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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. 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 ...

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