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

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 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) , .

  • The baby looks seriously unwell to a healthcare professional , .

  • Severe respiratory distress, indicated by:


    • Grunting , , .

    • Marked chest recession , .

    • A respiratory rate of over 70 breaths/minute , or over 60 breaths/minute with grunting or marked chest recession .


  • Central cyanosis , , .

  • Persistent oxygen saturation of less than 92% when breathing air , .

  • Signs of exhaustion, such as listlessness or decreased respiratory effort , .

  • Failure to maintain adequate oxygen saturation despite oxygen supplementation , .


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



  • A respiratory rate of over 60 breaths/minute , .

  • Difficulty with breastfeeding or inadequate oral fluid intake (50% to 75% of usual volume) , .

  • Clinical dehydration , .

  • Nasal flaring .

  • Abnormal response to social cues, decreased activity, or waking only with prolonged stimulation .


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



  • Chronic lung disease (including bronchopulmonary dysplasia) , .

  • Haemodynamically significant congenital heart disease , .

  • Age under 3 months , .

  • Premature birth, particularly under 32 weeks gestational age , .

  • Neuromuscular disorders , .

  • Immunodeficiency , .


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 .

  • Presence of grunting .

  • Heart rate below 100 or above 160 beats per minute .

  • Capillary refill time above 3 seconds .

  • Body temperature of 38°C or above, or 37.5°C on two occasions 15 to 30 minutes apart .

  • Oxygen saturation below 95% .

  • Presence of central cyanosis .


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 .

Related Knowledge Topics

Educational content only. Always verify information and use clinical judgement.