Introduction

If your newborn baby is experiencing breathing problems, neonatal respiratory therapy can provide the necessary support to help your child breathe comfortably in the first few weeks of life. Neonatal respiratory therapy can be described as the specialised clinical management given to babies to aid them in breathing properly if they have breathing issues. This article will describe the circumstances in which your newborn may need respiratory therapy and the types of respiratory therapies that may be recommended for your child.

How do newborns begin to breathe?

The lungs, the primary organ needed for breathing, begin to develop while your baby is still in the womb. For the lungs to grow properly in the baby, they are filled with lung fluid, which is secreted by the lining in the baby’s airways.¹ Additionally, the baby’s lungs and respiratory muscles are trained and strengthened through active breathing movements in the womb in preparation for breathing air after birth.²

However, prior to your baby’s birth and immediately after, there are a series of timely events that are needed including the clearance of lung fluid in order for the baby to begin breathing air effectively.¹

Hormonal and electrolyte changes

The beginning of labour triggers multiple hormonal and electrolyte changes in your baby, causing the secretion of lung fluid to stop and instructing the majority of the lung fluid to be removed from the lungs.¹ Hormonal changes are also triggered when the umbilical cord is clamped, which helps stimulate the baby to start breathing.¹

Vaginal birth

The contractions felt during labour and the squeezing of the baby as it passes through the birth canal during vaginal birth aid in the clearance of lung fluid.^1,2

Taking the initial breath

When the baby takes their first breath of air after birth, it allows air to fill the lungs, which in turn increases blood flow to the lungs and promotes the clearance of lung fluid.³ Rapid breathing after the first breath also helps to clear any residual lung fluid.¹

Any changes or disruptions in these events, among other reasons or risk factors, can impact your baby's ability to breathe properly. 

Risk factors for breathing problems in newborns

Some potential risk factors for breathing problems in newborns are listed below:^1,4

• Abnormalities in the baby’s lung structure
• Conditions experienced by the pregnant individual, such as gestational diabetes and asthma
• Meconium-stained amniotic fluid
• Infections of the placenta and amniotic fluid
• Premature labour and birth
• Caesarean section (C-section)

There is an increased risk of breathing problems in babies born before 37 weeks of pregnancy, as the lungs may not have developed adequately by this time. It is also important to note that despite the potential risk of breathing problems in babies delivered via C-section, it is often the safest option in some situations for both the baby and/or the pregnant individual. Additionally, the risks associated with C-sections are said to decrease when performed after 37 weeks of pregnancy.⁵ 

Respiratory conditions in newborns

When a baby is having breathing problems, they are unable to get sufficient oxygen into their body, which can have life-threatening outcomes. Therefore, it is important to determine whether the baby is having breathing problems and to understand the underlying respiratory cause or condition. Early detection and management of breathing problems can increase the chances of survival and reduce the likelihood of long-term complications.^4,5

There are various conditions that your newborn baby may be diagnosed with, such as transient tachypnea of the newborn and persistent pulmonary hypertension, but some of the more common conditions are described below.⁵

Neonatal/newborn respiratory distress syndrome (NRDS)

Neonatal/newborn respiratory distress syndrome (NRDS) is a serious respiratory condition in which the baby’s lungs cannot function properly because of a low quantity of the substance surfactant in the baby’s lungs.^1,3,5 Surfactant is naturally produced by the lungs and is important for allowing the lungs to expand comfortably for air to enter, as well as preventing the collapse of structures in the lungs, such as the alveoli (tiny air sacs).^1,3,5 Without enough surfactant, the baby will struggle to breathe, and these symptoms usually present soon after birth.⁶ 

Bronchopulmonary dysplasia (BPD)

