Newborn With Respiratory Distress

Case 7
Newborn with respiratory distress - Adam

Author: Maxine Clarke, M.B., B.S., FRCP (C) Queen's University.
Learning Objectives
Obtain a neonatal history using appropriate sources: Hospital chart, mother,
nursing staff.
1.
Complete the physical examination of the newborn, including using the
growth chart to assess gestational age.
2.
Recognize the symptoms of respiratory distress. 3.
Develop a differential diagnosis for neonatal respiratory distress. 4.
Determine appropriate investigations to evaluate neonatal respiratory
distress.
5.
Recognize the effects of maternal diabetes on the neonate. 6.
Identify and manage neonatal hypoglycemia. 7.
Recognize the factors that determine the neonate's readiness for discharge
from the hospital.
8.
Summary of clinical scenario: 34-week-gestation premature infant, Adam,
delivered via Caesarean section with no meconium and no premature rupture of
membrane (PROM) from a diabetic mother with fair glucose control and unknown
Group B strep status presents with respiratory distress. Apgar scores at delivery
were 8 at 1 minute and 9 at 5 minutes. On physical exam, the newborn is found
to be large for gestational age (LGA), tachypneic, with no heart murmur, good
perfusion, and equal breath sounds. After considering the differential diagnosis for
this patients respiratory distress, a chest X-ray was obtained. The X-ray
demonstrates wet-looking lungs, no consolidation, and no air bronchograms,
consistent with transient tachypnea of the newborn. As the infant of a diabetic
mother, Adam is also found to be hypoglycemic. Since his tachypnea hampers his
ability to breastfeed, Adam is given breast milk and formula through a feeding
tube. His respiratory symptoms and hypoglycemia subsequently stabilize within
36 hours.
medU | Instructors http://www.med-u.org/communities/instructors/clipp/case_sum...
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Key Findings from
History
Tachypnea
Infant of diabetic mother
34-week gestation
No meconium
C-section
No PROM
Key Findings from
Physical Exam
LGA
Respiratory distress
No heart murmur
Good perfusion
Equal breath sounds
Differential Diagnosis
Respiratory distress syndrome
Transient tachypnea of the newborn
Sepsis/pneumonia
Pneumothorax
Congestive heart failure
Hypothermia
Key Findings from
Testing
Glucose: 34 mg/dL
Chest X-ray: Significant perihilar
streaking and fluid in pleural space
Final Diagnosis Transient tachypnea of the newborn
Case highlights: This case focuses on the evaluation of neonatal respiratory
distress. Students work through an appropriate differential diagnosis, see
examples of respiratory distress and important components of the neonatal
examination, including examination of the hips to detect developmental dysplasia
of the hips (DDH). Additionally, students review Apgar scores and assess
intrauterine growth and gestational age. Students also explore common problems
with LGA infants, transitional issues, and breastfeeding. Multimedia features
include: Video of an infant in respiratory distress; video explaining how to perform
an infants hip exam; and chest X-ray with perihilar streaking and fluid in the
pleural space.
Key Teaching Points
Knowledge
Transition from intrauterine to extrauterine life:
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Intrauterine oxygenation
Oxygenated blood from placenta is transported to the fetus by the umbilical
vein
A portion of the oxygenated blood perfuses the liver
Remainder bypasses the liver through the ductus venosus and enters the
inferior vena cava:
One-third of this vena caval blood crosses through the patent foramen
ovale (PFO) to the left atrium and is pumped to the coronary,
cerebral, and upper body circulations.
The remaining two-thirds combines with venous blood from the upper
body in the right atrium, and is directed to the right ventricle and out
the pulmonary artery.
Vasoconstriction of the pulmonary arterioles produces high pulmonary
vascular resistance, allowing only 810% of the blood from the right
ventricle to flow through the pulmonary vasculature.
The remaining 9092% is shunted through the patent ductus arteriosus
(PDA) to the descending aorta.
Extrauterine oxygenation: Oxygenation changes dramatically at birth from a
passive, placenta-provided source to an active respiration-based process.
