Respiratory Support in Newborns: What Happens in Intensive Care?

After birth, most babies begin breathing on their own without any help. Some babies, however, are born early or had a difficult delivery, and their lungs may not yet be mature, or a problem may appear in the first hours after birth. This is when respiratory support in newborns comes into play. The stages of this process are described in Dr. Murat Palabıyık’s article on respiratory support in the neonatal intensive care unit.

Below I cover which situations may need respiratory support, which stages are used in intensive care, what is done for the baby while support is in place, and what families can do. Every decision is made by the team on the basis of the baby’s condition and the test results; none of these stages can be carried out at home or over the telephone.

Why breathing is different in a newborn

Breathing in a newborn works differently from that of an adult or an older child:

• The lungs are not yet mature. In babies born early, the amount of surfactant released by the lung cells may be low. Surfactant keeps the small air sacs of the lung open; when it is deficient, the sacs stick together and the lungs struggle to open.
• The chest wall is compliant. Because the rib cage is still flexible, more of the work of breathing falls on the diaphragm, and it tires more easily.
• There is little reserve. The oxygen carried in the blood and the ability to keep warm matter greatly in the first hours after birth.
• Fluid and glucose are fragile. A newborn’s fluid balance is easily upset, so the fluids given through a drip are adjusted carefully.

Several of these factors can come together in one newborn, and more than one form of support may be needed.

When respiratory support may be needed

Among the situations that lead to respiratory support in the neonatal intensive care unit are:

• Premature birth: Because the lungs are still immature, difficulty breathing related to surfactant deficiency may be seen.
• Oxygen deprivation around birth: A baby’s need for oxygen may rise during or right after delivery.
• Birth aspiration: Amniotic fluid or meconium entering the lungs.
• Transient respiratory distress: A faster breathing rate and a continuing need for oxygen after birth.
• Infections: An infection developing after birth can affect a baby’s breathing directly.
• Congenital heart and chest abnormalities: Heart failure or conditions affecting the anatomy of the lung.

Many are noticed immediately after birth, but breathing problems can also appear in the days that follow as the baby grows or an infection settles.

The stages of respiratory support

Support is applied in stages according to need:

1. Observation and oxygen: The baby’s breathing, colour and oxygen saturation are watched closely, and oxygen may be given by nasal cannula or mask.
2. High-flow nasal oxygen: Oxygen is delivered at a higher flow rate. The baby breathes more comfortably and the effort of breathing eases, with saturation monitored continuously.
3. Nasal CPAP: Continuous positive pressure through a nasal mask or prongs keeps the small air sacs open, supports oxygenation and, in some cases, reduces fluid that accumulates in the lungs. The baby keeps making its own effort to breathe.
4. Intubation and mechanical ventilation: A ventilator supports the baby’s breathing, and the assessment carried out with it shows whether the lungs are opening adequately. Treatments aimed at correcting surfactant deficiency may also be added.
5. Options for longer-term support: In very rare cases, more advanced options such as extracorporeal support come into consideration, assessed in centres with the appropriate equipment.

These stages are a pathway rather than a competition: as the baby improves, the level of support is reduced step by step.

What is done for the baby during support

Alongside respiratory support, the intensive care unit provides continuous monitoring and supportive care:

• Continuous monitoring: Heart rhythm, oxygen saturation, blood pressure, body temperature, breathing rate and urine output are followed, and blood gases are assessed regularly.
• Warmth and feeding: The baby’s temperature is maintained, and fluid and feeding needs are planned according to the condition. Where possible, feeding with breast milk is the aim.
• Pain and comfort: Newborns cannot tell us about pain; they show it through their facial expression and behaviour. Comfort measures are used during care, and a calm, low-stimulation environment is kept.
• Developmental support: Where conditions allow, measures such as kangaroo care, parental involvement and activities that support development are planned in.

The questions parents ask most often

Is my baby in pain?

Pain management is an important subject in the neonatal intensive care unit and is handled deliberately by the team. Care is carried out with reduced stimulation, with kangaroo care and with appropriate measures where needed. You can tell the team when your baby seems unsettled; your observations are part of the assessment.

How long will the stay in intensive care be?

That depends on how quickly the lungs mature and how the baby responds to support. Premature babies need time for their lungs to mature, and the transition to breathing on their own is planned as the need for support falls. A precise number of days would not be realistic.

Will my baby be able to feed?

During some periods a baby cannot be fed by mouth, and the method of feeding is decided by the team. Supporting breast milk is part of the plan, with help given to mothers in expressing and storing their milk safely for the baby.

What is my part in all this?

Most decisions are made by the team; your part is to be informed, to ask questions and, where possible, to take part in your baby’s care. When something is unclear, the question worth asking is: “Which stage are we at now, and what are we waiting for?”

After going home

Follow-up after intensive care covers breathing as much as development. Babies born prematurely, or who have needed respiratory support, are monitored closely for adjustment to their surroundings, for pauses in breathing and for growth and development. Noisy breathing, difficulty feeding or a delay in development should be seen by a doctor. If the baby turns blue, stops breathing (apnoea) or has severe difficulty breathing, call 112 or go to the nearest emergency department immediately.

Long-term follow-up of premature babies is a specialised area that requires experience of newborns, and it is carried out together with the checkups of the first three months and ongoing monitoring of growth and development.

In brief

• Respiratory support is a staged process; each stage is chosen according to the condition.
• Premature birth, birth aspiration, infection and congenital abnormalities are among the main reasons.
• Support may progress from nasal oxygen to CPAP and on to mechanical ventilation.
• Alongside breathing, temperature, feeding, pain and development are monitored.
• The most valuable contribution a family can make is to ask questions and share observations.
• Follow-up of breathing and development continues after discharge; warning signs need a doctor, and bluish colouring or pauses in breathing mean calling 112.

If you are worried about your newborn’s breathing or about the intensive care process, asking for a face-to-face assessment is reasonable. You can book at Elit Istanbul Medical Center in Florya and discuss your baby’s discharge and the follow-up needed. For appointments and information, call 0212 599 11 16.