What are the latest neonatology practice guidelines for newborn care?

Latest Neonatology Practice Guidelines

Umbilical Cord Management

For term and late preterm infants ≥34 weeks' gestation who do not require resuscitation, delayed cord clamping for at least 30 seconds is beneficial and should be standard practice. 1

• Delayed cord clamping (≥30 seconds) is superior to early cord clamping (<30 seconds) for term and late preterm newborns not requiring resuscitation 1
• Intact cord milking is not recommended for term and late preterm infants ≥34 weeks' gestation, as it offers no proven benefit over delayed cord clamping 1
• For nonvigorous term and late preterm infants (35-42 weeks), intact cord milking may be reasonable compared with early cord clamping 1

Preterm Infants <34 Weeks

• Delayed cord clamping (≥30 seconds) is beneficial for preterm infants <34 weeks' gestation who do not require resuscitation 1
• For preterm infants 28-34 weeks' gestation where delayed cord clamping cannot be performed, intact cord milking may be reasonable 1
• Intact cord milking is contraindicated in preterm infants <28 weeks' gestation 1

Neonatal Resuscitation

Effective positive-pressure ventilation is the absolute priority in newborns requiring support after birth. 1

Device Selection for Positive-Pressure Ventilation

• T-piece resuscitators are preferred over self-inflating bags for delivering positive-pressure ventilation 1
• This recommendation reflects the most current 2023 American Heart Association and American Academy of Pediatrics guidance 1

Immediate Postnatal Care

• Secure the umbilical cord with a ligature or rubber cord ring rather than a cord clamp to prevent trauma around the umbilicus 1, 2
• Cover any birth trauma with cling film or nonadherent dressing immediately to prevent further trauma, reduce pain, and minimize infection exposure 1, 2
• Apply emollient to suction catheter tips required for mucus or meconium removal to avoid friction damage to the mucosa 1
• Apply a padded layer around the neonate if stimulation for breathing is required after birth 1

Respiratory Support Strategy

Noninvasive respiratory support with continuous positive airway pressure (CPAP) should be first-line therapy to avoid intubation and minimize lung injury. 3, 4, 5

CPAP Implementation

• Stabilization on CPAP at birth decreases the composite outcome of death or bronchopulmonary dysplasia 4
• Bubble CPAP is effective as first-line cardiorespiratory support in the delivery room and upon NICU admission 5
• Effective CPAP use requires coordinated interprofessional team approach, ongoing assessment, troubleshooting the circuit, and parent education 3

Less Invasive Surfactant Administration (LISA)

• LISA should be adopted as an alternative to intubation for surfactant administration in preterm infants with respiratory distress syndrome 4
• LISA decreases the need for mechanical ventilation and improves outcomes compared to surfactant administration via endotracheal tube following intubation 4
• This practice is widespread in Europe and should become routine in US neonatal units 4

Inhaled Nitric Oxide

Inhaled nitric oxide at 20 ppm is indicated to improve oxygenation and reduce ECMO need in term and near-term neonates (>34 weeks) with hypoxic respiratory failure and pulmonary hypertension. 6

• The recommended dose is 20 ppm, maintained for up to 14 days or until oxygen desaturation resolves 6
• Doses greater than 20 ppm are not recommended and show no additional benefit 6
• Avoid abrupt discontinuation, as this may lead to worsening oxygenation and increasing pulmonary artery pressure 6
• Monitor methemoglobin levels, as they increase with nitric oxide dose 6
• Inhaled nitric oxide is not indicated for ARDS or prevention of bronchopulmonary dysplasia in preterm infants ≤34 weeks' gestation 6

Routine Newborn Care

Physical Examination and Monitoring

• Perform complete head-to-toe examination with growth parameters (weight, length, head circumference) plotted on appropriate growth charts 2
• Assess umbilical cord healing, especially if ligature or rubber cord ring was used 2
• Evaluate skin for jaundice and quantify with transcutaneous bilirubin or total serum bilirubin if present 2
• Conduct neurological assessment including tone, posture, primitive reflexes, and spontaneous movements 2

Laboratory Testing

• Use venous sample rather than heel prick for newborn genetic screening tests on day 2-3 of life to reduce friction and avoid degloving injury 1, 2
• Mark venous samples as "venous" on test card 1
• For jaundiced infants, measure total and direct bilirubin levels 2
• For jaundice beyond 3 weeks or sick infants, measure total and direct/conjugated bilirubin to identify cholestasis 2

Minimizing Trauma

• Weigh neonate wrapped in blanket with tared scale to reduce movement and avoid trauma from handling naked 1
• Attach hospital ID band over clothing or socks, not directly on skin 1
• Cluster blood tests to reduce tourniquet use and handling that might cause trauma 1
• Give vitamin K, hepatitis B vaccine, or country-specific vaccinations at birth with low-adherent dressing to cover site if required 1

Temperature Regulation

• Do not nurse neonates in incubators unless medically necessary (e.g., prematurity), as heat and humidity exacerbate blistering in vulnerable infants 1
• Use overhead heaters only during procedures; use blankets to maintain temperature 1
• Use pressure-relieving, soft mattress or extra soft padding on beds 1

Special Considerations for Epidermolysis Bullosa

Recognition and Referral

• Urgently refer suspected epidermolysis bullosa cases to dermatology and EB specialist center for subtype-specific management 7
• Obtain genetic testing if epidermolysis bullosa is suspected based on widespread blistering 7
• Do not delay referral, as early implementation of preventative care strategies reduces morbidity 7

Oral and Feeding Care

• Use oral saline swabs moistened with normal saline for gentle oral care 7
• Cover feeding tubes with emollient to reduce friction trauma 7
• Avoid adhesive products; use silicone medical adhesive removers (SMARs) if any tape must be applied 7
• Give nonsedating pain relief 20 minutes prior to feeding for neonates with oral blistering or plaque 1
• Use soft silicone or cleft-palate-style teat for neonates with oral pain and blistering, warming to soften before use 1

Pain Management

• Always monitor pain using validated neonatal pain scale such as Neonatal Infant Pain Scale (NIPS) or FLACC 1
• Use sucrose, paracetamol/acetaminophen, and/or oral morphine/oxycodone as first-line medications for pain relief, especially for degloved wounds 1
• Refer to acute pain team for complex and ongoing pain management if first-line medications are insufficient 1
• Implement nonmedication-based pain relief strategies including swaddling, patting, rocking, calm music, and singing 1

Wound Care

• Cover birth trauma with cling film or nonadherent dressing to prevent further trauma, reduce pain, and minimize infection exposure 1
• Avoid aggressive manipulation or biopsy of suspected epidermolysis bullosa lesions without specialist consultation, as trauma worsens blistering 7
• Monitor neonates closely for signs of sepsis, as neonatal sepsis can lead to rapid deterioration in severe subtypes 1
• Include dermatologist in planning wound management and rotation of neonatally appropriate wound irrigation products 1