196 ADVANCED MANAGEMENT

FIGURE 12–27. Cross-table lateral radiograph of abdomen showing portal venous gas at arrow.

11. Portal venous air (Figure 12–27). Air is demonstrated in the portal veins
(right upper quadrant on supine AP radiograph), often best seen on lateral
view. This finding may indicate bowel necrosis (advanced degree of NEC) or
intestinal infarction secondary to mesenteric vessel occlusion or iatrogeni-
cally introduced gas into the portal vein, which can occur during UVC or
exchange transfusion.

13 M
 anagement 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.

Gomella_Sec03_p0167_0300.indd 196 18/10/19 3:32 pm

 13: Management of the Extremely Low Birthweight Infant 197

I. Delivery room management

A. 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 par-
ents 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. Neo-
natal 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.
B. Resuscitation
1. Delayed cord clamping. Ask the OB for 30 to 60 seconds of delayed cord clamp-
ing 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 pre-
vents 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, sur-
factant 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 and minimal energy reserves, a constant neutral thermal environment
(environmental temperature that minimizes heat loss without increasing O2 consump-
tion 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.
A. Incubators and hybrid incubators. ELBW infants should be admitted into pre-
warmed double-walled incubators. Previously, 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 have become the standard.
B. Humidification. ELBW infants have increased insensible water loss secondary to
large body surface area and a greater proportion of body water to body mass. Trans-
cutaneous water loss is enhanced by their thin epidermis and underdeveloped stra-
tum 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

Gomella_Sec03_p0167_0300.indd 197 18/10/19 3:32 pm

 198 ADVANCED MANAGEMENT

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°C. The fluids used for humidification in
these systems should be changed every 24 hours.
2. Minimize nosocomial infection in humidified environments. Do not allow
nonmedical items inside the incubator and change linens regularly if the
infant’s condition is stable. Change bed every 7 to 10 days per manufacturer’s
recommendation.
C. 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°C to 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 of the danger of hyperthermia. Rectal ther-
mometers are not to be used for tiny infants; electronic thermometers have
become standard.
2. Record skin temperature. Using a servo-control skin probe, record skin
temperature and environmental temperature every hour until the skin tem-
perature 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 for management of fluids and electrolytes
after the third day of life. 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 posi-
tioning, 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.
D. 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 (IVH), 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 tempera-
ture. Continue to reduce the warmer temperature until desired temperature is
achieved. If increased temperature persists, consider evaluation for pathologic
conditions such as sepsis, IVH, or mechanical overheating by exterior lamps.
Do not turn off the warmer, as this may cause a sudden decrease in the infant’s
temperature.

Gomella_Sec03_p0167_0300.indd 198 18/10/19 3:32 pm

 13: Management of the Extremely Low Birthweight Infant 199

III. Fluids and electrolytes. Because of increased insensible water loss and immature renal
function, these infants have greater fluid requirements, necessitating IV fluid therapy
(see Chapter 10).
A. Intravenous fluid therapy
1. Insensible water loss. Insensible water loss increases with the use of radi-
ant 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 13–1 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 renal function (blood urea nitrogen,
creatinine, urine output), serum electrolyte concentrations (see Chapter 10), and
body weight (measured after third day of life).
4. Additional fluid may be required if phototherapy is used. The fluid volume
should be increased by 10 to 20 mL/kg/d.
a. Incubators/omnibeds. Fluid rates are based on 80% or higher humidity;
fluids should be increased incrementally with decreasing environmental
humidity.
B. Infusion of fluids. Confirm appropriate line placement and document before infu-
sion (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. Consider use of double-lumen catheters
for additional fluid and drug administration.
3. Broviac, Hickman, or percutaneous central venous catheters. Add 0.5 U heparin/
mL to maintenance fluids. Avoid placement in first 3 days of life, if possible, to
minimize stress.
4. Radial arterial line/posterior tibial arterial line. Add 2 U heparin/mL to
0.5 NS.
C. 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) as these solutions may cause red blood cell hemolysis.