Successful transition at birth involves:
Removal of low-resistance placental circulation by cutting the umbilical cord
Initiation of air-breathing
At delivery, infants first breath results in replacement of fluid in lung
with air.
Fluid is squeezed out of lungs during uterine contractions with vaginal
delivery and absorbed by pulmonary lymphatics
Delayed absorption can lead to transient tachypnea of the
newborn (TTN).
Reduction of the pulmonary arterial resistance
Closure of the PFO and PDA
Infant of a diabetic mother (IDM): Control of diabetes during pregnancy is an
important predictor of fetal outcome, especially with regard to the risk of birth
defects:
Incidence of major malformations is directly related to the hemoglobin A1c
level in the first trimester.
Infants born to women with A1c levels >12 have at least a 12-fold increase
in major malformations.
An IDM is also at risk of being LGA:
High levels of maternal serum glucose stimulate the fetal pancreatic beta
cells and the development of hyperinsulinemia.
Insulin is the primary anabolic hormone for fetal growth.
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High levels in the third trimester result in increased growth of the insulin-
sensitive organ systems (heart, liver and muscle) and a general increase in
fat synthesis and deposition.
This combination of increased body fat, muscle mass, and organomegaly
produces a macrosomic (LGA) infant.
Insulin-insensitive organs, such as the brain and kidneys, are not affected
by the elevated insulin levels and have appropriate size for gestational age.
Risk factors for neonatal respiratory distress:
Infection
Prematurity
Delivery by Caesarean section (C-section)
Maternal diabetes
Maternal drug exposure
Prematurity
PROM (rupture of membranes ! 18 hours prior to delivery)
Meconium in amniotic fluid
Cyanosis in the newborn: Important to first distinguish cyanosisfrom
acrocyanosis (see physical exam below).
Etiologies
Respiratory:
TTN
RDS
Pneumothorax
Diaphragmatic hernia
Choanal atresia
Pulmonary hypoplasia
Cyanotic congenital cardiac defects:
Tetralogy of Fallot
Transposition of the great arteries
Truncus arteriosus
Tricuspid atresia
Total anomalous pulmonary venous return
Pulmonary atresia
Central nervous system abnormalities:
Hypoxic-ischemic encephalopathy
Intraventricular hemorrhage
Sepsis/meningitis
Other:
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Infectious
Respiratory depression secondary to maternal medications
Hypothermia
Polycythemia/hyperviscosity syndrome
Developmental dysplasia of the hip (DDH): Dislocation of the hips is not
always detectable at birth. To decrease number of dislocated hips detected later in
infancy, the American Academy of Pediatrics has developed a Clinical Practice
Guideline for primary care providers. The main components are recognition of risk
factors and regular hip examinations to age 18 months.
Clinical features
Partial or complete dislocation or instability of the femoral head
Risk factors
Breech position: 3050% occur in infants born in breech position
Gender: 9:1 female predominance
Family history
Reference:
American Academy of Pediatrics Clinical Practice Guidelines: Pediatrics 2000;
105(4): 896.
Skills
Physical exam: Examine neonate immediately after birth to determine general
condition of cardiorespiratory, neurologic, and gastrointestinal systems and to
detect congenital abnormalities.
Apgar score: A method of describing the condition of the newborn immediately
after birth. Scores are assigned at 1 and 5 minutes of life, with 0 to 10 total points
possible:
Sign Score=0 Score=1 Score=2
Heart rate Absent Below 100 Above 100
Respiratory
effort
Absent
Weak, irregular,
or gasping
Good, crying
Muscle tone Flaccid
Some flexion of
extremities
Well flexed, or
active
movements of
extremities
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Reflex
irritability
No response
Grimace or weak
cry
Good cry or
active
withdrawal
Color
Blue all over, or
pale
Body pink,
extremities blue
Pink all over
Scoring provides a mechanism to record fetal-to-neonatal transition
When properly applied, the Apgar score is a tool for standardized
assessment.
