Premature newborn care

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

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

gestational age <28 weeks

1st line – assess for resuscitation + positive pressure ventilation (PPV) or nasal continuous positive airway pressure (CPAP) + transfer to neonatal intensive care unit (NICU)

Back

1st line –

assess for resuscitation + positive pressure ventilation (PPV) or nasal continuous positive airway pressure (CPAP) + transfer to neonatal intensive care unit (NICU)

Assess and resuscitate all newborn infants as necessary according to the American Heart Association and American Academy of Pediatrics guidelines.[29][30] American Heart Association: neonatal resuscitation algorithm - 2020 update Opens in new window

Early nasal CPAP starting in the delivery room is an option. This strategy has been shown to decrease duration of mechanical ventilation and the need for corticosteroids for bronchopulmonary dysplasia.[71] 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is needed to evaluate CPAP benefits for respiratory distress in preterm infants as available evidence is limited and outdated.[73][74][75]

This subgroup exhibits the greatest morbidity and mortality associated with premature birth. Early consultation with a neonatologist to maximize delivery of care and facilitate early transfer to a NICU is critical.

These infants have the highest risk for respiratory distress due to intrinsic lung immaturity, indicated by apnea, insufficient ventilation, retractions, nasal flaring, tachypnea, and cyanosis.

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 (<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.

Adequate gentle ventilation is imperative to reduce the likelihood of morbidity (e.g., pneumothorax, hyperventilation) associated with large tidal volumes. Decompress the stomach using an orogastric tube if sustained mask PPV is necessary. If ventilator use is necessary, limit baro-/volutrauma by using the lowest peak inspiratory pressures that result in adequate ventilation, as determined by arterial blood gas.

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 ventilatory modes decrease duration of ventilation and the risk of bronchopulmonary dysplasia.[70] Wean the ventilator settings as tolerated. A significant number of preterm infants (25% to 45%) develop ventilator dependency and chronic lung disease.

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] 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]

Because intracranial pressure fluctuations may increase risk for acute brain injury, position the infant’s head in a neutral, midline position, and elevate the head of the bed to 30º during the first 72 hours after delivery.[111]

Plus – 40% oxygen

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Plus –

40% oxygen

Treatment recommended for ALL patients in selected patient group

Avoid excessive oxygen exposure (100%) 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] [ ]

Increase the fraction of inspired oxygen (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]

Plus – temperature maintenance

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Plus –

temperature maintenance

Treatment recommended for ALL patients in selected patient group

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, or 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]

Hypothermia is associated with an increased risk for acute brain injury and death.[47][48] To help prevent hypothermia, the Canadian Paediatric Society recommends routine use of a polyethylene bag or wrapping, a thermal mattress, a preheated radiant warmer with servo-control, and a hat, and 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.[46]

Plus – umbilical vascular access

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Plus –

umbilical vascular access

Treatment recommended for ALL patients in selected patient group

Multiple-lumen central intravenous access including umbilical artery and/or vein catheterization is often necessary. 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 an umbilical arterial catheter decreases the likelihood of occlusion of an umbilical arterial catheter.[102] Remove umbilical catheters at around 10 days of age, and insert a peripherally inserted central catheter line if there is still a need for vascular access.

Plus – dextrose 10%

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Plus –

dextrose 10%

Treatment recommended for ALL patients in selected patient group

Avoidance of hypoglycemia (blood glucose <60 mg/dL) is critical. Administer intravenous fluid early (10% dextrose without additional electrolytes at 80 mL/kg/day).

An increase in fluid may be necessary, due to increased losses through immature skin, and can be guided by serum electrolyte measurements.[89][90][91]

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).

Start trophic feeds at 20 mL/kg/day and increase incrementally by 20 mL/kg/day until full feed volume is achieved. [ ] Exclusive human milk feeding decreases the incidence of necrotizing enterocolitis 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]

Plus – empiric intravenous antibiotics

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Plus –

empiric intravenous antibiotics

Treatment recommended for ALL patients in selected patient group

As the cause of many preterm deliveries is concurrent infection, timely administration of antimicrobial treatment with adequate gram-positive and gram-negative coverage is necessary, with gestational age-appropriate dosing according to neonatal specialist recommendations.[109][112] Obtain blood cultures prior to antibiotic treatment if possible.