Table 13–1. ADMINISTRATION RATES FOR THE FIRST DAY OF LIFE FOR INFANTS IN
HUMIDIFIED INCUBATORS/OMNIBEDS AND RADIANT WARMERS

Fluid Rate (mL/kg/d)

Birthweight (g) Gestational Age (wks) Incubatorsa Radiant Warmersb

500–600 23 60–80 140–200
601–800 24 60–80 120–150
801–1000 25–27 50–70 100–120
a
Fluid rates based on 80% or higher humidity; fluids should be increased incrementally with decreas-
ing environmental humidity.
b
Fluid rates may be decreased with the addition of a humidity tent.

Gomella_Sec03_p0167_0300.indd 199 18/10/19 3:32 pm

 200 ADVANCED MANAGEMENT

D. 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 pres-
sure 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 after the first 3 days of life (to
minimize stress). 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 imme-
diately after urination.
a. First 12 hours. Any amount of urine output is acceptable.
b. 12–24 hours. The minimum acceptable urine output is 0.5 mL/kg/h.
c. Day 2 and beyond. Normal urine output for the second day is 1 to 2 mL/kg/h.
After the second day of life and during a diuretic phase, urine output may
increase to 3.0 to 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.
a. Heart rate. The accelerated heart rate of the tiny infant averages 140 to
160 beats/min and is generally considered within normal limits. Tachycar-
dia, 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.
b. Arterial blood pressure. This is most accurately measured via an indwell-
ing 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 pres-
sure 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.
a. 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 postdiuretic 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 hypernatre-
mia during the same period usually indicates dehydration, often due to
excessive insensible water loss. For subsequent monitoring of the serum
sodium levels:
i. Hypernatremia: Na+ >150 mEq/L. Differential diagnosis is (a) prema-
ture addition of sodium in the pre-diuretic phase, or (b) dehydration, or
(c) excessive Na+ intake.
ii. Hyponatremia: Na+<130 mEq/L. Differential diagnosis is (a) fluid over-
load, or (b) inadequate Na+ intake, or (c) excessive Na+ loss.
b. Potassium
i. During the first 48 hours after birth. During this time, tiny infants
are prone to increased serum potassium levels of ≥5 mEq/L (range,

Gomella_Sec03_p0167_0300.indd 200 18/10/19 3:32 pm

 13: Management of the Extremely Low Birthweight Infant 201

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
ii. K+ >6 mEq/L mandates close electrocardiogram (ECG) monitoring
of T-wave changes and rhythm disturbances along with electrolyte
trends, acid-base status, and urine output. Acidosis should be aggres-
sively 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 (4 puffs every
2 hours; 1 puff = 90 µg) can reduce high levels. Serum K+ >7 mEq/L can
also be treated with insulin, sodium bicarbonate, and calcium gluconate
(see Chapter 65).
iii. 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 to 2 mEq/kg/d. Measure serum K+ every
6 to 12 hours until the level is stabilized.
IV. Blood glucose. ELBW infants should be supported with 4 to 6 mg/kg/min glucose
infusion; start with a 5% to 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 glu-
cose level of 50 to 90 mg/dL has been established. Abnormal values should be confirmed
with serum glucose.
A. 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 gly-
cogen stores. In addition, pathologic states such as sepsis, cold stress, or hyperin-
sulinemia need to be considered.
B. Hyperglycemia >150 mg/dL. This can cause osmotic glycosuria, resulting in
excessive fluid loss. Hyperglycemia may be secondary to increased glucose infu-
sion rate or pathologic causes such as sepsis, necrotizing enterocolitis (NEC), 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 3 mg/kg/min has been demonstrated to provide adequate glucose for cerebral
metabolism while not affecting proteolysis and protein turnover.
V. Calcium. 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 hypo-
calcemia is not treated with additional calcium because it resolves with time. Symp-
tomatic hypocalcemia is treated with calcium salts (for dosage, see Chapter 155). This
decrease usually happens on the second day of life.
VI. Nutrition for the metabolically stable infant
A. 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 to 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 to 4 g/kg/d.
B. Intravenous lipids (20%) should be started by 24 hours of age; start with 1 to
2 g/kg/d and increase to 3 g/kg/d in 24 hours if triglyceride level is <200 mg/dL.
Septic and thrombocytopenic infants require caution before advancing lipids.
A generally acceptable safe triglyceride level is <200 mg/dL.

