Primary Concerns for a 28-Week Preterm Infant Who Died in NICU After 12 Hours
The primary concerns for a 28-week preterm infant who died shortly after birth include temperature instability, respiratory distress, and inadequate physiologic transition, which require immediate specialized care to prevent mortality.
Temperature Management Concerns
- Hypothermia is a critical concern in extremely preterm infants and is associated with increased mortality and morbidity in 28-week gestation infants 1
- These infants should be completely covered in a polythene wrap or bag up to their necks without drying immediately after birth, then placed under a radiant heater 1
- Delivery room temperatures should be maintained at least 26°C for infants of <28 weeks' gestation 1
- A combination of exothermic mattresses and polythene wrapping is the most effective strategy to avoid hypothermia but may increase the risk of hyperthermia 1
- Hyperthermia (temperature >38.0°C) should be avoided as it can worsen outcomes 2
Respiratory Management Concerns
- Respiratory distress syndrome is a major concern in extremely preterm infants and is associated with 10.2 times higher mortality (AOR = 10.2; 95%CI = 3.7-27.9) 3
- Initial oxygen concentration management is critical - evidence suggests starting with lower oxygen concentrations (21-30%) rather than 100% oxygen 1
- Positive pressure ventilation should be initiated promptly if breathing does not improve with stimulation and warming 2
- Continuous monitoring of oxygen saturation using pulse oximetry is essential 2
- Endotracheal intubation should be considered if face mask ventilation is ineffective or if chest retraction worsens 2
Physiologic Transition Concerns
- Extremely preterm infants have immature organ systems that struggle with the transition from intrauterine to extrauterine life 4
- Metabolic acidosis is common and requires monitoring and management 2
- Blood glucose monitoring is crucial as hypothermia and acidosis increase the risk of hypoglycemia 2
- Intraosseous access may be needed if intravenous access cannot be established quickly 1
Mortality Risk Factors
- The mortality rate for extremely preterm infants (28 weeks) remains high, with survival rates as low as 20% for extremely preterm babies 3
- Hypothermia at presentation increases mortality risk by 7.2 times (AOR = 7.2; 95%CI = 1.9-28.1) 3
- Respiratory distress syndrome increases mortality risk by 10.2 times (AOR = 10.2; 95%CI = 3.7-27.9) 3
- Lack of active antenatal management (no antenatal corticosteroids, magnesium sulfate, or cesarean delivery for fetal indications) increases the risk of death or severe morbidity (adjusted OR, 1.86; 95% CI, 1.09-3.20) 5
Specialized Care Requirements
- Extremely preterm infants require specialized neonatal intensive care with multidisciplinary support 1
- Recent evidence suggests that for infants born at 28 weeks gestation, birth in either NICU or LNU settings can be safe with appropriate care 6
- Continuous monitoring by trained staff and frequent assessment of vital signs are essential during the first hours of life 1
- Safe positioning is critical - infant's head should be in "sniffing" position with nose and mouth not covered 1, 7
Cord Management Considerations
- Evidence supports delayed cord clamping in preterm infants to improve outcomes 1
- Umbilical cord milking may be considered as an alternative to immediate cord clamping in infants born at 28 weeks gestation 1
- However, intact umbilical cord milking is not recommended in infants <28 weeks gestation due to increased risk of severe intraventricular hemorrhage 1
The death of a 28-week infant within 12 hours of birth warrants thorough investigation to determine specific causes and potential areas for improvement in care. The most common preventable factors include inadequate temperature management, suboptimal respiratory support, and delayed recognition of deterioration.