12: Management of the Extremely Low Birthweight Infant During the First Week of Life

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. Ethics. 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 based on institutional statistics and the National Institute of Child Health and Human Development (NICHD) Neonatal Research Network calculator. Communication regarding treatment options for the 22–24 week gestation infant is crucial. Neonatal bioethics are discussed in detail in Chapter 21.

2. 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 is dried after being placed in a thermal-neutral environment in the neonatal intensive care unit (NICU).

   2. Respiratory support. Oxygen (O₂) use in resuscitation has been challenged in recent years. It takes 7–10 minutes 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, 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.

   3. 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.

Because the tiny infant has a relatively large skin surface area and minimal energy reserves, a constant neutral thermal environment (environmental temperature that minimizes heat loss without increasing O₂ consumption or incurring metabolic stress) is essential. To maintain minimal evaporative heat loss, it is best if the environmental humidity is 80%. Lower ambient humidity requires higher ambient temperatures to maintain infant skin temperature.

1. Incubators and hybrid incubators. ELBW infants should be admitted into prewarmed double-walled incubators. Until recently, only radiant warmers allowed accessibility to the infant; however, they caused large evaporative heat with water losses and somewhat higher basal metabolic rates. As a result, the development and exclusive use of hybrid humidified incubators has been on the rise, with many facilities converting to these multiuse incubators.

2. 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 stratum corneum. Increased environmental humidity can minimize these losses. Warm humidification within the incubator is recommended. Double-walled incubators provide the best control for monitoring humidity levels.

   1. Use a respiratory care humidification unit. Humidification and warming of administered ventilator gases are important to minimize insensible fluid losses and hypothermia. Infants receiving mechanical ventilation as well as noninvasive respiratory assistance require humidification. In-line warming of ventilator gas circuits minimizes “rainout” of the humidified air and O₂ and maintains airway temperature as close as possible to 35^o C. The fluids used for humidification in these systems should be changed every 24 hours.

   2. Minimize nosocomial infection in humidified environments. Minimize by not allowing nonmedical items inside the incubator and by changing linens regularly if the infant's condition is stable. Change bed every 7–10 days per manufacturer's recommendation.

3. Monitoring and maintenance of body temperature. Infants weighing <1000 g have poor mechanisms for regulation of temperature and depend on environmental support.

   1. Maintain axillary skin temperature of 36.0–36.5°C. If skin temperature is outside the range, you may need to change from servo control to manual control for warming the smallest infants. Use extreme caution while in the manual temperature mode because the danger of hyperthermia does exist. Rectal thermometers are not to be used for tiny infants. Electronic thermometers have become standard in obtaining infant temperatures.

   2. Record skin temperature. Using a servo-control skin probe, record skin temperature and environmental temperature every hour until the skin temperature is stable (36.0–36.5°C) and thereafter with recordings at 2-hour intervals.

   3. Record the incubator humidity. Record every hour until it is stable and then every 2 hours for maintenance.

   4. Weigh low birthweight infants at least once daily for management of fluids and electrolytes. The incubator should be equipped with an in-bed scale for continuous weighing of the infant to minimize handling and loss of the thermal-controlled environment.

   5. Other heat-conserving practices. These include the use of knit hats, fetal positioning, and air boost curtains on incubators.

   6. Accessory items for infant care must be prewarmed. These items include intravenous (IV) fluids, stethoscope, saline lavages, and any other items that come in direct contact with the infant. Placement of these items in the infant's incubator 30 minutes before use warms them to avoid heat loss by conduction from the infant.

4. Slow warming or cooling of infants. Infants who become hypothermic must be gradually rewarmed.

   1. Warming. If the infant's temperature is <36.0°C, set the warmer temperature 0.4°C higher than the infant's temperature. Continue this procedure until the desired temperature is achieved. Frequent observations of environmental and skin temperatures are essential to evaluate warming efforts. Do not rewarm faster than 1°C/h. When skin temperature of 36.5°C is achieved, rewarming efforts should be gradually discontinued and temperature maintenance by servo-control should be monitored. Rapid rewarming of ELBW infants must be avoided because core body temperatures >37.5°C cause increased insensible water losses, increased O₂ consumption, apneic episodes, increased incidence of intraventricular hemorrhage, deviations in vital signs, and a detrimental effect on neurodevelopment.