Gomella_Sec03_p0167_0300.indd 201 18/10/19 3:32 pm

 202 ADVANCED MANAGEMENT

C. Early feeds of small amounts of breast milk (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. Initial swabs of colostrum
0.1 mL to each cheek every 6 hours for the first 3 days, as available, should be con-
sidered. 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, donor breast milk should be used. Use of probiotics is a con-
sideration but controversial.
D. Controversy exists with regard to feeding infants while undergoing pharmacologic
treatment for PDA closure and during blood transfusions.
VII. Respiratory support. 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 noninvasive positive pressure ventilation
(NIPPV).
A. Endotracheal intubation
1. Type of endotracheal tube (ETT). When possible, use an ETT with 1-cm mark-
ings on the side. The internal diameter (ID) of the tube should routinely be
2.5 or 3.0 mm, according to body weight:
a. <500 to 1000 g. 2.5 mm ID.
b. 1000 to 1250 g. 3.0-mm ID.
2. ETT placement. Described in detail in Chapter 33. 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.
B. 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 to 30 cycles/min; others require 50 to
60 cycles/min with inspiratory times ranging from 0.25 to 0.35 seconds. The goal
is to use minimal pressure and tidal volume for optimal expansion of the lung,
avoiding volutrauma and atelectasis. Seek to maintain mechanical breath tidal
volumes of 4 to 6 mL/kg; this often may be achieved with as little as 8 to 12 cm of
inspiratory pressure and 3 to 5 cm of positive end-expiratory pressure. Pressures
can be kept to a minimum by allowing permissive hypercapnia (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 set-
tings for pressure-limited time-cycled ventilators in tiny infants are as follows
(see also Chapter 9):
a. Rate. 20 to 60 (usually 30) breaths/min.
b. Inspiratory time. 0.25 to 0.35 seconds.
c. Peak inspiratory pressure (PIP). Select PIP allowing optimal expansion of
lungs.
d. FiO2. As required to maintain O2 saturation of 88% to 92%.
e. Flow rate. 6 to 8 L/min.

Gomella_Sec03_p0167_0300.indd 202 18/10/19 3:32 pm

 13: Management of the Extremely Low Birthweight Infant 203

f. Synchronized intermittent mandatory ventilation and volume/pressure

control ventilators. These have internal controls that adjust flow delivery.
Current ventilators have incorporated enhancements for pressure sup-
port, 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 ven-
tilation, whereas others may require ventilation for a short period of time for
surfactant replacement. nCPAP has become a mainstay of respiratory manage-
ment 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 with-
out significant barotrauma. Care should be taken to use nasal prongs appropri-
ately 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. 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. Use has become more controversial.
C. Monitoring respiratory status
1. Oxygenation
a. Blood gas sampling. Arterial catheterization (see Chapter 27 for percutane-
ous arterial catheterization or Chapter 28 for umbilical arterial catheteriza-
tion) 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.
i. Desirable arterial blood gas values in the extremely low birthweight
infant:
(a) PaO2. 45 to 60 mm Hg.
(b) PaCO2. 45 to 60 mm Hg.
(c) pH. 7.25 to 7.32 is acceptable.
ii. Abnormal blood gas values. Indicate the need for assessment including
ETT placement, chest wall movement, effectiveness of ventilation, ven-
tilator malfunction, assessment for pneumothorax, and need for suction.
Actions may include immediate chest radiographs, chest wall transillu-
mination (see Chapters 12 and 44), and repeat blood gas determinations.
b. 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 bron-
chopulmonary dysplasia.
2. Chest radiograph
a. Indications
i. Abnormal change in blood gas values
ii. Adjustment of the ETT (to confirm proper positioning)
iii. Sudden change in the infant’s status
iv. Significant increase in O2 requirement or frequent desaturations

