This 28-hour-old white male was the product of an uncomplicated vaginal delivery by a G1 24-year-old mother whose pregnancy had also been uncomplicated. The infant was born pre-term at 36 weeks gestation and was appropriate for gestational age, weighing 2550 grams. Three hours after birth, the infant developed cyanosis and required 40% oxygen to maintain a pink color. Because of a worsening respiratory distress syndrome, the infant (1 day old) was transferred to a tertiary care hospital with a neonatal intensive care unit. Following the transfer, the respiratory distress progressed and the admitting arterial blood gases were pH 7.31, pCO2 PaCO2 35, and pO2 PaO2 35. The condition of the patient continued to deteriorate despite therapy, and he became "shocky" with efforts to increase blood volume. He developed a persistent bradycardia and died about 4 hours after admission.