Respiratory distress syndrome in newborns

How does this happen?

Lungs end in millions of tiny sacs where oxygen crosses into the blood. Each sac is wet inside, and wet surfaces pull themselves closed. surfactant is what stops that from happening.

A baby's lungs start producing surfactant in useful amounts late in pregnancy. A baby born before that has lungs that partly collapse at the end of every breath, so every breath has to reopen them from scratch. That is exhausting, and a small baby cannot keep it up. ¹

The lungs become stiff, oxygen levels fall, carbon dioxide builds up, and without support the baby tires.

Steroids given to the mother before birth speed up the baby's own surfactant production, and they are one of the most effective interventions in obstetrics. ^{2 3}

Surfactant given after birth, straight into the lungs through a tube, works immediately.

Other things can look like RDS and need distinguishing: transient tachypnea, which is fluid left in the lungs and clears in a day or two; pneumonia; and meconium aspiration syndrome. ⁴

What causes it?

Two different questions get mixed together here. The first is what leads to this injury in the body. The second is whether anyone could have prevented it. They are not the same question, and the answer to the first does not settle the second.

Happens even with perfect care

• Preterm birth, which is the dominant cause and is often unavoidable. ¹
• A birth too fast for a full course of steroids, which happens.
• Maternal diabetes, which delays lung maturity even at term. ⁵
• Cesarean birth without labor, since labor itself helps clear lung fluid and prompts surfactant release.
• Being a male baby or a twin, both of which carry somewhat higher risk.
• Genetic surfactant deficiency, which is rare and occurs in term babies.

Associated with gaps in care

These are situations where published standards say what the care team should watch for and do. A gap here does not prove anyone caused your child's injury. It points to where the medical records will have an answer.

• Antenatal corticosteroids not given when preterm birth was expected and there was time. This is the central question in most cases. ^{2 3}
• Magnesium sulphate not given before 32 weeks for fetal neuroprotection, which is a separate but parallel omission in preterm care. ⁶
• A mother not transferred before delivery to a hospital with the right level of newborn care, when the safest transfer of a very preterm baby is usually before birth. ⁷
• Resuscitation not following the newborn algorithm. ⁸
• Surfactant not given, or given late, in a baby who needed it.
• Infection not considered, since pneumonia can present identically. ⁴
• Oxygen not targeted, since both too little and too much cause harm, including to the eyes.

Whether any of this amounts to a departure from the standard of care takes a physician expert reading the whole record.

What are the signs, by age?

Signs change as a child grows. A newborn cannot show you a walking problem. Some children look fine at first and show differences months later.

At birth and the first hours

• Fast breathing.
• Grunting, which is the baby's own way of holding pressure in the lungs.
• Flaring nostrils.
• Drawing in of the chest between and below the ribs.
• Blue color.
• Symptoms that start at or soon after birth and worsen over the first hours.

The first week

• Increasing need for support over the first day or two, then usually gradual improvement.
• Need for CPAP, a ventilator, or surfactant.
• Air leaking from the lung, which is a recognized complication.
• Feeding held while breathing is difficult.
• Improvement in most babies within days.

Around 3 months

• Most babies have recovered.
• Some have BPD, chronic lung disease, needing oxygen at home. ¹
• Slow weight gain in babies working hard to breathe.
• Eye checks for ROP continue in babies born very early.

Around 6 months

• Ongoing oxygen for some.
• More severe illness with ordinary colds, particularly in babies with BPD.
• Developmental follow-up at corrected age. ⁹

Around 12 months

• Most children are off oxygen.
• Wheezing with viral illness is common in children who had BPD.
• Growth catching up.

Toddler years

• Increased respiratory illness in winter for some children.
• Developmental differences relating to prematurity rather than to the lungs themselves. ¹⁰

School age

• Most children have normal or near-normal lung function.
• Some have exercise limitation or asthma-like symptoms.
• Learning and attention differences relating to preterm birth. ¹

How is it diagnosed?

Diagnosis is made from the clinical picture in a baby born early, supported by imaging and blood gases.

