does parenting stress act as a moderator?

Objectives:Self-regulation is a key factor in cognitive and behavioural development. The present work explored the link between neonatal distress and effortful control skills of preterm born toddlers as well as parenting stress as a moderator of this association.Methods:The sample comprised 119 preterm born children without major neurological complications (periventricular leucomalacie, Grade 3 or 4 intraventricular hemorrhage, seizures) or sensory impairment. Assessment involved effortful control (multitask behavioural battery, parent report; 24 months corrected age [CA]), parenting stress (parent-report; 12, 24 months CA), and the number of potentially distressful neonatal intensive care procedures as well as severity of illness during the neonatal period (retrospective chart review).Results:Exposure to a higher number of distressful procedures was related to lower effortful control (behavioural measures only) at the CA of 24 months when adjusting for gestational age, severity of illness and socioeconomic status. In contrast to hypotheses, lower parenting stress did not buffer distress-related effects on effortful control, but independently facilitated the emergence of higher effortful control skills.Conclusion:Findings highlight the role of early adversity for the emergence of self-regulatory difficulties and suggest multiple opportunities for interventions yielding on the promotion of self-regulation in preterm born children.

PC.63 Adherence to NICE guidelines for postnatal observations of neonates delivered in meconium-stained liquor: an audit of practice in maternity units across Kent, Surrey and Sussex

BackgroundThe National Institute of Clinical Excellence (NICE) Guideline on Intrapartum care (2007) advises the duration and type of observations needed on neonates delivered in meconium-stained liquor.AimThis audit investigated current practice...

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Background and aims: High-flow nasal cannula (HFNC) therapy is a treatment for respiratory distress in neonates and children. Aims: The aim the study was to assess the effectiveness of HFCN therapy in a pediatric intensive care unit (PICU). Methods: In this observational study, we included all consecutive patients from 1 month to 18 years of age who were admitted to the PICU in Tepecik Teaching and Research Hospital, Izmir, Turkey and treated with a high-flow nasal cannula between October 1, 2013, and December 31, 2013. The vital parameters, respiratory clinical score (RCS), The Brussels Sedation Scale (BSS) and sPO2/FiO2 ratio were evaluated. Results: A total of 19 patients (median age: 48 month; 1–180 months; male/female: 12/7) were included the study. The indication for HFNC were postextubation (6 cases), asthma (5), bronchiolitis (2), pneumonia (2), pulmonary edema (2), croup syndrome (1), extrapulmonary acute lung injury (1). There were significant improvements in the oxygene saturation, pulse rate, respiratory rate, RCS, BSS and sPO2/FiO2 ratio. Conclusions: The HFCN therapy improves the respiratory parameters and sedation scale in pediatric respiratory distress syndrome. HFCN treatment carries an important role in PICU.

Neonatal outcomes of prenatally diagnosed congenital pulmonary malformations.

Congenital pulmonary malformations (CPM) are mostly recognized on prenatal ultrasound scans. In a minority of cases, they may impair breathing at birth. The factors predictive of neonatal respiratory distress are not well defined, but an understanding of these factors is essential for decisions concerning the need for the delivery to take place in a tertiary care center. The aim of this study was to identify potential predictors of respiratory distress in neonates with CPM. We selected cases of prenatal diagnosis of hyperechoic and/or cystic lung lesions from RespiRare, the French prospective multicenter registry for liveborn children with rare respiratory diseases (2008-2013). Prenatal parameters were correlated with neonatal respiratory outcome. Data were analyzed for 89 children, 22 (25%) of whom had abnormal breathing at birth. Severe respiratory distress, requiring oxygen supplementation or ventilatory support, was observed in 12 neonates (13%). Respiratory distress at birth was significantly associated with the following prenatal parameters: mediastinal shift (P = .0003), polyhydramnios (P = .05), ascites (P = .0005), maximum prenatal malformation area (P = .001), and maximum congenital pulmonary malformation volume ratio (CVR) (P = .001). Severe respiratory distress, requiring oxygen at birth, was best predicted by polyhydramnios, ascites, or a CVR >0.84. CVR >0.84, polyhydramnios, and ascites increased the risk of respiratory complications at birth in fetuses with CPM, and especially of severe respiratory distress, requiring oxygen supplementation or more intensive intervention. In such situations, the delivery should take place in a tertiary care center.

