Respiratory outcome

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Authors

Lehtonen L, Leemhuis AG, Wolke D, Parikka V

Click on the image to read the standard in brief.

Target group

Infants born very preterm or those infants with risk factors (see preamble Follow-up & continuing care), parents, and families


User group

Healthcare professionals (including general practitioners), neonatal units, hospitals, health services, and follow-up teams


Statement of standard

Respiratory health is evaluated as part of a follow-up care programme.


Rationale

Infants born very preterm or infants with risk factors are at increased risk of respiratory morbidity, especially an obstructive airway disease, as compared to full term infants. (1–3) Respiratory symptoms occur most frequently during the first two years (4) but persist through school age and into young adult age. (5–9) At school age, asthma medication is prescribed in up to one third of children born very preterm. (5,8,10) Respiratory disorders, including wheezing during respiratory infections, has been shown to be the most common reason for rehospitalisation in very preterm infants. (11–13)

Those born smallest or most immature or with more severe pulmonary problems during the first hospitalisation (having a diagnosis of bronchopulmonary dysplasia (BPD)) are more likely to have later respiratory and cardiovascular problems. (7,10,12,14–16) There are no published studies assessing the efficacy of routine lung function tests in the follow-up of very preterm infants. However, knowing the increased risks it is important to provide clinical respiratory surveillance for all high-risk infants to identify those who need more detailed tests or intervention. In particular, infants with neonatal bronchopulmonary dysplasia should be followed closely to identify those children needing treatment. In addition, their cardiovascular risk should be kept in mind in adulthood, because of a small increase in the risk of ischaemic heart diseases. (16)

Health promotion is important for this group, in particular, parents and families should avoid passive and active exposure to tobacco smoke and where possible environmental pollution (6,9,11,15–21) and they should protect themselves and the whole family with appropriate vaccinations. A reduced exercise capacity is reported in very low birthweight infants and BPD survivors, but a physical activity programme could improve exercise tolerance, exercise capacity and flexibility in preterm children. (22,23)


Benefits

Short-term benefits

N/A

Long-term benefits


Components of the standard

Component

Grading of evidence

Indicator of meeting the standard

For parents and family

  1. Parents and families are informed about and invited by healthcare professionals to attend follow-up programmes including respiratory assessment. (1,2)

A (High quality)
B (High quality)

Patient information sheet1

  1. Parents and children get recommendations for healthy life style and vaccinations by healthcare professionals. (1,2)

A (High quality)

Parent information sheet1

  1. Parents receive individual advice regarding day care attendance. (26)

B (Low quality)

Parent information sheet1

For healthcare professionals (including general practitioners)

  1. A unit guideline on follow-up including respiratory care is adhered to by all healthcare professionals.

B (High quality)

Guideline

  1. Training on the appropriate referral and treatment for high-risk infants with respiratory disease and about health promotion including cessation of household smoking is attended by all responsible healthcare professionals. (12,17,18)

A (High quality)
B (High quality)

Training documentation

For neonatal unit, hospital, and follow-up team

  1. A unit guideline on follow-up including respiratory care is available and regularly updated.

B (High quality)

Guideline

  1. Symptomatic individuals are referred to appropriate paediatric respiratory services for longer term surveillance.

B (Moderate quality)

Clinical records

  1. Training on the appropriate referral and treatment for high-risk infants with respiratory disease and about health promotion including cessation of household smoking is ensured.

B (High quality)

Training documentation

For health service

  1. A national guideline on follow-up including respiratory care is available and regularly updated.

B (High quality)

Guideline

  1. RSV immunisation is available for the infants with high risk for hospitalisation. (27–30) Its use should be suited to the local resources as the cost-effectiveness and long-term benefits are still unclear. (31)

A (High quality) 
A (Low quality)

Audit report2, guideline

1The indicator ‘patient information sheet’ is an example for written, detailed information, in which digital solutions are included, such as web-based systems, apps, brochures, information leaflets, and booklets.

2The indicator ‘audit report” can also be defined as a benchmarking report.


Where to go

Further development

Grading of evidence

For parents and family

N/A

For healthcare professionals

N/A

For neonatal unit, hospital, and follow-up team

A (High quality)

  • Benchmark and make available respiratory outcomes up to adulthood against similar services. (34)

B (Low quality)

For health service

  • Increase awareness of adverse effects of tobacco use and environmental pollution on respiratory health. (18–20)

A (High quality)

  • Include follow-up information on an electronic healthcare card.

B (Low quality)

  • Increase adult physicians’ awareness about the long-term consequences of preterm birth.

