Breathing Difficulties in Newborns and Young Infants (Chapter 5)

Learning Objectives

After completion of this chapter the participant should be able to:

Describe how to manage a neonate with respiratory distress.
Define apnoea and describe how to treat and prevent apnoea
Describe how a neonate and young infant with difficulties in breathing may present.
List the most likely causes of breathing difficulties in neonates and Young Infants.
Describe the management of the YI with breathing difficulties.
Know and use equipment required for management of babies with difficulty breathing.
Check the equipment section for more information:

Breathing Difficulties in the Newborn

Why are breathing difficulties in the newborn 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 fluid
Meconium in amniotic fluid
Infants born by Caesarean Section or after a quick delivery
Infants with birth asphyxia
Infants of diabetic mothers
Congenital abnormalities

Signs and Symptoms

Grunting
Nasal flaring
Cyanosis
Fast breathing- respiratory rate of more than 60 bpm
Severe lower chest wall in-drawing
Head nodding

Possible Causes: Newborn

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
Pneumonia
Meconium aspiration (note: not only born with meconium but born with meconium and has respiratory distress)
Birth asphyxia
Seizures

Respiratory Distress Syndrome
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 affected infants. Reduced risk with antenatal steroid use. Management: oxygen, CPAP , ventilation, antibiotics, NGT. Newborns usually develop RDS within 3 days of birth

Respiratory Distress Syndrome

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 affected infants.
Reduced risk with antenatal steroid use.
Management: oxygen, CPAP , ventilation, antibiotics, NGT.
Newborns usually develop RDS within 3 days of birth

Management of Respiratory Distress Syndrome (RDS)

Clear airway if necessary.
Put the baby in neutral (sniffing) position.
Give oxygen via nasal cannula 0.5-1 litre per minute(escalate as needed, but consider early CPAP ).
Give antibiotics if persistent respiratory distress after 4 hours of age or if the working diagnosis includes sepsis , pneumonia, or meconium aspiration syndrome.
Position with the thorax 30 degrees upright to ease the breathing.
Treat the underlying cause if identified

Consider CPAP early if the newborn condition does not improve from severe respiratory distress CPAP . Continuous positive airway pressure therapy is recommended for the treatment of preterm newborns with RDS and should be started as soon as the diagnosis is made (5).

Apnoea

Definition: cessation of breathing for longer than 20 seconds which may be associated with bradycardia. It may be due to prematurity or secondary to other conditions such as:

Respiratory distress
Infections
Cold-stressed babies who are being warmed
Low blood volume or low haematocrit
Low blood glucose
CNS disorders
Perinatal compromise
Prematurity

Investigations
– AFTER clinical examination:

Blood sugar
Temperature
Packed cell volume
Sepsis work-up (blood culture, urine dipstick and culture, LP, CXR, FBCs, Urea, creatinine and electrolytes)

Consider the possibility that the baby could be having a seizure

If a portable ultrasound is available, perform a cranial ultrasound to look for intracranial bleeds.

Treatment

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, gastro-oesophageal reflux, and treat accordingly.

Give aminophylline for prevention of apnoea of prematurity.

Aminophylline doses: 6 mg/kg PO stat loading dose followed by 2.5mg/kg BD (twice daily) PO. Dissolve aminophylline 100 mg tablets in 20 mls of water; each ml of solution then contains 5 mg of aminophylline. See for preparation and dosing Wall chart Aminophylline doses for the doses of oral aminophylline when using a solution made from atablet.

When to start aminophylline:

About 25% of neonates <34 weeks have apnoea of prematurity. Therefore, it is reasonable to start aminophylline prophylactically to all premature infants of gestational age < 34 weeks or weight <1800 grams.

When to stop aminophylline:

If the baby is symptomatic (having episodes of apnoea) start aminophylline immediately and stop when the patient has had 2 weeks with no apnoea episodes and is >35 weeks or >1800g. Observe for a further 7 days in hospital.

If the baby is asymptomatic (having no apnoea episodes) but is <35 weeks or <1800 g then start aminophylline. Stop when >35 weeks or >1800grams. Observe for a further 7 days in hospital.

If caffeine is available this would be the first choice over aminophylline.

Equipment for Management of a Baby with Breathing Problems

Essential equipment required to effectively manage a baby with breathing difficulties are listed below and will be discussed individually.

Breathing Difficulties in the Young Infant

YIs with breathing difficulties present with fast breathing and difficulties with feeding. On examination there may be grunting, head nodding, cyanosis, intercostal, sternal and subcostal recession. On auscultation there may be crepitations or/and wheezes.

The main differential diagnoses in this age group are:

Pneumonia
Pneumocystis jiroveci pneumonia (PJP), if exposed to HIV
Bronchiolitis
TB
Congenital Heart Disease

Supportive Treatment – Nutrition

If the baby is breathing < 60 bpm, breastfeeding may be tried. If the baby is struggling to feed, changeto oro- or nasogastric tube feeds.

If the baby is breathing fast (e.g. 60-80 bpm), feed by oro- or nasogastric tube every two hours with expressed breast milk (i.e., restricted maintenance volumes).

If the baby is breathing very fast > 80 bpm, consider IV fluids (100 mls/kg/day).

Oxygen Therapy – Escalate Stepwise

Before oxygen administration, ensure that the airway is clear. Then administer oxygen via nasal prongs or nasal catheter, start with 0.5 litres/minute. Assess after 15-30 minutes, if oxygen saturations remain <90%, escalate O2 quickly to 1 litre/minute with a maximum of 2 litres/minute. Reassess after 30 minutes and if the O2 saturation is still below 90%, administer O2 at 4 litres/minute through face mask.

Consider CPAP if there is no improvement on oxygen therapy and there are no contraindications.

Specific Treatment

Treat with IV antibiotics if pneumonia is suspected (cough, fever or crepitations on examination) – see wall charts for doses.

Give high dose cotrimoxazole and steroids if PJP is suspected, – see formulary for doses.

E 2 Pulse oximeter

Pulse oximeters should also be used during treatment for all sick or at-risk patients, or those being treated with oxygen therapy, CPAP, or any form of assisted ventilation. See pulse oximeter for more information.

E 3 Oxygen Concentrator

An oxygen concentrator is used on its own when oxygen needs to be delivered to one or two patients. Concentrators may also be used to share oxygen between multiple patients using a flow splitter or used with other treatment devices such as continuous positive airway pressure devices. Supplemental oxygen is indicated for sick children, especially those with hypoxia (SpO2 < 90%) which has many clinical causes.
See oxygen concentrator for more information.

E 4 Oxygen Cylinder

Oxygen cylinders may be used to provide supplemental oxygen directly to hypoxic patients, to be shared between patients using a flow splitter or used with other treatment devices such as continuous positive airway pressure devices. See oxygen cylinder for more information.

E 5 Oxygen Splitter

Flow splitters are used when oxygen from one source needs to be delivered to more than one hypoxic patient at low flows. See oxygen splitter for more information.