Gomella_Sec03_p0167_0300.indd 203 18/10/19 3:32 pm

 204 ADVANCED MANAGEMENT

b. Technique. A chest radiograph should be taken with the infant’s head in the
midline position to check for ETT placement.
c. 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 volutrauma and air trapping based on the age
of the infant and underlying disease process. Consider decreasing the peak
airway pressure if volutrauma is suspected. Underexpansion can be treated
with the use of CPAP or increasing pressures (peak airway pressure or positive
end-expiratory pressure) via the ventilator.
D. 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:
a. Breath sounds. Wet or diminished breath sounds may indicate secretions
obstructing the airways and the need for suctioning.
b. Blood gas values. If significant increase in PaCO2, consider ETT malposition,
secretions blocking the airway passages, inadequate ventilation, prior bicar-
bonate/acetate administration, or pain. Suctioning should be considered to
clear the airways and avoid the “ball-valve” effect of thick secretions.
c. 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.
d. Visible secretions in the ETT
e. Loss of chest wall movement
2. Suctioning technique
a. In-line suctioning is recommended to minimize airway contamina-
tion. Suctioning should be done only to the depth of the ETT. Use a suction-
ing guide or a marked (1-cm increments) suction catheter.
b. Suctioning without lavage solution is recommended. An exception is the
use of warm sterile normal saline lavage for thick secretions.
c. Suction should be regulated. 80 to 100 mm Hg for in-line suction (closed
system) and 60 to 80 mm Hg for open system.
E. Extubation
1. Prior to extubation. Consider use of caffeine citrate loading as it improves
respiratory drive and reduces 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 pres-
sure 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 parameters to be met for extubation:
a. Ventilator rate ≤20 breaths/min
b. 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 NIPPV.
F. 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 to use this therapy because of the frequency of IM injections. Vitamin A
delivery via IV fluids is not effective because it binds to the tubing.

Gomella_Sec03_p0167_0300.indd 204 18/10/19 3:32 pm

 13: Management of the Extremely Low Birthweight Infant 205

VIII. Surfactant. 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 sur-
factant are available; some have the advantage of smaller volume and dosing inter-
vals. 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
Figure 12–16).
IX. PDA. 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 for confirmation of
PDA when concerned. Efforts should be made to minimize the risk of PDA. Over-
hydration 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 114). Acetaminophen may also be consid-
ered. Renal and gastrointestinal adverse effects are less common with administration
of ibuprofen or with slower infusion rates of indomethacin. Indomethacin can also
be considered for IVH prophylaxis, especially in high-risk populations, although its
safety and benefit remain controversial. Concurrent administration of indomethacin
and steroids should be avoided because of the associated risk for spontaneous intes-
tinal perforation.
X. Transfusion. ELBW infants usually have low red blood cell volume, with a hematocrit
<40%, and they are subjected to frequent phlebotomies. Most centers keep the hema-
tocrit between 35% and 40%. Lower values may be acceptable if the infant is asymp-
tomatic. Each institution should have transfusion guidelines established to minimize
donor exposure and the number of transfusions.
XI. Skin care. 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 integ-
rity 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 breakdown 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.
A. 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.
B. 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.
C. 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.
D. Eye ointment for gonococcal prophylaxis. Should be applied per routine admis-
sion plan. If the eyelids are fused, apply along the lash line.

