Dear Readers in the world
Thank you for reading our templates.
We plan to compare the treatment strategy for ELBW in the first few days. Unfortunately,
there is no time for us to show them all in the workshop on October 7, 2023.
Thanks to the Chairperson, Prof. Tanaka, we have an opportunity to put them on thewebsite beforehand.
I would like you to download and compare your NICU with our 6 NICUs.
Hidehiko Maruyama
Seung Han ShinOur treatment strategy for ELBW
in the first few daysin Nagano, Japan

Nagano Children’s Hospital, Division of Neonatology
Arata Oda, MD

NICU introduction• NICU 42 beds (18 NICU bed and 24 step down bed)
• NICU staff 8, fellow 6, resident 1~2

Nagano Childrenʼs Hospital NICU

42

400

30

15

70

NICU beds

Admission/year

ELBW/year

DoctorNurse

250
Emergencytransport

100
CHD /year

NaganoChildren’s
Hospital

100
NAVA ventilation /10 year

Family centered care

Management in the delivery
room (DR)Location and temperature control• In case of C/S• DR is located next to OR.
• Ns transport OR to DR with holding.

• In case of vaginal delivery• DR is located in same floor, it takes 2 min.
• Dr and Ns transport the baby with incubator.

• Delivery room temperature:30℃• Temperature control modality for baby

• Warmer:>37, plastic bag(+), thermal mattress(-)• All procedures are done in the incubator.

Cord management• Provide delayed cord clamping?
• No• Provide cord milking?
• Yes• Any criteria or contraindication for milking?
• Born less than 28 wk• Provide skin to skin contact immediate after birth?
• No. The mother touch her baby’s hand and/or head.

Initial step and monitoring• Any range of birthweight or GA for skipping initial step?
• Initial step: warm, dry, position, suction, stimulation• Yes and No, we always provide initial step such as warm, dry, suction, rarely stimulation
if tolerated.

• Routine use of ECG monitoring?
• YesRespiratory support at delivery room
• Do you use T-piece resuscitator? (in the DR and during transport)• No• Do you routinely give CPAP?
• Yes and No, if infants have spontaneous breathing, then we do CPAP.

• Selective vs. Prophylactic surfactant• Prophylactic surfactant is done after checking ETT position by CXR.

Respiratory managementin the first 72 hours.

What is common practice for respiratory supports
in NICU?
Item

Comment

Primary mode if spontaneous
respiratory efforts are good

CPAP=mask CPAP
Maximum settings of pressures on nasal supports ?: 5-8cmH2O

Thresholds for intubation andearly rescue surfactant

Mandatory intubation
Rarely non-intubated management

Methods of surfactant
administration

INSURE/ INRECSURE/ LISA/ MIST :No

Mode of ventilation on first
0-3 days

SIMV+PS sometime use VG

Second dose surfactant

If oxygen demand is more than >30-40% and CXR finding shows the collapse.

The first 72 hours…
Targets in Blood gases(day 0-3)

pH >7.25
pCO2 upto what value is “permitted” :Approximately 40-50
pO2 : is it required if SpO2 is targeted:SpO2>94, pO2> 60

Target X ray findings

Posterior rib spaces :7~8
No collapse lung regions
ETT position ideal: Th 2

When is extubation first considered?

Based on respiratory drive, circulatory status, sensorium: Actually
30-32 week in 23-25 week

When is postnatal steroid considered?

Only after 7 days of life: As after as possible
How is risk for BPD assessed?:Bubbly/Cystic appearance on CXRWhat preparation and what regimen of steroids?:
HDC: 5-5-3-3-2-2-1-1mg/kg/d
Dex: 0.5-0.5-0.5-0.3-0.3-0.2-0.2mg/kg/dInhaled nitric oxide in preterm infants

Criteria for administration?: PH is suspected, use 1-5ppm

Often encountered complications/ adverse
events ?
Item

Comment

ET tube position changes

Methods of ETT fixation used in individual units: Erastikon tape

Pneumothorax

ICD insertion and fixation protocols: enough space to insert ICD is found

CPAP “Belly”

Feed escalation plans: increase 20ml/kg/d , any decompression methods actively
used, Use of glycerin enema as a routine, flatus let out tubes in rectum.