   2. Hyperthermia (skin temperature >37.0°C). In case of hyperthermia, set the warmer temperature control to 0.4°C lower than the infant's skin temperature. Continue to reduce the warmer temperature until desired temperature is achieved. If increased temperature persists, consider evaluation for pathologic conditions such as sepsis, intraventricular hemorrhage, or mechanical overheating by exterior lamps. Do not turn off the warmer, as this may cause a sudden decrease in the infant's temperature.

Because of increased insensible water loss and immature renal function, these infants have greater fluid requirements, necessitating IV fluid therapy (see Chapter 9).

1. Intravenous fluid therapy

   1. Insensible water loss. Insensible water loss increases with the use of radiant warmers and low ambient humidity. Under these circumstances in which increased insensible fluid loss can occur, additional fluid supplementation is required. However, excessive fluid intake may contribute to the development of a hemodynamically significant patent ductus arteriosus (PDA).

   2. First day of life. Table 12–1 gives suggested guidelines for total fluids per kilogram of body weight for the first day of life for infants in humidified incubators/omnibeds and on radiant warmers.

   3. Second and subsequent days of life. Fluid management on the second and subsequent days depends on changes in body weight, renal function (blood urea nitrogen, creatinine, urine output), and serum electrolyte concentrations (see Chapter 9).

   4. Additional fluid may be required if phototherapy is used. The fluid volume should be increased by 10–20 mL/kg/d.

      1. Incubators/omnibeds. Fluid rates based on 80% or higher humidity; fluids should be increased incrementally with decreasing environmental humidity.

      2. Radiant warmers. Fluid rates may be decreased with the addition of a humidity tent.

2. Infusion of fluids. Confirm appropriate line placement and document before infusion (see specific procedure chapter).

   1. Umbilical artery catheter. Use only for laboratory and hemodynamic monitoring if other IV access is available. Infuse 0.5 normal saline (NS) + 0.5 U heparin/mL or 0.5 sodium acetate + 0.5 U heparin/mL (sodium acetate aids in acid-base balance).

   2. Umbilical venous catheter. Fluids containing glucose and amino acids add 0.5 U heparin/mL to maintenance fluids.

   3. Broviac or percutaneous central venous catheters. Add 0.5 U heparin/mL to maintenance fluids.

   4. Radial arterial line/posterior tibial arterial line. Add 2 U heparin/mL to 0.5 NS.

3. For catheter flushes, use the same fluids as those infused as IV fluids. Avoid NS as a flush solution because of excessive sodium. In addition, avoid hypotonic solutions (<0.45 NS or <5% dextrose); these solutions may cause red blood cell hemolysis.

4. Monitoring of fluid therapy. The infant's fluid status should be evaluated at least twice daily during the first few days of life and the fluid intake adjusted accordingly. Fluid status is monitored via measurement of body weight, urine output, blood pressure measurements, serum sodium, hematocrit, and physical examination.

   1. Body weight. This is the most important method of monitoring fluid therapy. If an in-bed scale is used, weigh the infant daily. If unavailable, weighing may be delayed to every 48 hours, depending on the stability of the tiny infant, to prevent excessive handling and cold stress. A weight loss of up to 15% of birthweight may be experienced by the end of the first week of life. If weight loss is excessive, environmental controls for insensible fluid losses and fluid management must be carefully reviewed.

   2. Urine output. This is the second most important method of monitoring fluid therapy. For greatest accuracy, diapers should be weighed before use and immediately after urination.

      1. First 12 hours. Any amount of urine output is acceptable.

      2. 12–24 hours. The minimum acceptable urine output is 0.5 mL/kg/h.

      3. Day 2 and beyond. Normal urine output for the second day is 1–2 mL/kg/h. After the second day of life, and during a diuretic phase, urine output may increase to 3.0–5.0 mL/kg/h; values outside this range warrant reevaluation of fluid management.

