Premature newborn care

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Management of premature infants involves three steps:

Immediate resuscitation and stabilization of the infant after birth
Early consultation and referral to a neonatal intensive care unit (NICU)
Updating the parents about the baby's condition and the need for transfer to specialized care.

Where possible, arrange for very low-birth-weight infants to be born at a highly specialized hospital (commonly designated as a level III hospital).[35]

Immediate neonatal resuscitation in the delivery room

Assess and resuscitate all newborn infants as necessary according to the American Heart Association and American Academy of Pediatrics guidelines.[29][30][36] American Heart Association: neonatal resuscitation algorithm - 2020 update Opens in new window Prior preparation of both equipment and personnel is critical for success. Resuscitation should include clearing of the airway, proper head positioning, provision of warmth, drying the baby, appropriate stimulation, and assessment of breathing, heart rate, and color.

There is insufficient evidence to recommend an approach to cord clamping for infants who require resuscitation at birth.[29] Delay clamping the cord for ≥30 seconds in preterm infants who do not require resuscitation at birth.[29][30] In late preterm infants who are vigorous or deemed not to require resuscitation at birth, cord clamping can be delayed to ≥60 seconds.[37] The Canadian Paediatric Society recommends delayed cord clamping in all preterm infants who do not need immediate resuscitation because it has been shown to reduce brain injury.[38][39][40] [ ] One multicenter randomized clinical trial has found that delayed cord clamping in very preterm infants for ≥60 seconds reduced the risk of death or major disability at 2 years by 17%.[41]

Intact-cord milking is an alternative to delayed clamping for infants born between 28 weeks and 34 weeks gestational age (but not <28 weeks) who do not require resuscitation at birth.[29]

Many premature infants will require respiratory support immediately after delivery. Signs of respiratory distress include nasal flaring, retractions, apnea, and cyanosis. Respiratory support can be accomplished via blow by supplemental oxygen, positive pressure ventilation (PPV) by mask, continuous positive airway pressure (CPAP) by bag-mask-valve apparatus, or intubation. [ ] For PPV delivery, if resources permit, a T-piece resuscitator is recommended over the use of a self-inflating bag.[36]

Premature infants require smaller face masks and endotracheal tube sizes and can have severe long-term consequences from excessive ventilation due to high pressures (barotrauma) or fast rates (respiratory alkalosis) associated with aggressive bagging.[42] A 2018 Cochrane review of 7 trials concluded that in infants >1500 g or >34 weeks, use of laryngeal mask airway decreases resuscitation time and the need for endotracheal intubation compared with bag and mask ventilation (low- to moderate-quality evidence).[43]

Only after the infant has been adequately resuscitated should you undertake a thorough physical examination using the New Ballard Score to estimate gestational age and identify any potential abnormalities (e.g., dysmorphic signs, congenital defects).[32] The degree of prematurity, in most cases, directly correlates with the extent and severity of acute medical conditions.

The presence of parents and family members during the resuscitation of neonates is reasonable when circumstances and facilities allow, and when the relatives wish to be present; there is no evidence of harm for patients or their families based on the available literature.[36]

Subsequent management

Once you have resuscitated and stabilized the infant, consult a neonatologist to manage acute medical problems commonly associated with premature birth. These include respiratory distress, sepsis, glucose abnormalities, inadequate nutrition, temperature dysregulation, and blood pressure/perfusion abnormalities. Evaluate each premature infant carefully on an individual basis and treat as necessary.