The Apgar score alone correlates poorly with the future neurological
outcome of the term infant because it is affected by gestational age,
maternal medications, resuscitation, and cardiorespiratory and neurologic
conditions. (Poor neurologic outcome is better associated with documented
asphyxia.)
Reference:
Joint Policy Statement on The Apgar Score of the American Academy of Pediatrics
and the American College of Obstetricians and Gynecologists. Pediatrics.
2006Volume 117(4):1444-1447.
Vital signs
Most accurate when obtained when infant is quiet and at rest. If infant is
crying, heart rate (HR) and the respiratory rate (RR) may be falsely
elevated.
In the first hour of life, respiratory and heart rates (RR and HR) are often
elevated:
HR: 160180 beats per minute (bpm)
RR: 6080 breaths per minute (bpm)
With successful transition, HR will decrease to 120160 bpm and RR to
4060 bpm by two hours of life.
Signs of neonatal respiratory distress:
Tachypnea (>60 breaths/min)
Use of accessory muscles for respiration (nasal flaring, intercostals
retractions, grunting)
Hypoxia, hypercapnia
Acrocyanosis
Bluish discoloration of hands and feet
Commonly seen in the first few hours following birth
May recur through early infancy when the baby is cold.
After 45 hours, cyanosis is usually less marked in hands than feet.
If acrocyanosis is not resolved within 8 hours or with warming, may be sign
of cyanotic congenital heart disease.
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Classification of newborn by weight and gestational age: Weight is a good
indicator of the intrauterine environment.Plotting weight against gestational age
helps identify infants with abnormal growth and allows the anticipation of
potential problems associated with each group:
LGA (large for gestational age): > 90th percentile
Most important pathologic etiology is maternal diabetes mellitus
Potential clinical problems:
Delivery by C-section, forceps, or vacuum extraction
Birth injuries (clavicular fracture, brachial plexus injury, facial
nerve palsy)
Hypoglycemia
AGA (appropriate for gestational age): 10th to 90th percentile
SGA (small for gestational age): <10th percentile
Also called intrauterine growth restricted (IUGR)
An infant with low birth weight may be premature, but low birth
weight may also result from many other causes.
Potential clinical problems:
Temperature instability (hypothermia)
Hypoglycemia (due to inadequate glycogen stores)
&Polycythemia and hyperviscosity
Gestational age assessment: Gestational age and its relationship to birth
weight are important in identifying infants with abnormal fetal growth patterns.
The first system for evaluating gestational age was developed by Dubowitz
in 1970:
Detailed scoring system based on infant's external physical
characteristics and neurologic findings
Requires that infant be alert and active
Results often skewed in very immature or sick infants due to low
neurologic scores
The Ballard assessment, a method developed in 1979 and now more widely
used, is a shortened version of the Dubowitz exam:
Standardized score based on specific neuromuscular signs and
physical characteristics
Should be performed on every neonate
Most accurate when obtained at 1224 hours of life
Hip exam: Assess every newborn for developmental dysplasia of the hip (DDH):
Remove diaper so does not constrict movement. 1.
Do one side at a time. 2.
Stabilize pelvis with one hand. 3.
Bend infants leg and place fingers of hand on greater trochanter, thumb on
inside of femur.
4.
Perform Barlow maneuver:
Movement with leg in adduction
5.
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Push back to feel if femur head is in the joint or dislocating in and out.
Perform Ortolani maneuver:
Movement with leg in abduction
Push out with fingers on greater trochanter to see if clunk is felt
(clunk indicates relocation from dislocated position).
6.
Repeat on other side. 7.
Differential diagnosis
More likely diagnoses
Respiratory distress syndrome (RDS): Previously known as "hyaline
membrane disease," RDS is caused by a deficiency in lung surfactant. Most
common cause of respiratory distress in premature infants. Additional risk
factors include:
IDM (due to delayed lung maturation)
Sibling with history of RDS
Male
C-section delivery without labor
Perinatal asphyxia
A chest X-ray can help distinguish between TTN and RDS.
1.