   3. Hemodynamic monitoring. This is a valuable tool in assessing fluid status in the infant.

      1. Heart rate. The accelerated heart rate of the tiny infant averages 140–160 beats/min and is generally considered within normal limits. Tachycardia, with a heart rate >160 beats/min, may be a sign of hypovolemia, pain, inadequate ventilation, anemia, sepsis, or hyperthermia. Low heart rate (<100 beats/min) may be related to hypoxia or medication.

      2. Arterial blood pressure. This is most accurately measured via an indwelling arterial catheter and transducer. Cuff pressures are difficult to obtain because of the infant's small size and lower systemic pressures. A recognized standard is to maintain the infant's mean arterial pressure at or equal to the gestational age during the first 48 hours. Thereafter, mean blood pressure increases with chronological age. It is important to evaluate the infant's perfusion, urine output, and acid-base balance in conjunction with blood pressure monitoring.

   4. Electrolyte values. Serum electrolyte levels should be monitored at least twice daily or every 8 hours for the most immature infants. Sodium and potassium are added as diuresis begins.

      1. Sodium. Initially tiny infants have a sufficient sodium level (132–138 mEq/L), and if there are no ongoing fluid losses, they will not require additional sodium. Serum sodium level may begin to decrease in the post-diuretic phase (usually third to fifth days of life). Subsequently, sodium chloride should be added to the IV fluids (3–8 mEq/kg/d of sodium). Hyponatremia in the prediuretic phase usually indicates fluid overload, and hypernatremia during the same period usually indicates dehydration. Note: Hypernatremia in the prediuretic phase is due to excessive insensible water loss. This can be effectively treated with sterile water intragastric drip. This avoids use of hyposmolar IV fluids. For subsequent monitoring of the serum sodium levels:

         1. Hypernatremia Na⁺ > 150 mEq/L. Differential diagnosis is (a) premature addition of sodium in the prediuretic phase, or (b) dehydration, or (c) excessive Na⁺ intake.

         2. Hyponatremia Na⁺<130 mEq/L. Differential diagnosis is (a) fluid overload, or (b) inadequate Na⁺ intake, or (c) excessive Na⁺ loss.

      2. Potassium

         1. During the first 48 hours after birth. During this time, tiny infants are prone to increased serum potassium levels of ≥5 mEq/L (range, 4.0–8.0 mEq/L). Most clinicians recommend that no potassium be given during the prediuretic phase. The increase is mostly a result of the following:

            • (a) Relative hypoaldosteronism

            • (b) Shift of intracellular potassium to the extracellular space due to an immature Na+, K+-ATPase pump

            • (c) Immature renal tubular function

            • (d) Lack of arginine, a precursor to insulin

         2. K⁺ >6 mEq/L mandates close ECG monitoring T-wave changes and rhythm disturbances along with electrolyte trends, acid-base status, and urine output. Acidosis should be aggressively treated because this tends to cause intracellular potassium to leak out. Use of Kayexalate enemas is controversial in this age group and best avoided if possible. Albuterol metered-dose inhaler (MDI) (4 puffs every 2 hours; 1 puff = 90 mcg) can reduce high levels. Serum K⁺ >7 mEq/L can also be treated with insulin, NaHCO₃, and calcium gluconate (see Chapter 60).

         3. 3–6 days after birth. Usually by this time, the initially elevated K⁺ level begins to decrease. When K⁺ levels approach 4 mEq/L, add supplemental K⁺ to IV fluids. Begin with 1–2 mEq/kg/d. Measure serum K⁺ every 6–12 hours until the level is stabilized.

ELBW infants should be supported with 4–6 mg/kg/min glucose infusion; start with a 5–10% dextrose solution, depending on glucose needs. Amino acid used immediately after birth along with glucose solutions achieves better glucose homeostasis. Bedside glucose levels should be monitored frequently until a blood glucose level of 50–90 mg/dL has been established. Abnormal values should be confirmed with serum glucose.

1. Hypoglycemia is <40 mg/dL for first 48 hours, thereafter < 50 mg/dL. It may occur because of an inadequate glucose infusion rate or a physiologic lack of glycogen stores. Additionally, pathologic states such as sepsis, cold stress, or hyperinsulinemia need to be considered.