The "Golden Hour" represents the critical first hour of life, during which timely interventions can significantly impact the health and survival of these vulnerable infants.[44]

Neuroprotection measures

The first 72 hours after birth is the highest risk period for acute preterm brain injury.[45] The Canadian Paediatric Society makes the following recommendations to minimize risk for brain injury in infants born at ≤32+6 weeks' gestational age:[46]

Treat infants ≤32+6 weeks' gestational age born to mothers with chorioamnionitis or preterm premature rupture of membranes (PPROM) empirically with antibiotics for 36 to 48 hours, until results from a blood culture are negative, because PPROM for more than 72 hours is an independent risk factor for intraventricular hemorrhage (IVH) or intraparenchymal hemorrhage.
Delay cord clamping in all preterm infants who do not need immediate resuscitation because a delay has been shown to reduce acute brain injury.[38][39][40] [ ]
Hypothermia is associated with an increased risk for acute brain injury and death.[47][48] To help prevent hypothermia, routinely use a polyethylene bag or wrapping, a thermal mattress, a preheated radiant warmer with servo-control, and a hat, and take other precautions, such as maintaining the temperature of the delivery room at 77°F to 78°F (25°C to 26°C), for all infants ≤31+6 weeks' gestational age.
Multiple studies have associated the use of vasoactive drugs to treat hypotension in preterm infants with developing IVH, other brain injuries, and mortality.[49][50][51][52] Avoid routine use of vasoactive drugs to treat hypotension unless other clinical signs of inadequate perfusion exist, such as raised lactate, prolonged capillary refill time, reduced urine output, or low cardiac output. Avoid hypotension caused by lung hyperinflation or dehydration.
Because many patent ductus arteriosus close spontaneously and the side-effect potential from cyclo-oxygenase inhibitors is significant, treat only high-risk, extremely preterm infants with prophylactic indomethacin and base the decision to treat on combined risk factors including gestational age, exposure to prenatal corticosteroids, and birth location.[53]
Extremes of arterial partial pressure of carbon dioxide (PCO₂) and fluctuations in arterial PCO₂ are associated with periventricular leukomalacia and intraventricular hemorrhage. Aim for a target PCO₂ of 45 to 55 mmHg (maximum of 60 mmHg).[54][55]
Volume-targeted ventilation is the mode of first choice for all preterm infants in the first 72 hours after delivery.[56]
Neutral midline head positioning for infants is the standard of care in many neonatal intensive care units for neuroprotection, but evidence for the efficacy is currently weak.[57]

General care

In stable preterm infants, kangaroo care (i.e., skin-to-skin contact between a mother and her newborn, frequent and exclusive or nearly exclusive breastfeeding, and early discharge from hospital) improves patient outcomes and parent-infant bonding.[58][59] [ ] A study comparing standard neonatal intensive care unit (NICU) care and Family Integrated Care (FICare) of infants born at 33 weeks' gestation or earlier with no or low-level respiratory support showed that the primary outcome of weight gain at 21 days was improved with FICare. This may be an important advance in neonatal care; further research is required to determine effect on long-term outcomes.[60]

Gastroesophageal reflux (GER)

Occurs in most preterm infants. The American Academy of Pediatrics has published guidance on the management of GER:[61][62][63]

Measures such as left lateral body position, head elevation, and feeding regimen manipulation have not demonstrated a reduction in clinically assessed signs of GER in preterm infants
Advise parents of the importance of safe sleep approaches before discharge; always put the baby down in a supine position, do not to use devices designed to elevate the infant's head in the crib
Pharmacologic agents should be used with caution in preterm infants because of the lack of evidence of their efficacy and the small body of evidence of harm associated with gastric acid blockade.

Despite a lack of short- and long-term data, the use of antireflux medications has increased recently.[61][64][65] One Cochrane review found moderate quality evidence that use of an H2 antagonist reduces the risk of gastrointestinal bleeding in newborn infants at high risk of gastrointestinal bleeding, but insufficient evidence to state whether the intervention was safe or reduced mortality.[66] [ ]

Extreme prematurity: gestational age <28 weeks

This subgroup exhibits the greatest morbidity and mortality associated with premature birth.[67] Consult a neonatologist early to maximize delivery of care and facilitate early transfer to intensive care. Management of these babies requires meticulous attention to delivery room resuscitation methods and subsequent treatment.

