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This chapter addresses the initial care of premature infants of <1000 g birthweight. Many aspects of the care of extremely low birthweight (ELBW) infants are controversial, and each institution must develop its own philosophy and techniques for management. It is of utmost importance to follow the practices of your own institution. This chapter offers guidelines that the authors have found useful for stabilizing and caring for extremely small infants.


  1. Delivery room management

      1. Ethics. (See also Chapter 20.) The neonatologist and other health-care team members should make every effort to meet with the family before delivery to discuss the treatment options for the ELBW infant. Counseling should include discussions with the parents regarding survival rate and both short- and long-term complications. Moreover, counseling regarding treatment options for the 22–24 week gestation infant is crucial.

      1. Resuscitation

          1. Thermoregulation. A polyethylene wrap or bag used immediately after birth prevents heat loss at delivery in very preterm infants. The wrap is removed and infant dried after being placed in a thermal neutral environment in the neonatal intensive care unit (NICU).

          1. Respiratory support. Oxygen (O2) use in resuscitation has been challenged in recent years. It takes 7–10 min for oxyhemoglobin saturations to rise to 90% after delivery. The Neonatal Resuscitation Program recommends availability of pulse oximetry and blended O2 for resuscitation and low saturation protocol. For infants who require intubation, prophylactic surfactant is recommended; however, for infants breathing spontaneously it remains controversial. If the infant is breathing spontaneously and has a heart rate >100, continuous positive airway pressure (CPAP) of 4–6 cm of H2O should be initiated to prevent atelectasis. CPAP cannot be delivered with a self-inflating bag.

          1. Transport. As soon as possible the infant should be transported to the NICU. Transport must be in a prewarmed portable incubator equipped with blended O2 and CPAP availability. Occlusive wrap should remain in place, and the infant should be placed under warmed blankets with a knit hat. Infants transported from referring hospitals should be handled in a similar manner with the addition of an underlying thermal mattress.

  2. Temperature and humidity control. Because the tiny infant has a relatively large skin surface area and minimal energy reserves, a constant neutral thermal environment is essential (environmental temperature that minimizes heat loss without increasing O2 consumption or incurring metabolic stress). To maintain minimal evaporative heat loss, it is best if the environmental humidity is 60–90%. Lower ambient humidity requires higher ambient temperatures to maintain infant skin temperature.

      1. Incubators or radiant warmers. ELBW infants should be admitted into prewarmed double-walled incubators or under radiant warmers with polyethylene covers. Radiant warmers allow accessibility to the infant but cause large evaporative heat with water losses and slightly higher basal metabolic rates than the incubator. Use of the radiant warmer is dictated by the infant's clinical status and medical needs.

      1. Humidification. ELBW infants have increased insensible water loss secondary to large body surface area and a greater proportion of body water to body mass. Transcutaneous water loss is enhanced by their thin epidermis and underdeveloped ...

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