2. Hyperglycemia >150 mg/dL. This can cause osmotic glycosuria, resulting in excessive fluid loss. Hyperglycemia may be secondary to increased glucose infusion rate or pathologic causes such as sepsis, necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH), or a stress response. Determine the underlying etiology and recalculate glucose administration. Treatment with insulin infusion is controversial. An alternative is to decrease the glucose infusion rate (GIR); maintaining glucose infusion as low as 1.5 mg/kg/min has been demonstrated to provide adequate glucose for cerebral metabolism while not affecting proteolysis and protein turnover.

Serum calcium should be monitored daily. Hypocalcemia in preterm infants is a serum calcium <6 mg/dL. Some institutions also evaluate ionized calcium. In our institution, we provide daily maintenance calcium along with total parenteral nutrition soon after birth (eg, 2 mg of calcium gluconate/mL IV solution). Asymptomatic hypocalcemia is not treated with additional calcium because it resolves with time. Symptomatic hypocalcemia is treated with calcium salts (for dosage, see Chapter 148). This decrease usually happens on the second day of life.

1. Parenteral nutrition can be started on admission and continued until the infant is receiving sufficient enteral feeding to promote growth. Along with an adequate GIR of 4–6 mg/kg/min, amino acids are started at 2.5 g/kg/d and increased by 0.5 g/kg/d to a maximum of 3.5–4 g/kg/d.

2. Intravenous lipids (20%) should be started by 24 hours of age; start with 0.5 to 1 g/kg/d and increase by 0.5 g/kg/d every 24–48 hours up to 3 g/kg/d while monitoring triglyceride levels. Septic and thrombocytopenic infants require caution before advancing lipids. A generally acceptable safe triglyceride level is <200 mg/dL.

3. Early feeds of small amounts of breast milk or premature formulas (10–20 mL/kg/d) can promote gut development, characterized by increased gut growth, villous hypertrophy, digestive enzyme secretion, and enhanced motility. This approach is called trophic feedings. The decision to either advance or maintain trophic feedings at a constant level should take into account the clinical status of the infant. Trophic feeds should be started with maternal or donor breast milk. The incidence of infection, NEC, and retinopathy of prematurity is decreased when breast milk is used. Mothers should be provided information regarding the benefits of breast milk and should be encouraged to pump their breasts regularly. Once feedings are established, the breast milk can be fortified with supplements. If breast milk is not available, premature formulas can be used.

4. Controversy exists with regard to feeding infants while undergoing pharmacologic treatment for PDA closure and during blood transfusions.

ELBW infants have underdeveloped muscles of ventilation. Many of these infants initially require support by mechanical ventilation; however, others, if vigorous, may be supported with CPAP or high-flow nasal cannula (HFNC).

1. Endotracheal intubation

   1. Type of endotracheal tube (ETT). When possible, use an ETT with 1-cm markings on the side. The internal diameter (ID) of the tube should routinely be 2.5 or 3.0 mm, according to body weight:

      1. <500–1000 g. 2.5 mm ID.

      2. 1000–1250 g. 3.0-mm ID.

   2. ETT placement. Described in detail in Chapter 29. Confirm proper placement by a chest radiograph study, performed with the infant's head in the midline position, noting the marking at the gum. Note: In ELBW infants, the carina tends to be slightly higher than T4. As a means of subsequently checking proper tube position, on every shift the nurse responsible for the infant should check and record the numbers or letters at the gum line.

2. Mechanical ventilation. With the advancement of ventilation technology, various modes are available, including volume ventilation, pressure support, and high-frequency ventilation. Ventilation applied appropriately assists the clinician in avoiding overexpansion of the lung or atelectasis.

