Anika Kamisetty

Background:  Neonatal respiratory distress syndrome (RDS) is one of the leading causes of morbidity and mortality for premature infants in low-income and middle-income countries (LMICs)^1,6. RDS is due to deficiency in surfactant formation in premature lungs and is responsible for around 45% of preterm newborn deaths in some LMICs. Implementation of interventions commonly seen in high-income countries, including surfactant therapy, antenatal corticosteroids, and non-invasive respiratory support is hampered by cost and resource limitations⁵. This review discusses the gaps in the availability of necessary treatment equipment as well as the need for improvement in effective diagnostic tools.

Methods: PubMed searches included terms “resource-limited RDS”, “Innovations in RDS”, and “neonatal RDS” published 2019-2025.

Results: Numerous studies show high mortality rates associated with RDS in LMICs. In these settings, preterm births occurring before 28 weeks of gestation have a mortality rate of around 90%, whereas in high-income countries (HICs), this number drops to below 10%. Outcomes are even worse when compounded by comorbidities such as sepsis (82%), hypothermia (74%), and apnea (21.5%), making the management of RDS increasingly complex¹.  Interventions such as nurse training on standardized assessment tools (e.g., Silverman and Andersen score) have improved the accuracy of respiratory distress grading. This allows healthcare providers to better allocate resources, avoiding the waste of one-time use products³. The introduction of bubble continuous positive airway pressure (bCPAP) in rural hospitals has demonstrated relatively accurate pressure, oxygen delivery, and adequate humidification in simulated models. The newest bCPAP technology provides these results without the use of electricity, making them even more suitable for LMICs^2,4. Despite these advancements, significant barriers remain. Limited access to surfactant therapy, unreliable oxygen supply, inadequate heated humidification, and the ongoing need for staff training continue to hinder progress⁶. Surfactant replacement therapy combined with bCPAP can increase survival rates by 33% as opposed to the bCPAP on its own⁵. Additionally, bCPAP effectiveness is impacted by device variability, nasal injury risks, and challenges in implementation and monitoring⁴.

Conclusions: Although there is an introduction of new methods such as bCPAP and nurse training in neonatal care, RDS continues to have high neonatal mortality in LMICs due to systemic gaps in resources, training, and technology⁴. Research in LMICs remains limited despite the devastating mortality rate, emphasizing the urgent need for more focused trials. The research should focus on expanding access to respiratory devices and associated care to ensure life-saving interventions reach the most vulnerable infants in resource-limited settings.

Work Cited:

1. Bacha LT, Hailu WB, Geta ET. Clinical outcome and associated factors of respiratory distress syndrome among preterm neonates admitted to the neonatal intensive care unit of Adama Hospital and Medical College. SAGE Open Med. 2022;10:1-9. doi:10.1177/20503121221146068
2. Barker GA. The use of neonatal bubble Continuous Positive Airway Pressure in a rural hospital setting. N Z Med J. 2023;136(1584):67-72.
3. Cavallin F, Balestri E, Calia M, et al. Training on the Silverman and Andersen score improved how special care unit nurses assessed neonatal respiratory distress in a low-resource setting. Acta Paediatr. 2022;111(9):1866-1869. doi:10.1111/apa.16450
4. Dundek ML, Ng EK, Brazil AM, DiBlasi RM, Poli JA, Burke TF. Evaluation of a bubble CPAP system for low resource settings. Respir Care. 2021;66(10):1572-1581. doi:10.4187/respcare.08948
5. Ekhaguere OA, Okonkwo I, Batra M, Hedstrom E. Respiratory distress syndrome management in resource limited settings—Current evidence and opportunities in 2022. Front Pediatr. 2022;10:961509. doi:10.3389/fped.2022.961509
6. Koum Besson ES, Norris M, Ghazaryan L, et al. Infant and neonatal mortality during the Covid-19 pandemic: an interrupted time series analysis from five low- and middle-income countries. PLoS Med. 2023;20(8):e10441505. doi:10.1371/journal.pmed.10441505