What are the essential components of neonatal care?

Essential Components of Neonatal Care

Neonatal care must be stratified by gestational age and birth weight, with infants <32 weeks or <1500g requiring Level III facilities with continuously available neonatologists, specialized nurses, and life support equipment, while appropriate thermal management, respiratory support, nutritional optimization, and infection prevention form the core pillars of care across all levels. 1

Level of Care Determination and Facility Requirements

The appropriate level of care is the foundation of neonatal management and directly impacts mortality and morbidity:

• Infants born <32 weeks gestation or weighing <1500g must be cared for in Level III facilities with continuously available neonatologists, neonatal nurses, respiratory therapists, and comprehensive life support equipment for sustained duration 2, 1
• Level III facilities must provide advanced respiratory support including conventional ventilation, high-frequency ventilation, inhaled nitric oxide, and the capability for prolonged mechanical ventilation (≥24 hours) 2, 1
• Infants ≥32 weeks gestation and ≥1500g with moderate illness can be managed in Level II facilities if problems are expected to resolve rapidly and subspecialty services are not urgently needed 2, 1
• Level II facilities can provide CPAP and brief mechanical ventilation (<24 hours) with continuously available equipment including portable x-ray, blood gas analyzer, and respiratory therapists 2, 1
• Late preterm infants (34-36 weeks) who are physiologically stable may be cared for in Level I facilities, though they remain at increased risk for morbidity requiring close monitoring 1

Critical pitfall: Do not delay transfer of infants <32 weeks or <1500g to Level III facilities—these infants require subspecialty care that cannot be adequately provided at lower levels 1

Thermal Management and Thermoneutrality

Maintaining a thermoneutral environment is essential to enhance body growth and reduce neonatal illnesses and mortality:

• Target body temperature of 37.0°C with continuous monitoring is essential for all newborns 3
• Skin-to-skin contact is the easiest and most rapidly implementable method to prevent body heat loss and should be used whenever possible 3
• For infants <32 weeks gestation, use a skullcap and polyethylene bag in the delivery room or during transport to prevent heat loss 3
• Preterm infants weighing <1600g should be nursed in a closed, convective incubator with humidified and warmed inhaled gases to limit water loss 3
• Thermoneutral environment minimizes energy expenditure and oxygen consumption, resulting in enhanced growth, decreased respiratory support requirements, increased glucose stability, and reduced mortality 4

Infection Prevention and Management

Group B Streptococcal (GBS) Disease Prevention

• Any newborn with signs of sepsis requires immediate full diagnostic evaluation including blood culture, CBC with differential and platelet count, chest radiograph if respiratory signs present, and lumbar puncture if stable 2, 5
• Empiric antibiotic therapy must include intravenous ampicillin (active against GBS) plus an agent active against gram-negative organisms such as gentamicin, initiated within 1 hour of recognizing sepsis 2, 6
• Well-appearing infants born to mothers with suspected chorioamnionitis require limited evaluation (blood culture and CBC) and antibiotic therapy pending culture results 2, 5
• For well-appearing infants born to GBS-positive mothers who received adequate intrapartum prophylaxis (≥4 hours of penicillin, ampicillin, or cefazolin before delivery), routine clinical care is sufficient if born at ≥37 weeks with membrane rupture <18 hours 5

Sepsis Management Protocol

• Full diagnostic evaluation includes blood culture, CBC with differential and platelet count, chest radiograph, and lumbar puncture for any neonate with signs of sepsis 2, 6
• Aggressive fluid resuscitation with 20 mL/kg isotonic crystalloid boluses up to 60 mL/kg in the first hour for pediatric septic shock, followed by early inotropic support if fluid-refractory 6
• Therapeutic goals include restoring normal heart rate, capillary refill ≤2 seconds, and normal blood pressure for age within the first hour of sepsis recognition 6

Nutritional Management

Nutritional support must be tailored to the infant's age and growth phase:

• Early parenteral nutrition in the first days of life requires lower mineral intakes: calcium 0.8-2.0 mmol/kg/d, phosphorus 1.0-2.0 mmol/kg/d, magnesium 0.1-0.2 mmol/kg/d 1
• Use molar Ca:P ratio below 1 (0.8-1.0) when intakes are low to reduce incidence of early postnatal hypercalcemia and hypophosphatemia 1
• Growing premature infants require higher intakes: calcium 1.6-3.5 mmol/kg/d, phosphorus 1.6-3.5 mmol/kg/d, magnesium 0.2-0.3 mmol/kg/d 1
• Careful monitoring of plasma phosphate concentration within first days of life is essential in preterm infants with intrauterine growth restriction to prevent severe hypophosphatemia that can result in muscle weakness, respiratory failure, cardiac dysfunction, and death 1

Critical pitfall: Do not overlook hypophosphatemia risk in growth-restricted preterm infants on early parenteral nutrition, as this can lead to life-threatening complications 1

Discharge Planning and Follow-Up

Infant Readiness Criteria

• Sustained pattern of weight gain of sufficient duration must be demonstrated before discharge 2
• Adequate maintenance of normal body temperature fully clothed in an open bed with normal room temperature must be achieved 2
• A primary care physician (medical home) should be identified well before discharge to facilitate coordination of follow-up care planning 2

Follow-Up Coordination

• Pertinent information about the nursery course, including discharge summary and home-care plan, should be given to the primary care physician before discharge 2
• Arrangements for an initial appointment with the primary care physician should be made before discharge, with specific follow-up appointments with surgical specialists and pediatric medical subspecialists grouped for family convenience 2
• Periodic developmental evaluation is essential for identifying deviations in neurodevelopmental progress at the earliest possible point, facilitating entry into early intervention 2
• Periodic examination by a qualified ophthalmologist must be available for infants who still require evaluation for retinopathy of prematurity 2