   1. Conventional ventilation. Tiny infants respond to a wide range of ventilator settings. Some do relatively well on 20–30 cycles/min; others require 50–60 cycles/min with inspiratory times ranging from 0.25–0.35 seconds. The goal is to use minimal pressure and tidal volume for optimal expansion of the lung, avoiding volu-trauma and atelectasis. Seek to maintain mechanical breath tidal volumes of 4–6 mL/kg; this often may be achieved with as little as 8–12 cm inspiratory pressure and 3–5 cm positive end-expiratory pressure. Pressures can be kept to a minimum by allowing permissive hypercapnea (pH 7.25–7.32, Pco₂ 45–60 mm Hg). The following conventional ventilator support guidelines are offered for the initiation of respiratory care. Each tiny infant requires frequent reassessment and revision of settings and parameters. Recommended initial settings for pressure-limited time-cycled ventilators in tiny infants are as follows (see also Chapter 8):

      1. Rate. 20–60 (usually 30) breaths/min.

      2. Inspiratory time. 0.25–0.35 seconds.

      3. Peak inspiratory pressure (PIP). Select PIP allowing optimal expansion of lungs.

      4. Fio₂. As required to maintain O₂ saturation 88–92%.

      5. Flow rate. 6–8 L/min.

      6. Synchronized intermittent mandatory ventilation (SIMV) and volume/pressure control ventilators. These have internal controls that adjust flow delivery. Current ventilators have incorporated enhancements for pressure support, resulting in increased triggering sensitivity, shortened response times, reduced flow acceleration, and improved breath termination parameters.

   2. High-frequency ventilation. Uses small (less than dead space) tidal volumes and extremely rapid rates. The advantage of delivering small tidal volumes is that it can be done at relatively low pressures, reducing the risk of barotrauma. A slight disadvantage is that infant positioning is restricted.

   3. Nasal CPAP (nCPAP). Some ELBW infants may not require mechanical ventilation, whereas others may require ventilation for a short period of time for surfactant replacement. nCPAP has become a mainstay of respiratory management in these infants, initiating soon after birth. Infants requiring intubation and mechanical ventilation should be transitioned to nCPAP as clinical condition allows. nCPAP helps maintain lung expansion and improves oxygenation without significant barotrauma. Care should be taken to use nasal prongs appropriately to prevent nasal injuries and septal breakdown. A gel form of normal saline can help keep nasal passages moist and prevent such injuries.

   4. High-flow nasal cannula (HFNC). Nasal flows >1 L using blended gases are used as an alternative to NCPAP in the management of respiratory distress and apnea of prematurity. There are insufficient data to establish its safety and efficacy; thus caution should be used for this population, and it should be reserved for stable infants.

3. Monitoring respiratory status

   1. Oxygenation

      1. Blood gas sampling. Arterial catheterization (see Chapter 23 for percutaneous arterial catheterization or Chapter 24 for umbilical arterial catheterization) should be performed for frequent blood gas sampling. As the infant becomes clinically stable, frequency of laboratory testing should be decreased to minimize blood loss and the need for blood transfusions.

         1. Desirable arterial blood gas values

            • (a) Pao₂. 45–60 mm Hg.

            • (b) Paco₂. 45–60 mm Hg.

            • (c) pH. 7.25–7.32 is acceptable.

         2. Abnormal blood gas values. Indicate the need for assessment including ETT placement, chest wall movement, effectiveness of ventilation, ventilator malfunction, assessment for pneumothorax, and need for suction. Actions may include immediate chest radiographs, chest wall transillumination (see Chapters 11 and 40), and repeat blood gas determinations.

      2. Continuous O₂ monitoring. Should also be performed, preferably by pulse oximetry. To prevent skin breakdown, pulse oximetry sites should be changed every 8 hours and a protective barrier placed under the probe site. The O₂ mixture should be adjusted to maintain the pulse oximeter reading between 88% and 92% hemoglobin O₂ saturation. Excess oxygenation must be avoided in this group of infants. Failure to closely regulate the administration of O₂ can contribute to the development of retinopathy of prematurity and bronchopulmonary dysplasia.

   2. Chest radiograph

      1. Indications

         1. Abnormal change in blood gas values

         2. Adjustment of the ETT (to confirm proper positioning)

         3. Sudden change in the infant's status

         4. Significant increase in O₂ requirement or frequent desaturations

      2. Technique. A chest radiograph should be taken with the infant's head in the midline position to check for ETT placement.