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Background and aims: Respiratory morbidity is an important complication of ECS in term infants. The incidence of respiratory distress was reported in 6% of newborns delivered by ECS, 5 versus 1% in Infants born vaginally. Aims: Our objective was to find out the incidence of respiratory distress in term neonates delivered by elective cesarean section and compare it with neonates delivered vaginally. Methods: Cohort study with prospectively collected data of all the deliveries on mothers with gestational ages between 37 and 40 weeks that were performed in our Hospital from 1 January 2011 to 1 December 2013. Primary outcome measures of neonatal respiratory morbidity included transient tachypnoea of newborn, respiratory distress syndrome, persistent pulmonary hypertension of newborn, serious respiratory morbidity (oxygen therapy for more than two days, nasal continuous positive airway pressure, or need for mechanical ventilation). Results: Compared with newborns intended for vaginal delivery, an increased risk of respiratory morbidity was found for infants delivered by elective caesarean section at 37 +0 weeks’ gestation to 37+6 weeks (odds ratio 3.8, 95% confidence interval 2.4 to 6.5), 38+0 weeks’ gestation to 38+6 weeks (3.0, 2.1 to 4.3), and 39+0 weeks’ gestation (1.9, 1.2 to 3.0). and had higher rates of oxygen supplementation for delivery room resuscitation (41.5%). Conclusions: The odd ratio for neonatal respiratory distress was 3.8, almost fourthfold higher in cesarean section group than those delivered vaginally. When considering elective Caesarean section before 39 weeks of gestation, obstetricians should carefully balance these risks and if feasible avoid the procedure.

Naso-oropharyngeal choristoma (hairy polyps): an overview and current update on presentation, management, origin and related controversies.

This review presents a comprehensive and updated overview of bigerminal choristomas (hairy polyps) of naso-oropharynx/oral cavity, and discusses the controversies related to nosology and origin from a clinico-embryologic perspective. English-language texts of the last 25 years (January 1989-January 2014) were collected from the PubMed/MEDLINE database using the given keywords. Of the 330 records, 64 full-text articles (mostly case reports/series) were selected, incorporating clinical data from 78 patients, after screening through duplicates and the given exclusion criteria. With the available evidence, hairy polyps appear more common than generally believed, and are increasingly being recognized as an important, often-missed cause of respiratory distress and feeding difficulty in neonates and infants. Such a child without any apparent cause should be examined with flexible nasopharyngoscope to specifically look for hairy polyps which might be life-threatening, especially when small. The female preponderance as believed today has been found to be an overestimation in this review. These lesions are characteristically composed of mature ectodermal and mesodermal tissue derivatives presenting as heterotopic masses, hence termed choristoma. However, little is known about their origin, and whether they are developmental malformations or primitive teratomas is debatable. Involvement of Eustachian tube and tonsils as predominant subsites and the speculated molecular embryogenesis link hairy polyps to the development of the first and second pharyngeal arches. They are exceptionally rare in adults, but form a distinct entity in this age-group and could be explained as delayed pluripotent cell morphogenesis or focal neoplastic malformations, keeping with the present-day understandings of the expanded "teratoma family".

Neonatal Empyema Thoracis

Empyema thoracis, is a rare cause of respiratory distress in neonates. Only a few cases of neonatal empyema thoracis are described in medical literature. Empyema thoracis is not a well known entity in the neonates. It is fulminant with rapid progression with a high mortality. Compounding the problem is its uncertain etiopathogenesis and lack of definite treatment guidelines. We shall describe one case of neonatal empyema in a newborn aged five days caused by Pseudomonas aeruginosa. The neonate died subsequently. DOI: http://dx.doi.org/10.3126/jnps.v34i1.8233 J Nepal Paediatr Soc 2014;34(1):65-67

N‐terminal pro‐brain natriuretic peptide in the assessment of respiratory distress in term neonates