Spontaneous intestinal
perforation

With use of CPAP/ Nasal IMV: maximum settings tolerated: ８cmH2O
How to differentiate from peritonitis?
Threshold for surgical intervention ? : We do at least drainage if we find SIP.

VAP

Care bundles, Colostrum into the mouth Nurse: patient ratios = 1:2~3, Minimum
experience of nurse allocated to ELBW?

Circulatory managementin the first 72 hours.

What is your routine for circulatory management ?
Item

Comment

Heart rate

Acceptable range 100 - 160

SpO2

Acceptable range >94 withing 72 hours. 88-94 after 72 hours

Blood pressure

We try to get umbilical arterial line or peripheral arterial line.
Target mean BP will be over/same the number of gestational week.

Urination

Keep 1ml/kg/h and without lactate increasing

Blood test

Lactate; we often check it as circulatory status.
BNP; we use for heart failure for congenital heart disease. So we rarely use for
ELBW.

Input volume

Day 0; 60ml/kg/day+extra (RBC, FFP, Alb, IgG)
Day 1; 70
Day 2; 80
Day 3; 100

NIRS

never

How to diagnose “symptomatic PDA”?
Item

Comment

Echocardiography

We use it from the time of admission.
We use it 2-3 times / day.
We collect the data, LVDD, EF, LA/Ao, Lt PA diastolic flow, DA diameter, DA
flow velocity, DA flow pattern, and ACA-RI

UltrasoundWe also check the flow of anterior cerebral artery and systemic artery (such as
renal artery).

Heart rate

Consider if HR>180

Urination

Consider if Urination less than 1ml/kg/hHow to treat “symptomatic PDA”?
Item

Comment

Medication

Indomethacin;
For less than 25 weekers of less than 27weeks if STA given
Ibuprofen; rarely use.

Surgery…

Refractory cases for indomethacin 3 times or side effect could not torelate
Infants with low renal function

How to manage “hypotension”?
Cause

Comment

Hypokinesis

Excessive afterload-> Vasodilators: rare, Diuretics: sometime, sedation: sometime
No excessive afterload-> Inotropes, steroid
Dopamin :start 3-5mcg/kg/min, max 10
Dobutamin :start 3-5mcg/kg/min, max 10
Hydrocortisone: 1-2mg/kg/dose

Hypovolemia

Volume expander-> Saline, RBC(RCC), FFP, albuminPositioning and Handlingin the first 72 hours.

Positioning
Topics

Details/Comments• Infant’s
positioning• Do you usually put a baby in midline positioning?
• What positions of babies are allowed in your unit during thefirst 72 h? (supine only)• Age of infants you allow to put a baby in prone or otherpositions (after 72 h when UV/UA is removed)• Equipment used to support head/ positioning (kind of nest)• Leveling bed• Degree of head elevation (about 15°)

Handling
Topics

Details/Comment• Gentle
Handling• minimal and handling rules: don’t touch frequently• Diaper change• How many people your unit use ?:1 until when: <72h
• Special technique? : none

• Changing bed
sheet• How many people your unit use (1 or 2 )? until when?

• Weigh a baby

• How many times you weigh a baby/day?
• How many people your unit use (1 or 2)? until when ?

• X-ray• Do you usually use incubators with an X-ray cassette tray port

Handling
Topics• Holding or
Kangaroo care

Details/Comment• What ages of infants you allow parents to do Kangaroo care(<72, >72, >7 days?)

