Respiratory Distress in New born

1. Respiratory Distress in New born Presented by Dr. Ankit Agarwal Guided by: Dr. J.P. Jain Dept. of Pediatrics NIMS, Jaipur

2. Overview General Considerations Epidemiology Definition and Clinical Features Assessment of severity Causes Approach to a New born with resp. distress Meconium Aspiration Syndrome Epidemiology Etiopathogenesis Clinical Features Diagnosis Management Respiratory Distress Syndrome Epidemiology Etiopathogenesis Clinical Features Diagnosis Management Surfactant Therapy Complication Transient Tachypnea of Newborn Epidemiology Etiopathogenesis Clinical Features Diagnosis Management

3. Epidemiology C ommonest problem encountered within the first few hours of life. It occurs in approximately 1%-6% of live births Responsible for about 20% of neonatal mortality General Considerations

4. Definition and Clinical Features Tachypnea AND Expiratory Grunt OR Inspiratory Retraction Only Tachypnea is NOT Respiratory Distress Cyanosis Nasal Flaring Desaturation Lethargy/Poor feeding Pallor Decreased Breath Sounds +\- Rales or Ronchi Other Features General Considerations

5. General Considerations

6. Assessment of Severity Downe’s Scoring System Score 1 2 Respiratory Rate (rate/min) <60 60-80 >80 Cyanosis None in room air No cyanosis in 40% oxygen Requiring more than 40% ambient oxygen Retractions None Mild Moderate to Severe Grunting None Audible with Stethoscope Audible without Stethoscope Air Entry Good Decreased Barely Audible General Considerations Modified Downe’s Scoring System No cyanosis with oxygen support Cyanosis in spite oxygen support

7. Interpretation: <4: No Respiratory Distress 4-7: Clinical Distress >7: Impeding Respiratory Failure Downe’s Score should be noted every 30mins-1 hour to monitor progression of respiratory distress . General Considerations

8. Silverman-Andersen Retraction Scoring Interpretation Score 0-3 = Mild respiratory distress Score 4-6 = Moderate respiratory distress Score > 6 = Impending respiratory failure Score 10 = Severe Respiratory distress General Considerations

9. A progressively increasing O2 requirement to maintain saturation is also a sensitive indicator of the severity and progress of distress >95% Term baby, pulmonary hypertension (PPHN) 88-94% 28-34 weeks preterm 85-92% Below 28 weeks gestational age Guidelines for monitoring oxygen saturation levels by pulse oximetry MJAFI, Vol. 63, No. 3, 2007 General Considerations

10. Causes Pulmonary Extra-pulmonary General Considerations

11. Pulmonary Causes 1) Airway obstruction A ) Nasal – choanal atresia, nasal edema B ) Oral cavity – macroglossia , micrognathia , Glosoptosis C ) Laryngeal obstruction – laryngeal web, Subglottic stenosis of larynx, Laryngomalacia , cord paralysis D ) Neck obstruction – cystic hygroma , cong goitre E ) Tracheal obsruction – Tracheomalacia , TEF, Tracheal stenosis General Considerations

12. 2) Lung parenchyma Aspiration syndrome (MAS) Respiratory distress syndrome (HMD) Transient Tachypnea of new born Pneumonia Pleural effusion Pulmonary hemorrhage Air leak – Pneumothorax, Pneumomediastinum 3 ) Developmental defects Agenesis of lung Hypoplasia of lung Diaphragmatic hernia Tracheal agenesis TEF Asphyxiating Thoracic dystrophy ( Jeune Syndrome) General Considerations

13. Extrapulmonary Causes CNS Trauma or Birth Asphyxia Cardiac Failure Metabolic acidosis Persistent pulmonary hypertension Diaphragmatic Hernia Intercostal muscle Paralysis Others: Hypothermia/Hyperthermia, Hypoglycemia, Anemia/Polycythemia, General Considerations

14. Common Causes Medical Transient Tachypnea of new born RDS(HMD ) Aspiration syndromes Pneumonia/sepsis PPHN CCF Acidosis Surgical Pneumothorax Diaphragmatic hernia TEF Lobar emphysema Phrenic nerve paralysis General Considerations