      3. Radiograph evaluation. Check the chest radiograph for expansion of the lung, chest wall, and diaphragm. Overexpansion (exhibited by hyperlucent lungs and diaphragm below the ninth rib) and underventilation (exhibited by hazy, white lung field—atelectasis) must be avoided. If overexpansion is present, differentiate between volu-trauma and air trapping based on the age of the infant and underlying disease process. Consider decreasing the peak airway pressure if volu-trauma is suspected. Under-expansion can be treated with the use of CPAP or increasing pressures (peak airway pressure or positive end expiratory pressure) via the ventilator.

4. Suctioning. Should be done on an as-needed basis. The need for suctioning can be determined with the use of flow-volume loop monitoring, which can illustrate restricted airflow caused by secretions.

   1. Assessment of the need for suctioning. The nurse or physician should consider the following:

      1. Breath sounds. Wet or diminished breath sounds may indicate secretions obstructing the airways and the need for suctioning.

      2. Blood gas values. If significant increase in Paco₂, consider ETT malposition, secretions blocking the airway passages, inadequate ventilation, prior bicarbonate/acetate administration, or pain. Suctioning should be considered to clear the airways and avoid the “ball-valve” effect of thick secretions.

      3. Airway monitoring. By using airflow sensors and continuous computer graphic screen displays, abnormal waveforms indicative of accumulating secretions or airway blockage can be easily seen, and immediate steps can be taken to clear the airway.

      4. Visible secretions in the ETT.

      5. Loss of chest wall movement.

   2. Suctioning technique

      1. In-line suctioning is recommended to minimize airway contamination. Suctioning should be done only to the depth of the ETT. Use a suctioning guide or a marked (1-cm increments) suction catheter.

      2. Suctioning without lavage solution is recommended. An exception is the use of warm sterile normal saline lavage for thick secretions.

      3. Suction should be regulated. 80–100 mm Hg for in-line suction (closed system) and 60–80 mm Hg (open system).

5. Extubation

   1. Preextubation. Consider use of caffeine citrate loading as it improves respiratory drive and reduced length of time on mechanical ventilation. Recent reports also indicate caffeine to have neuroprotective effects when started at birth.

   2. Indications. When an ELBW infant has been weaned to a mean airway pressure of 6 cm H₂O and a low (30%) Fio₂, extubation should be considered. Most infants >26 weeks and 700 g birthweight can be extubated in the first 72 hours. These are the other indications for extubation:

      1. Ventilator rate ≤10 breaths/min

      2. Regular spontaneous respiratory rate

   3. Postextubation care. Frequent observation of breathing patterns, respiratory effort, auscultation of the chest, monitoring of vital signs, and blood gas analysis are necessary. After extubation, the infant is placed on CPAP or HFNC with blended O₂. Some neonatologists suggest that extubation to nasal prong or mask CPAP has beneficial effects on respiratory function and the prevention of atelectasis.

6. Vitamin A. Vitamin A as a mode of therapy for decreasing chronic lung disease in ELBW infants is well established in clinical trials. Dosing should begin the first week of life, 5000 IU intramuscularly (IM) 3 times per week for 4 weeks. Some institutions are reluctant in using this therapy because of the frequency of IM injections. Vitamin A delivery via IV fluids is not effective because it binds to the tubing.

Some literature supports early administration of surfactant during the first 4 hours of life to decrease chronic lung disease. Recent research supports early CPAP in the delivery room over prophylactic surfactant. Several preparations of surfactant are available; some have the advantage of smaller volume and dosing intervals. It should be administered according to the manufacturer's recommendations. Administration criteria for surfactant include absence of antenatal steroids, increased oxygen demand >30%, and a radiograph consistent with surfactant deficiency (see also Chapter 8).

Incidence of persistent PDA is inversely proportional to gestational age. Infants should be monitored clinically for signs and symptoms of PDA. An echocardiogram is recommended to rule out other structural heart defects and confirmation of PDA when concerned. Efforts should be made to minimize the risk of PDA. Overhydration must be avoided. Up to 30% of PDAs spontaneously close. Currently it is unclear whether a conservative, pharmacologic or surgical approach is advantageous. If the decision is made to treat a hemodynamically significant PDA, indomethacin or ibuprofen is generally accepted (see Chapter 118). Renal and GI adverse effects are less common with administration of ibuprofen or with slower infusion rates of indomethacin. Indomethacin can also be considered for IVH prophylaxis, although its safety and benefit remain controversial. Concurrent administration of indomethacin and steroids should be avoided because of the associated risk for spontaneous intestinal perforation.