Ventilatory support and oxygen

These infants have the highest risk for respiratory distress due to intrinsic lung immaturity. They are likely to need positive pressure ventilation (PPV) or endotracheal intubation, which may be necessary immediately after birth due to apnea, insufficient ventilation, retractions, nasal flaring, tachypnea, and/or cyanosis and a progressive increase in the amount of supplemental oxygen to relieve desaturations. Be careful to provide adequate but gentle ventilation to reduce the likelihood of morbidity (e.g., pneumothorax) associated with large tidal volumes.
Importantly, if sustained mask positive pressure is necessary, decompress the stomach using an orogastric tube.
If the infant requires intubation, verify endotracheal tube (ETT) placement by several means including a chest x-ray, end-tidal CO₂ detection, auscultation for breath sounds bilaterally, fog in the tube, and direct visualization of tube through the vocal cords. The size of the ETT (weight <1000 g: 2.5 mm ETT) and depth (6 + weight in kg = cm at lip) are very important. Premedication should be considered for all non emergency intubations in preterm infants.[68][69] Drug combinations vary according to local protocol. If a ventilator is necessary, limit baro-/volutrauma by using the lowest peak inspiratory pressure that results in adequate ventilation as determined by arterial blood gas. Volume-targeted ventilatory modes decrease duration of ventilation and risk of bronchopulmonary dysplasia.[70] [ ]
Nasal CPAP started in the delivery room instead of intubation and surfactant in infants younger than 28 weeks is currently an option, and such a strategy has been shown to decrease duration of mechanical ventilation and the need for corticosteroids for bronchopulmonary dysplasia (BPD). In one randomized, multicenter trial involving 1316 infants born between 24 and 27 weeks and 6 days of gestation comparing intubation with surfactant to CPAP treatment, no increase in adverse effects was noted in the CPAP group, and the primary outcome of death or BPD was similar in both the CPAP and the intubation group.[71] One review concluded that prophylactic nasal CPAP for very preterm infants, compared with mechanical ventilation at birth, decreases the need for mechanical ventilation, and decreases the incidence of BPD and the outcome of death and BPD.[72] However, further research is needed to evaluate CPAP benefits for respiratory distress in preterm infants as available evidence is limited and outdated.[73][74][75]
Avoid excessive oxygen exposure to reduce the likelihood of subsequent complications such as retinopathy of prematurity or chronic lung disease.[76] A Cochrane review assessed the effects of oxygen saturation (SpO₂) targeted to ranges of either 85% to 89% (low) or 91% to 95% (high) in randomized trials of babies born at less than 28 weeks' gestation. Results showed a trade-off between mortality and severe retinopathy of prematurity.[77] [ ] Increasing the fraction of inspired oxygen (FiO₂) by 10% increments is recommended if the infant does not respond to administration of 40% oxygen, until clinical effects are achieved. Oxygen is weaned based on targeted oxygen saturations (usually 91% to 95%). Saturation targeting <90% in preterm infants is associated with increased mortality.[78]
Exogenous surfactant administration may be necessary, owing to prematurity-related surfactant deficiency.[79][80] Minimally invasive surfactant administration, also known as less invasive surfactant administration (LISA), should be used when feasible in preterm neonates who are not ventilated through an endotracheal tube.[81][82][83] For intubated infants, confirm the position of the ETT prior to surfactant administration to avoid complications such as pneumothorax. Following surfactant treatment, adjust the settings on the ventilator to avoid delivery of excessive tidal volumes associated with increased compliance.
Use caffeine citrate in preterm infants with apnea and in the extubation of preterm infants born <34 weeks gestation.[59] Earlier initiation of caffeine may be associated with a greater reduction in time on ventilation; however, higher caffeine doses have not been shown to improve mortality prior to hospital discharge or neurodevelopment outcomes.[84][85] Consider caffeine citrate for any preterm baby born <34 weeks gestation for the prevention of apnea.[59][68]

Hypothermia

Hypothermia is extremely prevalent secondary to increased heat loss from convection, radiation, and evaporation. In addition to routine care, implementing the following measures may help to reduce the likelihood of hypothermia: a prewarmed radiant warmer with warmed infant blankets, placement of the lower extremities and torso of the infant in a clear plastic bag immediately after delivery, the use of plastic caps, or the use of a trans-warmer pad.[48][86][87] [ ] Normal temperature is between 97.7°F and 99.9°F (36.5°C to 37.7°C).[88]