Gomella_Sec03_p0167_0300.indd 205 18/10/19 3:32 pm

 206 ADVANCED MANAGEMENT

E. Cleansing for required procedures (eg, umbilical artery or chest tube). Use mini-
mal 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 institu-
tion guidelines.
F. 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.
G. An initial bath is 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.
H. Avoid the use of anything that dries out the skin (eg, soaps and alcohol). Bonding
agents should be avoided.
I. Sterile water-soaked cotton balls. Helpful for removing adhesive tape, probe cov-
ers, and electrode covers.
J. Environmental. Use of mattress covers or blankets in humidified environments
helps prevent skin breakdown.
K. 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.
XII. Other special considerations for the ELBW infant
A. 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 start-
ing empiric ampicillin and gentamicin. Drug levels must be monitored if using
aminoglycosides and the dose adjusted accordingly (see Chapter 155).
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 preven-
tion and containment of infection. All caregivers/visitors should be instructed
in appropriate hand hygiene. Consider removal of all jewelry, use of short
sleeves, no use of lab coats, and no cell phone use in the NICU. Nosocomial
infections should be contained by a cohort of infants and the use of dedicated
equipment and staff.
4. Chemoprophylaxis with fluconazole. ELBW infants in NICUs with moder-
ate (5%–10%) or high (>10%) rates of invasive candidiasis should receive
prophylaxis with fluconazole. Dosage: Start 48 to 72 hours after birth and
give 3 mg/kg IV twice a week for 4 to 6 weeks or until IV access is no longer
necessary.
B. Central nervous system hemorrhage. Cranial ultrasonography may be indicated
during the first 7 days for possible intracranial hemorrhage.
C. 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 Chapter 34).

Gomella_Sec03_p0167_0300.indd 206 18/10/19 3:32 pm

 13: Management of the Extremely Low Birthweight Infant 207

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.
D. 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, and blood pressure) and behavioral
indicators (facial expression, vocalization, and motor activity). ELBW pain assess-
ment 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 15).
E. Social problems. Many families have great difficulty in coping with the issues
related to their infant’s extreme prematurity. Parents should be invited to par-
ticipate 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 com-
munication 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 com-
plex 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.
F. 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. Consider minimizing hands-on care to every 6 hours, avoiding heel sticks,
and limiting ultrasounds/x-rays for the first 3 days of life.
2. Positioning. The fetus is maintained in a flexed position with head midline. Care
should be taken to simulate this positioning in the extremely premature infant.
For the initial 3 to 7 days, consider keeping the head elevated and midline and
body supine, and avoid lifting legs above the head to minimize IVH. 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 after the third
day of life. Many positioning aids are available and should be used per institu-
tion guidelines.
3. Kangaroo care. This has been defined as “intrahospital maternal–infant skin-
to-skin contact” (see Chapters 15 and 22). It promotes behavioral state orga-
nization, 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 ETTs 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 to <50 dB 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.

Gomella_Sec03_p0167_0300.indd 207 18/10/19 3:32 pm

 208 ADVANCED MANAGEMENT

14 Management of the Late Preterm Infant

I. Introduction. The most commonly agreed upon definition of a late preterm infant is an
infant born between 34 0/7 and 36 6/7 weeks’ gestation. Older literature refers to these
infants as near term, suggesting that they are equivalent to term infants. Approximately
10 years ago, the term late preterm was introduced into the medical literature to convey
an appropriate sense of these infants’ vulnerability and increased risk for both short-
and long-term complications. Since 2007, >500 articles about late preterm infants have
been published, underscoring the increased risk of morbidity and mortality compared
to term infants.
Late preterm births represent approximately 74% of all preterm births. Between
1992 and 2007, the incidence of late preterm births increased from 7.3% to 10.4% of
all births. More recently, the rate of late preterm births has decreased to 9.6% in 2014,
representing an 8% drop from 2007. This is likely related to an improved understanding
of the increased risk of poor neonatal outcomes in this population.
II. Potential etiologies. Improvements in obstetrical surveillance over time may contribute
to an increased incidence of medically indicated premature deliveries. Recent recom-
mendations from the American College of Obstetricians and Gynecologists that discour-
age induction or scheduled repeat cesarean deliveries before 39 weeks, as well as specific
guidelines for criteria for elective preterm delivery, likely contributed to the decreased
rate of late preterm births seen over the past several years. However, not all late preterm
deliveries are preventable, and potential etiologies include the following:
A. Preeclampsia
B. Spontaneous preterm labor and preterm premature rupture of membranes
C. Multifetal gestations
D. Antepartum bleeding
E. Fetal growth restriction
III. Complications of late preterm birth
A. Mortality. A systematic review investigating the outcomes of >2 million late preterm
infants found that these infants were 5.9 times more likely to die within the first
28 days of life as compared to term infants. While the absolute number of deaths of
late preterm infants is low, the relative risk is high.
B. Respiratory morbidity. A large systematic review showed that late preterm infants
are 17.3 times more likely to develop respiratory distress syndrome than term neo-
nates. This is secondary to immature lung architecture, surfactant deficiency, and
deprivation of normal hormonal changes occurring at term that promote the clear-
ance of lung fluid. The risk of respiratory distress increases with decreasing gesta-
tional age (relative risk [RR] of 10.9 in 36-week infants, 28.6 in 35-week infants,
and 48.4 in 34-week infants). Late preterm infants are also 4.9 times more likely to
require intubation and mechanical ventilation, 9.8 times more likely to need CPAP,
and 24.4 times more likely to require nasal oxygen compared to term infants. In one
review, 11% of late preterm infants with respiratory failure developed chronic lung
disease and 5% died, emphasizing the serious long-term consequences of respiratory
complications in this population.
C. Length of stay. Studies show that late preterm infants have a similar median length
of initial hospital stay as term infants but with wider variability. The most common
causes of delayed discharge are jaundice and poor feeding. Late preterm delivery
triples the cost of the infant’s initial hospital stay.
D. Jaundice. Late preterm infants are at increased risk of hyperbilirubinemia second-
ary to hepatic immaturity as well as difficulty establishing feeding. A large sys-
tematic review showed that late preterm infants are 5 times more likely to have
prolonged jaundice requiring treatment compared to term infants. Late preterm