Transient tachypnea of the newborn (TTN): Delayed clearance of lung
fluid after birth causing early onset mild respiratory distress. This is a
benign, self-limited disease related to newborn transition. No evidence that
TTN predisposes to long-term pulmonary dysfunction. Generally considered
a disorder of term infants, but can occur in premature infants. TTN risk
factors:
C-section delivery
Male
Macrosomic
IDM
A chest X-ray can help distinguish between TTN and RDS.
2.
Congestive heart failure (CHF): Important cause of tachypnea. Most
often caused by a congenital heart defect. There is an increased risk of
heart defect in IDMs, and therefore increased risk of CHF. Usually presents
with heart murmur.

3.
Sepsis/pneumonia: Early signs of neonatal sepsis are subtle and
nonspecific and may include symptoms such as poor feeding, lethargy, or
irritability. May alsopresent initially with tachypnea and progress to more
severe illness rapidly. Risk factors include:
PROM
GroupB streptococcal infection transmitted from the mother during
labor
4.
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Hypoglycemia: May be seen in IDMs due to the chronic hyperinsulinemic
state that occurred during gestation. May be more pronounced in premature
infants. Tachypnea is a non-specific response to this metabolic
derangement.
5.
Less likely diagnoses:
Congenital diaphragmatic hernia: A congenital malformation resulting
from a defect in the development of the diaphragm.
Occurs in 1 out of every 2,200 to 5,000 live births
Most common type is the Bochdalek hernia (posterolateral hernia),
which accounts for majority (> 95%) of cases:
Allows passage of abdominal organs into chest cavity and
severely impairs lung development.
Most defects occur on the left side.
Absent breath sounds or presence of bowel sounds on one side
of the chest are important diagnostic clues.
Pneumothorax: Caused by a collection of gas in the pleural space with
resultant collapse of lung tissue. Common risk factors:
Mechanical ventilation
Underlying lung disease (especially meconium aspiration or severe
infant RDS)
Absence of breath sounds on one side of the chest in combination with
respiratory distress is an important diagnostic clue.
Meconium aspiration syndrome: Passage of meconium in utero may
indicate fetal stress and hypoxia. Aspiration of meconium may occur in utero
with fetal gasping, or at first breath at delivery. Often presents with
symptoms of respiratory distress, including tachypnea.
Transposition of the great arteries (TGA): Congenital heart defect in
which the aorta and pulmonary arteries are transposed, resulting in
respiratory distress and severe cyanosis shortly after birth as PDA closes.
IDM is a risk factor. Often associated with other congenital heart defects
such as a VSD. Murmur may be heard on physical examination.
Hypothermia: Should be considered in the differential of a tachypneic
newborn. May be associated with neonatal sepsis. Small for gestational age
and premature infants are more at risk to become hypothermic because of
their small body size and relatively large surface area.
Severe coarctation of the aorta: May cause respiratory distress if there is
severe left ventricular outflow tract obstruction. Classically, diminished
pulses in the lower extremities or asymmetric blood pressure readings
suggest the diagnosis. In severely ill neonates, there may be no differences
in the pulses because cardiac output is so poor.
Studies
Complete blood count (CBC) with differential:
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Usefulto rule out neutropenia, leukopenia, abnormal immature-to-total-
neutrophil ratio, and thrombocytopenia as signs of sepsis maybe underlying
respiratory distress
Blood and CSF cultures:
Critical in the diagnosis and management of neonatal sepsis.
Arterial blood gas (ABG):
ABG helpful in determining the oxygenation (PaO2), ventilation (PaCO2),and
acid-base status (pH and HCO3) of the infant.
If infant is cyanotic, knowing pCO2 helps elucidate the cause.
If respiratory distress is mild, the infant pink in color, and the infant is not
otherwise at risk, blood gas determination is not essential.
Pulse oximetry:
Detects oxygen saturation of the blood.
Oxygen challenge test (hyperoxia test):
Can help differentiate between cardiac and pulmonary etiology in cyanotic
infants
Oxygen will increase the PaO2 of infant whose cyanosis is caused by a
respiratory condition, but not significantly increase PaO2 if cyanosis is
caused by a cardiac lesion.
