TRANSIENT TACHYPNEA OF THE NEWBORN

Created by :
Aldyi Septian Putra
Sayyidatunnisa Rizqi
Yohana Pestra

Supervised by :
dr. Nazardi Oyong, Sp.A
PEDIATRIC DEPARTMENT
MEDICAL FACULTY UNIVERSITY OF
RIAU 1
 INTRODUCTION
• Respiratory disorders are the most common cause of intensive neonatal care in both
term and preterm neonates
• Health ministry of Republic Indonesia 2013
567 cases of infants with TTN
• Hermina Jatinegara General Hospital
December 2017 - February 2018, 23% of babies (16 babies) treated in NICU
diagnosed with TTN
• Incidency of TTN
10% in neonates born at 33-34 weeks gestation
5% in neonates born at 35-36 weeks gestation
less than 1% in aterm neonates
Kliegman RM, et al. Nelson textbook of pediatricas. Edisi 18. USA : Elsevir Inc. 2007;p.1429
Jha K, Makker K. Transient tachypnea of the newborn. Statpearls publishing 2019.
Departemen Kesehatan Republik Indonesia. Riset kesehatan dasar. 2013.
Kasap B, Duman N, Ozer E, Tatli M, Kumral A, Ozkan H. Transient tachypnea of the newborn: predictive factor for prolonged tachypnea.  Pediatr Int. 2008 Feb;50(1):81-4.
 LITERATURE REVIEW
DEFINITION
• Transient Tachypnea of Newborn (TTN) is emergency
respiratory on newborn immediately after birth and the effect
from liquid absorption in alveoli.

• TTN generally is self limiting desease after birth of the

newborn.

• Gomella TL, Cunningham MD, Eyal F. Neoatology. Edisi 6. NY : Lange medical books. 2009;p.717-9.
• Hermansen C., Lorah K. Respiratory distress in the newborn. American Academy of Family Physicians. 2007:76. Hal. 987-94
 EPIDEMIOLOGY

Indonesia
• 10% of newborn have
TTN on the 33-34 weeks
gestation.
• 5% of newborn on the
Indonesia 35-36 weeks gestation.
• <1% of newborn on
• 567 cases
aterm pregnancy.
• at 2013

• Departemen Kesehatan Republik Indonesia. Riset kesehatan dasar. 2013.

• Hagen E, Chu A, Lew C. Transient tachypneu of the newborn. Neo reviews journal. 2017;p.18(3).
 Risk Factor

• Sectio caesaria on <38 weeks gestation of pregnancy.

• Boys newborn.
• Mother with asthma.
• Prolong parturition.
• Macrocemia and multiple gestation.
• prematurity.

• Gomella TL, Cunningham MD, Eyal F. Neoatology. Edisi 6. NY : Lange medical books. 2009;p.717-9.
• Hermansen C., Lorah K. Respiratory distress in the newborn. American Academy of Family Physicians. 2007:76. Hal. 987-94
 PATOPHYSIOLOGY
Excretion the lung fluid starting
on first pregnancy

There is not activation of sodium transport in

1 the end pregnancy
Absorption the alveolar fluid
with activation na+ channel on
the lung ephitelial / Epithelial
Natrium Channel (ENaC)
fluid alveolar retention

• Hagen E, Chu A, Lew C. Transient tachypneu of the newborn. Neo reviews journal. 2017;p.18(3).
• Gomella TL, Cunningham MD, Eyal F. Neoatology. Edisi 6. NY : Lange medical books. 2009;p.717-9.
 PATOPHYSIOLOGY 2
Respiratory distress of
Fluid alveolar retention newborn

grunting tachypnea grashping retraction

Hagen E, Chu A, Lew C. Transient tachypneu of the newborn. Neo reviews journal. 2017;p.18(3).
Gomella TL, Cunningham MD, Eyal F. Neoatology. Edisi 6. NY : Lange medical books. 2009;p.717-9.
 DIAGNOSIS
CLINICAL MANIFESTATION
• tachypnea (respiratory rate > 60 /minute)
• Grashping
• Grunting
• Intercostal, subcostal or suprasternal retraction

