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Original Investigation
February 3, 2020

Sustained Inflation vs Standard Resuscitation for Preterm Infants: A Systematic Review and Meta-analysis

Author Affiliations
  • 1Division of Neonatology, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 2Division of Neonatology, Department of Pediatrics, Leiden University, Leiden, the Netherlands
  • 3Newborn Research Center, The Royal Women’s Hospital, Melbourne, Victoria, Australia
  • 4Emma Children’s Hospital, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
  • 5Department of Pediatrics, Women and Infants Hospital of Rhode Island, Alpert Medical School of Brown University, Providence
  • 6Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
  • 7Department of Pediatrics, Sidra Medicine, Doha, Qatar
  • 8Department of Pediatrics, Neonatal Intensive Care Unit, Ospedale dei Bambini V.Buzzi ASST-FBF-Sacco, Milan, Italy
  • 9Department of Neuroscience, Psychology, Pharmacology and Child Health, University of Florence, Florence, Italy
  • 10Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 11Division of Biostatistics, Department of Public Health Sciences, University of Virginia, Charlottesville
JAMA Pediatr. 2020;174(4):e195897. doi:10.1001/jamapediatrics.2019.5897
Key Points

Question  Is sustained inflation a more effective intervention than standard intermittent positive pressure ventilation or continuous positive airway pressure for preterm infants who require respiratory support after birth?

Findings  In this systematic review and meta-analysis, sustained inflation was associated with a similar risk of in-hospital mortality compared with standard therapy. Sustained inflation was associated with an increased risk of mortality in the first 2 days compared with standard therapy, and there were no differences in the risk of any other secondary outcomes.

Meaning  These results do not support the use of sustained inflation after birth to improve outcomes for preterm infants.


Importance  Most preterm infants require respiratory support to establish lung aeration after birth. Intermittent positive pressure ventilation and continuous positive airway pressure are standard therapies. An initial sustained inflation (inflation time >5 seconds) is a widely practiced alternative strategy.

Objective  To conduct a systematic review and meta-analysis of sustained inflation vs intermittent positive pressure ventilation and continuous positive airway pressure for the prevention of hospital mortality and morbidity for preterm infants.

Data Sources  MEDLINE (through PubMed), Embase, the Cumulative Index of Nursing and Allied Health Literature, and the Cochrane Central Register of Controlled Trials were searched through June 24, 2019.

Study Selection  Randomized clinical trials of preterm infants born at less than 37 weeks’ gestation that compared sustained inflation (inflation time >5 seconds) vs standard resuscitation with either intermittent positive pressure ventilation or continuous positive airway pressure were included. Studies including other cointerventions were excluded.

Data Extraction and Synthesis  Two reviewers assessed the risk of bias of included studies. Meta-analysis of pooled outcome data used a fixed-effects model specific to rarer events. Subgroups were based on gestational age and study design (rescue vs prophylactic sustained inflation).

Main Outcomes and Measures  Death before hospital discharge.

Results  Nine studies recruiting 1406 infants met inclusion criteria. Death before hospital discharge occurred in 85 of 736 infants (11.5%) treated with sustained inflation and 62 of 670 infants (9.3%) who received standard therapy for a risk difference of 3.6% (95% CI, −0.7% to 7.9%). Although analysis of the primary outcome identified important heterogeneity based on gestational age subgroups, the 95% CI for the risk difference included 0 for each individual gestational age subgroup. There was no difference in the primary outcome between subgroups based on study design. Sustained inflation was associated with increased risk of death in the first 2 days after birth (risk difference, 3.1%; 95% CI, 0.9%-5.3%). No differences in the risk of other secondary outcomes were identified. The quality-of-evidence assessment was low owing to risk of bias and imprecision.

Conclusions and Relevance  There was no difference in the risk of the primary outcome of death before hospital discharge, and there was no evidence of efficacy for sustained inflation to prevent secondary outcomes. These findings do not support the routine use of sustained inflation for preterm infants after birth.

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