Guidelines for Admission and Management of the Extremely Low Birth Weight Newborn

 

Definition: Extremely low birth weight is <1000 grams, approximately 23-26 weeks

                   Very Low birth weight is 1001-1500 grams

                   Low birth weight is 1501-2500 grams

 

Morbidity And Mortality      (See also Limits of Viability: Antenatal and Perinatal Management)

          23 weeks: 25% survival, 95% morbidity

          24 weeks: 50% survival, 80% morbidity

          25 weeks: 75% survival, 50% morbidity

          26 weeks: 85% survival, 35% morbidity

 

Delivery Room Resuscitation

 

I. Establish an airway

          A. Gentle intubation with 2.5Fr. ETT using a 00 laryngoscope blade, insert ETT to 5.5-7cm

          B. Ventilate with low pressures to provide slight chest wall movement and equal breath sounds

          C. Administer rescue surfactant in the delivery room if <28weeks gestation.

II. Circulation

A. Establish respiratory resuscitation prior to beginning chest compressions

B. Chest compressions, rapid fluid boluses, and epinephrine can cause sudden swings in blood pressure increasing the incidence of IVH

III. Thermoregulation

          A. Place baby on “Portawarmer mattress”

          B. Use double layer hat with plastic liner between the two hats

          C. NRP recommends polyethylene wrap/cover

 

Initial Care by Systems

 

I. Respiratory

  1. Prophylactic surfactant is administered to <28 weeks gestation in the delivery room only if intubated for resuscitation.   

  2. Rescue surfactant is administered within 15 minutes of NICU admission if the oxygen requirement is > or equal to 40%, no chest x-ray is required if there are equal breath sounds.  Subsequent doses are given for oxygen requirement >30% for a total of 4 doses q6h.  Doses may be delayed with longer intervals if the oxygen requirement is <30%. All four doses may be spaced over the first 96 hours of life.

  3. Ventilator: if < 1000 grams choose pressure controlled ventilation to provide gentle chest rise

  1. PIP 12-18 and PEEP 4 (cmH20)   

  2. FIO2 start at 60-80%, avoid 100% due to the risk of retinopathy of prematurity, sat monitor 80-95%

  3. IMV 40 with IT 0.3 seconds

  4. Wean clinically during the first 15 minutes following surfactant administration

  5. Pressure support  4 cmH2

D. Ventilator if >1000 grams, initially choose pressure ventilation. Discuss use of volume ventilation with attending.  Use pressure ventilation if the baby has a pneumothorax or chest tube.

     Initial volume ventilator settings (SIMV):

                   1. 5mL/Kg of tidal volume

                   2. FIO2 start at 60-80%

                   3. IMV 40 with IT 0.3 seconds

                   4. pressure support 4 cmH20

E. Permissive hypercapnea

                   1. pH >7.25

                   2. pCO2 <60 mmHg

                   3. wean IMV for  pCO2 in 50’s mmHg

F. Extubation

1. Attempts are done early when oxygen requirement is in 30’s range, IMV 20. 

2. Load with caffeine and extubate to Aladdin NCPAP.  

3. Extubation failure usually requires a period of growth approximately a week and/or 100 gram weight gain.

 

II. Cardiovascular

          A. Establish vascular access   

1. UAC single lumen, use 2.5Fr if <800 Grams, may use 3.5Fr if baby is larger.  “High” Insertion depth in centimeters can be estimated by multiplying weight (kg) x 3 then adding 9.  The tip should be at T6-9.  Babies <1250 grams should receive ½ Na Acetate for arterial line fluids to prevent hyperchloremic metabolic acidosis.

2. UVC double lumen 3.5 Fr.  Insertion depth can be estimated by multiplying weight x 1.5 then adding 5, the tip should be at T6-9

a. if placement of a UAC is successful and lab sampling can be done through the  UAC, then the dextrose can be divided between the two ports of the UVC.

b. if  placement of a UAC has not been successful, use one port of the UVC for lab sampling and run ½ Na acetate (<1250Gms) or ½ Na Chloride (>1250Gms) through the larger port and run dextrose through the smaller port of the UVC

                    3. remove UAC when frequent blood sampling and invasive blood pressure monitoring is no longer needed, or around DOL# 7.

                    4. remove UVC around DOL#7.  Get consent for PICC insertion when UVC is removed, or if UVC is not placed.

B. Hypotension:

1. expect MAP to be equal to the estimated gestational age if the perfusion is good and there is good urine output. 

2. if perfusion is decreased or urine output is decreased, the MAP goal may be increased to equal the gestational age plus 7. 