ELBW infants usually have low red blood cell volume, with a hematocrit <40%, and they are subjected to frequent phlebotomies. Most centers keep the hematocrit between 35% and 40%. Lower values may be acceptable if the infant is asymptomatic. Each institution should have transfusion guidelines established to minimize donor exposure and the number of transfusions.

Maintenance of intact skin is the tiny infant's most effective barrier against infection, insensible fluid loss, protein loss, and blood loss and provides for more effective body temperature control. Minimal use of tape is recommended because the infant's skin is fragile, and tears often result with removal. Zinc-based tape can be used. Alternatives to tape include the use of a hydrogel adhesive, which removes easily with water. Hydrogel adhesive products also include electrodes, temperature probe covers, and masks. In addition, the very thin skin of the tiny infant allows absorption of many substances. Skin care must focus on maintaining skin integrity and minimizing exposure to topical agents. Transparent adhesive dressings can be used over areas of bone prominence, such as the knees or elbows, to prevent skin friction breakdown and under adhesive monitoring devices that are frequently moved. Use of humidity helps maintain skin integrity until skin is mature (2–3 weeks). Humidity can be weaned as tolerated after 2 weeks. Note: When the skin appears dry, thickened, and no longer shiny or translucent (usually in 10–14 days), these skin care recommendations and procedures may be modified or discontinued.

1. Use a hydrogel skin probe or cut servo-control skin probe covers to the smallest size possible (try a 2-cm diameter circle). This will help to reduce skin damage resulting from the adhesive.

2. Monitoring of O₂ therapy is best accomplished by use of a pulse oximeter. The probe must be placed carefully to prevent pressure sores. The site should be rotated a minimum of every 8 hours. Alternative means of O₂ monitoring include umbilical catheter blood sampling.

3. Urine bags and blood pressure cuffs. These should not be used routinely because of adhesives and sharp plastic edge cuts. Bladder aspirations should be avoided.

4. Eye ointment for gonococcal prophylaxis. Should be applied per routine admission plan. If the eyelids are fused, apply along the lash line.

5. Cleansing for required procedures (eg, umbilical artery or chest tube). Use minimal povidone-iodine solution to cleanse the area. After the procedure is completed, the solution should be sponged off immediately with warm sterile water. The use of chlorhexidine in the ELBW infant is controversial and should be used per institution guidelines.

6. Attach ECG electrodes using as little adhesive as possible. Options include the following:

   1. Consider using limb electrodes.

   2. Consider water-activated gel electrodes.

   3. Use electrodes that have been trimmed down and secured with a flexible dressing material.

7. An initial bath. Not necessary, but if HIV is a consideration, those infants should receive a mild soap bath when the infant's temperature has stabilized. Warm sterile water baths are given only when needed during the next 2 weeks of life.

8. Avoid the use of anything that dries out the skin (eg, soaps and alcohol). Bonding agents should be avoided.

9. Sterile water-soaked cotton balls. Helpful for removing adhesive tape, probe covers, and electrode covers.

10. Environmental. Use of mattress covers or blankets in humidified environments helps prevent skin breakdown.

11. Treatment of skin breakdown

    1. Clean skin breakdown/excoriated area with warm sterile water, leaving open to air.

    2. Apply topical antibiotic over broken-down infected areas, leaving open to air.

    3. Apply transparent dressings over excoriated areas.

    4. Administer IV antibiotics if necessary.

1. Infection

   1. Cultures. If the infant is delivered from an infected environment, blood and cerebrospinal fluid should be cultured. Spinal fluid may be deferred if unstable. Surveillance skin cultures may be necessary on admission if methicillin-resistant Staphylococcus aureus strains are a threat.

   2. Antibiotics. If the infant has a septic risk after obtaining cultures, consider starting empiric ampicillin and gentamicin. Drug levels must be monitored if using aminoglycosides and the dose adjusted accordingly (see Chapter 148).

