Transient Tachypnea of the Newborn (Case 29)

Chapter 66 Transient Tachypnea of the Newborn (Case 29)



Faizah N. Bhatti, MD, MS




Case


A 37-weeks’-gestation infant delivered 3 hours ago by cesarean delivery for failure to progress has developed tachypnea and grunting after attempting his first feed. Apgar scores were 6 and 9, with initial cyanosis that resolved quickly with administration of blow-by oxygen.




Differential Diagnosis











Pneumonia Respiratory distress syndrome (RDS)
Transient tachypnea of the newborn (TTNB) Neonatal sepsis


Speaking Intelligently


Transient tachypnea of the newborn (TTNB) occurs in term and near-term infants, usually presenting as mild to moderate respiratory distress, often with hypoxemia. Because TTNB is a diagnosis of exclusion, I consider the dangerous entities in the differential. If there are risk factors for sepsis, or the tachypnea lasts more than 4 hours, I initiate a targeted workup, the extent of which will be determined by the baby’s clinical status. Most important, supportive measures should be initiated promptly, and the neonatal intensive care unit (NICU) staff notified early for a potential transfer. The major goal is to ensure that a more serious diagnosis is not missed: TTNB can coexist with early sepsis or respiratory distress syndrome.



Patient Care



Clinical Thinking



• Review the events of labor. Were there fetal distress indicators such as heart rate instability (poor beat-to-beat variability, bradycardia, late decelerations)? Was meconium passed in utero?

• Are there risk factors for sepsis such as prolonged rupture of membranes or inadequate intrapartum antibiotic prophylaxis (IAP) for group B streptococcus (GBS)? Maternal fever raises the possibility of chorioamnionitis.

• Check vital signs, oxygen saturation, blood glucose level, and temperature stability.

• Initiate supplemental oxygen if needed.

• Provide close monitoring with frequent reassessment.

• Confer with NICU regarding the potential for transfer.


History



• Review maternal history. Were prenatal ultrasounds normal? Were there risk factors such as preeclampsia or infection? What was mother’s GBS status? If positive, was IAP administered?

• Was it a term gestation? If preterm, was a cause determined? Were antenatal corticosteroids administered? It can be difficult to distinguish TTNB from RDS, but RDS increases in frequency with degree of prematurity.

• Meconium aspiration is rare in infants less than 37 weeks gestation.

• Was it a precipitous vaginal or cesarean delivery? Was there a nuchal cord? What were the Apgar scores? Was resuscitation required in the delivery room?

• Has the infant tolerated feeding?


Physical Examination



• Check vital signs: heart rate, respiratory rate, temperature, weight, length, and head circumference.

• Perform a complete physical examination, with attention to respiratory effort, work of breathing (nasal flaring, intercostal and subcostal retractions), and aeration.

• Assess degree of alertness.

• Check pulse oximetry.

• Concerning signs for sepsis include temperature instability, hypoglycemia, tachypnea with hypoxemia, tachycardia, hypotonia, and/or lethargy.


Tests for Consideration



• Complete blood count (CBC): Neutropenia and/or an increased immature to total neutrophil (I : T) ratio and/or thrombocytopenia suggest infection $116

• C-Reactive Protein (CRP): Initial level with repeat at 12 and 24 hours may be helpful to exclude sepsis $69

• Blood culture: If concern for infection $152

• Cerebrospinal fluid culture: Is gold standard for meningitis diagnosis $152

• Cerebrospinal fluid Gram stain, glucose, protein, cell count (red and white cell counts): Provides quick assessment for meningitis $405

• Blood glucose level $70
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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on Transient Tachypnea of the Newborn (Case 29)

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