Gomella_Sec03_p0167_0300.indd 208 18/10/19 3:32 pm

 14: Management of the Late Preterm Infant 209

infants also may have an increased risk of bilirubin-induced neurologic dysfunc-

tion due to immaturity of the blood–brain barrier and decreased bilirubin binding,
as evidenced by the 25% of babies in the Kernicterus Registry who were born late
preterm. Hyperbilirubinemia is the most common reason for hospital readmission
of late preterm infants.
E. Poor feeding. Late preterm infants are 6.5 times more likely to have feeding dif-
ficulties as compared to term infants. Many late preterm infants with poor feeding
require a prolonged initial hospitalization and may require gavage feeds. Suck-
swallow coordination and intestinal motility remain immature, which impacts their
feeding ability. Late preterm infants may also lack the feeding skills to latch properly
and the stamina to take sufficient volumes of breastmilk, resulting in delayed milk
production and increased risk of lactation failure. At times, spoon feeding or formula
supplementation may be necessary. Breast-feeding protocols for this population that
are evidence based have been developed by the California Perinatal Quality Care
Collaborative (https://www.cpqcc.org/content/care-and-management-late-preterm-
infant-0) and the Academy of Breastfeeding Medicine (https://www.bfmed.org/
protocols). Problems with adequacy of breast feeding may persist until these babies
reach term equivalent age. Even babies being formula fed may require a nutrient-
enriched approach in order to ensure adequate caloric intake.
F. Temperature instability. Hypothermia is 10.8 times more common in late preterm
infants compared to term infants due to an immature epidermal barrier, higher sur-
face area–to–body weight ratios, decreased amount of brown adipose tissue, and
more frequent delivery room interventions.
G. Hypoglycemia. Late preterm infants are 7.4 times more likely to experience hypogly-
cemia compared to term infants. This is secondary to delay in the activity of hepatic
glucose phosphate, which is needed in the final step of gluconeogenesis. Hypoglyce-
mia in late preterm infants is further exacerbated by poor feeding, decreased body
weight, and low glycogen stores at birth.
H. Infectious morbidity. According to a large systematic review, late preterm infants
have an increased risk of culture-proven sepsis (RR, 5.6), pneumonia (RR, 3.5), men-
ingitis (RR, 21), and necrotizing enterocolitis (RR, 7.5) compared to term infants.
I. Sudden infant death syndrome (SIDS) and apnea. Immaturity of the autonomic
nervous system in late preterm infants increases the risk of apnea and bradycardia
of prematurity. Infants born between 33 and 36 weeks are twice as likely to die from
SIDS as those born ≥37 weeks.
J. Readmission. Late preterm infants are almost twice as likely to require readmission
after initial hospital discharge. Several studies have demonstrated that early follow-
up visits after hospital discharge or home nursing visits were effective at reducing
rates of readmission.
K. Respiratory syncytial virus (RSV) infection. Late preterm infants have an increased
susceptibility to RSV infection due to incomplete lung development, immature
immune function, and the relative lack of passively acquired maternal antibodies.
The risk of RSV bronchiolitis in infants born between 32 and 36 weeks is similar
to those born before 32 weeks. The risk of hospitalization due to RSV infection is
twice as high in late preterm infants compared to term infants. According to cur-
rent American Academy of Pediatrics (AAP) guidelines, late preterm infants do not
qualify for palivizumab prophylaxis unless they have additional risk factors such as
hemodynamically significant congenital heart disease. Precautions such as decreased
contact with sick individuals and good hand hygiene by those handing these infants
may be effective risk reduction strategies.
L. Long-term outcomes. Multiple studies have shown that late preterm infants are
at increased risk for long-term adverse neurodevelopmental and psychosocial out-
comes. A systematic review showed that late preterm infants are 3 times more likely
to develop cerebral palsy and 1.5 times more likely to develop mental retardation
compared to term infants. Late preterm infants are also more likely to have poor