IVH result

2019-2021
GA<28w(n=44)
Exclusion (n=0)
Chromosomal abnormality (n=0)
Critical anomaly (n=0)
IVH before birth (n=0)
Analyzed infants (n=44)
Inborn (n=40)
GA 26±5w
BW 802±239g

Death (n=2)
IVH (-) (n=0)
IVH 1 (n=1)
IVH 2 (n=0)
IVH 3 (n=0)
IVH 4 (n=1)

Discharge (n=42)
IVH (-) (n=32)
IVH 1 (n=9)
IVH 2 (n=0)
IVH 3 (n=1)
IVH 4 (n=0)

Our treatment strategy for ELBW in the first few days
- Seoul, The Republic of Korea
In Gyu Song MD, MPH, PhD
Division of Neonatology, Department of Pediatrics,
Severance Children’s Hospital,
Yonsei University College of Medicine

Severance HospitalSeverance HospitalFounded in 1886 by Dr. H. N. Allen
Total 2,437 beds
280 beds in the children’s hospital
NICU 52 beds
NICU 6 staffs, 2 fellows, 2 residents

Severance HospitalFounded in 1886 by Dr. H. N. Allen
Total 2,437 beds
280 beds in the children’s hospital
NICU 52 beds
NICU 6 staffs, 2 fellows, 2 residents

Managementin the delivery room (DR)Location and temperature control• In case of C/S• How far is DR from NICU (how far? how long it takes? any floor change? ):At another building and one floor below• How do you support during transport: portable ventilator• In case of vaginal delivery: a few cases• How far is DR from NICU: one floor above• How do you support during transport: portable ventilator• Delivery room temperature: 25⁰C
• Temperature control modality for baby
• Warmer, plastic bag, hat

Cord management• Provide delayed cord clamping?
• No• Provide cord milking?
• No• Any criteria or contraindication for DCC/milking?
• No• Provide skin to skin contact immediate after birth?
• No

Initial step and monitoring• Any range of birthweight or GA for skipping initial step?
• Initial step: warm, dry, position, suction, stimulation• No, we always provide initial step according to NRP• Routine use of ECG monitoring?
• YesRespiratory support at delivery room
• Do you use T-piece resuscitator?
- In DR yes, and we use a portable ventilator during transport.

• Do you routinely give CPAP?
- No• Selective vs. Prophylactic surfactant- Mostly ‘prophylactic’.
- In Korea it is covered by National Health Insurance (NHI) for GA < 30 or Bwt ≤ 1,250g

Respiratory managementin the first 72 hours.

What is common practice for respiratory supports
in NICU?
Item

Comment

Primary mode if spontaneous The primary mode would be one of invasive methods.
respiratory efforts are goodThresholds for intubation and Mandatory intubation
early rescue surfactant
Methods of surfactant admini Traditional method
stration
Mode of ventilation on first 0-3 days

Mostly SIMV (pressure control) + Pressure support(For 24 weekers, HFOV)Second dose surfactant

After 6 hrs (according to NHI), FiO2 > 0.4 and RDS features in chest x-ray

The first 72 hours…
Targets in Blood gases(day 0-3)

pH >7.2
We don’t check lactate.
pCO2 upto 55 mmHg

Target X ray findings

Posterior rib spaces: 8 ~ 9
ETT position ideal: T2 ~ 3

When is extubation first considered?

Based on respiratory drive, circulatory status, sensorium
What if sedation was being given? – may not extubate

When is postnatal steroid considered?

Only after 7 days of life? Yes.
How is risk for BPD assessed?
What preparation and what regimen of steroids?
- DART protocol (0.89mg/kg for 10 days)

Inhaled nitric oxide in preterm infants

Practice – 20 ppm
Criteria for administration – NHI- FiO2 ≥ 50 % and OI ≥ 15
- EchoCG: RL shunt, D-shape, TR

Often encountered complications/adverse events ?
Item

Comment

ET tube position changes

We don‘t change ET tube position within 2 weeks after birth.
If it is needed, we do it with 2 nurses. We don’t use NeoBar®.

