What are the appropriate steps to take when a newborn is sneezing?

Newborn Sneezing: Assessment and Management

Newborn sneezing is typically a normal physiological response that helps clear the nasal passages and requires no specific intervention in most cases. 1

Understanding Normal Newborn Sneezing

• Sneezing in newborns is a common and natural reflex that helps them clear their nasal passages of amniotic fluid, mucus, milk, and other irritants 1
• Newborns are obligate nasal breathers until approximately two months of age, making clear nasal passages essential for proper breathing and feeding 1
• The mechanics of sneezing in newborns involve increased oesophageal pressure and peak expiratory airflow that is significantly higher than during normal breathing, effectively clearing the nasal passages 2

When to Monitor vs. When to Intervene

Normal Sneezing (No Intervention Needed)

• Occasional sneezing without other symptoms of respiratory distress 1
• Clear nasal discharge without congestion 1
• Normal feeding patterns and weight gain 3
• Normal skin color and activity level 4

Warning Signs Requiring Attention

• Sneezing accompanied by respiratory distress (nasal flaring, grunting, retractions) 5, 6
• Feeding difficulties or poor weight gain potentially related to nasal obstruction 1
• Changes in skin color (cyanosis, pallor) 4
• Excessive irritability or lethargy 7
• Fever or other signs of infection 6

Appropriate Management Steps

For Normal Sneezing

• Reassurance to parents that sneezing is a normal physiologic function 1
• Ensure proper positioning during sleep and feeding with head in "sniffing" position to maintain airway patency 4, 3
• Monitor the infant's breathing pattern, activity, color, and tone during routine care 4

For Nasal Congestion

• Saline nasal lavage is recommended as a safe and effective treatment for nasal congestion in newborns 1
• Gentle nasal aspiration following saline drops can help clear secretions 1
• Avoid over-suctioning which can cause nasal irritation and increased mucus production 1

For Persistent or Concerning Symptoms

• If sneezing is accompanied by feeding difficulties, consider evaluation for swallowing dysfunction or gastroesophageal reflux 4, 7
• For persistent respiratory symptoms not relieved by basic measures, further evaluation may be needed to rule out other causes 5, 6
• Consider evaluation for milk protein allergy if symptoms persist with associated irritability, as this can co-exist with reflux symptoms in 42-58% of affected infants 7

Safe Positioning and Monitoring

• Ensure infant's face can always be seen and is not covered 4, 3
• Position infant's head in "sniffing" position with neck straight, not bent 4, 3
• Ensure nose and mouth are not covered 4
• Turn infant's head to one side when supine 4
• Cover infant's back with blankets while maintaining proper positioning 4, 3
• Monitor infant continuously, especially during the first 2 hours of life 3

Common Pitfalls to Avoid

• Mistaking normal sneezing for illness or respiratory distress 1
• Overuse of nasal suctioning, which can cause mucosal irritation and increased secretions 1
• Failing to recognize when sneezing is accompanied by true signs of respiratory distress requiring medical attention 5, 6
• Using over-the-counter medications not approved for infants 7
• Positioning that may obstruct the airway during sleep or feeding 4, 3

Special Considerations

• Preterm infants may have more pronounced respiratory symptoms due to immature lungs and may require closer monitoring 4
• Infants delivered by cesarean section may experience more transient respiratory issues in the first days of life 4, 5
• Sneezing with forceful vomiting warrants investigation to exclude other causes 7