Your newborn baby’s breathing
In early January 2012, a new book called Take a Deep Breath: Clear the Air for the Health of Your Child, by Dr Nina Shapiro (World Scientific), is due to be published. Dr Nina is the Director of Pediatric Ear, Nose and Throat at the Mattel Children’s Hospital, at America’s UCLA, and her book covers breathing issues for your newborn through to your 5 year old child.
Here we’re bringing you a sneak peek of just one of the many chapters relating to your baby in her first three months after birth. Find out:
You can also find Dr Nina tweeting @drninashapiro
(Following images not taken from publication, included for editorial purposes only)
When born, your baby’s vision is blurred, but he’ll be able to recognise you after a few weeks.
Wheezing: Can a newborn have Asthma?
Wheezing is the turbulent passage of airflow in the bronchi (lower windpipe passages) or alveoli (tiny air-filled sacs within the lungs). When we think of wheezing, we commonly think of older children with asthma. Newborn wheezing is a bit different. Asthma itself is a chronic inflammatory condition of the airways, which usually develops over time. Young infants can have asthma-like symptoms, and this is often termed reactive airway disease. The lower airways ‘reacts’ to respiratory illnesses or inflammation, thus the term ‘reactive’ airway disease. In the absence of a respiratory illness, wheezing in newborn is usually related to lung and/or airway immaturity. In this chapter, I will explain what causes a newborn to wheeze, how to recognize it, and when to call your doctor.
My baby’s chest sounds ‘congested’. She seems comfortable, but she sounds kind of ‘junky’, and I can feel some rattling sound when I hold her. What’s going on?
Many newborns have some degree of occasional chest congestion. They are learning to coordinate swallowing and breathing, and occasionally some milk/formula or saliva/mucus gets into their windpipe. This wet stuff settles in either their windpipe or lower airways and lungs, and you can hear some rattling. Chest congestion sounds ‘wet’, and you don’t usually hear any high-pitched squeaks from either the throat or the chest. For the most part, a little chest congestion in an otherwise comfortably breathing baby is not a concern. By ‘comfortably breathing’, I mean no retractions (where the chest, stomach, or neck is caving in with each breath), no rapid breathing (newborns breathe 24 to 38 times per minute), and no visible discomfort (arching, crying, skin discoloration). For occasional chest congestion, try holding your baby upright, with her head over your shoulder, as if you were burping her. Tap her back gently. This may encourage some coughing, and help loosen up the wetness. Ideally, she will cough it up into her mouth and then swallow it. If you notice more chest congestion after feeds, make sure your baby stays upright during and after feeding times.
Newborns should breathe 24 to 38 times per minute
How to count your baby’s breaths:
Have him lying comfortably, and count the number of breaths for thirty seconds.
Multiply this number by two for the number of breaths per minute.
Breathing rate can go up slightly during a respiratory illness or a fever.
If your baby is breathing more than 60 times per minute, call your doctor.
My five-year-old son has Asthma, and my newborn daughter sounds like she’s wheezing. Can she have Asthma so soon?
Probably not. Or at least not yet. While asthma can run in families, especially if it’s the type of asthma related to allergies, very young infants who wheeze do not necessarily have a diagnosis of true asthma. Asthma is a chronic lung condition that leads to swelling in the airways. The airways, in turn, produce more mucus, making it harder for air to pass through the tiny sacs and tubes in the lungs. In a newborn, recognition of a problem and treating that problem is more important than coming to a diagnosis of a chronic condition. ‘True’ asthma is diagnosed not only by wheezing, but also by lung function tests, whereby the child breathes in and out through a tube into a machine. The machine records the breathing capacity. Needless to say, a cooperative (and older) child is necessary. When you hear wheezing (a whistling sound usually when your baby breathes out, sometimes accompanied by retractions or pulling in of the neck, abdominal or chest muscles), the two most likely causes are lung immaturity. This is usually seen more commonly in premature babies, or in full-term babies during an acute respiratory illness. Over 50% of infants have at least one episode of wheezing in the first year, but only one-third of those go on to develop asthma.
Are there certain factors that predispose my baby to have Asthma in the future? Is there anything I can do to prevent this?