15. New Born with Respiratory Distress What to do??? General Considerations

16. History What we need to know Why we need to know Were there any risk factors in the antepartum period or evidence of fetal distress prior to delivery? Birth asphyxia or PPHN Did the mother receive antenatal steroids if it was a preterm delivery? Antenatal steroids decrease the incidence of HMD by 50% Was there a history of premature rupture of membranes and fever? Congenital pneumonia or sepsis Was there meconium stained amniotic fluid? MAS is a possibility General Considerations

17. What we need to know. Why we need to know Was resuscitation required at birth? Resuscitation trauma/ PPHN/ acidosis Did the distress appear immediately or a few hours after birth? HMD appears earlier than pneumonia Was it related to feeding or frothing at the mouth? Tracheo -esophageal fistula or aspiration Does the distress decrease with crying Choanal atresia General Considerations

18. Signs-Will depend on cause What we need to look for Why we need to look for A preterm baby weighing <1500 gms with retractions and grunt Likely to have HMD. Meconium stained amniotic fluid with an increase in the anterio -posterior diameter of the chest (full chest) Likely to be suffering from MAS A depressed baby with poor circulation Neonatal sepsis with or without congenital pneumonia. General Considerations

19. What we need to look for Why we need to look for A near term baby with no risk factors and mild distress. May have TTNB An asphyxiated baby May have PPHN/acidosis A growth retarded baby with a plethoric look May have polycythaemia . Check for an air leak by placing a light source over the chest wall in a darkened room. Air leak syndrome Inability to pass an 5F catheter through the nostril of a term baby Suggestive of choanal atresia. General Considerations

20. Investigation Complete Blood Count with a Peripheral blood smear Sepsis screen including C-reactive protein and μ ESR Arterial blood gas (ABG) analysis Blood glucose, Serum calcium Cultures: Blood , Surface swab (where indicated), maternal vaginal swab Chest radiograph with an oro -gastric tube in situ General Considerations

21. Management Clear the airway , ensuring adequate breathing and circulation. Continuous pulse oximeter monitoring . Warm, humidified oxygen is given with a head box. Maintenance of correct temperature is essential. Fluid and electrolyte management : Electrolyte balance , fluids, calcium and glucose homeostasis are all equally important. Maintenance of adequate hemoglobin : Any neonate with respiratory distress should have a packed cell volume (PCV) above 40% (but less than 75 %). All preterm babies with respiratory distress should be started on broad spectrum antibiotics. In term babies , decision to start antibiotics would depend on the clinical situation, but the threshold should be low. General Considerations

22. Respiratory Support Respiratory support is given in the form of continuous positive airway pressure (CPAP) or intermittent mandatory ventilation (IMV). Depends upon condition and severity of distress. 1 2 3 PaO 2 mmHg >60 50-60 <50 <50 PaCO 2 mmHg <50 50-60 61-70 >70 pH >7.3 7.20-7.29 7.1-7.19 <7.1 ABG Scoring System A score of >3 suggests ventilator/respiratory requirement General Considerations

23. Indications for starting CPAP are Downes ’ or Silvermann score of >6 at birth FiO2 requirement of >0.4 to maintain an acceptable saturation on pulse oximeter. ABG score of more than 3. CPAP is said to have failed when the FiO2 requirement is >0.6 or the pressure required to maintain oxygenation exceeds 7-8 cm of H2O. Mechanical Ventilation: Time cycled pressure limited ventilation is the modality of choice for ventilation. If patient triggered ventilation is used it is given as synchronized intermittent mandatory ventilation (SIMV ). Best outcome are seen in babies with impending respiratory failure or failed CPAP rather than in complete respiratory failure. General Considerations

24. Specific Management depends on the CAUSE of distress General Considerations

25. Meconium Aspiration Syndrome Definition MAS is defined as respiratory distress in an infant born through meconium-stained amniotic fluid (MSAF) whose symptoms cannot be otherwise explained J Perinatol . 2008 Dec Mec . Asp. Synd

26. Epidemiology Most common cause of respiratory distress in term and post-term infants . MSAF observed in 5-25% of all births out of which 10% develop MAS. One third require ventilator support 10 % develop air leaks 5-10 % of them have a fatal outcome Mec . Asp. Synd