Hypoglycemia and feeding

Delay feeding until transfer to a NICU, so that initial cardiorespiratory stabilization can be performed. Prematurity is the major risk factor for necrotizing enterocolitis (NEC).
Avoid hypoglycemia (blood glucose <45 mg/dL) through the early administration of adequate intravenous fluid (10% dextrose without additional electrolytes at 80-100 mL/kg/day). Increased fluid may be necessary due to increased losses through immature skin and can be guided by serum electrolyte measurements.[89][90][91]
Slowly start and increase enteral feeding (20 mL/kg/day). Breast milk and human milk based fortifiers are recommended to reduce the risk for NEC.[59][92][93][94] Exclusive human milk feeding decreases the incidence of NEC and the duration of parenteral nutrition.[95] Pasteurized donor breast milk may be used if maternal expressed breast milk is unavailable or otherwise contraindicated.[96][97]
There is some evidence that feeding high protein breast milk fortifier (≥1.4 g protein/100 mL of expressed breast milk [EBM]) increases in-hospital weight gain and linear growth, compared with feeding moderate protein fortifier (≥1 g to <1.4 g protein/100 mL EBM).[98] Feed volumes of ≥180 mL/kg/day of fortified human milk or preterm formula, or ≥200 mL/kg/day of unfortified human milk, probably increase in-hospital weight gain in preterm infants, compared with lower feed volumes.[99] Individualized breast milk fortification, according to breast milk composition or infant laboratory results, may increase short-term growth, compared with standard fortification.[100] Further research is needed to evaluate the long-term clinical outcomes of high protein fortifier use, higher feed volumes, and individualized fortification, and to determine the optimal regimen for individualized fortification.
Enteral iron supplementation is recommended for human milkfed preterm or low-birth-weight infants who are not receiving iron from another source.[59] Preterm infants are also at risk of zinc deficiency. One meta-analysis found moderate certainty evidence that enteral zinc supplementation improves short term weight gain, and low certainty evidence that it reduces mortality. Enteral zinc supplementation does not appear to prevent complications of prematurity.[101] Enteral zinc, vitamin A and vitamin D supplementation may be considered for human milkfed preterm (or low-birth-weight infants) who are not receiving them from another source.[59]

Vascular access

Multiple-lumen central intravenous access including umbilical vein or percutaneous central venous access is often necessary.[102] Umbilical or peripheral arterial access may be necessary for monitoring of blood pressure. New England Journal of Medicine: umbilical catheter placement video Opens in new window Peripheral vascular access can be technically challenging, and unshared intravenous access is necessary for incompatible medications. Heparinization of the fluid infused through umbilical arterial and percutaneous venous catheters decreases the likelihood of occlusion with thrombosis.[102]

Hypotension

The diagnosis of cardiac insufficiency in the very low birth weight (VLBW) infant (<1.5 kg) should not be based on a threshold blood pressure value alone, but based on multiple parameters including gestational age, weight, and postpartum age using standardized tables that recognize values >2 standard deviations below the mean.[103] Manage hypotension promptly in consultation with a neonatologist, as the risk for poor neurodevelopmental outcome is highest in patients exhibiting the least ability to autoregulate cerebral blood flow. Maintain adequate perfusion and a mean arterial pressure of at least 30 mmHg via cautious administration of crystalloids or vasoactive drugs such as dopamine.[104][105][106] Blood pressure fluctuation can increase the risk for intraventricular hemorrhage (IVH). Alternatively, if perfusion is poor, consider dobutamine to improve cardiac output and perfusion.[104][107]
Delayed cord clamping, decreased blood sampling, appropriate ventilatory management, and other attempts to avoid hypovolemia, anemia, and decreased cardiac output may help in avoiding hypoperfusion states in the VLBW infant.[103]
Start a prostaglandin infusion to maintain ductal patency if ductal-dependent congenital heart disease is suspected.[108]

Infection

As the cause of many preterm deliveries is concurrent infection, timely administration of antimicrobial treatment with adequate gram-positive and gram-negative coverage is frequently necessary unless the neonate was delivered solely for maternal indications (e.g., pregnancy-induced hypertension).
Obtain blood cultures prior to antibiotic treatment if possible.
Consult a neonatologist and prescribe antibiotic dose according to gestational age.
Continue antibiotics for 10 to 14 days when blood cultures are positive.
Discontinue antibiotics if blood cultures are negative and there are no clinical signs of infection.

