Timing of onset defines distinct prognostic phenotypes in neonatal ards: a multicenter cohort study

Neonatal acute respiratory distress syndrome (NARDS) is a severe form of lung injury that poses a substantial threat to neonatal survival. This study aims to investigate potential variations in in-hospital mortality rates among NARDS cases based on the timing of disease onset.

This study utilized data from a multicenter retrospective cohort established by the Jiangsu Neonatal Respiratory Failure Collaborative Network. NARDS cases that received tracheal intubation followed by invasive mechanical ventilation (IMV) were divided into the early-onset group (diagnosis within 72 hours after birth, n = 301) and the late-onset group (diagnosis after 72 hours of birth, n = 594) following the NARDS diagnosis.

Late-onset was linked to lower mortality [hazard ratio (HR): 0.69, 95% confidence interval (CI): 0.54-0.90]. After interaction adjustment, the HR derived from Cox regression analysis was 0.44 (95%CI: 0.28-0.70) with an E-value of 3.97. Interaction effect analysis identified an increased risk of death in late-onset NARDS complicated by pulmonary infection. Sensitivity analysis further confirmed the robustness of the results.

This study indicates that infants with late-onset NARDS who require intubation and IMV tend to have a more favorable prognosis, but newborns with concurrent pulmonary infections would have an increased mortality risk.

This is the first study to demonstrate that the timing of onset defines distinct prognostic phenotypes in neonatal acute respiratory distress syndrome (NARDS). We found that late-onset NARDS (developing >72 h after birth) is associated with significantly lower in-hospital mortality compared to early-onset NARDS. Crucially, this survival benefit is substantially attenuated in late-onset cases complicated by pulmonary infection, identifying a new, specific high-risk subgroup requiring heightened clinical vigilance. Our findings establish a simple yet powerful criterion for risk stratification and underscore the clinical heterogeneity within NARDS, paving the way for more tailored management strategies.