What are the key evidence-based practices in neonatology?

Key Evidence-Based Practices in Neonatology: A Rapid Review

Infection Prevention and Control

Preventing healthcare-associated infections (HAIs) is paramount in neonatal care, as approximately 2.8 million neonates globally contract bacterial infections annually, with 600,000-680,000 deaths. 1

High-Risk Populations

• Very-low-birth-weight and preterm infants face the highest risk due to underdeveloped immune systems, immature skin barriers, and frequent invasive device use 2, 1
• Transmission occurs through healthcare workers, caregivers, contaminated equipment, and patient-to-patient contact 2, 1

Prevention Strategies

• Implement multimodal infection control bundles including hand hygiene, environmental cleaning, and equipment sterilization 1
• Address organizational barriers: adequate staffing levels and manageable workloads are critical for compliance with infection control protocols 2, 1
• Involve family caregivers in infection prevention education and protocols 1
• Monitor for colonization with antibiotic-resistant organisms, not just active infections 1

Critical Pitfalls to Avoid

• Do not assume WHO empirical antibiotic recommendations are adequate without local antimicrobial resistance surveillance 1
• Do not overlook environmental contamination of incubators and shared equipment 1
• Avoid implementing single interventions rather than comprehensive care bundles 1

Blood Transfusion Management

A restrictive policy for RBC transfusions in neonates can be safely applied without expecting severe complications or differences in survival or neurodevelopment. 2

Transfusion Decision-Making

• Base RBC transfusion decisions on gestational age, day of life, cardiorespiratory support requirements, and presence of congenital heart disease 2
• Inform and involve parents in the decision-making process 2
• Nearly 50% of RBC transfusions are given to extremely low birth weight (ELBW) neonates in their first two weeks of life 2

Prevention of Anemia of Prematurity

• Delayed umbilical cord clamping 2
• Use umbilical cord blood for admission lab tests in very low birth weight neonates to decrease blood product requirements 2
• Minimize iatrogenic blood losses by reducing phlebotomies and using micro-methods with point-of-care devices 2
• Provide good feeding practices 2
• Supplement with 2-3 mg/kg iron in preterm neonates who are enterally fed, starting from the first 2-4 weeks of life 2

Erythropoietin (EPO) Use

• Routine administration of EPO in preterm infants is NOT recommended due to limited clinical benefits and potential increased risk of retinopathy of prematurity (ROP) 2
• EPO offers no benefit during the first weeks of life when transfusion need is highest 2

Respiratory Distress Syndrome Management

Surfactant Therapy (Poractant Alfa/CUROSURF)

• Administer 2.5 mL/kg (200 mg/kg) as initial dose for rescue treatment of RDS in premature infants 3
• Only administer by those trained and experienced in care, resuscitation, and stabilization of preterm infants 3
• Monitor for transient adverse reactions: bradycardia, hypotension, endotracheal tube blockage, and oxygen desaturation 3
• Do not suction airways for 1 hour after surfactant instillation unless signs of significant airway obstruction occur 3
• Requires frequent clinical and laboratory assessments as surfactant can rapidly affect oxygenation and lung compliance 3

Common Complications Associated with Prematurity and RDS

• Intracranial hemorrhage (51% in treated patients) 3
• Patent ductus arteriosus (60% in treated patients) 3
• Pneumothorax (21% in treated patients) 3
• Bronchopulmonary dysplasia (18% in treated patients) 3
• Pulmonary hemorrhage is a known complication of premature birth and very low birth weight 3

Point-of-Care Ultrasound (POCUS)

POCUS is increasingly used in neonatal intensive care for heart, lung, line placement, abdomen, and brain assessment, though high-quality evidence demonstrating improved outcomes is still emerging. 2

• Requires structured training programs and quality assurance 2
• Specific expertise required for extremely preterm neonates and non-sedated patients 2
• Guidelines provide substrate for curriculum development and standardization of clinical practice 2

Laboratory Values

Lymphocyte Counts in Newborns

• Lymphopenia in infants under 8 months is defined as <4,500/mm³, substantially higher than the adult threshold of <1,500/mm³ 4
• Premature infants (gestational age <37 weeks and/or birth weight <2,500g) may have lower lymphocyte counts as an isolated finding 4
• T-cell counts <1,500/mm³ in the context of suspected immunodeficiency warrant further evaluation with flow cytometry 4

Evidence-Based Medicine Implementation

Passive dissemination of research findings is generally ineffective in driving change; multifaceted approaches acting on different barriers to change are more effective. 5

• Network-based collaborative quality improvement programs facilitate continuous audit and benchmarking cycles 5
• Successful initiatives include reducing hospital-acquired bloodstream infections, optimizing surfactant use, reducing bronchopulmonary dysplasia, improving antibiotic stewardship, and promoting human milk use 5
• Quality improvement work in neonatology demonstrates improvement in clinical processes, outcomes, resource use, and healthcare costs 6