B (Moderate quality)


Getting started

Initial steps

For parents and family

  • Parents and families are informed by healthcare professionals about the importance of respiratory health, avoiding exposure to tobacco smoke and promoting a healthy lifestyle.
  • Parents are informed by healthcare professionals about potential signs of respiratory problems.

For healthcare professionals (including general practitioners)

  • Attend training on the appropriate referral and treatment for high-risk infants with respiratory disease and about health promotion including cessation of household smoking.

For neonatal unit, hospital, and follow-up team

  • Develop and implement a unit guideline on follow-up including respiratory care.
  • Develop information material about the need for respiratory assessment as part of follow-up programme and of recommendations for healthy life style for parents.
  • Support healthcare professionals to participate in training on the appropriate referral and treatment for high-risk infants with respiratory disease and about health promotion including cessation of household smoking.

For health service

  • Develop and implement a national guideline on follow-up including respiratory care.
  • Develop ways to keep track of high-risk infants including e-health applications.

  1. Korvenranta E, Lehtonen L, Peltola M, Häkkinen U, Andersson S, Gissler M, et al. Morbidities and hospital resource use during the first 3 years of life among very preterm infants. Pediatrics. 2009 Jul;124(1):128–34.
  2. Greenough A. Long-term respiratory consequences of premature birth at less than 32 weeks of gestation. Early Hum Dev. 2013 Oct;89 Suppl 2:S25-27.
  3. Rusconi F, Gagliardi L. Pregnancy Complications and Wheezing and Asthma in Childhood. Am J Respir Crit Care Med. 2018 Mar 1;197(5):580–8.
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  6. Doyle LW, Adams AM, Robertson C, Ranganathan S, Davis NM, Lee KJ, et al. Increasing airway obstruction from 8 to 18 years in extremely preterm/low-birthweight survivors born in the surfactant era. Thorax. 2017;72(8):712–9.
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  8. Simpson SJ, Logie KM, O’Dea CA, Banton GL, Murray C, Wilson AC, et al. Altered lung structure and function in mid-childhood survivors of very preterm birth. Thorax. 2017;72(8):702–11.
  9. Moschino L, Stocchero M, Filippone M, Carraro S, Baraldi E. Longitudinal Assessment of Lung Function in Survivors of Bronchopulmonary Dysplasia from Birth to Adulthood. The Padova BPD Study. Am J Respir Crit Care Med. 2018 Jul;198(1):134–7.
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  11. Gray D, Woodward LJ, Spencer C, Inder TE, Austin NC. Health service utilisation of a regional cohort of very preterm infants over the first 2 years of life. J Paediatr Child Health. 2006 Jun;42(6):377–83.
  12. Hennessy EM, Bracewell MA, Wood N, Wolke D, Costeloe K, Gibson A, et al. Respiratory health in pre-school and school age children following extremely preterm birth. Arch Dis Child. 2008 Dec;93(12):1037–43.
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  16. Crump C, Howell EA, Stroustrup A, McLaughlin MA, Sundquist J, Sundquist K. Association of Preterm Birth With Risk of Ischemic Heart Disease in Adulthood. JAMA Pediatr. 2019 Aug 1;173(8):736–43.
  17. Doyle LW, Olinsky A, Faber B, Callanan C. Adverse Effects of Smoking on Respiratory Function in Young Adults Born Weighing Less Than 1000 Grams. Pediatrics. 2003 Sep 1;112(3):565–9.
  18. Svanes C. Parental smoking in childhood and adult obstructive lung disease: results from the European Community Respiratory Health Survey. Thorax. 2004 Apr 1;59(4):295–302.
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  23. Mestre NM, Papaleo A, Hidalgo VM, Caty G, Reychler G. Physical Activity Program Improves Functional Exercise Capacity and Flexibility in Extremely Preterm Children With Bronchopulmonary Dysplasia Aged 4–6 Years: A Randomized Controlled Trial. Arch Bronconeumol Engl Ed. 636792192000000000;54(12):607–13.
  24. Razi CH, Cörüt N, Andıran N. Budesonide reduces hospital admission rates in preschool children with acute wheezing. Pediatr Pulmonol. 2017 Jun;52(6):720–8.
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  34. National Neonatal Audit Programme (NNAP) | RCPCH [Internet]. [cited 2018 May 25]. Available from: https://www.rcpch.ac.uk/work-we-do/quality-improvement-patient-safety/national-neonatal-audit-programme-nnap

September 2022 / 2nd edition / previous edition reviewed by Baraldi E and Bonadies L / next revision: 2025


Recommended citation

EFCNI, Lehtonen L, Leemhuis AG et al., European Standards of Care for Newborn Health: Respiratory outcome. 2022.