Bronchopulmonary dysplasia (BPD) is a condition in which the baby’s lungs and associated blood vessels do not develop properly, leading to breathing problems.⁷ The main cause of this condition is injury to the lungs, commonly caused by long-term use of equipment that supplies oxygen or air to babies with underdeveloped lungs that cannot provide enough oxygen to their bodies.⁸ However, for BPD to be diagnosed, the baby needs to be on oxygen-supplying therapy for at least 28 days.⁵

When injuries occur, the baby’s immune system activates and causes inflammation aimed at healing the damage.⁷ However, this inflammation can cause further lung damage and negatively affect the development of the lungs.^7,8

Meconium aspiration syndrome (MAS)

Meconium is a dark greenish substance naturally present in the first stool of a newborn baby, usually passed a few hours after birth.⁹ However, if the baby is struggling or is unwell in the womb or during delivery, they may pass stool too early, before they have left the womb, causing the amniotic fluid to become stained with meconium.⁵ The baby may then accidentally inhale the meconium-stained amniotic fluid, leading to breathing problems and other issues, such as infections.⁵ This is known as meconium aspiration syndrome (MAS).

Types of neonatal respiratory therapy

Advancements in neonatal care have led to the development of several therapies that can be administered. A summary of some of the available therapies is described below. The therapies either supply oxygen or air to the baby, prevent the lungs from collapsing, keep the airways open, or provide surfactant to babies with low quantities of it.

Continuous positive airway pressure

Continuous positive airway pressure (CPAP) therapy is when a CPAP machine supplies air at a specific pressure to the baby through a mask or using tubes that go into the baby’s nose.¹⁰ This helps prevent structures in the baby’s lungs from collapsing and improves lung function.¹⁰ This therapy can be used in NRDS and can reduce the risk of BPD developing.^3,5,10

Surfactant (Exogenous) therapy

Surfactant exogenous therapy is when surfactant is delivered to the baby because the baby has been unable to produce enough surfactant naturally. This therapy can be given to premature babies to reduce the risk of NRDS or when NRDS has been diagnosed in the child.^3,5,6 Surfactant can either be given in small amounts by inserting a small tube into the baby’s windpipe (less invasive surfactant administration) or, in one single dose quickly.^10,11

Mechanical and high-frequency ventilation

Mechanical ventilation is a breathing tube which is connected to a machine (ventilator), and is inserted into the baby’s windpipe to help the baby breathe and take any stress off the lungs. Mechanical ventilation is successful in providing respiratory support to newborns however, there is a risk that long-term use can lead to complications such as BPD for the baby.¹⁰ An alternative type of ventilation which is said to cause less injury to the baby’s lungs could be high-frequency ventilation.¹² 

Nasal high-flow therapy

Nasal high-flow therapy is when a tube (cannula) is inserted into the baby's nose to provide a heated and humidified blend of air and oxygen to the baby’s body.¹³ A healthcare professional may use this method instead of CPAP after carefully considering the benefits and risks of the two methods. This is because nasal high-flow therapy is more comfortable for the baby, causes less injury to the nose, is easy to use, and allows for more parental contact with the baby.¹³ 

FAQs

How can I tell if my newborn is having breathing problems?

There are signs and symptoms you can look out for in your newborn that may indicate breathing problems and the need for medical attention. A few of these signs include:

• If your baby’s stomach is sucking in under their ribs
• Noisy breathing, such as grunting sounds
• Lips or face turning pale or blue 
• Faster breathing than usual
• More than 10 seconds between each breath 

Summary

If your baby is struggling to breathe in the first few weeks of life, neonatal respiratory therapies are recommended. A number of respiratory conditions can develop if your baby has been exposed to risk factors that can negatively impact the baby’s ability to breathe naturally. These risk factors can be generated from the pregnant individual, abnormal developments in the baby whilst in the womb, or from events surrounding the birth of the baby. In such situations, some of the different respiratory therapies that may be given are CPAP, high-flow therapy, mechanical ventilation, and exogenous surfactant. They all have their benefits and risks but the most appropriate therapy will be decided based on your baby’s health.