Severe prematurity: gestational age 28 to 31 weeks

Medical conditions associated with severe prematurity are frequently less serious than with extreme prematurity and may even be absent. These infants require specialized care, with early neonatal consultation and transfer to a NICU after stabilization.

Ventilatory support and oxygen

As gestational age increases, the likelihood of severe respiratory distress requiring delivery room intubation decreases in the absence of other factors such as sepsis or severe perinatal respiratory depression. Many of the infants require CPAP only with minimal exposure to supplemental oxygen. Gentle PPV may be required in some infants.
Avoid excessive oxygen exposure to reduce the likelihood of subsequent complications such as retinopathy or chronic lung disease.[76] Increase the FiO₂ by 10% increments if the infant does not respond to 40% oxygen until clinical effects are achieved. Wean oxygen based on targeted oxygen saturations (usually 91% to 95%). Saturation targeting <90% in preterm infants is associated with increased mortality.[78]
If intubation is necessary, the recommended ETT size is 3 mm and depth (cm at lip) is 6 + weight in kg. Verify placement by several means including a chest x-ray, end-tidal CO₂ detection, auscultation for breath sounds bilaterally, fog in the tube, and direct visualization of the tube through the vocal cords. Premedication should be considered for all non emergency intubations in preterm infants.[68][69] Drug combinations vary according to local protocol.
Surfactant treatment may be necessary.[79][80] Minimally invasive surfactant administration, also known as less invasive surfactant administration (LISA), should be used when feasible in preterm neonates who are not ventilated through an endotracheal tube.[81][82][83] For intubated infants, confirm the position of the endotracheal tube prior to surfactant administration, to avoid complications such as pneumothorax.
Use caffeine citrate in preterm infants with apnea and in the extubation of preterm infants born <34 weeks gestation.[59] Earlier initiation of caffeine may be associated with a greater reduction in time on ventilation; however, higher caffeine doses have not been shown to improve mortality prior to hospital discharge or neurodevelopment outcomes.[84][85] Consider caffeine citrate for any preterm baby born <34 weeks gestation for the prevention of apnea.[59][68]

Hypothermia

Prevention of hypothermia remains a very important issue. Trans-warmers or clear plastic bags are not commonly used in this age group. A prewarmed radiant warmer, in conjunction with drying, is generally adequate immediately after delivery. After resuscitation, maintain normothermia using a radiant warmer. Normal temperature is between 97.7°F and 99.9°F (36.5°C and 37.7°C).[88]

Hypoglycemia and feeding

Withhold enteral nutrition until the infant has been safely transferred and fully assessed, due to the risks of NEC.
The risk of hypoglycemia remains high and requires early intravenous fluid administration (10% dextrose without additional electrolytes at 60 to 80 mL/kg/day).
Gastrointestinal immaturity associated with prematurity results in an increased risk of NEC in the premature infant. Slowly increase enteral feeding (20 mL/kg/day). Breast milk and human milk based fortifiers are recommended to reduce the risk for NEC.[92][93][94] Exclusive human milk feeding decreases the incidence of NEC and the duration of parenteral nutrition.[95] Pasteurized donor breast milk may be used if maternal expressed breast milk is unavailable or otherwise contraindicated.[96][97]
There is some evidence that feeding high protein breast milk fortifier (≥1.4 g protein/100 mL of expressed breast milk [EBM]) increases in-hospital weight gain and linear growth, compared with feeding moderate protein fortifier (≥1 g to <1.4 g protein/100 mL EBM).[98] Feed volumes of ≥180 mL/kg/day of fortified human milk or preterm formula, or ≥200 mL/kg/day of unfortified human milk, probably increase in-hospital weight gain in preterm infants, compared with lower feed volumes.[99] Individualized breast milk fortification, according to breast milk composition or infant laboratory results, may increase short-term growth, compared with standard fortification.[100] Further research is needed to evaluate the long-term clinical outcomes of high protein fortifier use, higher feed volumes, and individualized fortification, and to determine the optimal regimen for individualized fortification.
Enteral iron supplementation is recommended for human milkfed preterm or low-birth-weight infants who are not receiving iron from another source.[59] Preterm infants are at risk of zinc deficiency. One meta-analysis found moderate certainty evidence that enteral zinc supplementation improves short term weight gain, and low certainty evidence that it reduces mortality. Enteral zinc supplementation does not appear to prevent complications of prematurity.[101] Enteral zinc, vitamin A and vitamin D supplementation may be considered for human milkfed preterm (or low-birth-weight infants) who are not receiving them from another source.[59]