3. if the baby is hypothermic (vasoconstriction) on admission from the delivery room, the blood pressure may drop as the baby re-warms (vasodilation). Re-warm carefully.  See thermoregulation section above for ways to prevent hypothermia.

4. limit volume bolus to no more than one 10mL/kg of normal saline, blood transfusion may be needed.

5. if hypotension persists after one fluid bolus and any required blood transfusions, start dopamine at 5mcg/kg/min mixed with D5W

6. if needed, advance dopamine drip to 10mcg/kg/min. Add dobutamine starting at 5mcg/kg/min mixed with D5W.  This may be advanced to10mcg/kg/min.  Pressors may be mixed with D10W or NS if glucose is unstable.  Discuss further elevations of doses with the attending.

7. hypotension refractory to high dose pressors with concurrent hypoglycemia and hyponatremia may have adrenal insufficiency of prematurity and may require hydrocortisone.  Discuss with attending.

8. Weaning pressors: if using both dopamine and dobutamine, wean dopamine first to 5mcg/kg/min, then wean dobutamine off, then go back to weaning dopamine until 3mcg/Kg/min, then stop.  Occasionally, some babies require dopamine to be weaned to 1mcg/kg/min before stopping.

     C. Prophylactic indocin 

          1. confirm that mother has not received indocin in the last 72 hours prior to delivery.  Dose 0.2mg/ IV over 30 minutes at 12 hours of  age.

                   a. any baby <1000Grams regardless of ventilatory status

                   b. <1250 Grams and ventilated at 12 hours

       c. platelet count from admission CBC and electrolytes normal from q6h labs

                    d. no creatinine level is needed with prophylactic indocin. 

                    e. check the urine output prior to giving the dose.

             2.  there is no concern for heart disease, i.e. no murmur, and saturations are as expected.

      D. Therapeutic indocin 0.2mg/ IV over 30 minutes, q12h x3 doses

1. discuss with attending the preference for one dose and observing 24 hours followed with three doses q12h

2. discuss with attending the preference for beginning three dose course q12h x3

3. observe for adequate urine output, normal serum electrolytes, Cr <1.5,  platelets > 75,000 prior to giving the indocin.  Platelet transfusion may be required prior to the indocin dose.

 

III.  FLUIDS        

A. Total fluids of 90 mL/kg/d, be sure to include flush infusion in your calculations (1/2 Na acetate or ½ Na chloride) since this may add as much as 20mL/kg/d of fluids

B. Insensible water loss is estimated at 20mL/kg/d for each of the following: warmer and phototherapy. 

C. Decrease IWL with 70% isolette humidity and q12h aquaphor for 4 days

D. Observe for diuresis phase of hyaline membrane disease.  If  total hourly urine output exceeds total hourly intake and the serum Na is climbing, increase the daily intake by 20mL/kg/d.  Calculate the glucose infusion rate with this increase in volume.

E. Fluid restriction: the usual goal for total fluids is 150mL/kg/d with the following exceptions:

                    1. if signs of PDA or during indocin therapy, place NPO and restrict to 100-120mL/kg/d, discuss preferences with attending

                   2. if oxygen requirement restrict to 140mL/kg/d

                   3. if signs of chronic lung disease and occasional lasix use restrict to  130mL/kg/d

                   4. if post-op bowel surgery with third-spacing and no lung disease increase to180mL/kg/d, discuss with attending and surgeons

 

IV. ELECTROLYTES  

A. Hypernatremia >145 serum level. Monitor electrolytes q6h for the first 48 hours.  Then decrease frequency to q8h, then q12h, then q24h during the first week.

1. do not electively give any sodium (Na) in dextrose solution for first 24 hours.  Consider Na for replacement in first 72 hours unless serum    Na is increased.

2. if hourly total urine output exceeds hourly total intake during diuresis phase, increase total intake by 20mL/kg/d until the diuresis decreases. It may take 24 hours for the diuresis to resolve, and rarely up to 72 hours.

3. consider IWL and increase total intake by 20mL/kg/d if Na >145

          B. Hyperkalemia (non-oliguric)

1. do not give any K in dextrose solution until UOP is established and serum K is beginning to decrease.  This may take up to 72 hours.

2. treat hyperkalemia when non-hemolyzed specimen is >6.5.  Use insulin drip mixed with D10W.  Start with 0.02units/kg/min and recheck K in 30-60 minutes.  Wean insulin drip as the K drops to <6, since there will be a “drift” downward after stopping.  Sudden decreases in glucose and K can accompany insulin infusion as the delivery tubing becomes saturated with insulin and finally starts to deliver the calculated dose. 

