Chapter 13: Management of the Extremely Low Birthweight Infant During the First Week of Life

INTRODUCTION

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.

I. DELIVERY ROOM MANAGEMENT

1. Ethics/consult. The neonatologist and other healthcare team members should make every effort to meet with the family before delivery to discuss 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- to 24-week gestation infant is crucial. Neonatal bioethics are discussed in detail in Chapter 23. The consult should also include recommendations to the obstetrician (OB) for antenatal steroids (Chapter 117) and magnesium for neuroprotection.

2. Resuscitation

   1. Delayed cord clamping. Ask the OB for 30 to 60 seconds of delayed cord clamping unless there are maternal or neonatal contraindications, or cord milking may be considered (American Academy of Pediatrics and American College of Obstetricians and Gynecologists recommendations).

   2. Thermoregulation. Consider increasing the ambient temperature of the room to 25°C to 26°C. A polyethylene wrap or bag used immediately after birth prevents heat loss at delivery. In addition, an underlying thermal mattress placed under warmed blankets and a hat provide extra warmth and help stabilize the infant for transport. The wrap is removed and the infant is dried after being placed in a neutral thermal environment in the neonatal intensive care unit (NICU) with stabilization of the infant’s temperature.

   3. Respiratory support. Oxygen (O₂) use in resuscitation has been challenged in recent years. It takes 7 to 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, starting at 30% fraction of inspired O₂ (FiO₂), 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 beats/min, continuous positive airway pressure (CPAP) of 4 to 6 cm H₂O should be initiated to prevent atelectasis. CPAP cannot be delivered with a self-inflating bag.

   4. 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. Infants transported from referring hospitals should be handled in a similar manner.

II. TEMPERATURE AND HUMIDITY CONTROL

Because the tiny infant has a relatively large skin surface area ...