Survival of Respiratory Failure within the First 72 Hours in Preterm Infants with Respiratory Distress Based on the Downes Score Assessment

Document Type : Original Article


1 Child Health Laboratory, Faculty of Medicine, Universitas Islam, Bandung, Indonesia. Al-Islam Hospital, Bandung, Indonesia

2 Child Health Laboratory, Faculty of Medicine, Universitas Islam, Bandung, Indonesia Al-Ihsan Regional General Hospital, Bandung, Indonesia

3 Al-Islam Hospital, Bandung, Indonesia

4 Medical Student, Faculty of Medicine, Universitas Islam, Bandung, Indonesia


Background: Respiratory distress in neonates is the most common condition of preterm infants receiving treatment in the neonatal intensive care unit. As a clinical assessment of respiratory distress, the Downes score can predict the risk of respiratory failure. The present study aimed to determine the survival of respiratory failure in the first 72 h in preterm infants with respiratory distress based on the Downes score assessment.
Methods: A prospective cohort survival analysis was performed at three hospitals in Indonesia (Al-Islam Hospital, Bandung, Al-Ihsan Hospital, Bandung, and Cibabat Hospital, Cimahi) from April to July 2021. Subjects were infants aged 28-36 weeks, with respiratory distress based on the Downes score within the first 2, 6, 12, 24, 48, and 72 h after delivery. The analyzed variables included birth weight ([BW], <1500 vs. 1500-2500 g), gestational age ([GA], 28-32 vs. 32-37 weeks), and 5-min APGAR score (<7 vs. >7). Bivariate and multivariate analyses were conducted with Cox regression proportional hazard and the Kaplan-Meier estimate of survival rate was also performed. In addition, the adjusted hazard ratio (aHR) was calculated, and a P-value of less than 0.05 was considered statistically significant.
Results: Of the 89 subjects who met the criteria, 20 (22.47%) experienced respiratory failure. The multivariate analysis including BW (aHR: 1.846, 95%CI: 0.570-5.979, P> 0.05), GA (aHR: 2.273, 95 %CI: 0.697-7.416, P>0.05), and the 5-min APGAR score (aHR: 2.049, 95%CI: 0.811-5.179, P>0.05) estimated the survival rate for respiratory failure at the age of 72 h at 74.7% (standard error: 0.05%).
Conclusion: A GA of <32 weeks, a BW of <1500 g, and the condition of asphyxia simultaneously increased the aHR of respiratory failure, with an estimated survival rate of 74.7%.


  1. Monitoring the Situation of Children and Women CURRENT STATUS + PROGRESS: Neonatal Mortality.; 2018.
  2. Pusdatin Kemkes. Profil kesehatan Indonesaia. 2016.; 2016.
  3. Badan Pusat Statistik. Laporan Survei Demografi dan Kesehatan Indonesia;2017.
  4. Devine S, Taylor G. Every Child Alive: The urgent need to ned newborn death. UNICEF: 2018.; 2018.
  5. Maternal and Newborn Health Disparities in Indonesia.; 2016.
  6. Whitsett J, Rice W, Pryhuber G, Wert S. Acute Respiratory Disorders. In: MacDonald MG, Seshia MMK, penyunting Avery’s neonatology, patho-physiology and management of the newborn. 7th ed. Philadelphia: Wolters Kluwer; 2016. p. 397–415.
  7. Hedstrom AB, Gove NE, Mayock DE, Batra M. Performance of the silverman andersen respiratory severity score in predicting pco2 and respiratory support in newborns: a prospective cohort study. J Perinatol. 2018;38(5):505–11.
  8. Jackson J. Respiratory disorders in the preterm infant. In: Gleason CA, Juul SE Avery’s disease of the newborn. 10th ed. Philadelphia: Elsevier; 2018. p. 653–67.
  9. Goldsmith J, Karotkin E. Introduction to assisted ventilation. In: Goldsmith JP, Karotkin EH Assisted ventilation of the neonates. 5th ed. Missouri: Elsevier Saunders; 2011. p. 1–18.
  10. Gnanaratnem J, Finer NN. Neonatal acute respiratory failure. Curr Opin Pediatr. 2000;12(3):227–32.
  11. Shahidhar A, Pn SR, Jose J. Downes score vs. silverman anderson score for assessment of respiratory distress in preterm newborns. Pediatric Oncall. 2016 ;13(3).
  12. Permatagalih V. Hubungan antara Skor Downes dan Risiko Gagal Napas dalam 72 jam Pertama Kehidupan. [Bandung]: Universitas Padjadjaran; 2019.
  13. Downes JJ, Vidyasagar D, Morrow GM, Boggs TR. Respiratory distress syndrome of newborn infants: i. new clinical scoring system (rds score) with acid-base and blood- gas correlations. Clin Pediatr (Phila). 1970 ;9(6):325–31.
  14. Edwards MO, Kotecha SJ, Kotecha S. Respiratory distress of the term newborn infant. Paediatr Respir Rev. 2013 ;14(1):29–37.
  15. Baseer KAA, Mohamed M, Abd-Elmawgood EA. Risk factors of respiratory diseases among neonates in neonatal intensive care unit of qena university hospital, Egypt. Ann Glob Health. 2020;86(1):22.
  16. Reuter S, Moser C, Baack M. Respiratory distress in the newborn. Pediatr Rev. 2014;35(10):417–29.
  17. Soraisham A, Singhal N. Neonatal respiratory care in resource-limited countries. In: Goldsmith JP, Karotkin EH Assisted ventilation of the neonates. 5th ed. Missouri: Elsevier Saunders; 2011. p. 416–24.
  18. Parappil H, Rahman S, Salama H, Al Rifai H, Parambil NK, El Ansari W. Outcomes of 28+1 to 32+0 Weeks Gestation Babies in Qatar: Finding Facility-Based Cost-Effective Options for Improving the Survival of Preterm Neonates in Low-Income Countries. IJERPH. 2010;7(6):2526–42.
  19. John B, Venkateshwar V, Dagar V. Predictors of Outcome in Neonates with Respiratory Distress. J Nepal Paediatr Soc. 2015;35(1):31–7.
  20. Rusmawati A, Haksari EL, Naning R. Downes score as a clinical assessment for hypoxemia in neonates with respiratory distress. PI. 2016 15;48(6):342.
  21. Holme N, Chetcuti P. The pathophysiology of respiratory distress syndrome in neonates. Pediatrics and Child Health. 2012;22(12):507–12.
  22. Yismaw AE, Gelagay AA, Sisay MM. Survival and predictors among preterm neonates admitted at University of Gondar comprehensive specialized hospital neonatal intensive care unit, Northwest Ethiopia. Ital J Pediatr. 2019;45(1):4.
  23. Chanie ES, Alemu AY, Mekonen DK, Melese BD, Minuye B, Hailemeskel HS, et al. Impact of respiratory distress syndrome and birth asphyxia exposure on the survival of preterm neonates in East Africa continent: systematic review and meta-analysis. Heliyon. 2021;7(6):e07256.
  24. Yehuala S, Ayalew S, Teka Z. Survival analysis of preterm infants admitted to neonatal intensive care unit (nicu) in northwest ethiopia using semi-parametric frailty J Biomet Biostat. 2015;6(1):1–12.