Breathing difficulties in the newborn
See Breathing difficulties in the YI for respiratory problems in the young infant.
After completion of this session participants should be able to:
- Describe how to manage a neonate with respiratory distress
- Define apnoea and describe how to treat and prevent apnoea
Why are breathing difficulties in the new-born so important?
Breathing difficulties are the most common way that sick neonates present to the healthcare worker.
There are several different possible diagnoses and these need to be considered in order to provide
the correct management.
Newborns at risk of developing breathing problems
- Preterm infants
- Infants born to mothers with fever, prolonged rupture of membranes, foul-smelling amniotic
- Meconium in amniotic fluid.
- Infants born by Caesarean Section or after a quick delivery
- Infants with birth aspyxia
- Infants of diabetic mothers
- Congenital abnormalities
Signs and symptoms
- Nasal flaring
- Fast breathing - respiratory rate of more than 60bpm.
- Severe chest in-drawing.
- Respiratory Distress Syndrome (common in premature neonates)
- Transient Tachypnoea of the Newborn (TTN) (common in babies born by
Caesarean Section or after a quick delivery)
- Sepsis (more common in very premature and where there are risk factors for sepsis
such as prolonged rupture of the membranes)
- PPHN: persistent pulmonary hypertension of the newborn
- Meconium aspiration (Note: not born with meconium but born with meconium and has respiratory distress)
Respiratory Distress Syndrome
- RDS occurs primarily in premature infants; its incidence is inversely related
to gestational age and birthweight.
- It occurs in 60–80% of infants less than 28 weeks, 15–30% of those between
32 and 36 weeks, about 5% beyond 37 weeks, and rarely at term.
- Surfactant deficiency is the primary cause of RDS.
- Increased risk in maternal diabetes, multiple births, Caesarian Section,
precipitous delivery, asphyxia, cold stress, and a history of previously
- Reduced risk with antenatal steroid use.
- Management: oxygen, CPAP, ventilation, antibiotics, NGT
Management of breathing difficulties in the newborn
- Clear airway if necessary,
- Put the baby in neutral (sniffing) position
- Give oxygen via nasal cannula 0.5-1 litre per minute. (escalate deliver oxygen)
- Give antibiotics if persistent respiratory distress after 4 hours of age or if the working diagnosis includes sepsis, pneumonia or meconium aspiration syndrome.
- Feed via NGT if the baby is in severe respiratory distress.
Consider CPAP if the newborn condition does not improve.
Continuous positive airway pressure therapy is recommended for the treatment of preterm newborns with Respiratory Distress Syndrome and should be started as soon as the diagnosis is made (5).
Definition: cessation of breathing for longer than 20 seconds which may be associated with bradycardia. It may be primary due to prematurity or secondary to other conditions such as:
Investigations - AFTER clinical examination
Packed cell volume
Sepsis work-up (blood culture, urine culture, LP, CXR
Consider the possibility that the baby could be having a seizure:
If mobile ultrasound is available, perform cranial ultrasound to look for brain bleeds.
Determine cause and treat
General measures: tactile stimulation, correct anaemia, maintain normal body temperature, look for
electrolyte imbalance, intraventricular haemorrhage, signs or symptoms of sepsis, patent ductus
arteriosus, necrotising enterocolitis and gastro-oesophageal reflux, and treat accordingly.
Give aminophylline for prevention of apnoeas of prematurity.
Aminophylline doses: 6mg/kg PO stat to load (may also be given IV over 20 min) followed by 2.5mg/kg bd (twice daily) PO (may also be given IV).
Dissolve 100mg tablets in 20mls of water, each ml of solution contains 5mg of aminophylline
See doses of oral aminophylline when using a solution made from a tablet.
When to start aminophylline
About 25% of neonates <34 weeks have apnoeas of prematurity. Therefore it is reasonable to start
aminophylline prophylactically to all premature infants of gestational age <34 weeks or weight <1800
When to stop aminophylline
The gestational age >37 weeks (or weight of > 2500 g if gestational age is not known)
The infant has been apnoea-free for 7 days.