Risk Factors For Development Of Transient Tachypnea Of .
Risk factors for development of transient.Ghaith W. HamdoonRisk factors for development of transient tachypnea of newbornsGhaith W. HamdoonDepartment of Pediatrics, College of Medicine, University of Mosul, Mosul, Iraq.Correspondence: Ghaith W. Hamdoon. drsabaweemosul@yahoo.com.(Ann Coll Med Mosul 2018; 40 (1): 15-19).ndthReceived: 2 Oct. 2013; Accepted: 19 Mar. 2014.ABSTRACTBackground: Transient tachypnea of the newborn (TTN) is a frequently encountered form of neonatalrespiratory distress. The underlying mechanism involves residual lung fluid that is delayed in clearance. TTNprimarily occurs soon after birth and can last from 24 to 72 hours. Risk factors for TTN include electivecesarean section, male sex, late prematurity, low birth weight, macrosomia, polycythemia, maternal asthmaand maternal diabetes. Treatment is often supportive with observation and potential oxygensupplementation.Objective: To identify the risk factors associated with development of transient tachypnea of newborns whowere delivered either normally or through cesarean section, at 36 weeks or beyound and to compare theresults with those of others.Patients and methods: This is a case -control study of 200 newborns suffering from respiratory distressduring a period from the 1st of September 2011 to the 1st of September 2013 in the neonatal intensive careunit at AL-Kansaa Teaching hospital in Mosul. The perinatal history of newborns was analyzed. TTN wasdiagnosed on clinical basis and by exclusion of other diseases affecting the respiratory system includingsepsis. The study included 200 healthy newborns as control.Results: Multivariate analysis identified that the development of TTN was significantly associated withelective cesarean section 56% (p-value 0.001), male sex 66.5% (p- value 0.001), late prematurity 21% (pvalue 0.009), maternal diabetes 8% (P-value 0.014), maternal asthma 10.5% (p-value 0.01), birth asphyxia(low APGAR score) 9.5% (p-value 0.005), low birth weight 16.5% (p-value 0.003), prolonged labor or using(forceps or vacuum) 22% (p-value 0.037) and in vitro fertilization 2.5% (p-value 0.024).Conclusion: Transient tachypnea of newborns is strongly related to elective cesarean section, male sex,late prematurity, maternal diabetes, maternal asthma, birth asphyxia, low birth weight (1500-2500g),prolonged labor or using forceps or vacuum and in vitro fertilization.Keywords Transient tachypnea of newborn, elective cesarean section, low gestational weight, in vitrofertilization. ΓΩϻϭϟ ϲΛϳΩΣϟ ϝΎϔρϸϟ Εϗ ϣϟ αϔϧΗϟ ωέΎγΗ ΕϻΎΣ ϭηϧϟ ΓέϭρΧ ϥϭΪϤΣ ΡΎοϭ ΚϴϏ ϕ ήόϟ ˬϞλϮϤϟ ˬϞλϮϤϟ ΔόϣΎΟ ˬΐτϟ ΔϴϠϛ ˬϝΎϔρϻ ΐρ ωήϓ ΔλϼΨϟ ϝΎϔρϸϟ βϔϨΘϟ ήδϋ ΕϻΎΣ Ϧϣ ΰΠϛ Δό Ύθϟ ΕϻΎΤϟ Ϧϣ ΓΩϻϮϟ ϲΜϳΪΤϟ ϝΎϔρϸϟ ΖϗΆϤϟ βϔϨΘϟ ωέΎδΗ ΕϻΎΣ ήΒΘόΗ ΔϴϔϠΨϟ ϝΎϔρϸϟ ΖϗΆϤϟ βϔϨΘϟ ωέΎδΗ ΕϻΎΣ Ύϴ ΪΒϣ ˬ ϲ ϘΒΘϤϟ Δ ήϟ Ϟ Ύγ Δϟ ί· ήΧ Η ϦϤ πΘ Η ν ήϣϷ ϢϠ όϟ ΔϴΘΤΘϟ Δϴϟϵ ΓΩϻϮϟ ϲΜϳΪΤϟ ΓέϮτΨϟ Ϟϣ Ϯϋ ΔϋΎγ ϥϮόΒγϭ ϥΎϨΛ· ϰϟ· ϥϭήθϋϭ ΔόΑέ Ϧϣ ϕήϐΘδΗ ϥ ϦϜϤϣϭ ΓΩϻϮϟ ΪόΑ ΓήηΎΒϣ ΙΪΤΗ ΓΩϻϮϟ ϲΜϳΪΤϟ ϮΑήϟ ΕϻΎΣϭ ˬέϮϛάϟ ϭ ΔϳέΎϴΘΧϹ ΔϳήμϴϘϟ ΕΎϴϠϤόϟ Ϧϣ ϼϛ ϞϤθΗ ΓΩϻϮϟ ϲΜϳΪΤϟ ϝΎϔρϸϟ ΖϗΆϤϟ βϔϨΘϟ ωέΎδΗ ΕϻΎΤϟ ΕΎϬϣϸϟ ϱήϜδϟ Ω ΕϻΎΣ ˬΔϠϴϠϘϟ ϥ ίϭϷ Ε Ϋ Ε ΩϻϮϟ ϭ ˬήϴΒϜϟ ϢΠΤϟ ϭΫ ΞϳΪΨϟ ˬϱΩϻϮϟ ϕΎϨΘΧϹ ΕϻΎΣ ˬΕΎϬϣϸϟ ϲΒμϘϟ ΔΟΎΤϟ ϊϣ Ϟϔτϟ ΔΒϗ ήϣϭ ΔόΑΎΘϤϟ ϯϮγ ΝΎΘΤϳϻ ΕϻΎΤϟ ϩάϫ Νϼϋ ϲϋΎϨμϟ ΏΎμΧϹ ήϴΧ ϭ ΓήδόΘϤϟ Ε ΩϻϮϟ ΕϻΎΣϭ ϥΎϴΣϷ ξόΑ ϲϓ ϦϴΠϴδϛϭϷ ϝΎϤόΘγϹAnn Coll Med Mosul June 2018 Vol. 40 No. 115
Ghaith W. HamdoonRisk factors for development of transient. Ϧϋ Ϯγ ΎΜϳΪΣ ϦϳΩϮϟϮϤϟ ϝΎϔρϷ ϯΪϟ ΔΘϗΆϤϟ βϔϨΘϟ ωέΎδΗ ΔϟΎΤϟ ΓέϮτΨϟ Ϟϣ Ϯϋ κϴΨθΗ Ϯϫ Δγ έΪ ϟ ϩάϫ ϑΪϫ ϥ· ϑΪϬϟ ϯήΧϷ ΙϮΤΒϟ Ξ ΎΘϧ ϊϣ ΚΤΒϟ Ξ ΎΘϧ ΔϧέΎϘϣϭ ΔϳήμϴϘϟ ΓΩϻϮϟ ϭ ΔϴόϴΒτϟ ΓΩϻϮϟ ϖϳήρ ΎδϨΨϟ ϰϔθΘδϣ ϲϓ ΝΪΨϟ ΓΪΣϭ ϲϓ Ύϫ ήΟ· ϢΗ Ϊϗϭ ΎϬϴϠϋ ΪϫΎθϟ ϭ ΔϨϴόϟ Δγ έΩ ϲϫ Δγ έΪϟ ϩάϫ ΚΤΒϟ ΔϘϳήρϭ ΔϨϴϋ έΎϴΘΧ· ϢΗ ΚϴΣ ϝϮϠϳ Ϧϣ ϝϭϷ ϰΘΣϭ ϝϮϠϳ ήϬη Ϧϣ ϝϭϷ Ϧϣ ΪΘΑ· ΓήΘϔϠϟϭ ϞλϮϤϟ ϲϓ ϝΎϔρϸϟ ϲϤϴϠόΘϟ ˬβϔϨΘϟ ήδόΑ ϢϬΘΑΎλϹ ΝΪΨϟ ΓΪΣϭ ϰϟ· ϮϠΧΩ ήΜϛ ϓ ωϮΒγ ϥϮΛϼΛϭ ΔΘγ ϢϫέΎϤϋ ϦϴδϨΠϟ ϼϛ Ϧϣ ΓΩϻϮϟ ΚϳΪΣ Ϟϔρ Ϧϣ ˬϲϋΎόθϟ ήϳϮμΘϟ ϡ ΪΨΘγΈΑϭ ΎϳήΒΘΨϣϭ ξϳήϤϠϟ Δϳήϳήδϟ ν ήϋϷ ϰϠϋ ΪϤΘόϣ ΖϗΆϤϟ βϔϨΘϟ ωέΎδΗ ΔϣίϼΘϣ κϴΨθΗ ϥΎϛϭ Ϟϔρ Ϧϣ ΔϧϮϜϣ ϯήΧ ΔϨϴϋ άΧ ϢΗϭ ϲΠϤΨϟ ϡΪϟ ϢϤδΗ ΕϻΎΣϭ ϯήΧϷ ΔϴδϔϨΘϟ ν ήϣϷΎΑ ξϳήϤϟ ΔΑΎλ· ΩΎόΒΘγ · ϢΗϭ ΔϧέΎϘϤϟ ϞΟ Ϧϣ ϲη ϱ Ϧϣ ϥϮϧΎόϳ ϻϭ ΎΤλ ΓΩϻϮϟ ΚϳΪΣ ϥ Α ϦϴΒΗ ΎϬϠϴϠΤΗϭ ΕΎϣϮϠόϤϟ ϥΎϴΒΘγ·ϭ ΎΤλϷ ϝΎϔρϷΎΑ ΎϬΘϧέΎϘϣϭ ϰοήϤϟ Ϧϣ ΔϨϴόϟ ϚϠΗ ϰϠϋ Δγ έΪϟ ήΟ· ϢΗ ϥ ΪόΑ Ξ ΎΘϨϟ ˬΙΎϧϹ ϥϭΩ Ϧϣ έϮϛάϟ ϭ ˬ ΔϳέΎϴΘΧϹ ΔϳήμϴϘϟ ΕΎϴϠϤόϟΎΑ ΎρΎΒΗέ· Ϊη ϥΎϛ ΖϗΆϤϟ βϔϨΘϟ ωέΎδΗ ΕϻΎΣ ΙϭΪΣ ϭ ́ ΕΎϬϣϷ ϯΪϟ ϲΒμϘϟ ϮΑήϟ ϭ ϱήϜδϟ Ω ΕϻΎΣϭ ωϮΒγ ΓήϜΒϤϟ ΓΩϻϮϟΎΑ ΎϳϮϨόϣ ΎρΎΒΗέ· Ϫϟ ϥΎϛ Ϛϟάϛ Ε ΩϻϮϟ ΕϻΎΣϭ ϢϏ ΔϠϴϠϘϟ ϥ ίϭϷ Ε Ϋ Ε ΩϻϮϟ ϭ ̂ ϱΩϻϮϟ ϕΎϨΘΧϹ ΕϻΎΣ Ϛϟάϛϭ ϊΑΎΘΘϟΎΑϭ ϲϋΎϨμϟ ΏΎμΧϹ ήϴΧ ϭ ΓήδόΘϤϟ ΓήϜΒϤϟ Ε ΩϻϮϟ ϭ έϮϛάϟ ϭ ΔϳέΎϴΘΧϹ ΔϳήμϴϘϟ ΕΎϴϠϤόϟΎΑ ΎϳϮϨόϣ ΎρΎΒΗέ· ΎϬϟ ϥΎϛ ΖϗΆϤϟ βϔϨΘϟ ωέΎδΗ ΕϻΎΣ ϥ· ΕΎΟΎΘϨΘγϹ ϲϋΎϨμϟ ΏΎμΧϹ ήϴΧ ϭ ΓήδόΘϤϟ Ε ΩϻϮϟ ϭ ϱΩϻϮϟ ϕΎϨΘΧϹ ΕϻΎΣ Ϛϟάϛ ΕΎϬϣϷ ϯΪϟ ϮΑήϟ ΕϻΎΣϭ ϱήϜδϟ Ωϭ ˬΔϠϴϠϘϟ ϥ ίϭϷ Ε Ϋ Ε ΩϻϮϟ ˬΔϳέΎϴΘΧϹ ΔϳήμϴϘϟ ΕΎϴϠϤόϟ ˬΓΩϻϮϟ ϲΜϳΪΣ ϝΎϔρϸϟ ΖϗΆϤϟ βϔϨΘϟ ωέΎδΗ ϪϴΣΎΘϔϤϟ ϲϋΎϨμϟ ΏΎμΧϹ INTRODUCTIONTransient tachypnea of the newborn (TTN), firstdescribed by Avery in 1966, represents themost common cause of respiratory distress, andoccurs in approximately 6/ 1000 births.1,2 The incidence of neonatal respiratory distress inthe newborn is approximately 7%.1 In utero, fluid isproduced by the neonatal lung. Some of this fluidis swallowed by the neonate and excreted by thekidneys resulting in amniotic fluid. The fetal larynxperiodically opens and closes, so most of the fluidis swallowed but some fluid enters the lungs tokeep them expanded.3Lung fluid production drops as epinephrine levelsincrease, which also accelerates fluid transport