Pneumothorax

ICD insertion and fixation protocols – consult to thoracic surgeons

CPAP “Belly”

Feed escalation plans: 20 mL/kg/day
Decompression methods: low negative continuous pressure (30 ~ 40 mmHg)
Use of glycerin as a routine: not routinely but mostly

Spontaneous intestinal per
forationWith use of CPAP/ Nasal IMV: maximum settings tolerated ?
How to differentiate from peritonitis?
Threshold for surgical intervention ?

VAP

We have care bundles. One nurse (≥ 2 years of experience) takes care 1 extremely
preterm infants and other 1 or 2 patients.

Circulatory managementin the first 72 hours.

What is your routine for circulatory management ?
Item

Comment

Heart rate

Acceptable range 100 - 160

SpO2

Acceptable range 93 ~ 95 %Blood pressure

We try to get umbilical arterial line for ≤ 25 weekers.
Target mean BP will be over the number of gestational week.

Urination

Based on serum sodium level and body weight.

Blood test

Lactate; we don’t check.
BNP; For PDA treatment (usually 7 ~ 14 days)

Input volume

Day 0; 50 ~ 60 mL/kg/day
Day 1; 70 ~ 80 mL/kg/day
Day 2; 90 ~ 100 mL/kg/day
Day 3; 110 ~ 120 mL/kg/day

NIRS

We don’t use this routinely.

How to diagnose “symptomatic PDA”?
Item

Comment

Echocardiography

We use it once a day.
We collect the data, LA/Ao, DA diameter, R-L or L-R shunt

UltrasoundWe also check the flow of anterior cerebral artery and systemic artery(such as celiac trunk or SMA).

BNP

Trend

Chest x-ray

Cardiomegaly
Pulmonary edema

Urination

Trend

Blood pressure

Widening pulse pressure and low mean BP

Medication

We only have ibuprofen (IV and PO) in Korea.

Surgery

Refractory cases for ibuprofen 2 cycles.
Infants with low renal function or other contraindications of medical treatment.

How to manage “hypotension”?
Cause

Comment

Hypokinesis

Dopamine
Hydrocortisone- When dopamine > 10 mcg/kg/min, then HCS 1 mg/kg/dose q8hrs
Dobutamine

Hypovolemia

Volume expander- Saline > FFP > RBC(RCC) > 5% albuminPositioning and Handlingin the first 72 hours.

Positioning
Topics

Details/Comments• We put a baby in neutral position for the first week and then change (supine, side lyi
ng, prone)• Equipment used to support head/positioning: nest

Infant’s positioning

Leveling bed•

Degree of head elevation: 15 ~ 20◦

Handling
Topics

Details/Comment

Gentle Handling• We routinely use minimal and gentle handling rules.

Diaper change• How many people your unit use: one nurse

Changing bed sheet(with weighing a baby)• How many people your unit use: a baby with a ventilator(invasive or non-invasive), 3 people

Weigh a baby

• We weigh a baby once a day.
• How many people your unit use: 2 people

X-ray• Do you usually use incubators with an X-ray cassette tray port:
Yes

Holding or Kangaroo care

• What ages of infants you allow parents to do Kangaroo care:> 14 days and not intubated

IVH results

2019 - 2021
GA 24 - 27w(n = 72)

Analyzed infants (n = 70)
Inborn (n = 66)
GA 26 ± 1 wks
BW 824 ± 199g

Death (n = 1)
IVH (-) (n = 0)
IVH 1 (n = 1)
IVH 2 (n = 0)
IVH 3 (n = 0)
IVH 4 (n = 0)

Exclusion (n = 2)
Chromosomal abnormality (n = 0)
Critical anomaly (n = 1)
IVH before birth (n = 0)
Died before brain sono (n = 2)

Discharge (n = 69)
IVH (-) (n = 29)
IVH 1 (n = 28)
IVH 2 (n = 5)
IVH 3 (n = 1)
IVH 4 (n = 6)

Thank you for your attention!
igsong@yuhs.ac / pedigms@gmail.com

Strategy for EPIs within 72 hours
single center experience
Reporter: Pei Lu
Institution: Department of neonatology
Shanghai Children’s Hospital
Shanghai Jiao Tong University

History
NICU createdInitiate emergency neonataltransports

1959

1983

1999

The neonatology

Established as Shanghai

department createdChildren's Emergency Center

2001

2010

Neonatal Emergency Transportation
Center establishedIntroduction

Introduction
Highlighted Techniques
Neonatal ECMO, Neonatal CRRT, Neonatal transfer, etc.

Specialties
The percentage of challenging and critical cases is increasing
The percentage of VLBWs and ELBWs is rising drasticallyWorkload
Receiving neonates from 30 maternity hospitals
The number of NICU discharges has been stable at around 4,500 per year
2,500+ follow-up appointments annually for infants at high risk

Introduction

Neonatal CRRT
Since 2012
47 Cases

科室文化？

Introduction

Implement

Neonatal ECMO
Since 2018
6 CasesCatheter
insertion

Implement
2014年

Introduction of Neonatal Transfer
Transfer

Comprehensive management

Movable NICU
Pre-hospital treatment

In-hospital treatment

The "integrated and consolidated management" model unifies pre-hospital emergency transportation, inhospital critical illness treatment, post-hospital comprehensive follow-up, and health management, improves
the standard of care and survival rate for infants discharged from hospitals with critical illnesses

Transfer

2019: 1862 transfers
2020: 1008 transfers

Number of newborns transferred per year

TransferTransferpremature infants 96.7%

VLBWs 93.1%

GA：22+2W
BW：500g

GA：24W
BW：780g

ELBWs 80%

GA：25+4W
BW：665g/760g

Respiratory management
ü Start CPAP or (S) NIPPV as soon as possible in all babies at risk of RDS
ü Surfactant when FiO2 > 0.3 on CPAP pressure ≥6 cm or <30 weeks and intubatedü Use natural surfactant given by LISA techniqueü A second and third dose of surfactant can be given if there is ongoing evidence of RDS
ü Lung-protective modes such as VG if MV is requiredü Minimize the duration of MV, tolerate moderate hypercarbia but maintain pH above 7.22
ü Spontaneously breathing babies on MV will be extubated to CPAP or (S)NIPPVü Use caffeine routinely in infants <32 weeks to minimize need for MV
ü Oxygen saturation target should be between 90 and 94% with alarm limits 89% and 95%
ü Consider low-dose dexamethasone to facilitate extubation in infants ventilated > 1–2 weeks

Sweet DG, Carnielli VP, Greisen G, et al. European Consensus Guidelines on the Management of Respiratory Distress Syndrome: 2022 Update. Neonatology. 2023;120(1):3-23. doi:10.1159/000528914

Circulatory management
ü Fluids are initiated at about 70–80 ml/kg/day and adjustments individuallyü Treatment of hypotension will only be initiated when there is evidence of poor tissue
ü Treatment of hypotension will depend on the cause, dopamine is more effectiveü The targeted mean BP should be above the level of GA within the first 72 hours
ü Routine treatment of PDA closure is not considered good practiceü Pharmacologic closure will only be considered when hemodynamically significant PDA is recognizedü Ibuprofen or paracetamol can be used with a similar efficacy
ü Surgical ligation has a place only if medical therapy has failed

Sweet DG, Carnielli VP, Greisen G, et al. European Consensus Guidelines on the Management of Respiratory Distress Syndrome: 2022 Update. Neonatology. 2023;120(1):3-23. doi:10.1159/000528914

IVH Results
2019-2021
GA<28w(n=43)

Exclusion (n=1)
Chromosomal abnormality (n=1)
Critical anomaly (n=0)
IVH before birth (n=0)

Analyzed infants (n=42)
Outborn (n=42)
Mean GA 26.5w
Mean BW 900g
Death (n=10)
IVH (-) (n=1)
IVH 1 (n=2)
IVH 2 (n=0)
IVH 3 (n=1)
IVH 4 (n=3)
Data unavailable(n=3)

Discharge (n=32)
IVH (-) (n=13)
IVH 1 (n=10)
IVH 2 (n=5)
IVH 3 (n=2)
IVH 4 (n=2)

THANKS FOR LISTENING!