The antibiotic regimen stated is recommended by the American Academy of Pediatrics.[113] Recommendations vary between countries; consult local guidelines.

The first 72 hours after birth is the highest risk period for acute preterm brain injury.[45] 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 or intraparenchymal hemorrhage.[46]

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

Primary options

ampicillin: 100 mg/kg intravenously every 12 hours

and

gentamicin: 5 mg/kg intravenously every 48 hours

Plus – caffeine citrate

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Plus –

caffeine citrate

Treatment recommended for ALL patients in selected patient group

Caffeine citrate is the preferred methylxanthine in view of its safety profile.[59]

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]

Primary options

caffeine citrate: 20 mg/kg intravenously over 30 minutes initially, followed by 5 mg/kg intravenously over 10 minutes once daily starting 24 hours after initial dose; or 20 mg/kg orally as loading dose, followed by 5 mg/kg orally once daily starting 24 hours after initial dose

Consider – surfactant

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Consider –

surfactant

Treatment recommended for SOME patients in selected patient group

These infants have the highest risk for exhibiting respiratory distress due to intrinsic lung immaturity.

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 endotracheal tube prior to surfactant administration, to avoid complications such as pneumothorax. Subsequent adjustment to the pressure settings on the ventilator may be necessary to avoid excessive tidal volumes associated with increased compliance following surfactant treatment.

Administer a total of 2 or 3 doses of surfactant if necessary.

Primary options

calfactant intratracheal: 3 mL/kg divided into 2 aliquots via endotracheal tube

beractant intratracheal: 4 mL/kg divided into 4 aliquots via endotracheal tube

Secondary options

poractant alfa intratracheal: 2.5 mL/kg divided into 2 aliquots via endotracheal tube

Consider – crystalloids ± vasoactive drugs or ± hydrocortisone after specialist consultation

Back

Consider –

crystalloids ± vasoactive drugs or ± hydrocortisone after specialist consultation

Treatment recommended for SOME patients in selected patient group

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 who exhibit the least ability to autoregulate cerebral blood flow.

Maintain adequate perfusion and a mean arterial pressure of at least 30 mmHg via administration of crystalloids or vasoactive drugs such as dopamine.[104][105][106] This must be done with caution as blood pressure fluctuation can increase the risk for intraventricular hemorrhage (IVH). Alternatively, if perfusion is poor, consider dobutamine as it improves cardiac output and perfusion.[104][107]

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.

Hypotension that does not respond to dopamine or dobutamine may be treated with hydrocortisone for 2 to 3 days.

Primary options

dopamine: consult specialist for guidance on dose

dobutamine: consult specialist for guidance on dose

Secondary options

hydrocortisone: consult specialist for guidance on dose

Consider – prostaglandins

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Consider –

prostaglandins

Treatment recommended for SOME patients in selected patient group

Start prostaglandin E1 infusion to maintain ductal patency if congenital heart disease is suspected.[108]

Primary options

alprostadil: 0.02 to 0.1 micrograms/kg/min intravenous infusion

Consider – prophylactic intravenous indomethacin

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Consider –

prophylactic intravenous indomethacin

Treatment recommended for SOME patients in selected patient group

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 intravenous indomethacin and base the decision to treat on combined risk factors including gestational age, exposure to prenatal corticosteroids, and birth location.[46][53]

Primary options

indomethacin: consult specialist for guidance on dose

gestational age 28 to 31 weeks

1st line – assess for resuscitation + continuous positive airway pressure (CPAP) + transfer to neonatal intensive care unit (NICU)

Back

1st line –

assess for resuscitation + continuous positive airway pressure (CPAP) + transfer to neonatal intensive care unit (NICU)

Assess and resuscitate all newborn infants as necessary according to the American Heart Association and American Academy of Pediatrics guidelines.[29] American Heart Association: neonatal resuscitation algorithm - 2020 update Opens in new window

Transfer infants to NICU for specialized care once they are clinically stable and parents have been updated.