3. Monitor glucose and adjust glucose infusion rate as needed.

4.  It is rare to require Calcium, NaHCO3, or kayexelate.

          C. Hyperchloremic metabolic acidosis

1. use ½ Na acetate for peripheral arterial lines or UAC instead of ½ NaCl

2. minimize chloride in TPN (maximize acetate), omit cysteine until base excess is less than -2 with pH acidotic, or -4 with pH in normal range.

3. NaHCO3 is hypertonic and related to IVH risks and should be infusedcautiously over two hours to buffer metabolic acidosis.  The use of NaHCO3 is controversial in this population.  Evaluate for correctable causes of metabolic acidosis and discuss with attending before using.

          D. Hyperglycemia

1. <1500 Grams start with D10W and 30 Grams/L of protein, and 10mEq/L of calcium gluconate. Calculate your glucose infusion rate.

2.  accept glucose up to 180 if there is no hyperosmotic diuresis

3.  evaluate for catecholamine response to stresses such as reintubation,  resuscitation, albuterol treatment, lumbar puncture, PICC insertion, decadron or hydrocortisone therapy, etc.  These stresses may cause a transient elevation of glucose to 300’s, and a decrease  may be observed over the next few hours.  These events do  not require an insulin  drip.

4. decrease the glucose infusion rate (GIR) by “Y”-in of D5W with the same electrolytes.  Usually decreasing the GIR by total of 2mg/kg/min will correct hyperglycemia.  Discuss with attending before decreasing glucose infusion rate less than 5mg/kg/min since some sources classify D5W alone, without electrolytes as hypotonic;; D5W=252 osmoles -have an osmolality close to extracellular fluids (275-295 osmoles). D5W with electrolytes is iso-osmolar but will not give adequate calories.

5. insulin drip: start with 0.02units/kg/min and monitor glucose within 30 minutes and monitor potassium within 1 hour. Wean insulin drip off when glucose is <100.  Check glucose hourly as it decreases.

E. Hypercalcemia

           1.  use infant reference ranges for Ca/P:  iCa <3.2 - >6.5mg/dl  P<4.5 - >7.5mg/dl

2.     until a total of 1mEq/kg of either Na or K is added to TPN, order no more than 10mEq/L of Ca

3.     add Ca and phosphorus to TPN as soon as possible

4.     add Ca and P in 2:1 ratio – 30mEq/L of Ca and 15mmol/L of P is optimal

 

V. NUTRITION

A. Admission fluids for <1500 Grams baby is D10 with amino acids, calcium gluconate, and heparin.  This provides approximately 2.5-3.5gm/kg/d of protein.

B. TPN on DOL#1 continue with D10W, no sodium, no potassium, no cysteine, minimize Cl, Ca 10mEg/L,  phosphate cannot be added until the addition of  Na or K.  Since admission fluids contain amino acids, the first day of TPN  can start at the optimal 3.5gm/kg/d.

C. Intralipids (IL) should be started DOL#1.  Start at 1gm/kg/d and advance by 1gm/kg/d to 3gm/kg/d.  Check triglyceride level after reaching 3gm/kg/d.  Triglyceride levels should be kept <200.  If hypertriglyceridemia occurs, Intralipid administration should be transiently restricted to 0.5-1g/kg/d. Triglyceride level should be checked in 24 hrs and Intralipid amount increased if tolerated.

D. Advance dextrose every other day, or every third day, as tolerated, monitor glucose.

E. Vitamin A decreases chronic lung disease by 7%. The criteria for administration is the same as the indocin criteria (<1000Gms regardless of ventilatory status, or <1250Gms and ventilated at 12 hours of age).  Initially the dose is 2000 IU/K/dose IM qod.  Do not adjust dose while IM.  Change to po 4000 IU/kg/d when feedings  are 100mL/kg/d.  Adjust po dose weekly with weight gain.

          F. Weaning TPN and intralipids

1. calculate total fat intake of the combination of feedings and intralipids.  Decrease IL as feedings increase for goal of 2-4 gm/kg/d of fat.  Stop IL when feedings are 100 mL/kg/d.

2. calculate total protein intake of the combination of feedings and TPN.  Decrease TPN protein as feedings increase for goal of 4gm/kg/d.  Need to discuss with attending when to stop TPN, balancing the risk of TPN associated infections with the risk of malnutrition, depends upon the baby.

 

VI. GASTROINTESTINAL AND ENTERAL FEEDINGS

A. Begin enteral feedings when active bowel sounds are noted;  initial stools may not occur until after feedings are started.

