Causes of respiratory distress in term infants

PULMONARY CAUSES

Common

Transient tachypnoea of the newborn – Caused by delay in the resorption of lung fluid and is more common after birth by C-section. CXR may show fluid in the horizontal fissure and additional ambient oxygen may be required. Condition usually settles within first day of life but can take several days to resolve completely.

Less common

Meconium aspiration – Meconium is passed before birth by 8-20% of babies. Rarely passed by preterm infants and occurs increasingly the greater the gestational age, affecting 20-25% of deliveries by 42 weeks. Asphyxiated infants may start gasping and aspirate meconium before delivery. Meconium is a lung irritant and results in both mechanical obstruction and a chemical pneumonitis. In meconium aspiration the lungs are overinflated, accompanied by patches of collapse and consolidation.

Pneumonia – Prolonged rupture of the membranes, chorioamnionitis and low birthweight predispose to pneumonia. In this kind of case, we usually start broad spectrum antibiotics early

Pneumothorax – May occur spontaneously in up to 2% of deliveries. May occur secondary to meconium aspiration, RDS or as a complication of ventilation

Milk aspiration – More frequently in preterm infants and those with respiratory distress or neurological damage. Babies with bronchopulmonary dysplasia often have gastro-oesophageal reflux, which predispose to aspiration

Persistent pulmonary hypertension of the newborn – This life-threatening condition is usually associated with birth asphyxia, meconium aspiration, septicaemia, or respiratory distress syndrome. As a result of high pulmonary vascular resistance, there is right-to-left shunting within the lungs and at atrial and ductal levels. Cyanosis occurs soon after birth. CXR may show pulmonary oligaemia. Most infants require mechanical ventilation and circulatory support in order to achieve adequate oxygenation. Inhaled nitric oxide, a potent vasodilator, is often beneficial. Extracorporeal membrane oxygenation (ECMO), where infant is placed on heart and lung bypass for several days, in indicated for severe cases.

Other rare causes

Diaphragmatic hernia, Tracheo-oesophageal fistula, Pulmonary hypoplasia, Airways obstruction, Pulmonary haemorrhage

NON-PULMONARY

Congenital heart disease, Intracranial birth trauma, Encephalopathy, Severe anaemia, Metabolic acidosis

News from Neonatal Intensive Care Unit (NICU)

I have been in NICU for bout 2 days. Its really terrible and saddening to see those newborns admitted to NICU. Some of them are jaundiced, some with breathing difficulties, some with Down syndrome and even some with congenital heart disease in failure. Some of them got ill due to maternal problem but some just got it without any reasons. Imagine you are a parent who just got a child and suddenly the doctor who delivered your child suspect your child to be Down syndrome. How do you feel? It really an agony to hear that, just like the world is crushing on you.

Today while oncall, I got to meet parents of a newborn in NICU. It was their first child, and the child was infected with multiple organism, both fungal and bacteria. The doctors suspected it to be immune deficiency and started the newborn on multiple antibiotics to cover fungal, gram positive and gram negative bacteria. The father seems to be in distress, asking me questions bout his child. But im doesnt really know the child and its problems, although the child seems stable currently. Then the father went on saying that some parents just throw their child away after giving birth but he and his wife has been trying hard to get a child. And when they finally got a child, it was not without problems…

I guess that’s how the world functions. Things that are easily obtained are owiz being unappreciated…

Recently Im beginning to accept those selfish kiasu coursemates of mine. My dad once said to me, these people are non-christians, many things they dun know and dun understand, we should pray for them. These kiasu ppl, I cant change their behavior, being upset over them is not going to do any better either… So now Im learning and trying to accept them as they are, hoping that one day they will realise wat they have been doing…

Neonatal Examination

These are the few tips I learned today on neonatal examination…

1. Firstly we look at the child’s general appearance. See whether the child is in respiratory distress, discomfort, pain. Also we should observe the patient’s posture and movements. (For us to do this, the baby needs to be fully undressed)

2. Find out the patient’s gestational age. If we suspect the patient’s is a pre-term baby, use the Ballard score to assess his/her gestational age. (I will share on Ballard score later…). Also we should not forget to measure his/her birthweight, length and head circumference and plot the growth chart. Take note if the patient’s birthweight/ length or head circumference is below 5th percentile or above 95th percentile.

3. Palpate both anterior and posterior fontanelle. Feel whether is it tense or not. A tense fontanelle when the baby is not crying may be due to raised intracranial pressure and cranial ultrasound should be performed to check for hydrocephalus. Also we should palpate the sutures. The sagittal suture is often separated and the coronal suture may be overriding.

4. Observe the face. Look for any syndromic facies such as flat occiput, flat nasal bridge, hypertelorism, low set ears, unslanting of palpebral brigde, cleft lips, increase intercanthal distance, small jaw. etc etc. This features could indicate Down, Edward, Patau or Turner syndrome.

5. Also look at the face for any plethoric, cyanosis, jaundice or paleness. If yes, check the haematocrit to identify polycythaemia or anaemia. Central cyanosis is best seen on tongue. Jaundice within 24 hours of birth requires further evaluation.

6. Examina the eyes, checked for red reflex with an ophthalmoscope (cataracts, retinoblastoma and corneal opacity). Inspect the palate, including posteriorly to exclude posterior cleft palate.

7. Observe patient’s breathing and chest wall movement. Look for any sign of respiratory distress such as subcostal recession and chest wall indrawing. Confirm it by counting the respiratory rate. ascultate the heart for any murmur and count the pulse rate. The normal rate in babies is 110-160 beats/min, but may drop to 85 beats/min during sleep

8. Palpate the abdomen. Feel for any intraabdominal masses which most commonly is renal in origin. The liver normally extends 1-2 cm below the costal margin, the spleen tip may be palpable, as may the left kidney.

9. Inspect the genitalia and anus. In boys, look for presence of testis in scrotum. In girls, look for labia majora and labia minora. You should be able to differentiate between the two. Also look for any fistula or discharges.

10. Palpate for femoral pulses. Femoral pulses is reduced in case of coarcation of the aorta. This can be confirmed by measuring the blood pressure in the arms and legs. Femoral pulses is increased in case of patent ductus arteriosus.

11. Assess the muscle tone by observing limb movements and on sitting the baby while supporting the head. Most babies will support the head briefly when the trunk is held vertically.

12. Whole of back and spine is observed looking for any midline defects of the skin

13. The hips are checked for development dysplasia of the hips (DDH). This is left last as the procedure is uncomfortable.