PHYSICAL EXAMINATION
Auscultation :
• Decrease sound of breathing
• ronkhi

• Hagen E, Chu A, Lew C. Transient tachypneu of the newborn. Neo reviews journal. 2017;p.18(3).
• Gomella TL, Cunningham MD, Eyal F. Neoatology. Edisi 6. NY : Lange medical books. 2009;p.717-9.
DIAGNOSIS
RADIOGHRAFY
FINDINGS
• Prematurity with TTN can be
found on the radiography like
• Fluid on interlobar lungs,
bilateral alveolar hight composition lung fluid
• Intersisial oedema retention.
• Perihilar sign
• Hiperinflation lung

• Hagen E, Chu A, Lew C. Transient tachypneu of the newborn. Neo reviews journal. 2017;p.18(3).
• Gomella TL, Cunningham MD, Eyal F. Neoatology. Edisi 6. NY : Lange medical books. 2009;p.717-9.
 TREATMENT
SUPPORTIVE THERAPY CURATIVE THERAPY
• Maintain of electrolyte • nasal canulla
balance • nasal CPAP
• Maintain of fluid balance • Increase oxygenation for
• Maintain glucose maintain normal saturation.

• Hagen E, Chu A, Lew C. Transient tachypneu of the newborn. Neo reviews journal. 2017;p.18(3).
• Gomella TL, Cunningham MD, Eyal F. Neoatology. Edisi 6. NY : Lange medical books. 2009;p.717-9.
 PROGNOSIS

• Prognosis of TTN generally bonam. And the sign can be

threated within 48 hour at most of the newborn.

• Tachypnea can be found on 1 weeks and rarely more than 1

weeks.

• Gomella TL, Cunningham MD, Eyal F. Neoatology. Edisi 6. NY : Lange medical books. 2009;p.717-9.
• Hermansen C., Lorah K. Respiratory distress in the newborn. American Academy of Family Physicians. 2007:76. Hal. 987-94
 Risk factor on HIV infection from mother to child
Mothers Newborn Obstetric
HIV concentration (Viral Prematurity and birth of Type of labour
Load) weight
CD4 Time of feeding Time of labour
Pregnancy nutrition Prolong feeding Premature rupture of membrane

Infection on pregnancy   Episiotomy, vacuum

ekstraction and
Forceps

Problem on the breast    

(during lactation)

Fondoh V.N, Mom N.A., Mother to child transmission of HIV and its predictors among HIV-exposed Infants. African Journal of Laboratory
Medicine. 2017:6(1).
Kassa G.M., Mother to child transmission of HIV infection and its associated factors in Ethiopia: a systematic review and meta-analysis.
PMC. 2018:18. Hal 216.
TREATMENT
Recomendation ART for pregnancy with HIV infection and ARV
prophylaxis for newborn:

World Health Organization. Treatment HIV/AIDS during pregnancy. 2013.

CASE REPORT

14
Patient’s Identity

Name : By. EM / Girl

Date of birth/ Age : November 30 2019 / 45 minutes
MR Number : 01030183
Address : Jl. Garuda Sakti Km. 6 Tampan
Date of admission : November 30 2019
Date of Examination : December 1 2019
Date of Discharge : December 3 2019 b

15
 Anamnesis

Chief Complaint:
Term infant 45 minutes age with respiratory
distress

16
 History of Present Illness
• Neonate was born on November 30, 2019 at 11:40 WIB
in the OK IGD of Arifin Achmad Regional Hospital by
Sectio Caesarea on indications of HIV positive mothers.
• Neonate born immediately crying, good muscle tone,
full term, active movements. APGAR value in the first
minute was 8 and in the fifth minute was 9.

17
 Cont…
• Neonate was given routine treatments such as Neo K injection,
eye ointment and anthropometric measurements. At the age of
30 minutes, neonate was grunting, chest retraction, respiratory
rate increase 66 times / minute and there was peripheral
cyanosis (Down Score 4).
• Neonate was planned to be transferred to the Neonatal Care
Installation (IPN) to receive further treatment. Neonate was
brought to IPN in by using nasal oxygen 2 L / min.

