What are the key clinical signs and symptoms of Respiratory Distress Syndrome (RDS) in premature infants that I should look for during assessment?

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

Posted: 17 August 2025Updated: 17 August 2025 Guideline-Aligned (High Confidence) Clinically Reviewed
Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX

When assessing premature infants for respiratory distress syndrome, key clinical signs and symptoms that should be evaluated include:

  • Respiratory Effort and Pattern: Look for grunting ,, marked chest recession or moderate/severe chest indrawing ,, and the use of accessory muscles of respiration while the baby is at rest . Observe for nasal flaring ,. Assess the respiratory rate; a rate over 60 breaths/minute indicates tachypnoea ,, and over 70 breaths/minute suggests severe respiratory distress . Apnoea, whether observed or reported, is a critical sign . Be aware that listlessness or decreased respiratory effort may indicate impending respiratory failure , as can poor respiratory effort or a silent chest .
  • Oxygenation and Circulation: Check for cyanosis, which can appear as bluish lips or extremities , or pale, mottled, ashen, or blue skin, lips, or tongue ,. Central cyanosis is a sign of severe distress . Measure oxygen saturation using pulse oximetry; a persistent saturation of less than 92% when breathing air or ≤ 95% in air is concerning. Continuous pulse oximetry should be used to measure oxygen saturation in preterm babies . Record the baby's pulse, noting any tachycardia (e.g., over 160 beats/minute in an infant under 12 months) ,, and blood pressure . Assess capillary refill time; a time of three seconds or more indicates poor circulation ,.
  • General Condition and Hydration: Note the baby's agitation and consciousness, as agitation and behavioural changes can be a sign of hypoxia . Look for signs of exhaustion . Observe for altered consciousness, such as not waking, not staying awake if roused, or not responding to normal social cues ,. Assess feeding difficulties, such as difficulty with breastfeeding or inadequate oral fluid intake (50–75% of usual volume) , or poor feeding in infants . Evaluate for clinical dehydration, indicated by reduced skin turgor, dry mucous membranes, and/or reduced urine output ,. Record the baby's temperature, especially noting a temperature of 38°C or higher in an infant aged three months or less .

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