A year ago, doctors at a private hospital in Bangalore decided to perform an emergency c-section delivery for a woman who was 24-weeks pregnant and had started developing contractions.
The baby’s expected weight was around 650 grams. Categorized ‘extreme preterm’ at birth, the baby was delivered after 24 weeks and five days of pregnancy. Immediately after birth, the baby developed severe breathing difficulties and doctors from the Neonatal Intensive Care Unit (NICU) decided to start administering surfactant, a method of treating respiratory distress syndrome in preterm babies, right in the delivery room.
Dr Anand Patil, consultant – pediatrics & neonatal intensive care unit, Manipal Hospitals, Bangalore, who treated the baby says that post the surfactant therapy, the doctors decided to initiate Continuous Positive Airway Pressure (CPAP), a type of non-invasive ventilation to help the baby breathe. When this also failed to work, the baby had to be put on a mechanical ventilator.
After 48 hours of invasive ventilator support, the baby was shifted back to CPAP support. “The baby had to stay in the NICU for nearly 34 weeks before being discharged. This was one of the critical cases that we handled,” Dr Patil tells Happiest Health.
Today, the baby is one-year old, weighs around 8.5 kilos and as per doctor Patil, is ‘absolutely normal, development-wise’.
What is surfactant?
Dr Patil says that the baby suffered from a deficiency of surfactant in the lungs, a molecule which helps in reducing the surface tension in the lung alveoli, thus preventing its collapse. The condition is commonly seen among preterm babies- babies born before 37 weeks of pregnancy, he adds.
Babies with a surfactant deficiency usually present with breathing difficulties at birth and would require oxygen support.
Pulmonary surfactants are released by the type II alveolar cells.
The surfactants spread across the tissues surrounding alveoli. Once the surface tension in the lung alveoli reduces, it reduces the pressure required for the alveoli to expand, making it easy to inhale.
Surfactants play a vital role in maintaining stability of the small air sacs in the lungs and promote efficient exchange of gases.
Surfactant deficiency in newborns
Dr Patil says that since the lungs of preterm babies are not developed enough, pulmonary surfactant is either absent or present in very reduced quantities. “That’s when babies commonly manifest breathing difficulties.
“We then have to supplement this molecule (surfactant) to help mature the baby’s lungs,” he adds.
Dr Ashish Jaiswal, consultant pediatrician and neonatologist at Motherhood Hospitals, Indore says that when there is surfactant deficiency in newborns, their lungs become less compliant, and the effort required to inflate the lungs increases. “This can result in respiratory distress, leading to hypoxia (low oxygen levels and high CO2 levels) and respiratory failure,” he says.
Studies have shown that respiratory distress syndrome (RDS) is the prototypical disease of surfactant deficiency in preterm newborn infants.
Signs and symptoms of surfactant deficiency in newborns
Dr Patil says that newborns with a deficiency of pulmonary surfactant mainly present with symptoms like breathing difficulties, fast or rapid breathing, dizziness, and respiratory distress syndrome.
Dr Jaiswal says that other signs include labored breathing, producing grunting sounds while breathing, flaring of the nostrils and skin turning bluish (also known as cyanosis) due to lack of adequate oxygen.
Who is at a higher risk of surfactant deficiency at birth?
Dr Patil says that in the clinical cases he has handled, he noticed that lesser the gestational age, higher the extent of surfactant deficiency. “Earlier the baby is born, the higher the risk of surfactant deficiency.”
Dr Jaiswal, says that premature infants are at a higher risk of surfactant deficiency, as surfactant production typically increases in the last trimester of pregnancy.” Other risk factors include gestational diabetes, cesarean section delivery without labor, and certain maternal infections,” he says.
Pregnant women who have high chances of delivering a preterm delivery are given a type of medication called corticosteroids. “If the mother has received maternal antenatal corticosteroids during her pregnancy- which is usually administered intravenously, it can stimulate surfactant production,” he says, adding that if this has not been done, it can complicate the case for the baby.
Treatment of surfactant deficiency
Treatment of surfactant deficiency in newborns depends on the analysis of the clinical manifestations and estimate of the ventilatory requirement or oxygen requirement of the baby as well, says Dr Patil. Calculated doses of surfant is administered to pre-term babies in some cases. Both synthetic surfactants and animal derived surfactants are available for use.
“If the baby is extreme pre-term (less than 30 weeks) we do not wait for the results of the newborn’s X-ray. To prevent complications, we sometimes directly administer the surfactant in the delivery room itself to the baby. We put a tube in the baby’s airpipe and administer the molecule,” said Dr Patil.
If surfactant is not administered, then the baby will definitely have a prolonged oxygen requirement, says Dr Patil. “Sometimes, we need to balance it out- the sooner we administer surfactant, sooner the lungs will mature and sooner the baby will be off oxygen support,” he added.
Takeaways
Preterm babies are often at risk for respiratory distress syndrome at birth due to a deficiency of surfactant in their lungs. Surfactant, a lipoprotein complex reduces surface tension in the lung alveoli, thus preventing their collapse during exhalation. It also plays a crucial role in facilitating the exchange of oxygen and carbon dioxide, in the alveoli.