viasodiumchannels.Recentstudieshavedemonstrated that certain genetic abnormalities incatecholamine receptors can predispose a4newborn to TTN.Malignant TTN has been reported in infants bornby elective cesarean section who initially presentwith signs and symptoms of TTN that may lastmore than 72 hours. These infants demonstraterefractory hypoxia due to pulmonary hypertensionand may require extracorporeal membraneoxygenation (ECMO).516Transient tachypnea of the newborn representsthe most frequent cause of neonatal respiratorydistress among all newborns, constituting over40% of cases.6Newborns with TTN usually present withtachypnea intercostal or subcostal retractions,grunting, nasal flaring and poor feeding. Cyanosisis not common but could be present in severecases. Symptoms can last from few hours to over2 or 3 days. Although hypoxemia is not typical, itcan be present.7Chest x-ray (CXR) can show hyperaeration,parenchymal infiltrates, and intralobar fluidaccumulation. CXR findings, however, are oftenshared by other causes of respiratory distress andrarely fit classical description. TTN diagnosis isusually based on the clinical assessment.7 Copettiand Cattarossi demonstrated that differences inultrasonographic findings between the upper andlower lung fields could potentially be diagnostic ofTTN and can differentiate it from other causes ofrespiratory distress. Although tested in a smallstudy using a high-resolution linear probe, theauthors achieved a sensitivity and specificity rateof 100%. These findings suggest the need forlarger, blinded, prospective studies.7Ann Coll Med Mosul June 2018 Vol. 40 No. 1
Risk factors for development of transient.Ghaith W. HamdoonRisk factors for the development of TTN7-9clear vesicular breath sound without rales orinclude: elective cesarean section delivery withoutrhonchi and the chest radiograph showedpreceding labor (especially with gestational age prominent pulmonary vascular markings, fluid in38 weeks),maternal diabetes , maternal asthma,theintralobarfissures,overaeration,flatmale sex ,multiple gestations, macrosomia (birthdiaphragms and rarely small pleural effusions.weight 4 Kg) and precipitous delivery. LessThe study also included two hundred healthycommon risk factors for TTN 10,11 include: delayednewborns as a control group, who were deliveredclamping of umbilical cord (optimal time 45either by cesarean section or normally. Theseconds) which leads to increased placentalperinatal and post natal history of these newborntransfusion and this causes left ventricularwere also reviewed for the presence of risk factorsG\VIXQFWLRQ IOXLG RYHUORDG RI WKH PRWKHUÃespeciallyof TTN.with oxytocin infusion, negative amniotic fluidThe studied risk factors for development of