N-terminal pro-brain natriuretic peptide (NT-proBNP) is used as a biomarker to differentiate congestive heart failure from lung disease in adults and children. The clinical significance of its use in term neonates has not yet been extensively studied. NT-proBNP level was measured in 62 term neonates admitted for respiratory distress (RD): 38 with congenital heart disease (CHD) and 24 with pulmonary disease. The control group consisted of 28 healthy neonates. Findings of auscultation, chest radiography, Silverman-Anderson score and echocardiography were recorded for each patient. Blood samples for measuring NT-proBNP were collected on admission, when blood sampling was indicated for the clinical management of the newborn. In the control group NT-proBNP was significantly higher during the first week of life compared to the rest of the neonatal period (P < 0.001). The RD group, regardless of etiology, had significantly higher NT-proBNP than the control group (P < 0.001). Neonates with more severe RD had significantly higher NT-proBNP (P = 0.002). No significant difference was found between the RD group with CHD and those with pulmonary disease. Neonates with CHD and myocardial hypocontractility had significantly higher NT-proBNP than those with normal contractility (P = 0.022). Term neonates with RD have significantly higher NT-proBNP than healthy neonates. A single measurement of NT-proBNP level cannot be used as the sole biomarker for distinguishing between cardiac and pulmonary cause of RD in term neonates.

Congenital Lung Malformations: Cause of Respiratory Distress in Neonates

Congenital Lung Malformations: Cause of Respiratory Distress in Neonates

Structure, function and deficiency diseases of lung surfactant protein-c

Pulmonary surfactant is a mixture of lipids and hydrophobic surfactant proteins B (SP-B) and SP-C and hydrophilic proteins SP-A and SP-D. Pulmonary surfactant reduces the surface tension at the air-water interface of the lung alveoli by forming a surface active film. In this way, it prevents alveoli from collapsing and facilitates the process of breathing. SP-C cooperates with SP-B to enhance the surface active properties of surfactant phospholipids. Reports on the association of lung disease with SP-C deficiency have led to new insights into the importance of SP-C for proper surfactant homeostasis. In most animal species the major form of SP-C is a 35-residue peptide chain which contains two thioester-linked palmitoyl groups, giving a total molecular mass of 4.2 kDa. Though t he function of SP-C in vivo remains unclear, but effects of SP-C on the adsorption, spreading, and stability of lipid films at an air ⁄ water interface have been documented in a number of in vitro studies. Genetic disorders disrupting normal surfactant metabolism (surfactant dysfunction disorders) have been recognized in the neonatal and pediatric populations. Although rare, these disorders cause significant mortality and morbidity, including acute respiratory distress and failure in full-term neonates, and interstitial lung disease (ILD) in older infants, children, and adults. The genes involved in these disorders are critical for surfactant production and function in the lung and include SP-C gene ( SFTPC ) besides others . More than 40 mutations in the SFTPC gene have been identified in people with dysfunction of lung surfactant. Mutations in the SFTPC gene result in the reduction or absence of mature SP-C and accumulation of abnormal forms of SP-C, resulting into breathing problems in newborns and onset of breathing difficulties in children and adults. SFTPC gene mutations associated with surfactant dysfunction affect the processing of the SP-C protein. Many of these mutations occur in a region of gene called the BRICHOS domain, which appears to be involved in the processing of SP-C protein. It is not known which of these outcomes causes the symptoms of SP-C dysfunction. Recent reports suggest that abnormally processed SP-C proteins form altered three-dimensional shape and accumulate inside lung cells. These misfolded proteins may trigger a cellular response that results in cell damage and death. Mutations in BRICHOS domain of SP-C have been associated to ER stress, proteasome dysfunction, and apoptosis. This article reviews information on structure and function of SP-C and the associated mutations in SFTPC gene in relation to SP-C deficiency diseases.

