Neonatal and paediatric respiratory conditions

1Neonatal chest physiotherapy: precautions and contraindications

Asked as 7 marks in W18. Learn this section first.

2Neonatal respiratory distress syndrome (RDS)

Definition and cause

Breathing failure in premature babies because the lungs lack surfactant, so alveoli collapse at the end of each breath. Commoner with more premature birth and maternal diabetes.

Key features

• Within hours of birth: fast breathing, grunting, nasal flaring, rib and sternal recession, cyanosis.
• X-ray: small lungs with a "ground-glass" appearance and air bronchograms.

Medical point

Antenatal steroids to the mother, CPAP, surfactant given into the airway, ventilation if needed.

PT management

• Routine chest physiotherapy is not needed; the lungs are stiff, not full of secretions.
• Positioning for comfort and oxygenation (prone positioning is used only under continuous monitoring in neonatal units), developmental positioning, minimal handling.
• Airway clearance only if secretions build up later (for example on a ventilator).

Exam points

• Surfactant deficiency; grunting; ground-glass X-ray; CPAP and surfactant; minimal handling.

3Meconium aspiration syndrome

Definition and cause

Breathing problems in a term or post-term baby who inhaled meconium (first stool) passed into the amniotic fluid, often after fetal distress.

Key features

• Meconium-stained fluid and skin; breathing distress from birth.
• Meconium blocks airways (with air trapping and pneumothorax risk), inflames the lungs (chemical pneumonitis) and inactivates surfactant; it can cause persistent pulmonary hypertension.
• X-ray: patchy shadows and over-inflation; possible pneumothorax.

Medical point

Supportive: oxygen, CPAP or ventilation, surfactant, nitric oxide for pulmonary hypertension. Current resuscitation guidance (ILCOR) no longer recommends routine laryngoscopy and tracheal suction of non-vigorous babies born through meconium; start effective breathing support promptly.

PT management

• Airway clearance (gentle positioning, modified drainage, suction) only when secretions are clearly retained.
• Minimal handling, especially with pulmonary hypertension.

Exam points

• Term or post-term; air trapping, pneumothorax, chemical pneumonitis, pulmonary hypertension.

4Pneumonitis and pneumonia in children

Definition and causes

• Pneumonitis: lung inflammation from aspiration of milk or stomach contents (reflux, poor swallowing), chemicals (kerosene ingestion in children is a classic Indian example), or infection.
• Pneumonia: bacterial or viral infection; a major cause of death in children under 5 in India.
• Bronchiolitis (viral, under 2 years) often looks similar: wheeze, crackles, feeding difficulty.

Key features

Fast breathing for age, chest in-drawing, fever, cough, poor feeding; low SpO₂ in severe cases.

Signs of respiratory distress in children (3 marks in W24)

• Work of breathing: nasal flaring; chest in-drawing (subcostal, intercostal, suprasternal); tracheal tug; use of neck muscles; head bobbing in infants; see-saw (paradoxical) movement of chest and abdomen.
• Noises: grunting (the baby breathes out against a closed glottis to keep alveoli open), stridor, wheeze.
• Effects: cyanosis and low SpO₂; fast heart rate; cannot feed or talk; sweating.
• Danger signs (tiring): drowsiness or poor response, pauses in breathing (apnoea), slowing breathing in an exhausted child, silent chest. Call for urgent help.

PT management

• Bronchiolitis (Cochrane 2023): conventional chest physiotherapy (vibration, percussion) does not improve severity; forced expiratory techniques cause vomiting and breathing instability. Slow passive expiratory techniques may give a small benefit in moderate cases.
• Pneumonia: no routine airway clearance; use positioning, mobilisation and play; airway clearance if secretions are retained (for example a collapsed lobe).
• Aspiration: head-up positioning, feeding advice with speech and language therapy.

Exam points

• Chest physiotherapy is not routine for bronchiolitis or uncomplicated pneumonia in children.

5Chronic lung disease of prematurity (bronchopulmonary dysplasia)

Definition and cause

Long-term lung damage in premature babies who needed oxygen and ventilation; usually defined by an ongoing oxygen need at 36 weeks after conception.

Key features

Fast breathing, oxygen dependence, recurrent wheeze and infections, poor growth.

PT management

• Airway clearance during infections; positioning; developmental care (tummy time when awake and monitored, head control, motor milestones).
• Parent education on home oxygen, signs of infection and feeding.
• Later: active play and exercise as tolerated.

6Paediatric ARDS

Acute, severe lung inflammation in a child after pneumonia, sepsis, drowning or trauma, with low oxygen and bilateral shadows on X-ray, needing ventilation. Physiotherapy: positioning (prone positioning as directed by the ICU team), careful secretion clearance, minimal disconnection from the ventilator, early mobilisation and rehabilitation after recovery.

7Childhood asthma and cystic fibrosis

See the asthma page (paediatric rehabilitation, parent and teacher counselling) and the cystic fibrosis page.

8Exam corner

• W18 Q2(a), 7 marksPrecautions and contraindications for postural drainage in a neonate.
• S18 Q2(d), 7 marksPaediatric pulmonary rehabilitation for children with bronchial asthma (asthma page).
• W24 Q1(e), 3 marksSigns and symptoms of respiratory distress in children (section 4).

Technique cards for this topic: postural drainage, airway clearance, oxygen therapy.

Answer skeleton: precautions and contraindications in a neonate

1. Indications: retained secretions, collapse; not routine.
2. Precautions: minimal handling, monitoring, warmth, timing with feeds, head-up or flat positions, gentle techniques, safe suction.
3. Contraindications: instability, intraventricular haemorrhage, pulmonary hypertension, undrained pneumothorax, fragile ribs or bleeding, raised intracranial pressure.
4. Modified techniques: positioning, gentle vibration, assisted breathing, suction.