Gomella_Sec03_p0167_0300.indd 209 18/10/19 3:32 pm

 210 ADVANCED MANAGEMENT

school performance, a learning disability, or attention deficit hyperactivity disorder

and have a lower likelihood of completing high school. Late preterm infants have
increased healthcare utilization during the first year of life and are more likely to have
special healthcare needs or a chronic medical condition as compared to term infants.
IV. Recommendations for management. Iatrogenic prematurity should be prevented
by prolonging pregnancy whenever medically feasible. Specific guidelines from the
American College of Obstetricians and Gynecologists regarding indications for preterm
delivery can help prevent unnecessary late preterm births. There is recent evidence to
suggest that antenatal betamethasone administered to women at risk for late preterm
delivery may decrease short-term respiratory morbidities in this population. Additional
evidence is necessary before this intervention can be recommended for all women with
threated late preterm delivery due to the unknown long-term risks of fetal exposure to
corticosteroids, a large number needed to treat to prevent a negative outcome, and a
higher rate of neonatal hypoglycemia in the steroid-treated group.
Because late preterm infants are at risk for neonatal complications, as discussed ear-
lier, specific management strategies should be developed for both their initial manage-
ment after birth as well as their care after discharge home. Early monitoring of respiratory
status, temperature, feeding ability, and bilirubin and glucose levels is critical. The AAP
has published guidelines for screening and management of hypoglycemia in the late pre-
term infant. The AAP has also provided specific recommendations for discharge criteria
for late preterm infants. In addition to fulfilling discharge criteria for term infants, the
late preterm infant requires:
A. Accurate gestational age assessment
B. Absence of medical condition requiring further hospitalization (ie, hyperbiliru-
binemia, respiratory distress).
C. Demonstration of physiologic stability
1. Maintaining normal cardiorespiratory control with stable vital signs for at least
12 hours prior to discharge.
2. Maintaining thermoregulation with axillary temperature of 36.5°C to 37.4°C
(97.7–99.3°F) in an open crib.
3. At least 24 hours of successful feeding in the absence of excessive weight loss.
4. Formalized evaluation of breast feeding when applicable.
5. Passing at least 1 stool spontaneously.
6. Successful completion of a car seat safety study to observe for apnea, bradycar-
dia, and oxygen desaturation.
D. Screening for hyperbilirubinemia with arrangement of appropriate follow-up
E. Assessment of family and home environment risk factors
F. Individualized timing of discharge based on the infant’s condition
G. Follow-up visit with an identified primary care provider 24 to 48 hours after
discharge
In summary, late preterm infants represent a unique patient population with
increased risk for both short- and long-term adverse health outcomes. Close monitor-
ing of health status after birth as well as specialized management strategies in the first
several days to weeks of life are needed to ensure optimal outcomes for these vulner-
able infants.
V. Late and moderately preterm (LMPT) infants. There is emerging literature investigat-
ing the differences in long-term outcomes of infants born late and moderately preterm
(32 0/7–36 6/7 weeks’ gestation) compared to both infants born at term as well as infants
born very preterm (<32 weeks’ gestation). Risk of adverse neurodevelopmental outcomes
is well documented in the very preterm population, but the risk for LMPT infants is just
beginning to be understood. One study showed that LMPT infants were 3.6 times more
likely to have a positive Modified Checklist for Autism in Toddlers (M-CHAT) autism
screen compared to term infants. Another study demonstrated that LMPT infants are
more likely than term infants to have oral motor problems and picky eating, particu-
larly in those LMPT infants requiring prolonged nasogastric feedings or with behavioral