Chest X-ray:
Integral part of initial assessment of the newborn with respiratory distress
Size and shape of heart may yield some clues to the diagnosis
Appearance of lungs may suggest pneumonia, meconium aspiration, RDS,
etc.
Normal inspiratory films should have eight or more intercostal spaces of
lung fields on both sides.
Findings typical of TTN include:
Significant perihilar streaking due to interstitial fluid and engorged
lymphatics
Coarse, fluffy densities that represent fluid-filled alveoli
Fluid in the pleural space and fissures
Findings typical of RDS include:
Air bronchograms
Diffuse reticulogranular appearance of lung fields ("ground-glass
appearance")
Findings in infant with diaphragmatic hernia include:
Air-filled loops of bowel in left side of chest
Displacement ofheart and mediastinum to contralateral side
Echocardiogram:
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Gold standard in diagnosis of congenital cardiac lesions and persistent
pulmonary hypertension of the newborn
Indicated when there is persistent cyanosis and no indication of lung
disease, or when there are other signs suggesting a heart defect, such as a
murmur, abnormal electrocardiogram (ECG), or chest X-ray showing
abnormal cardiac contour
Glucometer test:
The glucometer test is a screening test only, and must not be used to
confirm hypoglycemia.
Confirm glucometer reading with serum or plasma glucose level.
If low, start treatment immediately; do not delay until laboratory results are
available.
Management
Transient tachypnea of the newborn (TTN):
Monitor to ensure signs of respiratory distressincluding tachypnea
resolve.
If respiratory symptoms do not improve, suspect pneumonia. Order a repeat
chest X-ray and start antibiotics.
Feeding and respiratory distress:
Recommendations vary, depending on physicians experience or the policy
of the neonatal unit.
No evidence from controlled studies that feeding a tachypneic infant by
mouth is contraindicated (although many physicians are reluctant to try this
because they feel that oral feedings place the infant under greater stress)
Some infants may need nasogastric feeding or IV fluids if respiratory
distress worsens with feeding
Infants with respiratory rates of > 80 per minute will have difficulty with
both oral and nasogastric feedings and often require intravenous fluid
support.
Use of a nasogastric feeding tube avoids use of a bottle (after feeding from
a bottle, some babies may get frustrated when they breastfeed because the
milk does not flow as fast from the breast as from a bottle).
Hypoglycemia: Glucose is the primary substrate for brain metabolism in the
neonate, and even asymptomatic hypoglycemia may have negative consequences
for long-term neurodevelopment:
Goal: Maintain glucose levels between 4150 mg/dL.
Threshold values for initial intervention:
Asymptomatic infants and infants at risk for hypoglycemia: < 35
mg/dL
Symptomatic infants: < 45 mg/dL
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Milk feeding (formula or breast) raises glucose levels, maintains stable
levels, and avoids rebound hypoglycemia that is associated with glucose
water.
Monitor glucose levels until levels are stable (> 40 mg/dL). If the
blood glucose is not > 40 mg/dL with the first enteral feeding, initiate
IV dextrose infusions.
Frequency of monitoring depends on severity of the hypoglycemia;
may range from every 30 minutes to every 3 hours prior to feeds.
Prematurity:
Before discharge, establish breastfeeding and self-maintenance of body
temperature.
Confirm:
Physical examination without major defects
Minimal or no jaundice
No blood group incompatibility
Breastfeeding well every two to four hours
Six or more wet diapers daily
Transition from meconium to seedy, soft, tan-yellow stools
Weight loss < 10%
Car seat available
Good support for mother at home
Back-to-sleep program reviewed
Prescription for Vitamin D completed (for exclusively breastfeeding
infants, recommended 200 IU of vitamin D daily)
Follow-up visit arranged identified primary care physician
Risks of co-bedding (with parent or other children) reviewed:
Infant may be brought into bed for nursing or comforting but
should be returned to their own bassinet or crib when parent is
ready to return to sleep
Infant should not be brought into bed when parent is
excessively tired or using medications or substances that could
impair his or her alertness.
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Case 7

Newborn with respiratory distress - Adam

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