Most infants in this subgroup require only nasal CPAP with minimal exogenous oxygen. Wean nasal CPAP as tolerated based on clinical respiratory distress.

As gestation 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 depression.

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]

Plus – temperature maintenance

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Plus –

temperature maintenance

Treatment recommended for ALL patients in selected patient group

Prevention of hypothermia remains a very important issue. A prewarmed radiant warmer, in conjunction with drying, is generally adequate immediately after delivery. Trans-warmer or clear plastic bags are not commonly in use in this age group. After resuscitation, maintain normothermia using a radiant warmer.[86]

Normal temperature is between 97.7°F and 99.9°F (36.5°C to 37.7°C).[88]

Plus – dextrose 10%

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Plus –

dextrose 10%

Treatment recommended for ALL patients in selected patient group

The risk of hypoglycemia remains high and requires early intravenous fluid administration (10% dextrose without additional electrolytes at 60 to 80 mL/kg/day).

Withhold enteral nutrition until the infant has been safely transferred and fully assessed, due to the risks of necrotizing enterocolitis. Initiate early feeding in the neonatal intensive care unit. Start trophic feeds at 20 mL/kg/day and increase incrementally by 20 mL/kg/day until full feed volume is achieved. [ ] Exclusive human milk feeding decreases the incidence of necrotizing enterocolitis 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]

Plus – caffeine citrate

Back

Plus –

caffeine citrate

Treatment recommended for ALL patients in selected patient group

Caffeine is the preferred methylxanthine in view of its safety profile.[59]

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 outcome.[84][85] Consider caffeine citrate for any preterm baby born <34 weeks gestation for the prevention of apnea.[59][68]

Primary options

Consider – positive pressure ventilation (PPV)

Back

Consider –

positive pressure ventilation (PPV)

Treatment recommended for SOME patients in selected patient group

If necessary, use gentle PPV. If resources permit, a T-piece resuscitator is recommended over the use of a self-inflating bag.[37]

If intubation is necessary, the recommended endotracheal tube 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 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.

Adequate gentle ventilation is imperative to reduce the likelihood of morbidity (e.g., pneumothorax, hyperventilation) associated with large tidal volumes. Decompress the stomach using an orogastric tube if sustained mask positive pressure is necessary. If ventilator use is necessary, limit baro-/volutrauma using the lowest peak inspiratory pressures that result in adequate ventilation, as determined by arterial blood gas.

Consider – 40% oxygen

Back

Consider –

40% oxygen

Treatment recommended for SOME patients in selected patient group

Avoid excessive oxygen exposure (100%) to reduce the likelihood of subsequent complications such as retinopathy of prematurity (ROP) or chronic lung disease.[76] Increase the fraction of inspired oxygen (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]

Consider – surfactant

Back

Consider –

surfactant

Treatment recommended for SOME patients in selected patient group

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 endotracheal tube prior to surfactant administration, to avoid complications such as pneumothorax.

If the infant is being ventilated, adjust the pressure settings on the ventilator to avoid excessive tidal volumes associated with increased compliance following surfactant treatment.

Administer a total of 2 or 3 doses of surfactant if necessary.

Primary options

calfactant intratracheal: 3 mL/kg divided into 2 aliquots via endotracheal tube

beractant intratracheal: 4 mL/kg divided into 4 aliquots via endotracheal tube

Secondary options

poractant alfa intratracheal: 2.5 mL/kg divided into 2 aliquots via endotracheal tube

Consider – empiric intravenous antibiotics

Back

Consider –

empiric intravenous antibiotics

Treatment recommended for SOME patients in selected patient group

Sepsis is a clinical possibility in this age group. Give appropriate antibiotics; obtain blood cultures prior to administration.[109][112]

The antibiotic regimen stated is recommended by the American Academy of Pediatrics.[113] Recommendations vary between countries; consult local guidelines.

Continue antibiotics for 10 to 14 days when cultures are positive. Discontinue antibiotics if 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: blood cultures are positive; or blood cultures are negative, but there was a strong clinical suspicion of sepsis.[109] A longer course may be needed depending on the neonate’s clinical condition or the pathogen identified.