Maternal Stress and Pregnancy Outcomes

Aims of the study: To seek for magnitude of stress conditions among pregnant women, the clinical profile of stressed pregnant women and the potential of stress on adverse maternal and perinatal outcomes in Kinshasa. Methods: This is a multicentre 6-month case-control study dealing with consenting women having given birth at 13 biggest maternities of Kinshasa, the capital of DR Congo. Mother-infant pairs were considered cases (obviously stressed women) and controls (light or not stressed women) at the end of data processing according to their perceived stress scores (PSS). Stress events, potential stress factors and maternal general and physical characteristics were registered along with maternal and perinatal outcomes. Odds ratios calculation allowed finding influence of stress on occurrence of adverse outcomes. Results and conclusions: Our study concerned 1082 women whose 57.1% (n = 618) qualified as the stressed. General characteristics found significantly different between stressed and non-stressed women were marital status (the married and widowed more frequent among the stressed), instruction level (the educated more frequent among the stressed), socioeconomic status (the elevated more frequent among the stressed) and religion status (both the traditional and new charismatic more frequent among the stressed). Obstetric risk factors were similar in both groups that were different only according to stress factors, whether emotional (relationships) or pregnancy (preciousness) related. The 3 most prominent stress factors were parent’s death (p 0.000), tension in family (p 0.000) and tension in couple (p 0.003). All expectedly compensating factors appeared significantly more frequent among stressed women. As of organic pregnancy outcomes infection, gastritis, hypertensive disorders and preterm labor were maternal ones significantly more frequent among stressed women. All non-organic outcomes (insomnia and depression) were significantly predominant among stressed women. In offspring, prematurity, low birth weight and perinatal death were significantly dominant among those born to stressed women. Odds ratios calculation showed significant potential of stress conditions on occurrence of all maternal complications but cesarean section. In offspring too, risk of outcomes’ occurrence was enhanced by stress, except for macrosomia and neonatal distress.

Epidural analgesia in labour and neonatal respiratory distress: a case-control study

BackgroundEpidural analgesia is the commonest mode for providing pain relief in labour, with a combination of bupivacaine and fentanyl most often used in practice.ObjectiveTo test whether late-preterm and term neonates...

Group B Streptococcus Exposure and Self-Limited Respiratory Distress in Late Preterm and Term Neonates

Background: Self-limited respiratory distress is a common neonatal respiratory morbidity for which effective treatments are lacking. Supportive care with non-invasive respiratory support is the norm. Animal models suggest that intrapartum exposure to group B Streptococcus (GBS) may cause mild pulmonary hypertension in the neonate, resulting in self-resolving respiratory distress. Treatments for pulmonary hypertension are currently not provided to neonates with self-limited respiratory distress empirically. Objectives: This study examines the hypothesis that the incidence and severity of self-limited respiratory distress are altered by intrapartum exposure to GBS and antibiotic prophylaxis (IAP) in a human population. Methods: This is a 10-year single-center cohort study of retrospective data of late preterm and term neonates diagnosed with self-limited respiratory distress. Multiple logistic models were fitted to examine associations between exposure to GBS and IAP, and markers of self-limited respiratory distress severity. Additional linear regression models were fitted to examine the association between exposure to GBS and IAP, and duration of respiratory support for self-limited respiratory distress. Finally, crude and gestational age-adjusted incidence of self-limited respiratory distress among GBS-exposed and -unexposed infants, as well as the odds of self-limited respiratory distress based on GBS exposure were calculated. Results: 584 neonates met study criteria. Neither GBS exposure nor IAP exposure was associated with severity of self-limited respiratory distress in multiple models. Crude and adjusted incidence of self-limited respiratory distress among neonates did not differ by GBS exposure history. Conclusions: Although animal studies indicate that GBS-mediated pulmonary hypertension may contribute to self-limited respiratory distress, neither exposure to GBS nor IAP was associated with an increased severity or incidence of self-limited respiratory distress in our human study population. Treatments for pulmonary hypertension are unlikely to speed symptom resolution for patients with self-limited respiratory distress.

Founder Mutation inRSPH4AIdentified in Patients of Hispanic Descent with Primary Ciliary Dyskinesia

Primary ciliary dyskinesia (PCD) is a rare, autosomal recessive, genetically heterogeneous disorder characterized by ciliary dysfunction resulting in chronic oto-sino-pulmonary disease, respiratory distress in term neonates, laterality (situs) defects, and bronchiectasis. Diagnosis has traditionally relied on ciliary ultrastructural abnormalities seen by electron microscopy. Mutations in radial spoke head proteins occur in PCD patients with central apparatus defects. Advances in genetic testing have been crucial in addressing the diagnostic challenge. Here, we describe a novel splice-site mutation (c.921+3_6delAAGT) in RSPH4A, which leads to a premature translation termination signal in nine subjects with PCD (seven families). Loss-of-function was confirmed with quantitative ciliary ultrastructural analysis, measurement of ciliary beat frequency and waveform, and transcript analysis. All nine individuals carrying c.921+3_6delAAGT splice-site mutation in RSPH4A were Hispanic with ancestry tracing to Puerto Rico. This mutation is a founder mutation and a common cause of PCD without situs abnormalities in patients of Puerto Rican descent.

