When should I consider referring a neonate with RDS to a specialist unit for advanced care?

When considering referring a neonate with respiratory distress to a specialist unit for advanced care, immediate emergency hospital care should be sought if the neonate presents with any of the following:

• Apnoea (observed or reported) ³, ⁴.
• The baby looks seriously unwell to a healthcare professional ³, ⁴.
• Severe respiratory distress, indicated by:
• Grunting ², ³, ⁴.
• Marked chest recession ³, ⁴.
• A respiratory rate of over 70 breaths/minute ³, or over 60 breaths/minute with grunting or marked chest recession ⁴.
• Central cyanosis ², ³, ⁴.
• Persistent oxygen saturation of less than 92% when breathing air ³, ⁴.
• Signs of exhaustion, such as listlessness or decreased respiratory effort ³, ⁴.
• Failure to maintain adequate oxygen saturation despite oxygen supplementation ³, ⁴.

Consider referring a neonate to hospital if they have any of the following:

• A respiratory rate of over 60 breaths/minute ³, ⁴.
• Difficulty with breastfeeding or inadequate oral fluid intake (50% to 75% of usual volume) ³, ⁴.
• Clinical dehydration ³, ⁴.
• Nasal flaring ⁴.
• Abnormal response to social cues, decreased activity, or waking only with prolonged stimulation ⁴.

Factors that should lower the threshold for hospital admission or specialist referral include:

• Chronic lung disease (including bronchopulmonary dysplasia) ³, ⁴.
• Haemodynamically significant congenital heart disease ³, ⁴.
• Age under 3 months ³, ⁴.
• Premature birth, particularly under 32 weeks gestational age ³, ⁴.
• Neuromuscular disorders ³, ⁴.
• Immunodeficiency ³, ⁴.

For neonates with any degree of meconium, a neonatologist should assess the baby and transfer both the woman and baby if they are at home or in a freestanding midwifery unit, if there is:

• Respiratory rate above 60 breaths per minute ².
• Presence of grunting ².
• Heart rate below 100 or above 160 beats per minute ².
• Capillary refill time above 3 seconds ².
• Body temperature of 38°C or above, or 37.5°C on two occasions 15 to 30 minutes apart ².
• Oxygen saturation below 95% ².
• Presence of central cyanosis ².

Specialist neonatal respiratory care units are equipped for advanced interventions such as invasive ventilation for stabilisation in the early postnatal period, including volume-targeted ventilation (VTV) or high-frequency oscillatory ventilation (HFOV), and surfactant administration ¹.