What is the management approach for extremely preterm infants?

Management Approach for Extremely Preterm Infants

The management of extremely preterm infants should focus on delayed cord clamping, early CPAP with selective surfactant administration, and careful temperature regulation to optimize survival and reduce morbidity. 1

Initial Delivery Room Management

Umbilical Cord Management

• Delay umbilical cord clamping for at least 30 seconds in extremely preterm infants who do not require immediate resuscitation (Class IIa, LOE C-LD) 1
• Avoid routine use of cord milking for infants born at less than 29 weeks of gestation outside of a research setting due to limited evidence regarding safety of rapid blood volume changes 1
• For infants requiring immediate resuscitation, the optimal cord management remains unresolved and is the subject of ongoing research 1

Temperature Management

• Maintain temperature of extremely preterm infants between 36.5°C and 37.5°C after birth through admission and stabilization (Class I, LOE C-LD) 1
• Use multiple strategies to prevent hypothermia in infants born at less than 32 weeks' gestation, including:
  • Increased room temperature
  • Thermal mattresses
  • Plastic wrap with cap
  • Warmed humidified resuscitation gases (Class IIb, LOE B-R, B-NR, C-LD) 1
• Avoid hyperthermia (>38.0°C) due to potential associated risks (Class III: Harm, LOE C-EO) 1

Respiratory Support

Initial Approach

• Use CPAP immediately after birth with subsequent selective surfactant administration as an alternative to routine intubation with prophylactic surfactant administration (Level of Evidence: 1, Strong Recommendation) 1, 2
• Many extremely preterm infants, even those as immature as 24-25 weeks' gestational age, can be successfully managed with CPAP alone 1, 3
• When positive pressure ventilation is administered to preterm newborns, approximately 5 cm H2O PEEP is suggested 2

Surfactant Administration

• If respiratory support with a ventilator is needed, early administration of surfactant followed by rapid extubation (INSURE strategy: intubation, surfactant, and rapid extubation) is preferable to prolonged ventilation (Level of Evidence: 1, Strong Recommendation) 1, 2
• The need for mechanical ventilation and surfactant can be reduced with early CPAP strategy 1, 4

Pharmacological Management

Caffeine Therapy

• Administer caffeine citrate for prevention and treatment of apnea of prematurity 5
• Rule out other causes of apnea (e.g., central nervous system disorders, primary lung disease, anemia, sepsis, metabolic disturbances, cardiovascular abnormalities) before initiating caffeine therapy 5
• Monitor serum caffeine levels periodically throughout treatment to avoid toxicity, particularly in infants with impaired renal or hepatic function 5
• Be vigilant for signs of caffeine overdose, including tachypnea, jitteriness, insomnia, fine tremor, hypertonia, and seizures 5

Discontinuing Resuscitative Efforts

• In infants with an Apgar score of 0 after 10 minutes of resuscitation with undetectable heart rate, it may be reasonable to stop assisted ventilation 1
• The decision to continue or discontinue resuscitative efforts must be individualized, considering:
  • Whether the resuscitation was optimal
  • Availability of advanced neonatal care (e.g., therapeutic hypothermia)
  • Specific circumstances before delivery (e.g., known timing of insult)
  • Family wishes (Class IIb, LOE C-LD) 1

Long-term Considerations

• Despite improvements in survival rates, extremely preterm infants remain at high risk for respiratory morbidities, neurodevelopmental impairment, and other complications 6, 7
• Survival without major morbidity has improved in centers with proactive prenatal and postnatal management strategies 3, 7
• Regular training of healthcare providers in neonatal resuscitation is recommended at intervals more frequent than every 2 years (Class IIb, LOE B-R) 1

Common Pitfalls and Caveats

• Avoid the myth that all extremely preterm infants need immediate intubation to survive - many can be successfully managed with less invasive approaches 8, 4
• Beware of hyperthermia when using multiple warming strategies simultaneously 1
• Monitor for complications of caffeine therapy, particularly in infants with cardiovascular disease or impaired renal/hepatic function 5
• Recognize that there are significant international variations in respiratory management strategies for extremely preterm infants, reflecting the evolving nature of evidence in this field 4