Chest X-ray shows a characteristic hazy, finely granular appearance with air outlining the airways.

Blood gases show oxygen and carbon dioxide levels and how hard the baby is working.

Infection screen, because pneumonia, particularly from Group B strep, can look identical on X-ray and needs antibiotics. Most babies are started on antibiotics while this is sorted out. ⁴

Distinguishing from transient tachypnea, which is fluid left in the lungs, usually appears in term or near-term babies, and settles in a day or two.

Echocardiogram where oxygen levels are very low, to check for persistent pulmonary hypertension of the newborn or a heart defect. ¹¹

Ask two things: how early was my baby, and were antenatal steroids given and when. Those two facts explain most of what happens next.

What is the treatment?

CPAP first, in most units. CPAP holds the lungs open with continuous pressure through nasal prongs while the baby breathes for themselves. Starting with CPAP rather than a breathing tube, where the baby can manage it, is now standard practice in many units because it is gentler on the lungs. ¹

surfactant, given directly into the lungs. Some babies get it through a brief intubation and are then returned to CPAP.

Mechanical ventilation where CPAP is not enough.

Oxygen, carefully targeted. Too little harms the brain and too much harms the eyes and lungs, so units work to defined saturation targets and adjust frequently.

Caffeine, which is given to many preterm babies to stimulate breathing and reduce apnea.

Antibiotics while infection is excluded. ⁴

Nutrition, usually intravenous at first, then milk by tube, with breast milk strongly preferred where available.

Prevention next time. If you have another pregnancy, tell the team about this history early, because it changes the plan for steroids and for monitoring. ³

What is the long-term outlook?

Most babies with respiratory distress syndrome recover within days to weeks and go on to have normal lung function. ¹

The main determinant is how early the baby was born rather than the RDS itself.

BPD, chronic lung disease, is the main respiratory complication, and it affects babies who needed prolonged support. Those children often need oxygen at home for a period and are more severely affected by ordinary respiratory viruses in the first years. Most improve substantially as they grow. ¹

Long-term developmental outcomes relate mostly to prematurity in general rather than to RDS specifically, which is why developmental follow-up is arranged for preterm babies as a group. ⁹

What does daily life look like?

In the NICU: weeks of watching the settings come down, day by day, with setbacks.

At home with oxygen, if that is your situation: tubing everywhere, monitors, and a genuine adjustment. Ask for a clear plan on what to do during illnesses, and about immunizations and any preventive treatment against respiratory viruses.

Winter is the hard season for children with BPD. Hand washing and avoiding sick contacts matter more than they do for other children.

Corrected age governs the first two years for milestones. ¹

What does care cost over a lifetime?

NICU care for preterm babies is among the most expensive hospital care there is, and the length of stay is driven by gestational age.

No agency publishes a current per-child lifetime cost for respiratory distress syndrome, and this site does not invent one. National inpatient data on children's hospital stays is collected in the Kids' Inpatient Database. ¹²

See paying for care for the programs that cover this, including Medicaid and state programs. ¹³

What can you do this week?

1. Ask whether antenatal steroids were given, how many doses, and when.
2. Ask whether magnesium sulphate was given, if the birth was before 32 weeks.
3. Ask whether surfactant was given and how many doses.
4. Ask what the oxygen targets are and how the team decides to change settings.
5. Ask whether infection is being treated or excluded.
6. Ask about eye screening for ROP and when it starts.
7. Ask to be enrolled in developmental follow-up before discharge.

What should you ask each specialist?

Take these with you. Write the answers down in the moment, because you will not remember them later.

For the neonatologist

• Were antenatal steroids given, and how long before delivery?
• Is this RDS, infection, or both?
• What support is my baby on, and what would it take to come down a step?
• Has surfactant been given?
• What are we watching for over the next few days?

For the obstetric team

• Why was my baby born early?
• Were steroids offered, and was there time for a full course?
• Was magnesium given for the baby's brain?
• What would you do differently in a future pregnancy?

You can also build a printable list with the question generator.