Respiratory Distress in the Newborn

Aka: Respiratory Distress in the Newborn, Newborn Respiratory Distress, Neonatal Respiratory Distress

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II. Epidemiology

  1. Incidence of need for immediate respiratory support at birth: 10%
  2. Incidence of need for advanced Resuscitation in the term newborn: 5%

III. Risk Factors

  1. Premature delivery
  2. Antepartum Risk Factors
    1. Maternal Preeclampsia
    2. Multiple Gestation
    3. Non-term delivery (Preterm delivery, Postterm delivery)
    4. Abnormal intrauterine fluid (oligohydramnios, polyhydramnios)
    5. Fetal hydrops
    6. Abnormal size for dates (IUGR, macrosomia)
    7. Fetal malformation
  3. Intrapartum Risk Factors
    1. Emergency Cesarean delivery
    2. Assisted Delivery (vacuum or forceps)
    3. Chorioamnionitis

IV. History

  1. See Newborn History
  2. Key questions
    1. Estimated Gestational Age
    2. Amniotic fluid color

V. Signs

  1. Tachypnea
    1. Respiratory Rate >60 per minute
    2. A normal newborn Respiratory Rate: 40 to 60 bpm
  2. Increased work of breathing
    1. Nasal flaring
    2. Grunting
    3. Intercostal retractions (or subcostal retractions)
  3. Other findings
    1. Cyanosis
    2. Decreased feeding
    3. Hypothermia
    4. Hypoglycemia

VI. Causes

  1. See Neonatal Distress Causes
  2. Common (all are immediate onset except Pneumonia, Neonatal Sepsis)
    1. Transient Tachypnea of the Newborn
    2. Respiratory Distress Syndrome in the Newborn
    3. Meconium Aspiration Syndrome
    4. Delayed transition
    5. Pneumonia (e.g. Group B Streptococcal Pneumonia)
    6. Neonatal Sepsis
      1. Frequently presents with respiratory distress (90% of cases)
    7. Pneumothorax in the newborn
  3. Less common
    1. Anemia
    2. Persistent Pulmonary Hypertension of the Newborn
      1. Onset of Dyspnea within first 24 hours
    3. Congenital malformations
      1. Pulmonary hypoplasia
      2. Congenital Diaphragmatic Hernia
      3. Esophageal atresia
      4. Airway obstruction (e.g. Choanal Atresia, Tracheomalacia, Macroglossia)
      5. Congenital Heart Disease
    4. Neurologic conditions
      1. Hydrocephalus
      2. Intracranial Hemorrhage
      3. Maternal agents causing sedation and central respiratory depression
    5. Metabolic disorders
      1. Hypoglycemia (always check a Glucose)
      2. Hypocalcemia
      3. Inborn Errors of Metabolism

VII. Evaluation

  1. See Newborn History
  2. See Newborn Exam
    1. Observe for apnea or Tachypnea
    2. Observe for Cyanosis
    3. Auscultate for cardiac murmurs suggestive of Congenital Heart Defect
    4. Auscultate lungs for asymmetry suggestive of Pneumonia or Pneumothorax
    5. Specific pattern of periodic breathing is normal
      1. Normal Respiratory Rate (40 to 60 bpm) with interspersed pauses of 5-10 seconds
      2. Respiratory pauses >20 seconds is apnea (NOT normal)
      3. Other periodic breathing patterns may be abnormal

VIII. Labs

  1. See Neonatal Sepsis
  2. Serum Glucose (bedside Glucose)
  3. Blood Culture
  4. Capillary gas (sufficient in most cases unless high oxygen needs) or Arterial Blood Gas
  5. Complete Blood Count with Platelets and differential
  6. C-Reactive Protein (C-RP)

IX. Imaging

  1. Chest XRay

X. Diagnostics

  1. Pulse Oximetry
    1. Pre-ductal (right hand)
    2. Post-ductal (left leg)
  2. Findings suggesting diagnosis OTHER THAN Neonatal Sepsis
    1. Immature to total Neutrophil ratio <0.2
      1. High Negative Predictive Value, but 50% False Positive Rate if elevated
      2. Murphy (2012) Pediatr Infect Dis J 31(1):16-9
    2. C-RP <10 mg/L
      1. Negative Predictive Value 94% in first 48 hours of life
      2. Himayun (2009) Internet J Pediatr Neonatol 11(2)
        1. http://ispub.com/IJPN/11/2/5613

XI. Management

  1. Precautions
    1. Respiratory distress is among the most common NICU presentations
    2. Prompt and appropriate respiratory intervention averts progression to cardiopulmonary collapse and arrest
  2. ABC Management
    1. See Newborn Resuscitation
    2. Initial warming, drying, stimulating, positioning airway and suctioning as needed
    3. Resuscitation protocol is triggered by Heart Rate <100, apnea, gasping, labored breathing, Cyanosis in minute 1
      1. PPV is best performed with T-piece resuscitator (if not available, use self-inflating BVM)
      2. Laryngeal Mask Airway (LMA) may be needed (Gestational Age>34 weeks)
  3. General Measures
    1. Supplemental Oxygen
    2. Mild Tachypnea can be observed for 10-20 minutes
    3. Maintain warm environment
    4. Obtain finger-stick Blood Glucose
    5. Withold oral feedings when Respiratory Rate is rapid (>80/minute)
    6. Consider neonatology Consultation
  4. Supplemental Oxygen
    1. Blended oxygen with FIO2 <50% to keep Oxygen Saturation >90% is preferred
    2. FIO2 approaching 100% is associated with an increased neonatal mortality
      1. Saugstad (2008) Neonatology 94(3): 176-82 [PubMed]
  5. Ventilation
    1. Non-invasive ventilation
      1. N-CPAP
      2. Nasal intermittent Positive Pressure Ventilation
    2. Standard invasive ventilation Endotracheal Intubation
      1. Non-invasive ventilation (as above) is preferred if adequate
      2. Intubation may also be initiated in RDS for surfactant delivery
        1. Then Extubation, weaning to N-CPAP
  6. Neonatal Sepsis evaluation
    1. Early Onset Sepsis Calculator
      1. https://www.mdcalc.com/calc/10528/neonatal-early-onset-sepsis-calculator
    2. Workup and Antibiotics for suspected Neonatal Sepsis or Neonatal Pneumonia
      1. Labs (CBC, VBG or ABG, C-RP, Blood Culture, LP, Glucose monitoring)
      2. Chest XRay
  7. Follow specific management for suspected causes
    1. See each specific condition for guidelines
    2. Surfactant for Respiratory Distress Syndrome in the Newborn
    3. Needle decompression of Pneumothorax
  8. Indications for NICU transfer or Consultation
    1. Condition worsens or fails to improve within 2 hours
    2. Supplemental Oxygen requirements >40%
    3. Chest XRay abnormalities

XII. References

  1. Buel (2026) Am Fam Physician 113(1): 35-41 [PubMed]
  2. Hermansen (2007) Am Fam Physician 76(7): 987-94 [PubMed]
  3. Hermansen (2015) Am Fam Physician 92(11): 994-1002 [PubMed]
  4. Hein (1998) J Fam Pract 46:284-9 [PubMed]

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