What criteria should I use to decide when to refer a newborn with respiratory distress to a neonatal unit?

Criteria for referring a newborn with respiratory distress to a neonatal unit include:

• Presence of severe respiratory distress signs such as grunting, marked chest recession, or a respiratory rate over 70 breaths per minute.
• Observed or reported apnoea (pauses in breathing).
• Central cyanosis (bluish discoloration of the skin indicating low oxygen levels).
• Failure to maintain adequate oxygen saturation despite oxygen supplementation, particularly persistent oxygen saturation below 92% when breathing air.
• Signs of exhaustion such as listlessness or decreased respiratory effort.
• Difficulty with feeding or inadequate oral fluid intake (50% to 75% of usual volume), or clinical dehydration.
• Known risk factors for more severe respiratory illness, including prematurity (especially under 32 weeks gestation), chronic lung disease, haemodynamically significant congenital heart disease, neuromuscular disorders, immunodeficiency, or age under 3 months.
• Additional clinical concerns such as abnormal heart rate (<100 or >160 beats per minute), prolonged capillary refill time (>3 seconds), or abnormal body temperature (≥38°C or repeated 37.5°C readings).

In preterm babies, especially those born before 32 weeks, referral is also indicated if respiratory support is needed soon after birth, including the need for invasive ventilation or surfactant administration.

Referral pathways should be established to ensure timely transfer and care by neonatal specialists.

These criteria align with NICE guidelines on bronchiolitis, specialist neonatal respiratory care, and intrapartum care.

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