Respiratory outcome


Lehtonen L, van Wassenaer-Leemhuis A, Wolke D, Parikka V

Target group

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

User group

Healthcare professionals, neonatal units, hospitals, health services, and follow-up teams

Statement of standard

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


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 adolescence. (5–8) At school age, asthma medication is prescribed in up to one third of children born very preterm. (5,8,9) Respiratory disorders, including wheezing during respiratory infections, has been shown to be the most common reason for rehospitalisation in very preterm infants. (10–12)

Those born smallest or most immature or with more severe pulmonary problems during the first hospitalisation (having a diagnosis of bronchopulmonary dysplasia) are more likely to have later respiratory problems. (7,9,11,13,14) 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.

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) Physical training in childhood is known to improve cardiopulmonary fitness. (22,23).


Short-term benefits

Long-term benefits

  • Improved identification of individuals who require further diagnostic tests or treatment of respiratory conditions (consensus)
  • Reduced risk of rehospitalisations (24)
  • Reduced school absence (25)
  • Reduced number of days of restricted activity (25)
  • Reduced emergency room visits (25)
  • Improved respiratory health (consensus)

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 sheet
2. Parents and children get recommendations for healthy life style by healthcare professionals. (1,2) A (High quality) Parent information sheet
For healthcare professionals    
3. A unit guideline on follow-up including respiratory care is adhered to by all healthcare professionals. B (High quality) Guideline
4. 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. (11,15,16,22) A (High quality)
B (High quality)
Training documentation
For neonatal unit, hospital, and follow-up team    
5. A unit guideline on follow-up including respiratory care is available and regularly updated. B (High quality) Guideline
6. Symptomatic individuals are referred to appropriate paediatric respiratory services for longer term surveillance. B (Moderate quality) Clinical records
7. 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    
8. A national guideline on follow-up including respiratory care is available and regularly updated. B (High quality) Guideline
9. RSV immunisation is available for infants following neonatal bronchopulmonary dysplasia. (26–28) A (Moderate quality) 
B (Moderate quality)
Audit report, guideline

Where to go

Further development Grading of evidence
For parents and family  
For healthcare professionals  
For neonatal unit, hospital, and follow-up team  
A (High quality)
  • Benchmark and make available respiratory outcomes up to adulthood against similar services. (32)
B (Low quality)
For health service  
  • Increase awareness of adverse effects of tobacco use and environmental pollution on respiratory health. (16–18)
A (High quality)
  • Include follow-up information on an electronic healthcare card.
B (Low 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
  • 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.


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  32. National Neonatal Audit Programme (NNAP) | RCPCH [Internet]. [cited 2018 May 25]. Available from:

November 2018 / 1st edition / next revision: 2021

Recommended citation

EFCNI, Lehtonen L, van Wassenaer-Leemhuis A et al., European Standards of Care for Newborn Health: Respiratory outcome. 2018.

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