Gomella_Sec03_p0167_0300.indd 210 18/10/19 3:32 pm

 15: Pain in the Neonate 211

problems. A recent survey of parents in the United Kingdom whose children were 6, 12,
and 24 months old found that parents with LMPT children were more likely to report
overall poorer health, increased minor respiratory symptoms and need for prescribed
inhalers, increased incidence of mild neurosensory impairment, increased frequency of
cognitive difficulties, and increased incidence of socioemotional developmental delay
compared to parents of children born at term. The pattern of abnormal development
and cognitive impairment seen in children born LMPT appears to be milder and of
unclear clinical significance compared to that observed in children born very preterm.
These recent studies indicate that close monitoring of the long-term health and neuro-
developmental progress of former LMPT infants is imperative, and continued research
may lead to better long-term outcomes in this population.

15 Pain in the Neonate

Before the 1980s, it was a common belief that preterm infants lacked the neurodevelopmental
capacity to feel pain. This resulted in severe undertreatment of pain in the neonate during
hospitalization. It is now known that infants have the required neuroanatomical connections to
feel pain, and actually experience a higher degree of sensitivity to pain as compared to children
and adults. Neonates are subject to many painful procedures, especially the most immature
infant. Although neonatology has made strides in the past 20 years to understand pain, it
remains a challenge to effectively assess and treat the various types of pain experienced in the
neonatal intensive care unit (NICU). A recent study revealed that there is a worldwide trend of
undertreatment of neonatal pain and that more attention should be given to pain prevention,
assessment, and treatment. Countries with nationally accepted guidelines for pain manage-
ment (such as France, Sweden, and the Netherlands) do a better job in treating neonatal pain
than those countries without guidelines. The American Academy of Pediatrics (AAP) recently
updated the recommendations for managing procedural pain in neonates. These recommen-
dations include the following:
1. E very institution caring for neonates should implement a pain prevention program
that includes written guidelines for a stepwise pain prevention and a treatment plan.
2. Validated neonatal pain assessment tools should be used consistently before, during,
and after painful procedures.
3. Nonpharmacologic strategies decrease pain scores during short-term mild to moder-
ately painful procedures and should be used. These include facilitated tucking, breast
feeding or providing expressed human milk, nonnutritive sucking, sensorial stimula-
tion, and others.
4. Oral sucrose/glucose solutions are effective with mild to moderately painful procedures,
either alone or combined with other pain-relief strategies. If used, these solutions need
to be tracked as medications.
5. Healthcare providers need to weigh actual benefits and burdens when using phar-
macologic treatment methods. It is important to remember that some of the medi-
cations can potentiate the hypotension and respiratory depression that can occur
with opioid use. Use caution when using newer medications that do not have data
in neonates.
6. All providers should receive continuing education on the recognition, assessment, and
management of pain.
7. More research needs to be done in this area.
Some have suggested that pain assessment should be considered the fifth vital sign, so
with each vital sign determination, pain assessment should be done and recorded.

Gomella_Sec03_p0167_0300.indd 211 18/10/19 3:32 pm