18
 Cont…
• Neonate arrived at IPN at the age of 45 minutes with still
grunting, chest retraction, cyanosis, with a down score of 4, the
temperature was 36.6 C, O2 saturation was 74%. Neonate was
placed in infant warmer, then BCPAP was installed with PEEP 6
and FiO2 30% and Orogastric Tube (OGT) No. 8
• After using BCPAP, O2 saturation was 90%. Neonate performed
the BCPAP installation for 9 hours from 12:30 to 21:30 WIB

19
 Cont…
• Neonate was fasted and a D10% infusion of 8.5 cc per
hour was performed. Neonate was placed in the NICU
room in an incubator.
• at the age of 1 hour, neonate was had blood glucose
check and the results was 50 mg / dL, then at the age of
3 hours neonate was given 15 mg of zidovudin therapy.

20
 Cont…
• Neonate was planned to have a baby gram examination
at the age of 6 hours and a septic marker examination at
the age of 12 hours for infection screening. Neonate was
also planned to be consulted to Voluntary counseling
and testing (VCT).

21
Pregnancy History
Ante natal care (ANC) was 9 times, 7 times to the
midwife and twice to a specialist. Blood pressure,
Leopold, and ultrasound examination was performed.
Diagnosis of maternal pregnancy was G1P0A0H0 with
gestational age 37-38 weeks and HPHT was on
February 8 2019.

22
 Cont…
• During pregnancy there was no vaginal discharge and
fever. Mothers also didnt smoking, didn’t drink alcohol
and herbal medicine during pregnancy. History of
hypertension and diabetes mellitus also denied. But
mother was diagnosed with HIV since 1 year ago and
didn’t have any treatment

23
 Cont…
• Before giving birth at Arifin Achmad Regional Hospital,
an HIV test was re-done and a reactive HIV result was
obtained and it was concluded that the mother was HIV
positive.

24
 New Ballard Score
Neuromuscular maturity : 21
Physical maturity : 11
Total Score : 32

Maturity : 36 – 38 weeks
 Physical Examination (at an hour age)
Generalized condition : redness skin, good tonic, active,
good posture, mild chest retraction
Consciousness : alert
Vital sign :
RR : 66 times/minute
HR : 136 bpm, reguler, strong
T : 36,6 ͦ C
warm acral, CRT<2s

27
 Growth status
Birth weight : 2400 gr
Current weight : 2555 gr
Birth length : 46 cm
Head circumference : 33 cm
Chest circumference : 32 cm
Abdominal cirumference : 28 cm
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30
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Central Nervous System
Redness skin, alert, isokor pupil, pupillary reflex
(+/+)

Head
normal fontanelle, normal suture, central sianosis
(-), low set ear (-)
Respiratory System
Respiratory rate 66 times/min, mild chest retracion,
grunting (+), vesicular (+/+), Down score 4

33
Cardiovascular system
Heart rate 136 bpm, S1 S2 regular, murmur (-), gallop (-), CRT <2 second

Gastrointestinal system
Redness abdomen skin, abdominal circumference 28 cm, mass (-),
patent anus, peristaltic (+) 10 times/min

Extremity
Symmetrical extremity, CTEV (-), Polydactily (-), normal pelvic and arm
joints

Genitalia
Female, congenital anomaly (-)
Working Diagnosis

•NCB SMK BBLC (ICD 10 P03.4)

•Respiratory distress (ICD 10 P22.8)

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 Initial Treatment
▷ Neonate was treated in NICU
▷ Keep warmth (incubator)
▷ BCPAP (PEEP 6, FiO2 30%)
▷ IVFD D10% 8,5cc/hour
▷ NPO
▷ Zidovudin 15mg/12h

36
 Examination
▷ Routine blood check
▷ Blood glucose
▷ Rontgen babygram
▷ Consul VCT

37
 Laboratory findings
▷ Hb : 16,4 gr
▷ Leu : 14.100/mm3
▷ Ht : 50,3%
▷ Trombosit : 94.000/mm3
▷ GDS : 50 mg/dl
▷ CRP kuantitatif : 46,0