Primary options

ampicillin: 100 mg/kg intravenously every 12 hours

and

gentamicin: <30 weeks: 5 mg/kg intravenously every 48 hours; 30-34 weeks: 4.5 mg/kg intravenously every 36 hours

Consider – crystalloids ± vasoactive drugs or ± hydrocortisone after specialist consultation

Back

Consider –

crystalloids ± vasoactive drugs or ± hydrocortisone after specialist consultation

Treatment recommended for SOME patients in selected patient group

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 administration of crystalloids or vasoactive drugs such as dopamine.[104][105][106] Alternatively, if perfusion is poor, consider dobutamine to improve cardiac output and perfusion.[104][107]

Multiple studies have associated the use of vasoactive drugs to treat hypotension in preterm infants with developing intraventricular hemorrhage (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.

The risk of IVH from blood pressure fluctuations is still present, but is significantly lower than in neonates below 28 weeks' gestation.

Hypotension that does not respond to dopamine or dobutamine may be treated with hydrocortisone for 2 to 3 days.

Primary options

dopamine: consult specialist for guidance on dose

dobutamine: consult specialist for guidance on dose

Secondary options

hydrocortisone: consult specialist for guidance on dose

Consider – prostaglandins

Back

Consider –

prostaglandins

Treatment recommended for SOME patients in selected patient group

If congenital heart disease is suspected, start prostaglandin E1 infusion to maintain ductal patency.[108]

Primary options

alprostadil: 0.02 to 0.1 micrograms/kg/min intravenous infusion

gestational age 32 to 33 weeks

1st line – assess for resuscitation + transfer to neonatal intensive care unit (NICU)

Back

1st line –

assess for resuscitation + transfer to neonatal intensive care unit (NICU)

There is insufficient evidence to recommend an approach to cord clamping for infants who require resuscitation at birth.[29][37] Delay clamping the cord for ≥30 seconds in preterm infants who do not require resuscitation at birth.[29][30] 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% among very preterm infants.[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.[37]

Transfer infants to NICU for specialized care once they are clinically stable and parents have been updated.

Plus – temperature maintenance

Back

Plus –

temperature maintenance

Treatment recommended for ALL patients in selected patient group

An inability to maintain normothermia, between 97.7°F and 99.9°F (36.5°C and 37.7°C),[88] remains an important possibility with this group, and temperature management via a radiant warmer or isolette is important.[86]

Plus – dextrose 10%

Back

Plus –

dextrose 10%

Treatment recommended for ALL patients in selected patient group

Hypoglycemia may be commonly encountered, and therefore transitional intravenous fluids (10% dextrose without additional electrolytes) are necessary.

Consider – ventilatory support ± oxygen

Back

Consider –

ventilatory support ± oxygen

Treatment recommended for SOME patients in selected patient group

Transient nasal continuous positive airway pressure may be required, but intubation and positive pressure ventilation are rarely necessary.

Avoid excessive oxygen exposure (100%) to reduce the likelihood of subsequent complications such as retinopathy of prematurity or chronic lung disease.[76]

Consider – surfactant

Back

Consider –

surfactant

Treatment recommended for SOME patients in selected patient group

Exogenous surfactant administration may be necessary, owing to prematurity-related surfactant deficiency.[79][80]

For intubated infants, confirm the position of the endotracheal tube prior to surfactant administration, to avoid complications such as pneumothorax. Adjust the pressure settings on the ventilator if necessary to avoid excessive tidal volumes associated with increased compliance following surfactant treatment.

Administer a total of 2 or 3 doses of surfactant if necessary.

Primary options

calfactant intratracheal: 3 mL/kg divided into 2 aliquots via endotracheal tube

beractant intratracheal: 4 mL/kg divided into 4 aliquots via endotracheal tube

Secondary options

poractant alfa intratracheal: 2.5 mL/kg divided into 2 aliquots via endotracheal tube

Consider – nasogastric feeding

Back

Consider –

nasogastric feeding

Treatment recommended for SOME patients in selected patient group

Withhold enteral nutrition until the infant has been safely transferred and fully assessed, due to the risks of necrotizing enterocolitis (NEC). Slowly 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] Pasteurized donor breast milk may be used if maternal expressed breast milk is unavailable or otherwise contraindicated.[96][97]

Consider – empiric intravenous antibiotics

Back

Consider –

empiric intravenous antibiotics

Treatment recommended for SOME patients in selected patient group

Screen for and/or treat suspected infection with antibiotics if necessary.[109][112] Blood cultures should be obtained prior to antibiotic treatment if possible.