   3. Nosocomial infection. The ELBW infant is at higher risk for nosocomial infection because of immature immune system, poor skin integrity, and extended hospitalization. Hand hygiene is extremely important in the prevention and containment of infection. All caregivers/visitors should be instructed in appropriate hand hygiene. Nosocomial infections should be contained by a cohort of infants and the use of dedicated equipment and staff. At our institution, Bacitracin is applied to nares daily to minimize risk.

   4. Chemoprophylaxis with fluconazole. ELBW infants in NICUs with moderate (5–10%) or high (>10%) rates of invasive candidiasis should receive prophylaxis with fluconazole. Dosage: Start 48–72 hours after birth and give 3 mg/kg IV twice a week for 4–6 weeks or until IV access is no longer necessary.

2. Central nervous system hemorrhage. Cranial ultrasonography maybe indicated during the first 7 days for possible intracranial hemorrhage.

3. Hyperbilirubinemia

   1. Risk. Efforts should be made to keep the serum bilirubin <10 mg/dL. Serum bilirubin may need to be monitored twice daily. An exchange transfusion should be considered when the bilirubin approaches or exceeds 12 mg/dL (see Chapters 58 and 100).

   2. Phototherapy. To reduce the serum bilirubin level, phototherapy may be needed and can be used to minimize the need for exchange transfusion. Some centers start phototherapy immediately after birth; others when approaching 5 mg/dL. If the infant is treated with phototherapy, reassess fluid needs.

4. Pain. Even the smallest of infants have shown response to painful stimuli. Several multidimensional pain assessment tools are available that include both physiologic (heart rate, O₂ saturation, respiratory rate, blood pressure) and behavioral indicators (facial expression, vocalization, and motor activity). ELBW pain assessment is very difficult, and none of these tools have been standardized. Our unit uses a pain assessment tool that allows for gestational age adjustment. Pain should be assessed as the fifth vital sign and more often as indicated by pain scores (see Chapter 14).

5. Social problems. Many families have great difficulty in coping with the issues related to their infant's extreme prematurity. Parents should be invited to participate in the infant's care from the beginning. Parent–infant bonding should be promoted, and parents should be encouraged to assist in caring for their child. A social service consultation should be mandatory. Participation in a parent-to-parent support group appears to improve maternal–infant relationships. Experienced nurses and the use of a primary nurse together with ongoing communication from the medical team can decrease the parents' stress and keep them up to date on their infant's medical problems. Parent conferences involving the physician, social worker, and primary nurse help the family understand the complex extended care of their infant. Additional discussions may include quality of life, death, dying, withholding and withdrawal of support, and parental religious or spiritual beliefs.

6. Developmental issues

   1. Minimal stimulation. These infants do not tolerate handling and medically necessary procedures well. Other stressors include noise, light, and activity such as moving the incubator. Routine tasks should be clustered to allow the infant undisturbed and prolonged periods of rest; each task should have a time limit as well.

   2. Positioning. The fetus is maintained in a flexed position. Care should be taken to simulate this positioning in the extremely premature infant. A flexed side-lying or prone posture with supportive boundaries is preferred. A change in position is recommended every 4 hours or at the infant's cue. Many positioning aids are available and should be used per institution guidelines.

   3. Kangaroo care. This has been defined as “intrahospital maternal infant skin-to-skin contact” (see Chapter 20). It promotes behavioral state organization, increased parental attachment/confidence, and nurturing behaviors that support growth and development. Temperature, heart rate, respiratory rate, and O₂ saturation remain within normal limits during kangaroo care. It can be a safe practice for infants with endotracheal tubes and central catheters in place, if experienced NICU nurses participate closely with cooperative and well-informed parents.

   4. Environmental issues. Infants are unable to control their own environment, so efforts must be made to decrease ambient noise and provide cyclic lighting to support their circadian rhythms.

   5. Parental education. Family-centered care should be encouraged on admission. Parents should be educated about behavioral cues that invite interaction or signal overstimulation. Parents should be instructed on containment techniques and calming interactions.