RAPID BREATHING (Respiratory Distress Syndrome/Transient Tachypnea)

Definition: Rapid breathing in the early days of life due to immaturity of the lungs or

decreased absorption of fetal lung fluid.

1. What caused this condition?

Rapid breathing (tachypnea) is a sign of an abnormality in the lungs. Causes for the rapid breathing can be lung fluid that did not clear quickly (transient tachypnea of newborn), inadequate levels of a substance (surfactant) in the lungs that prevents them from collapsing (respiratory distress syndrome), or infection (pneumonia).

2. What is actually taking place in the lungs?

The lungs are stiffer than normal and have a decreased ability to get oxygen into the bloodstream and carbon dioxide out. In some cases, there may be gradual collapsing of the small air sacs that, as it progresses, makes the condition worse.

3. How does it differ from pneumonia?

Pneumonia is caused by an infection. This condition is caused by either too much fluid in the lungs after delivery or decreased amounts of a chemical that stops the air sacs in the lungs from collapsing.

4. What tests are needed to further define this condition?

Chest X rays are the main test, but many of these conditions can appear the same on chest X ray. Often the way the baby acts after several hours will determine whether there is just fluid or if there is collapse occurring. Since infection is always a concern, a blood count and blood culture are also almost always done. A blood gas to deter- mine how well the lungs are functioning is also frequently performed.

5. How dangerous is this condition, and can we expect a complete recovery?

If there is extra fluid only, the condition is mild, and the baby gener- ally starts to get better several hours after treatment. If there are decreased amounts of surfactant present, then the baby will most likely need some type of breathing support. Decreased surfactant is a more significant condition with potentially more complications and a longer need for treatment. In both conditions the affected newborn generally makes a complete recovery.

6. What kind of treatment will be needed, and are there any potential negative side effects from the treatment? 

In most cases either additional oxygen support and/or breathing support with a machine will be needed. An artificial form of the chemical to prevent lung collapse, surfactant, will be given to babies meeting levels of support to warrant its use. If artificial surfactant replacement is needed, then a breathing tube will be placed into the baby’s airway (trachea), and the chemical will be given directly into the lungs. The breathing tube may then be removed or kept in place and a form of breathing support will be started. This breathing support can either be through prongs that go in the baby’s nose or by a breathing machine (ventilator) attached to the breathing tube.

     As with any abnormality in the lungs and need for breathing assis- tance, a hole can develop in the lung(s) that allows air to escape from the lung into the chest cavity (pneumothorax). As this air accumulates, it may compress the lungs and cause further worsening of the breathing condition. Many of these leaks require a drainage tube (chest tube) placed into the chest to remove this trapped air. Occasionally, these leaks can also occur within the lungs (pulmonary interstitial emphysema), under the skin, or around the heart. These may require different drainage tubes or special ventilators to treat.

7. How long will my baby need to stay in the hospital?

Depending on the severity and whether it is excess fluid or low levels of surfactant, the baby may stay in the hospital from three days to several weeks. Infants with excess fluid and mild surfactant shortage respond quickly and will have shorter stays. In all cases, the breathing concerns have to be resolved and the baby feeding by mouth prior to going home.

8. Will the treatment or the disorder weaken the lungs in the future and predispose my baby to future respiratory tract problems?

In most babies that are close to their due date or at their due date there are minimal long-term effects on the lungs. The majority of these babies will have no further respiratory concerns.

9. Will I be able to stay in the hospital until my baby is fully recovered?

The usual hospital stay for a mother is two to four days, depending on the type of delivery. Babies with excess fluid have a better chance of being able to be discharged with the mother. Mothers of infants with surfactant immaturity will most likely be discharged prior to the baby’s recovery.

10. Will any treatment be needed at home following discharge, and, if so, who will help me administer it?

It is unusual for babies that are not very premature to require any treatments after discharge. More premature babies may require supplemental oxygen, intermittent breathing treatments, or rarely, additional breathing support. Parents of babies with these needs will be trained prior to discharge and often spend one to two days and nights in the hospital with their baby prior to discharge. Sometimes a home nurse may assist or check in regarding the care of the baby after discharge.

11. Do we need to consult with a neonatologist (newborn specialist) or a pulmonary (lung) specialist?

Most babies with breathing issues that require them to be transferred to the neonatal intensive care unit will be cared for by a neonatologist. Pulmonary specialists are generally consulted near discharge if the baby is going to require breathing support at home.

12. Is this hospital capable of dealing with this disorder, or does my baby need to be transferred to another hospital that is more capable of dealing with difficult illnesses?

This depends on each hospital’s capabilities and pediatrician’s comfort level in treating sick newborns. Many smaller hospitals will attempt to take care of babies with excess fluid that just need additional oxygen and are stable or improving. If the baby’s condition is getting worse and breathing support is needed, that is generally done at larger hospitals that have special areas called neonatal intensive care units (NICUs) and neonatologists (newborn specialists).