B. Indocin: NPO during indocin therapy and for 24 hours after last dose.

C. Expressed breast milk (EBM) is best choice.  If mother is planning to provide breast milk you may wait up to 3 days before starting enteral feeds for breast milk to become available rather than starting formula.  Give whatever amount of EBM available in small aliquots (up to 10ml/kg/day) while waiting for mother’s milk supply to come in.  

               Supplemental fortifiers can be added at the following times:

               EBM at 40-50mL/kg/d fortify with Similac Special Care (SSC) 1:1.

               EBM at 100-120mL/kg/d fortify with Human Milk Fortifier (HMF).

               If mother is having difficulty establishing or maintaining supply, use liquid Similac Special Care 1:1 ratio with EBM to extend the supply of EBM.

D. Premature formulas: use Similac Special Care 24 cal/oz if no EBM is available.

E. Trophic feedings: 10mL/kg/d.  Feed as a bolus feeding since it is more physiologic at first.  Advance feedings by 10mL/kg/d.  The baby may need to feed over 1 hour, 2 hours, or continuously, when the feedings reach approximately 40-50mL/kg/d and the baby can no longer tolerate the larger volume as a bolus feeding.  Stooling pattern should also be established by then.     

F. Residuals: tolerate 1/3-1/2 of the q3h feeding as residual.  Monitor girth, stools, guaiac, color of residual.  Green residuals can occur if the NG tube is inserted too far, or can be one early signal of necrotizing enterocolitis.

G. Oral medications: Change only one hyperosmolar medication or supplement each day to po. Change vitamin A to po when feedings are 100mL/kg/d.  H. Beneprotein (protein supplement): consult the dietitian when the baby reaches 80Kcal/kg/d of feedings.  Achieve the calorie goal prior to adding protein supplements.  Protein supplements can be added by the dietitians into the dietary kitchen computer.

I.  Calories goal is 120cal/kg/d.  Calorie concentration may need to be increased due to fluid restriction.  Fluid restriction: the usual goal for total fluids is 150mL/kg/d with the  following exceptions:

1. if signs of PDA or during indocin therapy, NPO and restrict to 100-120mL/kg/d, discuss preferences with attending.

2. if oxygen requirement restrict to140mL/kg/d.

3. if signs of chronic lung disease and occasional lasix restrict to: 130mL/kg/d  (see dietary requirements during lasix therapy under osteopenia section).

4. if post-op bowel surgery with third-spacing and no lung disease increase to 180mL/kg/d, discuss with attending and surgeons.

J.  Gastric perforations: use silastic feeding tubes with carefully measured insertion depth.  Notice placement on x-rays.

K. Reflux: can be related to obstructive apnea.  GER can be reduced by changing bolus feedings to over 1 hour, or over 2hours, or continuous  NG/OG, or if needed continuous NJ/OJ (tip position should be confirmed by KUB).  GER may also be reduced by placing the baby prone or on his/her left side after feedings.

 

VII.  HEMATOLOGY  

          A. Blood transfusions

1. goal of PCV 40 during the first week of life to replace iatrogenic blood loss or treatment of hypovolemic shock.

2. transfuse pRBC over 2-3 hours through PIV or UVC, Lasix is not required after transfusion if the blood is replacement for iatrogenic loss.

3. anemia of prematurity, transfuse 10mL/kg/d for a goal  PCV over 35%  if on significant oxygen, otherwise observation is sufficient, follow transfusion with dose of Lasix if baby’s  fluid status is tenuous.

4. state screen must be done prior to first transfusion. 

5. parental consent should be obtained, if not an emergency.

B. Coagulopathy

1. administer vitamin K half dose on admission (0.5mg IM)

2. fresh frozen plasma 10mL/kg/d: persistant oozing and abnormal PT >18, elevated PTT which was not drawn through a heparinized line (heparin interferes with intrinsic clotting cascade),  elevated INR, depressed fibrinogen

3. platelet transfusion 10mL/kg/d for platelet count <50,000

          C. Hyperbilirubinemia

                   1. bruising at birth: start prophylactic phototherapy

                   2. check 12 hour total and conjugated bilirubin, thereafter, check total bilirubin

                   3. follow qd total bilirubin until it decreases, “light level” is ¼ of gestational age, “exchange level” is ½ gestational age

                   4. phototherapy increases insensible water loss by approx 20mL/kg/d

 

VIII.  INFECTIOUS DISEASE

          A.  Possible sepsis

                   1. preterm labor, premature rupture of membranes, or prolonged (>18 hours) premature rupture of membranes

                   2. chorioamnionitis

                   3. delivered due to PIH but having respiratory distress

                   4. leukopenia or elevated CRP

          B. Ampicillin is in the Stahlman NICU pyxis and should be given as a STAT drug as soon as a blood culture is drawn.  Dose 100mg/kg/d q12h

          C. Gentamicin 5mg/kg/dose q48h, <30 weeks, <30 days

D. Fluconazole protocol < 750 Grams, <26 weeks, 3mg/kg/dose Monday and Thursday. Continue for the first 6 weeks of life if a central line is in place or subsequent central lines have been replaced.