While one episode of wheezing does not mean that your newborn has (or will have) asthma, there are certain early signs that may keep you on the lookout for asthma in the future. A high risk factor for asthma is tobacco smoke exposure — both, before your baby is born and after birth. Before birth, toxins such as nicotine and carbon monoxide are absorbed into the bloodstream of the fetus, leading to higher chance of prematurity (and consequent, lung immaturity), low birth-weight, and inflamed airways. Tobacco smoke exposure after birth is known to be associated with chronic airway inflammation, and higher risk of acute as well as chronic respiratory illnesses. DON’T SMOKE DURING PREGNANCY OR AFTERWARDS. This will lower your baby’s risk of asthma. Babies and young children with asthma related to tobacco exposure are also harder to treat — the chronic inflammation in their airways does not respond as well to medications. These children are not only prone to developing asthma, but they are also more prone to developing asthma-related breathing complications requiring hospitalization.
Another risk factor is family history. Newborns whose parents or siblings have asthma or environmental allergies (not allergies to medications or insect stings) have a higher likelihood of developing asthma in the future. Newborns with eczema (a skin condition whereby a baby has dry, fl aky, itchy skin patches) may also have a predisposition to environmental allergies and asthma in the future.
As far as prevention goes, don’t smoke when you are pregnant or after your baby is born, and don’t let anyone smoke in your baby’s home. If you have a strong family history of asthma, being aware of signs of breathing problems will be the best method of prevention. While you wont necessarily be able to prevent asthma from developing, you can be more proactive when it comes to recognizing early signs of asthma or allergies in your newborn. In the early months of life, a newborn predisposed to asthma may be more likely to develop wheezing during a respiratory illness. Recognition by you, and alerting your doctor, will maximize their treatment early on, and minimize the likelihood that his symptoms will progress to respiratory difficulties.
My baby was born via Caesarian section. We just brought her home at age of 4 days, and she sounds a little ‘wheezy’. Is this normal?
Babies born via C-section (either planned or unplanned), even if full-term, often have a little fluid collection in their lungs. Unlike during a vaginal delivery, babies born via C-section go from a fluid-filled environment directly to an air-filled one relatively ‘smoothly’, in that they are not squeezed through a tight space. During vaginal delivery, pressure that the muscles of the vaginal walls and pelvic bones put on the baby’s ribcage actually helps to clear the amniotic fluid from their lungs and throat before they are delivered. This helps to squeeze out some of the fluid as the baby is being born. In a C-section delivery, the baby is lifted out, without being ‘squeezed’. The fluid is suctioned out of their mouth immediately, but their lungs often retain a bit of residual amniotic fluid. Most babies have no visible symptoms from this, as the fluid usually clears in a matter of hours or a day or two. But some may take a little bit longer. Your baby will be checked several times by the hospital’s doctors and nurses before he is discharged, so you will probably know about this chest congestion before you go home. A little residual noise is fine, but remember that babies are very good self-regulators, and very good at showing signs of a problem. Even at just a few days old, rapid breathing (more than 60 breaths per minute), blue skin discoloration, or signs of struggling, where the chest, abdomen, or neck muscles cave in, needs immediate medical attention.
My baby was born prematurely. How does this impact his lungs, and what can I expect in breathing problems now and in the future?
The degree of lung immaturity really depends on how prematurely your baby was born. For the first 7 to 8 months of pregnancy, a baby’s lungs have not yet developed the capacity to function on their own. A substance called surfactant is produced by the lungs between 32 and 34 weeks gestation, which is usually sometime in the 8th or 9th month of pregnancy. Surfactant is a mixture of fats and proteins, and it prevents the tiny airways in the lungs from collapsing onto themselves during expiration and inhalation. If you know in advance that your baby needs to be born prematurely, doctors can take a small sample of amniotic fluid to determine the amount of surfactant in your baby’s lungs, which in turn will determine their lung maturity. If your doctor anticipates that your baby will be born early, she might give you medications to hasten your baby’s lung maturity. The most common medication that an obstetrician will administer is steroids. This medication promotes the immature lungs to produce surfactant, even before they would normally do so.
After birth, premature babies receive multiple therapies to help with lung development. These therapies may include oxygen supplementation in an incubator, or mechanical ventilation, whereby your baby will have a small breathing tube placed into his windpipe. This breathing tube will be attached to a breathing machine, which will help your baby breathe and receive oxygen until he is able to do so on his own.
Some babies who are born prematurely with lung problems may develop bronchopulmonary dysplasia (BPD). This is more common in very premature babies who are born before 28 weeks, or before you enter your 8th month of pregnancy. It is a chronic lung disorder we see in babies who require long periods of mechanical ventilation (breathing tubes on a breathing machine). The baby’s lungs may develop swollen air passages, and he may need to receive oxygen at home, even several months after leaving the hospital. Because of this chronic swelling, these babies are more susceptible to develop lung infections such as bronchitis or pneumonia when they get colds.