TTNphosphatidylglycerol, birth asphyxia, excessivewere: elective cesarean section, male sex,maternal sedation and analgesia, exposure to BJHVWDWLRQDO DJH ZHHNV mimetic agents, prolonged labor and polycythemia.maternal asthma, birth asphyxia (low APGARscore), prolonged labor or by using forceps orAims of the studyvacuum, history of in vitro fertilization, macrosomia,fluid overload of the mothers specially with1. To identify the risk factors associated withoxytocin infusion, breech delivery, exposure to Bdevelopment of transient tachypnea ofmimetic agent, precipitous delivery and multiplenewborns.gestations.2. To compare the results with others.Statistics were calculated by mean of chi-squaretest for categorical variables. Odd ratios and 95%PATIENTS AND METHODSconfidence intervals (CIs) were also calculated.This is a case-control study, it was conducted overStatistical analysis was performed and P-value oftwo years period, from the 1st of Sep. 2011 to the 0.05 was considered as a significant.1st of Sep. 2013 in the neonatal intensive care unitat AL-Kansaa Teaching hospital in Mosul.RESULTSThe perinatal history of two hundred newbornsTable 1 showed that the risk factors; male sex, latewere reviewed regarding risk factors of TTN. Theyprematurity, maternal diabetes, maternal asthma,were delivered either by cesarean section orbirth asphyxia (low APGAR score 7 at 1 minute),QRUPDOO\ DW allZHHNV of them RI JHVWDWLRQ low birth weight (1500-2500 g), prolonged labor orwere suffering from respiratory distress thatby using forceps or vacuum and in vitrolasted 6 hours after delivery. Cases withfertilization, were significant causes of TTN (Psuspicion of TTN were validated through thevalues were 0.001, 0.009, 0.014, 0.01, 0.005,absence of other morbidities affecting precipitateddelivery,multiplepulmonary hypertension and meconium aspirationgestations, exposure to B- mimetic drugs, maternalsyndrome. Complete perinatal and post natalPET, maternal thyrotoxicosis, birth weight and fluidhistory was taken to rule out other causes ofoverload with oxytocin infusion failed to reach arespiratory distress. They were investigated bysignificant level.complete blood count, sepsis screen and chest xTable 2 showed the mode of delivery among theray. All sepsis screen results including (blood2 groups. The number of patients who developedculture, c-reactive protein and complete bloodTTN was higher in those who were delivered bycount) were negative.Cesarean section than normally with significantThe diagnosis of TTN was based on exclusionassociation (P 0.001). Among those patients whoand observation of clinical features based onwere delivered by cesarean section, a higherclinical features of tachypnea, chest retractions,number of patients with TTN were seen in thoseexpiratory grunting and occasionally cyanosis thatdelivered by elective cesarean section comparedis relieved by minimal oxygen supplementationto emergency cesarean section.( 40%).The chest examination revealed generallyAnn Coll Med Mosul June 2018 Vol. 40 No. 117