          E. Labs

                   1. admission: blood culture, CBC, platelet count, differential, CRP,

                   2. gentamicin trough with 2nd dose (q48h dosing)

                   3. 48 hour follow up: CBC, platelet count, differential, CRP

 

IX.  NEUROLOGY

          A. IVH Prevention

1. blood pressure swings: give fluid boluses, medications, transfusions slowly, re-warm carefully if hypothermic from delivery room or referring hospital to prevent sudden vasodilation.  Provide gentle ventilation and bagging.

          B. IVH Detection

1.  head ultrasounds at DOL#7, or earlier HUS if symptomatic; 90% of IVH occurs in the first 3 days of life, 95% by the first week.  Late onset IVH is associated with sepsis.

2.  head ultrasounds at DOL#30 to detect PVL, more predictive of CP and poor long term neurologic outcome than IVH

3. 15% of  <1500Gram babies with a normal HUS will have serious neurodevelopmental morbidities (MR, CP, blindness, deafness).  The average IQ of the <28weeks baby is 85. Of the ELBW without serious neurologic sequelae, >50% will have learning disabilities and behavioral problems.

C. Pain and Agitation Control-discuss with attending.  Use of sedation for non-surgical infants is discouraged and is associated with worse outcomes.

1. give fentanyl 0.5mcg/kg/dose IV q2h prn for discomfort.

2. the baby may need a fentanyl drip for comfort, mix with same dextrose as the TPN fluid

3. weaning: any baby on fentanyl >5 days should be weaned slowly from fentanyl, any baby on fentanyl >7 days should be given a methadone taper (see wiz orders for guidance).

 

X.  OPHTHALMOLOGY

          A. Retinopathy of prematurity exams are done at 6 weeks of age (or 31-32 weeks postmenstral age)

          B. O2 saturation monitors should be set 80-95% to prevent hyperoxia and wide swings in saturations.

 

XI.  AUDIOLOGY

          A. Hearing screen prior to discharge or when baby achieves weight >1500Grams

          B. Follow up will be recommended for babies on ventilator >7 days, ototoxic drugs such as gentamicin, lasix for >7 days

 

XII. OSTEOPENIA OF PREMATURITY

A.   Use the infant range of lab results: iCa 3.2-6.5mg/dL, P 4.3-7.5mg/dL.

B.   Add calcium and phosphate to TPN as soon as possible in a 2:1 ratio,

e.g., 30 mEq/L Ca to 15mmol/L P. (See Section 6-7 or Calcium and Phosphorus: Optimal Intake Guidelines in vuneo.org, for guidelines regarding administration of calcium and phosphate in TPN.)

C.  Limit use of Lasix. Change to QOD Lasix as soon as possible.  Consider adding HCTZ to Lasix therapy, or changing from Lasix to HCTZ to spare calcium loss.

D.  Dietary requirements while on Lasix and fluid restricted (130-140mL/kg/d).  SSC provides the highest concentration of Ca/P.

1. If feeding premature formula, use SSC.

2. If feeding EBM/SSC, change to EBM/HMF and alternate with SSC  feedings.

3. If feeding EBM/HMF, alternate with SSC feedings.

E.  Obtain alkaline phosphatase level on DOL #30.

F.  Provide optimal Vitamin D:  At 80ml/kg/day of enteral feeds, start vitamin D at 400 IU day and consider increasing to 800 IU day if on diuretic therapy , discuss with attending and dietician.  See NICU Vitamin D Protocol.  

                  

XIII.  NICU FOLLOW UP     

  1. NICU Follow Up Clinic for <1500 gm neonate; encourage families to attend return appointments

  2. Tennessee Early Intervention Services (TEIS) referral for babies <1250 gms are made by Case Managers

  3. Families qualifying for Supplemental Security Income (SSI) automatically receive referrals to TEIS

  4. Case Managers will also make appointments for circumcisions, home oxygen and apnea monitor, hip ultrasounds, ophthalmology, or other referrals for consults

  5. Back transports: discuss with Case Managers and Back Transport nurse. Babies need to be >1500 gms for BT unless to a Level II unit. They also need to have had a first eye exam, and the ability to be followed for continued eye exams must be possible.  Infants BT’d to Gateway and Maury Regional may be sent prior to first eye exams depending on the current availability of pediatric ophthalmologists in those centers.

 

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