Respiratory distress in a moderately preterm baby often presents diagnostic and management challenges to the attending paediatrician. Many of these babies will require little or no intervention, but it is known that early intervention in babies with acute respiratory distress often prevents further complications. Most current research evidence relates to extremely preterm newborns, yet moderately preterm infants are numerically far more common. This article explores the differential diagnosis of respiratory distress in this population and presents an evidence based approach to treatment.