Ghaith W. HamdoonRisk factors for development of transient.Table 1. Distribution of risk factors among patients with TTN and control group.TTNControlRisk factors(n 200)(n 200)No.%No.%Male13366.59648SexFemale6733.51045236 wks42212211Gestational age ZNV1587917894Maternal diabetic16852.5Maternal asthma2110.589Macrosomia !4kg8473.5Precipitous delivery4221Multiple gestation20178.5Birth asphyxia. (APGAR score 7 at 1199.552.5minute)Low birth wt3316.5147Birth wt.Normal birth wt16783.518693Prolonged labor or by using (forceps or44222816.5vacuum)Breech delivery8422Exposure to B-mimetic agent2100Maternal PET10.500Maternal thyrotoxicosis10.500Fluid overload oxytocin infusion20.210In vitro fertilization52.500Table 2. Mode of delivery among the patients with TTN and control group.Patients withControl groupTTNMode of deliveryN 200N 200No.%No.%Elective112565829Cesarean sectionemergency3718.52914.5Normal vaginal OR95%CIP value6.8174.399-10.5630.001(s)No significant association was found betweenthe most frequently encountered birth weightThe present study showed that TTN was more(2500-3000 grams) and TTN, and this may be duecommon in males (66.5%) than females (38.5%),6to small sample in this study.which was comparable with Kasap B et al (2008),1213A significant association was found betweenAsenjo M (2007), and AL-jurjari Z (2012), and14elective cesarean section delivery and TTN. ThisErol Tutdibi et al (2009).was similar to those found by Levine EM. (2001),9The TTN was more common in those newbornsAL-jurjari Z (2012),13 LiemJJ (2007),15 and ErolZLWK JHVWDWLRQDO DJH RI ZHHNV ,ODWH SUHPDWXUH14Tutdibi et al (2009), who found an increase of21%), which was comparable with Kasap B et al614TTN by 2-3 folds in the neonates delivered by(2008) and Erol Tutdibi et al (2009) who found aelective cesarean section than those deliveredsignificant association between TTN and latenormally (P 0.001). Infants delivered throughprematurity.elective cesarean section often are deprived of theThere was a significant association between lowlabor-related physiological stress response patternbirth weight (1500-2500) and TTN (P 0.003), as15at birth and consequently experience failure ofalso found by Liem JJ (2007), and Tutdibi Erol14postnatal respiratory transition.(2010). Both found a significant relationshipDISCUSSIONbetween TTN and low birth weight.18Ann Coll Med Mosul June 2018 Vol. 40 No. 1