Vascular access

Central intravenous access may or may not be necessary, depending on the infant's clinical condition.
Peripheral intravenous access alone may be adequate if the baby tolerates appropriate introduction and escalation of enteral nutrition.

Hypotension

Hypotension is a clinical possibility in this age group. Manage hypotension in consultation with a neonatologist prior to transfer to an appropriate facility. The risk of IVH remains but is significantly reduced compared with the extreme prematurity group.
Start a prostaglandin infusion to maintain ductal patency if ductal-dependent congenital heart disease is suspected.[108]

Infection

Sepsis is a clinical possibility in this age group. Give appropriate antibiotics but obtain blood cultures prior to administration.
Continue antibiotics for 10 to 14 days when blood cultures are positive.
Discontinue antibiotics if blood cultures are negative and there are no clinical signs of infection.
Guidelines from the UK National Institute for Health and Care Excellence (NICE) advise that antibiotics are given for 7 days if:[109]
- blood cultures are positive, or
- blood cultures are negative, but there was a strong clinical suspicion of sepsis.
A longer course may be needed depending on the neonate’s clinical condition or the pathogen identified.

Moderate prematurity: gestational age 32 to 33 weeks

Infants in this category experience less acute morbidity than those in the severe and extreme premature groups. Follow NRP guidelines for resuscitation if necessary. These infants may require specialized care, with early neonatal consultation and subsequent transfer to a NICU after stabilization.

Common problems include hypoglycemia and mild respiratory distress.
These neonates may need transient nasal CPAP, but intubation and surfactant treatment are rarely necessary.
Start and increase enteral feeding very slowly: intravenous fluids (10% dextrose without additional electrolytes) are often required to avoid hypoglycemia.
An inability to maintain normothermia, 97.7°F to 99.9°F (36.5°C to 37.7°C), remains an important possibility with this group, and temperature management via a radiant warmer or isolette is important.
Screen for and treat suspected infection with antibiotics and manage hypotension as necessary.[109]

Near-term: gestational age 34 to 36 weeks

This group is least likely to manifest severe problems associated with prematurity.

The risk of respiratory distress necessitating intervention is very low. However, some infants may require transient nasal CPAP. Inability to maintain a normal temperature, between 97.7°F and 99.9°F (36.5°C and 37.7°C), when adequately wrapped, is infrequent. Treat infection with antibiotics and manage hypotension as necessary.[109] Consider the increased risk for jaundice in infants between 35 and 36 weeks' gestation.[110]

Transfer infants below 35 weeks' gestation who require feeding support to a NICU. [ ] Provide transitional intravenous fluids to avoid hypoglycemia in infants who cannot tolerate adequate feeds orally (especially in infants of 34 weeks' gestation).
Infants between 35 and 36 weeks' gestation may do well clinically after delivery and can be sent to the newborn nursery with routine orders. However, they need to be watched more closely than term infants, as they may have feeding difficulties and associated hypoglycemia due to prematurity requiring admission to the NICU for supportive therapy.

Use of this content is subject to our disclaimer