13. After discharge from the hospital, what kind of follow-up will be needed?

This is dependent on the age of the baby at birth. If the baby was near its expected birth date, then usually care with the pediatrician is needed. The more premature the baby was will increase the potential need for pulmonology and developmental specialty care. 

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PNEUMONIA - NEONATAL

Definition: Infection of the lungs in the newborn period.

1. What caused this condition?

In the majority of cases, bacteria has gotten into the lungs causing an infection. This can be the only site of the infection, or pneumonia can be present when there is a generalized infection of the blood- stream also.

The bacteria can get into the baby’s lungs from the placenta, during the delivery process, or after birth. Occasionally, the pneumonia may be caused by viruses or other infectious agents such as chlamydia, a sexually transmitted infection.

2. How dangerous is this condition, and what complications can occur?

All infections in newborns can be serious and potentially life threatening. Depending on the severity of the pneumonia, the baby may only have fast breathing with need for additional oxygen or could require support with a breathing machine and high levels of additional oxygen.

3. What is the proposed treatment?

As with all bacterial infections, antibiotics need to be started as soon as any infection might be suspected. The antibiotics will ultimately cure the infection. As pneumonia can cause the lungs to not function normally, the baby may need additional oxygen or support with a breathing tube and breathing machine. The length of antibiotic treatment in the hospital is at least seven days and may be more.

4. What potential side effects can occur from the treatment?

Most antibiotics have little to no side effects. Some antibiotics may require blood levels performed to make certain they are in a range to treat the infection, but not cause side effects. If some type of breathing support is needed, holes in the lungs (pneumothorax), or injury to the lungs can occur.

5. How long will it take for my baby to improve once the treatment has begun?

Generally, the newborn will begin to get better twenty-four to forty- eight hours after the antibiotics have been given.

6. What additional diagnostic tests should my baby have?

A chest X ray, blood count, and blood culture are done on babies with suspected pneumonia. Other blood tests that may be done are a measurement of inflammation, c-reactive protein, and a blood gas, which determines how well the lungs are functioning. If a breathing tube is required, a sample of the secretions from the airways may be sent to determine if bacteria are present or not.

7. After the condition is resolved, will my baby be more prone to respiratory tract infections in the future?

No.

8. Do we need to consult with a neonatologist (newborn specialist) or a pulmonologist (lung specialist)?

If the baby requires additional oxygen or breathing support, a neonatologist is consulted. Some babies that have very mild cases or “suspected” pneumonia may stay in the regular newborn nursery under the pediatrician’s care.

9. What kind of follow-up will be needed with you in the future?

For mild to moderate cases of pneumonia, routine follow-up with the pediatrician is all that is necessary. In severe cases, a developmental specialist may also monitor your child’s progress. 

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MECONIUM ASPIRATION

Definition: When the newborn or fetus inhales meconium (first stool) into the lower

respiratory tract.

1. What caused this condition?

The baby had a bowel movement while still inside the mother’s uterus. Meconium is the name for the first stools that a baby passes. The meconium gets into the fluid surrounding the baby and can be swallowed into the lungs or breathing passageways prior to or at the time of birth. Babies that are under stress or go beyond their expected due date have a higher incidence of passing meconium while still in the uterus. Generally, meconium aspiration is seen in babies that are not premature.

2. Is this condition dangerous, and what kind of damage can it cause?

If the meconium gets into the airways leading to the lungs, it causes a blockage of the passageways. This stops or impedes the flow of air into and out of portions of the lungs. This can lead to low oxygen levels or a buildup of carbon dioxide.

     If significant, this disruption in the functioning of the lungs can lead to a continued high blood pressure in the blood vessels leading to the lungs. When this occurs, there is further inability of the lungs to get oxygen into the bloodstream and to remove carbon dioxide due to blood bypassing the lungs.

     Another common complication of meconium aspiration is the development of a hole in the lung(s). This is called a pneumothorax. Air escapes from the lung into the chest cavity and is trapped between the chest wall and lung. As the air builds up, it compresses the lung and again disrupts normal lung function.

3. What tests are needed to further define the condition?

The presence of meconium is noted when the water is broken either naturally or by the obstetrician. The fluid will have a greenish discoloration. The thickness and degree of discoloration indicates the amount of meconium present. After the baby is born chest X rays will confirm the findings of meconium aspiration if present. A sample of blood called a blood gas along with oxygen-level monitoring (pulse oximeter) will show low oxygen levels and disturbances in lung functioning.