Risk factors for development of transient.A significant association between TTN anddiabetic mothers was found, this was similar to that813found by Dani C (1999), AL-jurjari Z (2012), andNazarzaki (2008).16 Also a significant associationwas found between TTN and asthmatic mothers,which is the same in AL-jurjari Z (2012),13 Liem, JJ1517(2007), and Subramanian KNS et al (2006),studies.Birth asphyxia (low APGAR score 7 at 1 minute)was also found to be significantly associated withTTN, which is similar to Michael S (1991),18 results.Prolonged labor or by using forceps or vacuumalso had a significant correlation with TTN, inwhich it may cause dysfunctional catecholamineregulation, mild pulmonary capillary leak andmyocardial dysfunction, which was similar to Erol14Tutdibi et al (2009) findings.A significant correlation was found between TTNand in vitro fertilization, which is comparable toTakayata et al (2008)19 findings.CONCLUSIONTransient tachypnea of newborns is significantlycorrelated with elective cesarean section, lateprematurity, male sex, maternal asthma, maternaldiabetes, birth asphyxia prolonged labor and invitro fertilization.RECOMMENDATIONS1. Good antenatal care is crucial in detectingearly problems during pregnancy that mayhave relation to increase incidence of TTN.2. Good obstetric care during delivery has animportant role in prevention of perinatalasphyxia which by itself may lead to increaseincidence of TTN.REFERENCES1. Kumar A and Bhat BV. Epidemiology of respiratorydistress of newborns. Indian J. Pediatr 1966; 63(1): 93 98.2. Avery ME, Gatewood OB, Brumley G. Transienttachypnea of newborn possible delayed resorption offluid at birth. Am. J. Dis. Child. 1966; 111(4): 380 385.3. Blackburn ST: Maternal fetal and neonatal physiology:rda clinical perspective (3 Edition). Elsevier HealthSciences, MO, USA; 2007: 338.4. Aslan E, Tutdibi E, Martens S, et al. Transienttachypnea of the newborn (TTN): a role forpolymorphisms in the b-adrenergic receptor (ADRB)encoding genes? Acta Paediatr. 2008; 97(10): 1346 1350.Ann Coll Med Mosul June 2018 Vol. 40 No. 1Ghaith W. Hamdoon5. Waldemar A. carlo. Respiratory tract disorders in NBBehram, Richerd, Robert M et al Nelson Textbook ofpediatrics.19th ed. Philadelphia, WB Saunders Co: 2011;95.4:P579-99.6. Kasap B, Duman N, Ozer E, et al Transient tachypneaof the newborn: predictive factor for prolongedtachypnea. Pediatr Int.2008; 50:81 84.7. &RSHWWL 5 &DWWDURVVL / An7KH µultrasound sign diagnostic of transient tachypnea of thenewborn. Neonatol. 