The antibiotic regimen stated is recommended by the American Academy of Pediatrics.[113] Recommendations vary between countries; consult local guidelines.

Primary options

ampicillin: 100 mg/kg intravenously every 12 hours

and

gentamicin: 4.5 mg/kg intravenously every 36 hours

Consider – crystalloids ± vasoactive drugs or ± hydrocortisone after specialist consultation

Back

Consider –

crystalloids ± vasoactive drugs or ± hydrocortisone after specialist consultation

Treatment recommended for SOME patients in selected patient group

If hypotension is present, manage it 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 administration of crystalloids or vasoactive drugs such as dopamine.[104][105][106]

Alternatively, if perfusion is poor, consider dobutamine to improve cardiac output and perfusion.[104][107]

The risk of IVH from blood pressure fluctuations is significantly lower than in neonates below 28 weeks' gestation.

Hypotension that does not respond to dopamine or dobutamine can be treated with hydrocortisone for 2 to 3 days.

Primary options

dopamine: consult specialist for guidance on dose

dobutamine: consult specialist for guidance on dose

Secondary options

hydrocortisone: consult specialist for guidance on dose

Consider – prostaglandins

Back

Consider –

prostaglandins

Treatment recommended for SOME patients in selected patient group

If congenital heart disease is suspected, start prostaglandin E1 infusion to maintain ductal patency.[108]

Primary options

alprostadil: 0.02 to 0.1 micrograms/kg/min intravenous infusion

gestational age 34 to 36 weeks

1st line – assess for resuscitation + transfer to nursery or neonatal intensive care unit (NICU)

Back

1st line –

assess for resuscitation + transfer to nursery or neonatal intensive care unit (NICU)

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

There is insufficient evidence to recommend an approach to cord clamping for infants who require resuscitation at birth.[29][37] 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]

Infants below 35 weeks' gestation requiring feeding support should be transferred to a NICU. [ ]

Infants between 35 and 36 weeks' gestation may do very well clinically after delivery. Send them to the newborn nursery with routine orders. However, they need to be watched more closely than term infants, as they may manifest feeding difficulties and associated hypoglycemia due to prematurity, and may require admission to the NICU for supportive therapy.

Plus – temperature maintenance

Back

Plus –

temperature maintenance

Treatment recommended for ALL patients in selected patient group

Inability to maintain a normal temperature, between 97.7°F and 99.9°F (36.5°C to 37.7°C),[88] when adequately wrapped, is infrequent. Maintain temperature via a radiant warmer or isolette if necessary.[86]

Consider – ventilatory support ± oxygen

Back

Consider –

ventilatory support ± oxygen

Treatment recommended for SOME patients in selected patient group

Transient nasal continuous positive airway pressure may be required, but intubation and positive pressure ventilation are rarely necessary.

Avoid excessive oxygen exposure (100%) to reduce the likelihood of subsequent complications such as retinopathy of prematurity or chronic lung disease.[76] Increase the fraction of inspired oxygen (FiO₂) by 10% increments if the infant does not respond to 40% oxygen, until clinical effects are achieved.

Consider – nasogastric feeding

Back

Consider –

nasogastric feeding

Treatment recommended for SOME patients in selected patient group

Withhold enteral nutrition until the infant has been safely transferred and fully assessed, due to the risks of necrotizing enterocolitis. Slowly advance enteral feeding. Breast milk and human milk-based fortifiers are recommended.[93] Pasteurized donor breast milk may be used if maternal expressed breast milk is unavailable or otherwise contraindicated.[96][97]

Consider – dextrose 10%

Back

Consider –

dextrose 10%

Treatment recommended for SOME patients in selected patient group

Transitional intravenous fluids to avoid hypoglycemia may be required in infants below 35 weeks' gestation, due to the need for slow advancement of enteral feeds to avoid the risk of necrotizing enterocolitis.

