Background Respiratory distress syndrome is one of the most common problems of newborns. Respiratory distress syndrome occurs when there is no enough surfactant in the lungs. Heavy metals are naturally occurring elements that have a high atomic weight and a density at least 5 times greater than that of water. Lead is a heavy metal, it is important environmental toxicant; the toxic effects of lead include many systems in the body like central and peripheral nervous system. Cadmium is heavy metal that exerts toxic effects on the kidney, the skeletal and the respiratory systems, and is classified as a human carcinogen. Nicotine, the main alkaloid of tobacco. It is readily absorbed from tobacco smoke, and its concentration rises over 6-8 hours during the day in regular smokers. About 70 to 80% of nicotine is metabolized to cotinine. Methods The study was carried out for 50 newborns divided in two groups: Group 1: 25 newborns with respiratory distress syndrome. Group 2: 25 newborns without respiratory distress syndrome. Results According to Demographic characteristics there are no significant differences when compered the age, gender, duration of pregnancy and the age of the mothers of newborns with respiratory distress syndrome and normal newborns (p<0. 05). the whole blood lead and serum cotinine concentration in newborns with respiratory distress syndrome was significantly higher compering with normal newborns (p<0. 05). The whole blood cadmium concentration in newborns with respiratory distress syndrome was not significantly different comparing with normal newborns (p<0. 05). Conclusions Newborns with respiratory distress syndrome have high serum level of cotinine and whole blood lead when compared to healthy newborns