What is the immediate care for a baby who is small for gestational age (SGA) or premature?

Immediate Care for Small for Gestational Age (SGA) or Premature Infants

For premature infants born at <37 weeks' gestation who do not require immediate resuscitation, defer umbilical cord clamping for at least 60 seconds to reduce mortality, followed by immediate thermal management, respiratory support as needed, and transfer to an appropriate level NICU based on gestational age and clinical stability. 1

Initial Delivery Room Management

Cord Management (First 60 Seconds)

• Defer cord clamping for at least 60 seconds in all preterm infants <37 weeks who do not require immediate resuscitation—this intervention reduces mortality with a number needed to treat of 18 1
• For infants 28+0 to 36+6 weeks who cannot receive delayed cord clamping, umbilical cord milking is a reasonable alternative to improve hematologic outcomes 1
• Avoid intact cord milking in infants <28 weeks' gestation due to safety concerns 1
• If immediate resuscitation is required, proceed directly to resuscitation without delayed cord clamping 1

Immediate Resuscitation and Stabilization

• Dry and stimulate the infant immediately after delivery to assess breathing and heart rate 1
• If the newborn is stable after initial assessment, place skin-to-skin with cord attached until clamping at 60 seconds 1
• Initiate positive pressure ventilation immediately if the infant fails to establish adequate spontaneous respirations after drying and stimulation 1
• Have equipment ready for continuous positive airway pressure (CPAP) delivery, as this should be readily available for preterm infants with respiratory distress 1, 2

Thermal Management

Immediate Temperature Control

• Place the infant under a radiant warmer immediately or in a servo-controlled incubator to maintain normothermia (36.5-37.5°C) 3
• Cover the infant's head with a cap and use prewarmed blankets to prevent heat loss 1
• Monitor temperature continuously or every 15-30 minutes to prevent both hypothermia and iatrogenic hyperthermia (>38.0°C), which increases mortality risk 3
• For premature infants, thermal mattresses should not be used in term infants due to increased hyperthermia risk 3

Skin-to-Skin Care Considerations

• Initiate immediate skin-to-skin care for stable infants, positioning the infant with face visible, head in "sniffing" position, nose and mouth uncovered, and neck straight 1
• Continuous staff observation is mandatory during the first 2 hours of life when sudden unexpected postnatal collapse risk is highest 1
• High-risk situations requiring increased vigilance include infants requiring any resuscitation, low Apgar scores, late preterm (35-37 weeks), and mothers receiving sedating medications 1

Metabolic Management

• Check blood glucose immediately as hypothermia and prematurity are strongly associated with hypoglycemia 3
• Treat hypoglycemia promptly per standard protocols if blood glucose is low 3
• Monitor glucose levels frequently during the first 24-48 hours, particularly in SGA infants who have limited glycogen stores 4

Respiratory Support

Initial Assessment and Intervention

• Assess respiratory effort, heart rate, and oxygen saturation immediately after birth 1
• For infants <32 weeks' gestation, consider CPAP immediately after birth even without respiratory distress to reduce need for mechanical ventilation 1, 2
• Provide advanced respiratory support including conventional and/or high-frequency ventilation as needed based on clinical status 1
• Inhaled nitric oxide should be available for infants with persistent pulmonary hypertension 1

Facility-Level Triage

Level I (Well Newborn Nursery)

• Can stabilize preterm infants 35-37 weeks who are physiologically stable 1
• Must be able to stabilize infants <35 weeks until transfer to higher level of care 1

Level II (Special Care Nursery)

• Appropriate for moderately ill newborns ≥32 weeks' gestation or ≥1500g with problems expected to resolve rapidly 1
• Can provide brief mechanical ventilation (<24 hours) and continuous positive airway pressure 1
• Must have portable x-ray, blood gas analyzer, and specialized personnel continuously available 1

Level III (NICU)

• Required for all infants <32 weeks' gestation, <1500g, or with medical/surgical conditions regardless of gestational age 1
• Must have continuously available neonatologists, neonatal nurses, respiratory therapists, and life support equipment 1
• Provides advanced respiratory support, imaging, laboratory services, and subspecialty consultation 1

Level IV (Regional NICU)

• Required for infants needing surgical repair of complex congenital or acquired conditions 1
• Maintains full range of pediatric medical and surgical subspecialists on site 1

Nutritional Support

• Initiate exclusive breastfeeding as the standard of care for SGA and preterm infants when clinically stable 4
• Expressed breast milk or donor milk may require fortification to meet higher nutrient needs of growth-restricted newborns 4
• Support breastfeeding with direct observation of positioning, latch quality, and swallowing effectiveness at follow-up visits 5
• For infants unable to breastfeed, provide expressed milk or donor human milk with appropriate fortification 2, 4

Kangaroo Mother Care

• Initiate Kangaroo Mother Care immediately after birth for all preterm or low birth weight infants except those critically ill, in shock, unable to breathe spontaneously after resuscitation, or requiring ventilatory support 2
• Continue KMC both in the facility and at home as routine care, as this intervention can halve mortality in babies <2000g 6, 2
• Ensure family involvement and support to enable ongoing care 2

Follow-Up Planning

• Schedule examination by a qualified healthcare professional within 3-5 days (72-120 hours) after hospital discharge 5
• Earlier or more frequent follow-up is mandatory for infants with gestational age 35-38 weeks, jaundice in first 24 hours, blood group incompatibility, exclusive breastfeeding with intake concerns, or discharge before 48 hours 5
• At follow-up, measure weight, assess hydration status, evaluate jaundice with objective bilirubin measurement (not visual estimation), and review all screening results 5
• Monitor for catch-up growth, as most SGA children experience spontaneous catch-up by age 2 years, but rapid catch-up increases risk of metabolic complications 7

Common Pitfalls to Avoid

• Never delay cord clamping assessment—make the decision about immediate resuscitation need within seconds of delivery 1
• Do not rely on visual assessment alone for jaundice—always measure total serum or transcutaneous bilirubin if any doubt exists 5
• Avoid excessively high warmer settings that increase hyperthermia risk 3
• Do not assume gestational age alone determines prognosis—consider birth weight, appropriateness for gestational age, maternal steroid use, and other factors 1
• Never leave mothers unsupervised during skin-to-skin care in the first 2 hours when sudden collapse risk is highest 1