Is Epidural Analgesia in Labor Associated with Respiratory Distress in Term and Near-Term Neonates? – A Case-Control Study

Is Epidural Analgesia in Labor Associated with Respiratory Distress in Term and Near-Term Neonates? – A Case-Control Study

Encéphalopathie néonatale: quand évoquer une maladie métabolique héréditaire ?

Inborn errors of metabolism (IEM) are individually rare but collectively numerous. Clinical presentations of IEM should be various, including neonatal encephalopathy mimicking a perinatal asphyxia. The diagnosis of IEM should be considered in all situations of neonatal distress that persist and remain unexplained after usual investigations and the initial treatment. It is essential to do not misdiagnose IEM because this diagnosis may modify therapeutic strategy and prognosis, allow predicting the risk of disease recurrence, and may have medico-legal implications in some cases. Metabolic investigations must be proposed when symptoms cannot easily be attributed to perinatal asphyxia or some other common cause. Diagnosis of IEM should also be considered in situations of consanguinity, or of similar symptoms in siblings. When an IEM is suspected, simple metabolic investigations are helpful to orient diagnosis and treatments. Practically, four conditions may be individualized: neurological distress with lactic acidosis or with multi-organ dysfunction, generalized seizures and neurological distress after a symptom-free period.

Increasing caesarean section rates among low-risk groups: a panel study classifying deliveries according to Robson at a university hospital in Tanzania

BackgroundRising caesarean section (CS) rates have been observed worldwide in recent decades. This study sought to analyse trends in CS rates and outcomes among a variety of obstetric groups at a university hospital in a low-income country.MethodsWe conducted a hospital-based panel study at Muhimbili National Hospital, Dar es Salaam, Tanzania. All deliveries between 2000 and 2011 with gestational age ≥ 28 weeks were included in the study. The 12 years were divided into four periods: 2000 to 2002, 2003 to 2005, 2006 to 2008, and 2009 to 2011. Main outcome measures included CS rate, relative size of obstetric groups, contribution to overall CS rate, perinatal mortality ratio, neonatal distress, and maternal mortality ratio. Time trends were analysed within the ten Robson groups, based on maternal and obstetric characteristics. We applied the χ2 test for trend to determine whether changes were statistically significant. Odds ratios of CS were evaluated using multivariate logistic regression, accounting for maternal age, referral status, and private healthcare insurance.ResultsWe included 137,094 deliveries. The total CS rate rose from 19% to 49%, involving nine out of ten groups. Multipara without previous CS with single, cephalic pregnancies in spontaneous labour had a CS rate of 33% in 2009 to 2011. Adjusted analysis explained some of the increase. Perinatal mortality and neonatal distress decreased in multiple pregnancies (p < 0.001 and p = 0.003) and nullipara with breech pregnancies (p < 0.001 and p = 0.024). Although not statistically significant, there was an increase in perinatal mortality (p = 0.381) and neonatal distress (p = 0.171) among multipara with single cephalic pregnancies in spontaneous labour. The maternal mortality ratio increased from 463/100, 000 live births in 2000 to 2002 to 650/100, 000 live births in 2009 to 2011 (p = 0.031).ConclusionThe high CS rate among low-risk groups suggests that many CSs might have been performed on questionable indications. Such a trend may result in even higher CS rates in the future. While CS can improve perinatal outcomes, it does not necessarily do so if performed routinely in low-risk groups.

A clinical analysis on 13 full-term newborns with acute respiratory distress syndrome

Objective To investigate the risk factors and prevention of acute respiratory distress syndrome (ARDS) in full-term infants.Methods The high-risk factors,chest X-ray manifestations,and treatment process were retrospectively analyzed in 13 full-term newborns diagnosed as neonatal acute respiratory distress syndrome.Results After administration with mechanical ventilation,12 newborns were successfully saved.The remaining one complicated by severe persistent pulmonary hypertension of newborn was dead because of abandoning treatment.Conclusions Prevention should be taken first in fullterm newborns with acute respiratory distress syndrome.We should strictly follow the indications of Cesarean section,grasp correct cardiopulmonary resuscitation of neonatal asphyxia,and avoid neonatal asphyxia.Only early diagnosis and treatment can reduce the mortality rate and improve the cure rate. Key words: Acute respiratory distress syndrome; Full-term; Newborns; Clinical analysis