27. What is meconium? The term was coined by Aristotle from the Greek word “ meconium arion ” meaning “ opium like ” Consists of gastrointestinal, hepatic and pancreatic secretions, cellular debris, swallowed amniotic fluid, lanugo, vernix caseosa and blood Appear in the fetal intestines by the 10th week of life gradually increasing in amount to reach 200gms at birth Mec . Asp. Synd

28. Cause of MSAF The passage of meconium from the fetus into amnion is prevented by lack of peristalsis (low motilin level) , tonic contraction of the anal sphincter , terminal cap of viscous meconium . Vagal Stimulation due to in utero hypoxia, acidosis, cord or head compression cause increased peristalsis and a relaxed anal sphincter. Fetal maturation (post term) causes high motilin level  increased peristalsis Mec . Asp. Synd

29. Risk factors for MAS Post term pregnancy Primigravida Maternal Anemia Chorioamnionitis Prolonged Labour Fetal Distress IUGR Maternal Age >30yrs Maternal DM Maternal heavy cigarette smoking Pre-eclampsia / eclampsia Oligohydramnios Antepartum Hemorrhage Mec . Asp. Synd

30. Pathophysiology Mechanical obstruction of airways Chemical Pneumonitis Surfactant Inactivation Mec . Asp. Synd

31. Mechanical obstruction of airways With onset of respiration – meconium migrates from central to peripheral airways. Thick particulate and viscous meconium lead to complete or partial airway obstruction. Complete obstruction  Atelectasis  Ventilation-Perfusion (V-Q) mismatch Partial obstruction  Ball-valve – air trapping  Obstructive Emphysema  R isk of pneumothorax (15 – 33 %) Mec . Asp. Synd

32. Chemical pneumonitis Meconium in the airways initiates an inflammatory reaction Meconium inhibits oxidative burst and phagocytosis by neutrophil  increased risk of infection Meconium induces production of inflammatory cytokines  Injury of parenchyma and vascular leakage  injury similar to ARDS Mec . Asp. Synd

33. Surfactant inactivation Bilirubin , fatty acid, triglycerides, cholesterol and proteins present in meconium alter phospholipid structure of surfactant  reduced s urfactant function Bile has cytotoxic effect on Type II Pneumocytes  Reduced surfactant production. Mec . Asp. Synd

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35. Clinical Features History Maternal risk factors present Term or Post term Infants Meconium Stained Amniotic fluid (Thick  pea soup /Thin) IUGR. Many babies are depressed at birth.(in utero aspiration) Mec . Asp. Synd

36. Physical examination   Evidence of postmaturity : peeling skin, long fingernails, and decreased vernix . The vernix , umbilical cord, and nails may be meconium-stained, depending upon how long the infant has been exposed in utero. In general, nails will become stained after 6 hours and vernix after 12 to 14 hours of exposure . umbilical cord staining (thick-15min, thin-1hour) Mec . Asp. Synd

37. Meconium stained umbilical cord Mec . Asp. Synd

38. Meconium stained nails Mec . Asp. Synd

39. Features of respiratory distress within first few hours of birth The chest typically appears barrel-shaped, with an increased anterior-posterior diameter caused by over inflation. Auscultation reveals rales and rhonchi -immediately after birth. Some patients are asymptomatic at birth and develop worsening signs of respiratory distress as the meconium moves from the large airways into the lower tracheobronchial tree . In case of massive meconium aspiration, meconium pigments may be absorbed from lungs excreted in urine. Urine may appear dark brown in colour . Mec . Asp. Synd

40. Diagnosis MAS must be considered in any infant born through MSAF who develops symptoms of Respiratory Distress with typical chest x ray findings Mec . Asp. Synd

41. Diagnosis A chest radiographs is characterized by hyperinflation of the lung field and coarse nodular opacities due to areas of atelectasis and consolidation. There are coarse irregular patchy infiltrates A pneumothorax and pneumomediastinum may be present . Mec . Asp. Synd

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46. Diagnosis Arterial blood gas measurements typically show hypoxemia and hypercarbia . Infants with pulmonary hypertension and right-to-left shunting may have a gradient in oxygenation between preductal and postductal samples. Echocardiogram for evaluation of Persistent Pulmonary Hypertension. Mec . Asp. Synd

47. Management Prenatal management: Key management lies in prevention during prenatal period. Identification of high risk pregnancies and close monitoring. Pregnancy that continue past due date, induction as early as 41 weeks may help prevent meconium aspiration. If there is sign of fetal distress corrective measure should be undertaken or infant should be delivered in timely manner. Amnioinfusion has no role . Mec . Asp. Synd