Оur treatment strategy for
ELBW in the first few daysin Ulaanbaatar, Mongolia

Narantsetseg.Ch
MD. MSc
Division of NICU, Children’s hospital.
National Center for Maternal and Child
Health.

NEONATOLOGY UNITED DEPARTMENT
OBG hospital

CHILDRENʼS HOSPITALNICU / BEDS -12/

NICU-Highly specialized area in the hospitalwhere critically ill, high risk newborn /Neonatal
cared reduce mortality and morbidity wholecountry-Management of complex life threatening diseaseprovision of Intensive monitoring & initiation of life
sustaining therapies in and organized manner tocritically high risk newborn-Higher equipped ; Ventilator management/SIMV, IMV, NIV HFOV, blended oxygentherapies
Hip, ROP, Hearing screening .Metabolic sometest
LEVEL-III

Preterm NICU

Neonatal
Pathology
45 beds

bed-15/
Nursery beds ‒ 60

Preterm NICU
Grow care
Follow up highrisk PRETERM
HIP and ROP,Hearing
screening +LEVEL-III

Initial stabilizing
RESPIRATORY
care of preterm
and term
newborn
HIP screening +LEVEL-III

Introduction: NCMCH NICUs• We have 2 NICUs in separate buildings , one NICU with 15 beds andthe other for preterm infants with 12 beds
• NICU staff – 29 in the NICU and 56 in the preterm nursery• Neonatologists – 6/9/7 total -22 physician• In the NICU, there are 4 pediatric (residents) on for 2 week rotations• 1-3 Neonatology fellows for 6 month rotations• One nurse shift : 4-5 person• 4 nursing assistants every shift in the NICU

Management in the delivery
room (DR)Location and temperature control
C/S Deliveries:• From the delivery room to NICU Preterm deliveries are on the same floor as the nursery; (1-2
minutes away)• Full term deliveries occur 4 floors above the NICU (about 5-10 minutes depending on the elevator)• During transportation we mostly use PPV by Ambubag and Neo Puff, and swaddle the infants forthermoregulation• Vaginal deliveries:• Between DR and NICU takes around 5 minutes by elevator. The delivery room for term
infants is on the sixth floor and the nursery is on the second floor• We swaddle the infants with a blanket during transport ; respiratory support by PPV or
oxygen by mask or cannula or ... Ambubag is used for full term babies and flow inflating maskfor preterm infants.
• Delivery room temperature: Average 24-25 degrees celcuis• Temperature control modality for baby
• For preterm infants : Infant warmer, plastic wrap, thermal mattress, incubator• For term infants : Infant warmer and swaddle, hat, with a blanket during transport

Cord management• We successfully implemented (ENC) essential newborn care for every delivery
and delayed cord clamping until the cord pulsations stop - at least for 60
seconds• We do not routinely milk the umbilical cords.
• Delayed cord clamping is not performed if the baby requires emergency
resuscitation NRP or but we …
• Skin to skin contact is provided immediately after birth for most vaginal
deliveries, breathing well if there are no difficulties during birth.

Initial steps and monitoring
For all other infants, we same always provide initial step according to
NRP (AAP guidelines )üWe skip initial some steps ELBW and <1000 gr birth weights, andonly suction , if visible secretions in the mouth; most cases are
directly intubated in the DR.
üWe do not routinely monitor the ECG on all babies because we do
not have small enough gel electrodes (the big size is too difficult)üA pulse oximeter is used on all babies .