4. What is the treatment?

Prevention is the main treatment. If meconium stained fluid is noted, the obstetrician may infuse sterile salt water into the uterus to dilute the meconium. At the time of delivery, the obstetrician will attempt to clean out the nose and mouth prior to the delivery of the rest of the baby. The baby may then have a breathing tube passed into the trachea, the main passage to the lungs, and suction applied while it is removed.

     If the baby has further or continued problems, then additional oxygen and/or a breathing machine may be needed. If a breathing tube is needed, the instillation of a medication called surfactant may be given through it to help break up the meconium and improve the function of the lungs. If the baby has significant breathing concerns, a ventilator called an oscillator may be used.

     If the baby develops a pneumothorax, or hole in the lung(s), a drainage tube may be needed. This drainage tube is called a chest tube, and it is placed between the ribs on the side of the air leak to prevent the lung from collapsing.

5. What side effects can occur from the treatment?

The most common early side effect is a hole in the lung(s) from air being trapped by the meconium or from the degree of ventilator support required to get acceptable oxygen and carbon dioxide levels. It is treated as mentioned above.

     The lungs can be injured from being on the ventilator. They may develop an inflammatory reaction to the irritation of the meconium and being on the ventilator and high oxygen concentrations. If this occurs, it may delay coming off of the ventilator and additional oxygen. This inflammatory response can occasionally lead to the baby having feeding problems due to increased work of breathing and needing extra oxygen at the time of discharge.

     Infrequently, a baby may have severe meconium aspiration along with severe elevations in the blood pressure in the blood vessels leading to the lungs. This may require treatment with a heart-lung bypass (ECMO).

6. How long will it take for my baby to show improvement?

Most babies get better in seven to ten days. A baby with severe meconium aspiration may require a longer hospital stay, potentially up to a month, to be well enough to be discharged.

7. What complications can develop?

The more frequent complications are the same as the side effects from being treated. Holes in the lung (pneumothoraces) or the failure of the blood pressure to lower in the lungs after birth (pulmonary hyper- tension) may be present and complicate the meconium aspiration. Occasionally, babies may have some inflammation in their lungs that delays their improvement.

8. Can pneumonia develop?

Pneumonia caused by bacteria is not associated with the meconium aspiration itself. Infection may occur in any patient that has a breathing tube in place and receives ventilatory support for a period of time, especially longer than fourteen days.

9. Will this condition weaken my baby’s lungs for the future?

Both the presence of meconium and being on a breathing machine with exposure to high concentrations of oxygen can cause an inflammatory response in the lungs. In some cases this can lead to delayed recovery and some lung abnormalities for the first several months of life. Most babies with mild-to-moderate meconium aspiration will not have any long-lasting lung problems.

10. After discharge from the hospital, what kind of follow-up will be needed?

In most cases, your child’s pediatrician will be all that is necessary. In severe cases of meconium aspiration, the baby may be at more risk for developmental delays and a developmental specialist may be required. 

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LUNG RUPTURE (Pneumothorax or Pneumomediastinum)

Definition: Free air in the chest cavity.

1. What has caused this condition?

There was a tear or rupture in the air sacs (alveoli) in the lungs. This tear allowed air to escape out of the lung and into either the space between the lung and the chest wall (pneumothorax) or into the tissues along the blood vessels (pneumomediastinum). Pneumothorax is relatively common in newborn babies, occurring in approximately 1 percent of all newborns. Many babies have no symptoms. Others have symptoms related to the compression of the lung(s) by the leaked air and need treatment and/or supplemental oxygen. Babies that have other breathing prob- lems and require breath assistance from a breathing machine are at potentially higher risks to develop air leaks in their lungs.

2. How is it treated?

In a lot of cases when the baby is otherwise healthy and without symp- toms, observation is all that is needed and the tear will heal itself and the air be reabsorbed. In cases where the air leak is larger and the baby is having symptoms, the air may need to be pulled out (aspirated) by putting a needle in the baby’s chest wall. After the air in the chest cavity is pulled out, the needle is removed, and the baby is monitored for recurrence. If the leak continues or if the baby is on a breathing machine for support, a drainage tube (chest tube) is placed in the chest wall to continuously drain the air until the leak heals. Many babies that have symptoms due to the free air will also require extra oxygen to keep their oxygen levels in an acceptable range. During this time, your baby may be breathing faster than normal or harder than normal and not be able to feed by mouth. This may require feedings via a tube, or the feedings withheld and IV fluids started. 

3. How long will it take to correct itself?

This depends on the size of the leak. Many babies with small leaks that seal over rapidly are better in twelve to twenty-four hours, sometimes without symptoms. Babies that require needle aspiration or drainage tube placement may require two to three days or more to close the tear and allow the lungs to heal.