48. Delivery Room Management Baby delivered through MSAF Intrapartum Suctioning Assess the baby after 10-15 sec Vigorous HR > 100/min Spontaneous Respiration Crying Reasonable tone No intervention Non Vigorous Intubate Tracheal Suction Mec . Asp. Synd

49. When the infant is not vigorous: Place under radiant warmer but delay stimulation. Clear airways as quickly as possible. Intubation and then suction directly to the ET tube.  repeat until either ‘‘little meconium is recovered, or until the baby’s heart rate indicates that resuscitation must proceed without delay’’. May also require saline lavage to remove thick particles. After all meconium is sucked out, ventilate the baby with bag and mask. Mec . Asp. Synd

50. Postnatal Management Shift to NICU setup with respiratory support facilities available Gastric wash with normal saline to reduce gastritis and aspiration of meconium stained products. Close monitoring for Respiratory distress. Most infants who develop symptoms will do so in the first 12 hours of life. Mec . Asp. Synd

51. Postnatal Management Approach to the ill newborns : Maintain temperature O 2 support by hood 2/3 rd restricted IV fluids Look for and manage hypoglycemia/ hypocalcemia/ hypotension ??? Antibiotics Initiate CPAP/ventilation if indicated ??? Surfactant therapy (Bolus/ Trachebroncial Lavage) - should be used in setups where ECMO facility is unavailable iNO (Inhaled Nitric Oxide) – when PPHN complicates MAS ECMO (Extra Corporeal Membrane Oxygenation) Keep high suspicion for Air Leaks and PPHN Mec . Asp. Synd

52. Respiratory Distress Syndrome (RDS) Also known as Hyaline Membrane Disease (HMD) Commonest cause of preterm neonatal mortality RDS occurs primarily in premature infants; its incidence is inversely related to gestational age and birth weight Nelson Textbook of Pediatrics, 18 th Ed. Gestational age Percentages Less than 28 wks 60-80% 32-36 wks 15-30% 37-39 wk 5% Term Rare Resp. Dis. Syn.

53. Risk Factors Increased Risk Decreased Risk Maternal diabetes multiple births cesarean section delivery perinatal asphyxia cold stress history of previously affected infants Chronic or pregnancy-associated hypertension maternal heroin use prolonged rupture of membranes antenatal corticosteroid prophylaxis Resp. Dis. Syn.

54. Etiology & Pathophysiology Lack of surfactant due to immaturity of lungs is the basic abnormality. Surface-Active-Agent (Surfactant) which is produced by type II alveolar cells, reduces surface tension and maintains alveolar stability at low pressure so that end-expiratory alveolar atelectasis does not occur. Surfactant production is also compromised in birth asphyxia, acidosis, hypothermia, Rh incompatibility, antepartum hemorrhage and shock Resp. Dis. Syn.

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57. Surfactant deficiency End-Expiratory Alveolar Atelectasis Hypoventilation Hypo-perfusion of lungs Epithelial Necrosis Transudation of Plasma Formation of Hyaline Membrane V/Q mismatch Reduced Compliance ↓p0 2 ↑ pCO 2 ↓ pH PPHN Surfactant deficiency Resp. Dis. Syn.

58. Clinical Features Maternal Risk factors present in history Preterm Infant Features of respiratory distress usually appear within few minutes of birth to upto 6 hours of birth Breath sounds may be normal or diminished with a harsh tubular quality Fine rales may be heard, especially posteriorly over the lung bases Apnea and irregular respirations occur as infants tire and are ominous signs requiring immediate intervention Respiratory failure may occur in patients with rapid progression of the condition Resp. Dis. Syn.

59. Patient may have a mixed respiratory-metabolic acidosis, edema, ileus and oliguria . In most cases, the symptoms and signs reach a peak within 3 days, after which improvement is gradual Death is rare on the 1st day of illness, usually occurs between days 2 and 7 associated with alveolar air leaks (interstitial emphysema, pneumothorax), pulmonary hemorrhage, or IVH. Resp. Dis. Syn.

