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Respiratory distress

Some babies develop respiratory distress or breathlessness after birth and may require assistance for breathing. Such babies would need observation in nursery. Respiratory distress in newborn babies can be due to many causes like deficiency of surfactant in premature babies, wet lungs, air leak from lungs or infection. Respiratory distress is characterised by baby using accessory muscles for breathing which would manifest in the form of baby’s part of neck above the breast bone, stomach beneath the chest and the part of the chest in between the ribs sucking in when baby inhales. Respiratory distress usually is accompanied by fast breathing rate. Sometimes severe respiratory distress can manifest as grunting or flaring of nostrils. Grunting is natures way of providing continuous positive airway pressure to splint open the lung bubbles as babies are exhaling against partially closed glottis.

TTN or Transient Tachypnoea of Newborn (Wet lungs) – Babies lungs are filled with amniotic fluid in their intrauterine life. They are expected to squeeze this fluid out and breathe normally after birth. Babies born vaginally often undergo this transition from intrauterine life to outer world rapidly and smoothly. However, some babies born via caesarean section may take some time to get rid of the fluid in their lungs and breathe normally.

Respiratory Distress syndrome – Baby’s lung bubbles have natural tendency to collapse and a substance produced by their lungs called ‘surfactant’ help to splint it open by reducing the surface tension inside it when baby breathes in. Babies born prematurely may not have surfactant in sufficient amount in their lungs. These babies may require respiratory support, artificially extracted surfactant administered by a tube down their airway, and at times artificial ventilatory support.

Air leak in lungs – This is when the air leaks out of the lungs within its outer covering called ‘pleura’. This can in severe situations lead to compression of lungs and displacement of airways to the opposite side due to air accumulating in the pleural space under tension. Chest X-ray is usually done to diagnose or rule out air leak in lungs.

Presumed infection – Babies requiring respiratory assistance for their breathing are presumed to have infection. This is because babies do not often show obvious signs of infection and they can deteriorate rapidly if not treated early. Hence, these babies are are observed closely, usually screened for presumed sepsis by doing blood test and commenced on intravenous antibiotics. The antibiotics usually are ceased after the blood culture is negative by 48 hours of incubation and the inflammatory blood markers like CRP are normal. Note that baby requiring the IV antibiotics do not require admission to nursery.
Risk factor for sepsis:
• Maternal fever during delivery >/= 38 degree
• Rupture of membranes > 18 hours
• GBS +ve vaginal swabs
• Respiratory distress

Management –Respiratory assistance in these situations is mostly provided by giving continuous positive airway pressure (CPAP) to splint open the lung bubbles. Babies with minimal distress and those who maintain their oxygen saturation can be just observed for few hours on continuous pulse oximetry. We usually check their blood gases to keep track of O2 and CO2 exchange through their lungs and their blood pH. These babies cannot be fed orally as this can lead to gut complications. Hence, these babies may require intravenous fluids to keep their hydration and their blood glucose levels within normal limits. However, if the Paediatrician anticipates that the respiratory distress would settle in first couple of hours then we can just monitor their O2 saturation with pulse oximetry and start oral feeding when there is no longer any respiratory distress. Babies requiring assistance with their breathing for > 4 hours may need to be transferred to Level 3 nursery like KEMH or PCH. However, we endeavour to avoid this situation as much as possible and try to keep babies with their mothers.