Infants between 35 and 36 weeks' gestation may also manifest feeding difficulties and associated hypoglycemia due to prematurity, and require intravenous fluids.

Consider – empiric intravenous antibiotics

Back

Consider –

empiric intravenous antibiotics

Treatment recommended for SOME patients in selected patient group

Screen for and/or treat suspected infection with antibiotics if necessary.[109][112] Obtain blood cultures prior to antibiotic treatment if possible.

The antibiotic regimen stated is recommended by the American Academy of Pediatrics.[113][114] Recommendations vary between countries; consult local guidelines.

Primary options

ampicillin: 100 mg/kg intravenously every 12 hours

and

gentamicin: 34 weeks: 4.5 mg/kg intravenously every 36 hours; ≥35 weeks: 4 mg/kg intravenously every 24 hours

Consider – crystalloids ± vasoactive drugs or ± hydrocortisone after specialist consultation

Back

Consider –

crystalloids ± vasoactive drugs or ± hydrocortisone after specialist consultation

Treatment recommended for SOME patients in selected patient group

If hypotension is present, manage it promptly in consultation with a neonatologist, as the risk for poor neurodevelopmental outcome is highest in patients who exhibit the least ability to autoregulate cerebral blood flow.

The risk of IVH from blood pressure fluctuations is significantly lower than in neonates of below 28 weeks' gestation.

Hypotension that does not respond to dopamine or dobutamine may be treated with hydrocortisone for 2 to 3 days.

Primary options

dopamine: consult specialist for guidance on dose

dobutamine: consult specialist for guidance on dose

Secondary options

hydrocortisone: consult specialist for guidance on dose

Consider – prostaglandins

Back

Consider –

prostaglandins

Treatment recommended for SOME patients in selected patient group

If congenital heart disease is suspected, start prostaglandin E1 infusion to maintain ductal patency.[108]

Primary options

alprostadil: 0.02 to 0.1 micrograms/kg/min intravenous infusion

Use of this content is subject to our disclaimer

Premature newborn care

Treatment algorithm

gestational age <28 weeks

assess for resuscitation + positive pressure ventilation (PPV) or nasal continuous positive airway pressure (CPAP) + transfer to neonatal intensive care unit (NICU)

40% oxygen

temperature maintenance

umbilical vascular access

dextrose 10%

empiric intravenous antibiotics

Primary options

caffeine citrate

Primary options

surfactant

Primary options

Secondary options

crystalloids ± vasoactive drugs or ± hydrocortisone after specialist consultation

Primary options

Secondary options

prostaglandins

Primary options

prophylactic intravenous indomethacin

Primary options

gestational age 28 to 31 weeks

assess for resuscitation + continuous positive airway pressure (CPAP) + transfer to neonatal intensive care unit (NICU)

temperature maintenance

dextrose 10%

caffeine citrate

Primary options

positive pressure ventilation (PPV)

40% oxygen

surfactant

Primary options

Secondary options

empiric intravenous antibiotics

Primary options

crystalloids ± vasoactive drugs or ± hydrocortisone after specialist consultation

Primary options

Secondary options

prostaglandins

Primary options

gestational age 32 to 33 weeks

assess for resuscitation + transfer to neonatal intensive care unit (NICU)

temperature maintenance

dextrose 10%

ventilatory support ± oxygen

surfactant

Primary options

Secondary options

nasogastric feeding

empiric intravenous antibiotics

Primary options

crystalloids ± vasoactive drugs or ± hydrocortisone after specialist consultation

Primary options

Secondary options

prostaglandins

Primary options

gestational age 34 to 36 weeks

assess for resuscitation + transfer to nursery or neonatal intensive care unit (NICU)

temperature maintenance

ventilatory support ± oxygen

nasogastric feeding

dextrose 10%

empiric intravenous antibiotics

Primary options

crystalloids ± vasoactive drugs or ± hydrocortisone after specialist consultation

Primary options

Secondary options

prostaglandins

Primary options