38
Radiology finding
▷ Result : TTN

39
 Diagnosis
• NCB SMK BBLC (ICD 10 : P03.4)
• Respiratory distress ec Transient Tachypnea of
Newborn (ICD 10 : P22.1)

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 Follow Up
Dates S O A P
1/12/2019 Breathless (+), Conciousness : Alert Respirato incubator
grunting (-), fever (-), HR : 136 bpm ry O2 nasal kanul 1 L /
convulsion (-), RR : 52 times/min distress min
yellow skin (-), T : 37,1oC ec TTN D10% 1/5Ns : 8,5 cc /
defecation (+), SpO2 : 97% hour
urinate (+) BW: 2400 gram plus KCL 5cc/kolf
Recent weight: 2620 gram 30 cc/3 hours
Fluid balance: 77,6 (formula milk)
Head : nostril breath(-) Zidovudin (day II)
Thorax : symmetrical, retraction intercosta (+), 15 mg/12 hours
vesicular breath sound, ronkhi (-), wheezing (-), S1
S2 regular, murmur(-), gallop(-)
Abdomen : Flat, mass (-), supple, organomegaly
(-), normal turgor
Extremity : edema (-), warm acral, CRT<2 second,
sianosis (-)

41
 Follow Up
Dates S O A P
2/12/2019 Breathless (-), Conciousness : Alert TTN 40 cc/3 hours (formula
(SCN I) grunting (-), fever HR : 144 bpm milk)
(-), convulsion (-), RR : 50 times/min Zidovudin (day III) 15
yellow skin (-), T : 36,6oC mg/12 hours
defecation (+), BW: 2400 gram
urinate (+) Recent weight : 2620 gram
Head : nostril breath(-)
Thorax : symmetrical, retraction intercosta (-),
vesicular breath sound, ronkhi (-), wheezing
(-), S1 S2 regular, murmur(-), gallop(-)
Abdomen : Flat, mass (-), supple,
organomegaly (-), normal turgor
Extremity : edema (-), warm acral, CRT<2
second, sianosis (-)

42
 Follow Up
Tanggal S O A P
3/12/2019 Breathless (-), Conciousness : Alert TTN Zidovudin (day IV) 15
(Rawat grunting (-), fever (-), HR : 140 bpm mg/12 hours
Gabung convulsion (-), yellow RR : 48 times/min Discharge
skin (-), defecation (+), T : 36,8oC
urinate (+) BW: 2400 gram
Recent weight: 2620 gram
Head : nostril breath(-)
Thorax : symmetrical, retraction intercosta (-),
vesicular breath sound, ronkhi (-), wheezing (-),
S1 S2 regular, murmur(-), gallop(-)
Abdomen : Flat, mass (-), supple, organomegaly
(-), normal turgor
Extremity : edema (-), warm acral, CRT<2
second, sianosis (-)

43
 DICUSSION
Neonates are born by sectio caesaria (SC) on the indication of mothers with B20.
SC is one of the risk factors for the occurrence of respiratory distress in neonates
since there’s no chest compressions and the lack of proper catecholamine
surges, which causes low release of counter-regulatory hormone during labor.
Hampered gas exchange causes some newborns to experience rapid breathing
and requires additional effort. This is in line with research conducted by Berrin in
2012 which states that there is a significant relationship between SC actions on
the occurrence of TTN .

Subramanian KN. Transient Tachypnea of the Newborn. E. Medicine. 2006

Berrin G. retrospective analysis on transient tachypnea of the newborn: is it associated with spinal anesthesia after cesarean section?. Gaziantep Medical Journal. 2012:18(2).77-80
Dwijayanti J. Tindakan seksio sesaria dan kejadian transient tachypnea of the newborn (TTN). Jurnal kesehatan ibu dan anak. 2014.5(1):68-71.
 DICUSSION
Management in neonates aims to reduce morbidity by providing supportive
care. Neonatal Intensive Care Unit (NICU) support is needed for
cardiopulmonary monitoring, neutral environmental temperature requirements,
optimizing fluid balance, checking blood glucose levels and observing signs of
infection. Fluid or nutritional requirements can be provided through intravenous
access, because neonates with tachypnea and respiratory disorders are likely to
have a delay in the progress of enteral feeding.