60. Diagnosis Amniotic Fluid Lecithin/Sphingomyelin Ratio ≥2 suggests lung maturity. ≤1.5 associated with HMD Phosphatidyl Glycerol estimation More specific than L/S ratio Absence is invariably associated with HMD Gastric Aspirate Shake Test Unreliable if gastric aspirate is contaminated with blood or meconium Serial tests can be done to assess maturity of lungs during course of disease Resp. Dis. Syn.

61. ABG initially shows hypoxemia and later worsening of hypoxemia, hypercapnia and metabolic acidosis On X-Ray Chest Initial X-ray may be normal Typical pattern develop at 6-12 hours Grade 1 (mild cases): symmetrical reticulogranular pattern due to scattered atelectasis Grade 2: widespread air bronchogram become visible Grade 3 : reticulogranular pattern becomes increasingly confluent leading to formation of ground glass opacity due to marked underaeration Grade 4: complete white lung fields with obscuring of the cardiac shadow due to global atelectasis Resp. Dis. Syn.

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63. Prevention Suppress Premature labor to gain gestational maturity Delay induction of labour till pulmonary maturity is assured by L/S ratio Antenatal Steroids to mother Betamethasone (12mg IM every 24 hr for 2 doses) Dexamethasone(6mg IM every 12 hr for 4 doses) Resp. Dis. Syn.

64. Management Shift to NICU setup with respiratory support facilities available Close monitoring for Respiratory distress . Maintain temperature O 2 support by hood 2/3 rd restricted IV fluids Look for and manage hypoglycemia/ hypocalcemia/ hypotension ???Antibiotics Initiate CPAP/ventilation if indicated Surfactant therapy if indicated Vitamin E ???Post natal steroids Resp. Dis. Syn.

65. Surfactant Surfactant reduces surface tension, improves lung compliance, and stabilizes lung volumes at a lower transpulmonary pressure Surfactant’s secondary function is to enhance macrophage activity and mucociliary clearance, and to reduce inflammation. Types of Surfactant N atural or Synthetic Indications Prophylactic Premature infants at high risk of developing RDS secondary to surfactant deficiency ( eg 32 weeks or low birth weight 1, 300 g) Infants in whom there is laboratory evidence of surfactant deficiency such as lecithin/sphingomyelin ratio 2:1 or the absence of phosphatidylglycerol Resp. Dis. Syn.\surf

66. Indication Rescue or therapeutic administration is indicated in preterm or full-term infants who are suspected of having surfactant deficiency by inactivation and who require endotracheal intubation and mechanical ventilation secondary to respiratory failure OR who require an FiO 2 ≥ 40% or a PEEP of ≥7 to maintain adequate PaO 2 and Sp O 2 and have Clinical and radiographic evidence of neonatal RDS or MAS. Surfactants may be used as a vehicle to deliver other drugs such as antibiotics, anti-inflammatory agents , and bronchodilators. Resp. Dis. Syn.\surf

67. Indication Postoperative development of ARDS following cardiac surgery. Reduces time on ventilation and ICU and hospital stay. Porcine surfactant in RSV induced respiratory failure may improve gas exchange and respiratory mechanics and shorten the duration of ventilation and hospital stay. Contraindication P resence of congenital anomalies incompatible with life beyond the neonatal period R espiratory distress in infants with laboratory evidence of lung maturity Diagnosis of congenital diaphragmatic hernia. Studies have shown that early use of surfactant increases mortality. Patient hemodynamically unstable Active pulmonary hemorrhage Resp. Dis. Syn.\surf

68. Frequency Multiple doses of surfactant to infants with ongoing respiratory insufficiency appears to be the most effective treatment regimen It has resulted in greater improvements in oxygenation and ventilatory requirements, a decreased risk of necrotizing enterocolitis , and decreased mortality. Additional doses of surfactant, given at 6–24-hour intervals, may be indicated in infants who experience increasing ventilator requirements or whose conditions fail to improve after the initial dose Name Type Dose Calfactant Bovine 105 mg/kg/dose (3 mL/kg) Beractant Bovine 100 mg/kg/dose (4 mL/kg) Poractant alfa Porcine 100–200 mg/kg/dose (1.25–2.5 mL/kg) Lucinactant Synthetic 5.8 mL/kg Availability Resp. Dis. Syn.\surf