4. Do we need to consult with a neonatologist (newborn specialist) or a pediatric surgeon?

If the baby has symptoms or requires aspiration, drainage tube place- ment, or extra oxygen, a neonatologist is often involved in the care. Babies that are just breathing a bit fast or have no symptoms are often watched in newborn nursery by the pediatrician. It is rare that a surgeon or surgery is needed.

5. What tests need to be done to further define the condition?

An X ray of the chest is the test that absolutely confirms that a pneumothorax or pneumomediastinum is present. It can also provide some information as to how much air and compression on the lungs has occurred. Prior to the chest X ray, you may be able to suspect an air leak by listening to the chest and hearing decreased breath sounds on the side with the leak. You can also place a light on the front of the chest (transillumination), which may indicate air has leaked out of the lung and accumulated in the chest.

6. What kind of future complications can we anticipate as a result of this illness?

The majority of babies will have no long-term effects from the air leak itself. The rupture or hole will heal by itself. Any future complications are most likely to occur if the baby is premature or there was another lung problem that required treatment.

7. Are the lungs left weakened from this condition and, if so, in what way?

No, the lungs will heal the tear and recover in almost all cases. If there were other lung problems that were also present, some breathing abnormalities could persist until the lungs are healed from those conditions.

8. After discharge from the hospital, what kind of follow-up will be needed?

As the rupture or tear in the lung is healed at the time of discharge, just routine follow-up with the pediatrician is necessary. 

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KIDNEY ENLARGEMENT (Hydronephrosis)

Definition: Swelling of the kidney as a result of obstruction to the flow of urine.

1. What caused this condition?

Hydronephrosis in most babies is a minor condition that goes away on its own. It likely represents increased urine production by the fetus prior to delivery that goes away with time. Occasionally, hydronephrosis may be due to an obstruction that is caused by abnormal development of the ureter (the tube that carries the urine from the kidney to the bladder). Hydronephrosis may also represent the backwash of urine from the bladder to the kidney known as vesicoureteral reflux.

2. What tests are needed to further define the disorder?

In most cases, ultrasound imaging is used to discover kidneys that are hydronephrotic. Once a kidney has been determined to be hydronephrotic, depending on the age and gender of the baby, a bladder X ray should be performed to look for backwash of urine up to the kidney (vesicoureteral reflux) or blockage in the urethra if the child is male. In other instances where the condition is quite severe, a nuclear medi- cine renal scan should be performed to rule out obstruction of the kidney. An obstruction might require surgical intervention to preserve the kidney. If the hydronephrosis involves both kidneys, then further evaluation with a standard blood test should be performed in the hospital or office to make sure that kidney function is normal.

3. Is this condition causing my baby any pain or discomfort?

If the kidney is significantly swollen (dilated) or it is obstructed, the baby may have pain, nausea or vomiting, or even blood in the urine. However, most degrees of hydronephrosis do not cause any pain or discomfort.

4. Is it correctable, and will surgery be necessary?

Most hydronephrosis is minor and will resolve or improve on its own as the baby gets bigger. However, if the dilation is significant or severe, then this may represent an obstruction of the kidney that will require surgery to resolve the obstruction. If the dilation of the kidney is related to vesicoureteral reflux, and if the reflux does not resolve as the baby gets older, then correction of the reflux may be necessary. Blockage of the male urethra must be corrected with surgery.

5. Will it predispose my baby to kidney disease or infection in the future?

Most hydronephrosis does not predispose the kidney to disease or infection; however, if the dilation is related to vesicoureteral reflux, reflux is a risk factor for developing both bladder and kidney infections. If the dilation is severe and involves both kidneys, then kidney disease is a possibility.

6. Do we need to consult a urologist and, if so, when?

Once the diagnosis of hydronephrosis is made, the urologist should be consulted to review the X rays, perform a complete history and physical examination of the baby and then determine if any other further studies are necessary. While this is generally not an urgent condition, if the child is having pain, significant infections, or it involves both kidneys, then the urologist should see the child immediately.

7. How will the condition be monitored following discharge from the hospital, and what tests will need to be done?

An ultrasound and further studies are usually recommended approximately four to six weeks following discharge. Depending on whether or not the hydronephrosis is severe, a renal scan may need to be performed. If the hydronephrosis involves both kidneys, then a stan- dard blood test would need to be performed to determine kidney function. If the child has not had an evaluation for vesicoureteral reflux, then a bladder X ray test would be necessary.

8. What danger signs should we look for after leaving the hospital that would indicate that the kidney problem might be getting worse?

The most common symptoms associated with severe hydronephrosis or an obstructed kidney is abdominal, side, or back pain and vomiting. Fever may represent a urinary infection.

9. After discharge from the hospital, when do you wish to see my baby again?

After the child is discharged, we will normally see the child back in our office for an ultrasound and further studies approximately four to six weeks later. See question #7 for details. 

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