Another respiratory problem that premature babies may develop is called apnea of prematurity. Apnea occurs when the baby stops breathing. This can occur because he temporarily ‘forgets’ to breathe as a result of an immature nervous system, and is termed central apnea. It may also occur as he tries to breathe but the airway collapses, this is termed as obstructive apnea. Most premature babies, especially those born before 28 weeks, have both central and obstructive apneas, termed as mixed apnea. If the episodes of apnea occur several times per day, the baby may remain in the hospital, and will need to be connected to a monitor measuring heart rate, oxygen levels, and breathing rates. These monitors will alarm when there is an apnea event. The hospital staff will be alerted, and will assist the baby’s breathing, either by stimulating him (rubbing his back or chest), or giving him some extra oxygen to breathe with an oxygen mask. The oxygen mask is similar to the type you see on airplanes during the emergency demonstrations. Doctors and nurses can also give medications such as aminophylline and caffeine to stimulate the baby’s immature respiratory system and reduce the frequency of central apnea. Most babies ‘grow’ out of apnea of immaturity by the time they are ‘full-term’ (equivalent of 40 weeks old, including the number of weeks of pregnancy and the number of weeks after birth). For instance, a baby born at 30 weeks will be considered ‘full-term’ when he is 10 weeks old.
The big picture
Wheezing in newborns is relatively common. At least half of newborn babies will have wheezing at some point. This does not necessarily mean that these babies have asthma, nor does it mean that they will become asthmatic. Wheezing in a newborn baby sounds like a whistling sound when she breathes out. It may be a sign that she is developing a respiratory illness, or it may be transient chest congestion from a Caesarian section birth or from a bit of milk/formula or mucus traveling into the small air passages in the lungs. A brief period of wheezing in a comfortably breathing baby should resolve on its own, but wheezing in a newborn who is struggling to breathe, either by fast breathing or retracting, warrants a call to your doctor right away. Newborns with a family history of asthma may be more predisposed to become asthmatic as well, so these babies should be watched more closely by your pediatrician for early signs of asthma. Babies born prematurely have a higher likelihood of having breathing problems as newborns, due to their lung immaturity. Premature babies with wheezing need close medical attention. They are more susceptible to respiratory illnesses, and more liable for these illnesses to progress to a more serious condition such as pneumonia.
As you will read in every section, and in every chapter, you’ll read it here again: don’t smoke — before or after your baby is born. And don’t let anyone smoke near your baby, inside or outside of your home. Not only will it increase your baby’s risk of asthma, but it will also make it harder for your baby’s asthma to be treated.
If your newborn has very brief periods of wheezing, but is breathing comfortably, eating well, and does not have rapid breathing or struggling, the wheezing noise will most likely resolve on its own. It does not necessarily mean that he has or will have asthma. That said, if your baby’s breathing pattern changes, even if briefl y, and you’re not sure what’s going on, give your pediatrician a call. It may be something that you can describe over the phone. If there’s any concern on your pediatrician’s part, she’ll ask you to come in for a check.
If your baby is wheezing, and at the same time, seems to be breathing rapidly, or is using chest, neck, or abdominal muscles to move air in and out, call your doctor right away, go to the emergency room, or call 999. If your baby shows any signs of blue discoloration of their lips, tongue, or skin while wheezing (cyanosis), this is also a reason to get medical attention right away. While various breathing noises are to be expected in a newborns, he should not be struggling to breathe at any time.
- If your baby sounds a little ‘junky’, with ‘wet’ breathing, hold him upright, over your shoulder. Remember to support his head. Gently tap on his chest. This will help loosen any secretions or congestion in his chest, promoting a cough or a burp.
- Many babies have brief periods of wheezing, with a whistling sound coming from their lungs when they breathe out. As long as this sound goes away on its own, it is not an emergency. Let your doctor know that it occurred, but it may not happen more than once.
- If you hear wheezing/whistling from your baby’s chest, accompanied by rapid breathing rate, cyanosis (blue discoloration), or retractions, seek medical attention right away.
- If there is a family history of asthma, and you hear wheezing in your newborn, let your pediatrician know.
- Eliminate any unnecessary risks for wheezing and eventual asthma in your newborn. The number one way to do this is not to expose your baby to cigarette smoke.
- If there is a family history of asthma or allergies, avoid exposing your baby to potential allergens that are known to trigger asthma attacks in family members, such as dust, pollen, or pets.