69. DELIVERY TECHNIQUES INSURE (In tubation, Sur factant, E xtubation) This technique features early surfactant replacement therapy with prompt extubation to nasal CPAP. The technique is associated with less need for mechanical ventilation, lower incidence of BPD, and fewer air leak syndromes. Selective surfactant replacement therapy with mechanical ventilation followed by extubation from lower ventilator settings This technique is initiated upon clinical evidence of RDS, such as radiological findings , increased FIO2 requirement , and/or increased work of breathing. Pharyngeal instillation before first breath There have been no randomized controlled trials in humans to validate this technique. Animal studies have confirmed improvement of lung expansion and better survival rates. Resp. Dis. Syn.\surf

70. Laryngeal mask airway (LMA) administration In an animal studies on surfactant delivery, it was reported that surfactant delivery could be accomplished sooner in the LMA group than ETT with equivalent efficacy. While far from conclusive, this method holds hope for areas in which ETT intubation skills are lacking. Bronchoalveolar lavage Bronchoalveolar lavage has shown promise in the treatment of MAS. Studies have demonstrated that surfactant lavage is a safe and effective alternative treatment for MAS. In animal studies, it is shown that distribution of intratracheally instilled surfactant has been largely determined by gravity, and unaffected by the position of the chest. Therefore, leaving the chest in a horizontal position may result in the most even distribution of surfactant to the lungs. Resp. Dis. Syn.\surf

71. Complication of Surfactant Therapy Procedural complications Physiologic complications Plugging of endotracheal tube (ETT) by surfactant Hemoglobin desaturation and increased need for supplemental O2 Bradycardia due to hypoxia Tachycardia due to agitation, with reflux of surfactant into the ETT Pharyngeal deposition of surfactant Administration of surfactant to only one lung ( ie , right mainstem intubation) Administration of suboptimal dose Apnea Pulmonary hemorrhage from right to left shunting Increased necessity for treatment for patent ductus arteriosus Marginal increase in retinopathy of prematurity Volutrauma resulting from increase in lung compliance failure to change ventilator settings accordingly Hyperventilation or hypoventilation, both of which can alter blood flow to the brain, leading to further complications Complication can be prevented by slow administration of surfactant and by decreasing Fio2 and mean airway pressure after administration

72. Complication of RDS Intraventricular Hemorrhage Air Leaks Pulmonary Infection Pulmonary Hemorrage Hypoglycemia DIC Cardiac Failure Metabolic alterations Resp. Dis. Syn.

73. Transient Tachypnea of Newborn Also called Wet Lung Syndrome or Type II Respiratory Distress Syndrome The most common cause of neonatal respiratory distress constituting more than 40 percent of cases 11 per 1,000 live births.. Represents a milder form of HMD or due to failure of drainage of alveolar fluids resulting in pulmonary edema  decreased compliance and increased airway resistance  Respiratory Distress Tran. Tachy . Newborn

74. Risk Factors Term or Near Term Babies Male Child Cesarean Section Delayed cord clamping or cord milking Macrosomia Maternal Sedation Large amount of IV Fluids to mother during labor Maternal Asthma Maternal Diabetes Tran. Tachy . Newborn

75. Clinical Features Tachypnea immediately after birth or within 6hrs after delivery with mild to moderate respiratory distress. These manifestations usually persist for 12-24hrs , but can last up to 72hrs Auscultation usually reveals good air entry with or without crackles Usually maintain good color and are alert. Tran. Tachy . Newborn

76. X-Ray Chest Hyperinflation of the lungs Linear streaking at hila due to dilated lymphatics Interlobar Fluid Mild Cardiomegaly Chest x-ray usually shows evidence of clearing by 12-18 hrs with complete resolution by 48-72 hrs Tran. Tachy . Newborn

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78. Fluid in the inter lobar fissure Tran. Tachy . Newborn

79. TTN is a clinical diagnosis of exclusion Tran. Tachy . Newborn

80. Management Continuous Monitoring of distress. Supportive Management O 2 by hood if required Provide adequate nutrition ???Furosemide ???Antibiotics Usually a self limited condition and no active management is required Tran. Tachy . Newborn