Guglani G. transient tachypneu of newborn. Pediatric in review. American academy of pediatric. 2008:29(11).
 DICUSSION
Infants are fasted and given intravenous dextrose 10% upon arrival at the NICU.
Infants are fasted to prevent aspiration of fluid into the lungs due to the
patient's rapid breathing frequency. IV catheter placement aims to stabilize the
patient. Management newborns with respiratory distress in RSUD Sheikh Yusuf is
giving dextrose 5% fluids.

Karslen KA. The stable program, pre-transport / post-resuscitation stabilization care for sick infant guidelines for neonatal healthcare provider. Edisi 5. USA : 2006.
Ningtiyas TN. Manajemen asuhan kebidanan bayi baru lahir dengan asfiksia berat di RSUD Syekh Yusuf. Jurnal Midwifery : 2011.
 DICUSSION
Respiratory management in this neonate is the administration of oxygen using
CPAP to meet oxygen needs. CPAP is widely used for the care of preterm and
aterm babies who have respiratory problems shortly after birth, such as TTN.
The purpose of giving CPAP is to help air exchange. CPAP can reduce tachypnoea
and increase oxygen pressure, reduce intrapulmonary shunts and improve lung
development. Weintraub et al reported that 45% (336/745) of newborns with
TTN require CPAP or high-flow nasal cannula to help with breathing.

Celebi MY. Impact of prophylactic continuous positive airway pressure on transient tachypnea of the newborn and neonatal intensive care admission in newborns delivered by elective cesarean
section. American journal of perinatology.2015.
 DICUSSION
Radiological examination is an important examination to diagnosis of TTN. The
results of radiographic examinations on this neonate show the results of
pulmonary perihiler vascular images showing the appearance of TTN.
Radiographic findings on TTN can include the presence of fluid in the interlobar
cleft, bilateral alveolar and interstitial edema with cardiomegaly, hyperaeration,
and pleural effusion.

Yoon HK. Interpretation of neonatal chest radiography. J Korean Soc Radiol. 2016 May; 74(5):279-290.
 DICUSSION
In this case, neonates were born SC to prevent the transmission of HIV virus
from mother to child. Purnaningtyas states that breastfeeding and vaginal
delivery are risk factors for HIV occurrence in infants. CD4 cell count,
prophylactic ARV administration to infants and ARV consumption during
pregnancy are not determinants in HIV transmission to infants.

Kliegman RM, et al. Nelson textbook of pediatricas. Edisi 18. USA : Elsevir Inc. 2007;p.1429
Purnaningtyas DA, Dewantiningrum J. persalinan pervaginam dan menyusui sebagai faktor risiko kejadian HIV pada bayi. M Med Indones : 2011.
 DICUSSION
Patient get zidovudin 2 x 15 mg at the age of 3 hours as prophylaxis of HIV
infection in newborns with HIV mothers. It is said that zidovudin as prophylaxis
is given under 12 hours of age. this can reduce perinatal HIV transmission by
<8%. Prophylaxis given to babies with HIV mother in Central General Hospital in
Denpasar is Niverapin (NVP) at the age of 40-72 hours.

Kliegman RM, et al. Nelson textbook of pediatricas. Edisi 18. USA : Elsevir Inc. 2007;p.1422.
Saputri LO, Niruri R, Kumara KD. Pelaksanaan intervensi pencegahan penularan HIV dari ibu ke anak (PPIA) di RSUP Sanglah Denpasar tahun 2007-2011. Jurnal farmasi udayana. 2013.
 DICUSSION
Patient is planned for control to VCT at the age of 6 weeks to assess patient’s
HIV status. Virological testing is performed on infants with HIV-infected mothers
to make a clinical diagnosis at 6 weeks of age. Examination of HIV status in
infants at the Adam Malik Central General Hospital was performed since the
baby was under 18 months of age, the examination carried out was a PCR
examination.

Kementrian kesehatan Republik Indonesia. Pedoman penerapan terapi HIV pada anak. 2014
Mithila J. Profil bayi baru lahir dari ibu dengan HIV dan AIDS yang bersalin di RSUP Haji Adam Malik Medan periode tahun 2012-2014. Universitas Sumatera Utara. 2017.
Thank you