2007; 91: 203 209.8. Dani C, Reali MF, Bertini G, et al. Risk factors forthe development of respiratory distress syndromeand transient tachypnea in newborn infants. EurRespir J. 1999; 14: 155-159.9. Levine EM, Ghai V, Barton JJ, Strom CM. Mode ofdelivery and risk of respiratory diseases in newborns.Obstet Gynecol 2001; 97: 439 42.10. Tutdibi E, Gries K, Bucheler N, et al. Impact of laboron outcome in transient tachypnea of the newborn.Pediatrics 2010; 125: 577- 583.11. John P. Cloherty, Eric C Eichenwald, Anne R.Honsen. Manual of neonatal care.17th ed. Philadelphia,PA: Lippincott Williams & Wilkin; 2012; 24G: PP403-405.12. Asenjo M. Transient tachypnea of the newborn. Emedicine.1; 2007:943-987.13. ALjurjari Z. Risk factors for Transient tachypnea ofnewborn. Dissertation submitted to the Iraqi Board formedical specialization in partial fulfillment for the degreeof fellowship of the Iraqi Board for medical specializationin pediatrics. 2013.14. Tutdibi, Erol; Gries, Katharina; Bücheler, Monika;Misselwitz, Bjorn; Schlosser, Rolf L; Gortner, Ludwig.Impact of labor on outcomes in transient tachypnea ofthe newborn: population based study. Pediatrics 2010;125: 577-583.15. Liem JJ, Huq SI, Ekuma, O, Becker AB, KozyrskyiAL. Transient tachypnea of the newborn may be an earlyclinical manifestation of wheezing symptoms. J Pediatr2007; 151:29.16. Zeki N. Risk factors for Transient tachypnea ofnewborn. Dissertation submitted to the Iraqi Board formedical specialization in partial fulfillment for the degreeof fellowship of the Iraqi Board for medical specializationin pediatrics.2008.17. Subramanian KNS, Bahri M, Kicklighter DS.Transient tachypnea of the new born. E medicine 2006;54:1-11.18. Michael S, Robert S, Clement P. Hoffman, Brian S,Kathleen M, Alan B Forsythe. Increase transienttachypnea of newborn in infants of asthmatic mothersAm J Dis Child. 1991; 145(2):156-158.19. Takayata A, Igarashi M, Nakajima M, Miyaki H,Shima Y, Zusuki S. Risk factors for transient tachypneaof newborn in infant delivered vaginally at 37 weeks orlater. J Nippon Med Sch 2008; 75: 269-273.19
Background: Transient tachypnea of the newborn (TTN) is a frequently encountered form of neonatal respiratory distress. The underlying mechanism involves residual lung fluid that is delayed in clearance. TTN primarily occurs soon after birth and can last f
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Den kanadensiska språkvetaren Jim Cummins har visat i sin forskning från år 1979 att det kan ta 1 till 3 år för att lära sig ett vardagsspråk och mellan 5 till 7 år för att behärska ett akademiskt språk.4 Han införde två begrepp för att beskriva elevernas språkliga kompetens: BI
**Godkänd av MAN för upp till 120 000 km och Mercedes Benz, Volvo och Renault för upp till 100 000 km i enlighet med deras specifikationer. Faktiskt oljebyte beror på motortyp, körförhållanden, servicehistorik, OBD och bränslekvalitet. Se alltid tillverkarens instruktionsbok. Art.Nr. 159CAC Art.Nr. 159CAA Art.Nr. 159CAB Art.Nr. 217B1B