81. Bibliography Alok Kumar, B. Vishnu Bhat Epidemiology of respiratory distress of newborns The Indian Journal of Pediatrics January–February 1996, Volume 63, Issue 1, pp 93-98 Antonowiez I, Schwachman H. Meconium in health and disease. Adv Paediatr 1979; 26:275-92. Basu S, Kumar A, Bhatia BD. Role of antibiotics in meconium aspiration syndrome. Ann Trop Paediatr . 2007 Jun;27(2):107-13. Brian K Walsh, Brandon Daigle, Robert M DiBlasi , and Ruben D Restrepo AARC Clinical Practice Guideline. Surfactant Replacement Therapy: 2013Respir Care, February 2013 58:2  367-375 Canadian Pediatric Society, “Recommendation for neonatal surfactant therapy,”  Paediatrics and Child Health, vol. 2, no. 10, pp. 109–116, 2004. Carbine DN. Meconium aspiration. Paediatr Rev 2008; 29: 212-3 Clark P, Doff P. Inhibition of neutrophil oxidative burst and phagocytosis by meconium.Am J Obstet Gynecol 1995; 173:1301-5. Fanaroff AA. Meconium aspiration syndrome: historical aspects. J Perinatol . 2008 Dec;28 Suppl 3:S3-7 I. El Shahed , P. Dargaville , A. Ohlsson , and R. F. Soll , “Surfactant for meconium aspiration syndrome in full term/near term infants,” Cochrane Database of Systematic Reviews, no. 3, Article ID CD002054, 2007 .

82. Jones CA. Early production of pro inflamatory cytokines in the pathogenesis of neonatal ARDS associated with meconium aspiration.Pediatr Res 1994; 35:339. Kamala Swarnam , Amuchou S. Soraisham , and Sindhu Sivanandan , “Advances in the Management of Meconium Aspiration Syndrome,” International Journal of Pediatrics, vol. 2012, Article ID 359571, 7 pages, 2012. doi:10.1155/2012/359571 Mechanical Ventilation in Neonatal Medicine zuhair aldajani National Neonatal-Perinatal Database Report 2002-2003 Nelson Textbook of pediatrics 18th edition SAUNDERS Nelson Textbook of pediatrics 19th edition SAUNDERS Neonatal morbidity and mortality. Report of the national neonatal perinatal database. Indian Pediatrics 1997; 34: 1039-42 Neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Kattwinkel J, Perlman JM, Aziz K, Colby C, Fairchild K, GallagherJ , Hazinski MF, Halamek LP, Kumar P, Little G, McGowan JE, Nightengale B, Ramirez MM, Ringer S, Simon WM, Weiner GM, Wyckoff M, ZaichkinJ . Circulation. 2010;122:S909 –S919. Sankhyan Naveen, Sharma Vijay Kumar, Sarin Ritu , Pathania Kushla . Predictors of meconium stained amniotic fluid : a possible strategy to reduce neonatal morbidity and mortality J Obstet Gynecol India Vol. 56, No. 6 :November/December 2006

83. Soll RF, Blanco F. Natural surfactant extract versus synthetic surfactant for neonatal respiratory distress syndrome. Cochrane Database Syst Rev 2001(2):CD000144. Surg Cdr SS Mathai , Col U Raju , Col M Kanitkar . Management of Respiratory Distress in the Newborn Medical Journal Armed Forces India 2007; 63 : 269-272 Text book on Care of Newborn 8th edition,Meharban Singh, CPS publication U Raju, Maj V Sondhi , Maj SK Patnaik . Meconium Aspiration Syndrome : An Insight Medical Journal Armed Forces India, Vol. 66, No. 2, 2010 Vain NE, Szyld EG, Prudent LM, Wiswell TE, Aguilar AM, Vivas NI. Oropharyngeal and nasopharyngeal suctioning of meconium-stained neonates before delivery of their shoulders: multicentre , randomised controlled trial. Lancet. 2004;364:597– 602. W. P. Kanto Jr.v , “A decade of experience with neonatal extracorporeal membrane oxygenation,”Journal of Pediatrics, vol. 124, no. 3, pp. 335–347, 1994 Wiswell TE, Gannon CM, Jacob J, Goldsmith L, Szyld E, Weiss K, Schutzman D, Cleary GM, Filipov P, Kurlat I, Caballero CL, Abassi S, Sprague D, Oltorf C, Padula M. Delivery room management of the apparently vigorous meconium-stained neonate: results of the multicenter, international collaborative trial. Pediatrics. 2000;105(1 Pt 1 )

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