Respiratory support in the delivery room
• We use a T-piece resuscitator in the DR but not during transport• Do you routinely give CPAP? Any indication?
-CPAP is routinely given to Babies <30 weeks gestation or with BW <1000g,
to those with moderate and severe respiratory failure and topreterm infants with RDS- Before and after Surfactant replacement therapy-CPAP is also given after admission if the baby’s respiratory status is worsening.
-Apnoec episode more than >3 times a day, required PPV• Selective vs. Prophylactic surfactant. Any indication?
-We following the AAP Clinical guidelines for RDS updated 2022
-In addition, surfactcant is given if X ray shows severe RDS and ground glass
appearance or if-There is continued high FIO2>0.4-0.5 requirements after CPAP and CMV

Respiratory managementin the first 72 hours.

What is common practice for respiratory support
in the NICU?
Item

Comment

Primary mode if
spontaneous respiratory
efforts are good

We use initially CPAP and SIMV modes short time, also simple Bubble nCPAP
Our ventilator mode does not offer NIPPV ..?
Maximum settings of pressures on nasal supports ?
PEEP <6-8 cm H2OFlow 5-10 l/min

Thresholds for intubationand early rescue surfactant

Mandatory intubation/ trial non invasive methods/ need of FiO2 >30-40% forIntubation; If on NIV the infant needs more than FIO2>0.5 and RDS worsening

Methods of surfactant
administration

Most of them INSURE methods given Curosurf
Now we changed to LISA methods , (small feeding tube and angiocath…)

Mode of ventilation on first
0-3 days

SIMV and PC/AC mode pressure support

Second dose surfactant

If X ray still continued worse sign, clinically not stable, high FIO2 required: weThe first 72 hours…
Targets in Blood gases pH>7.28. Lactate < 4 permitted pCO2 up to 50 mm Hg; Po2>60 mm Hg(day 0-3)
SpO2 targeted >90-95%
Target X ray findings

Posterior rib spaces (8)No collapse lung regions
ETT position ideal? Determined by auscultation, and clinical observation

When is extubation
first considered?

Based on respiratory drive and hemodynamic status
We avoid to use for preterm ; IF needed we use short time fentanyl 0.5 mcg /kg or
phenobarbital
Sedation is stopped at least 4 hours prior to extubation

When is postnatal
steroid considered?

Delay of administration is desired, (7day) but often given by three days of life…
How is risk for BPD assessed?
Clinical findings , X-ray findings and oxygen requirements after 28 days of age;
Considered high risk if intubated AND ventilator supporting more than 7 days;
Dexamethasone; 0.15 mg/kg once daily at least 3 days
BPD diagnosed: We use DART protocols 9 days

Inhaled nitric oxide in

We do not have this available yetOften encountered complications/ adverse events ?
Item

Comment

ET tubepositionchanges

The ET is taped to the side of the mouth
We do not change between 7 days. If no any self extubation or any mispositioning

Pneumothorax

ICD insertion and fixation protocols: Not own protocol yet, but in emergency situation
Neonatologist do needle aspiration , than the surgeon insert tube and secures it
We have a lot of case complication pneumothorax and air leaks syndrome… ?

CPAP “Belly”-We use open feeding tube for decompression before feeding time and actively suction if
dependent drainage is not successful-Skip feeding one time and decrease oral intake 4-5 ml/per feeding

Spontaneous
intestinal
perforation

With use of nCPAP/ Nasal IMV: Maximum PEEP of 7 cm
We have few cases of SIP ;How to differentiate from peritonitis? Clinical evalution and critiria of infection
Threshold for surgical intervention ? Check in X-ray (free air) and clinical appearance ofabdomen

VAP

Care bundle .1:2-3 nurse: patient ratio Respiratory hygiene is important, routinely care mouthCirculatory managementin the first 72 hours.

What is your routine for circulatory management ?
Item

Comment

Heart rate

Acceptable range 100 – 160.
Newborn 120-160 preterm <180

SpO2

Acceptable range 88-96% saturation: We do not aim at SpO2 >95% with oxygen.
We monitor by oxygen saturation target by GA target

Blood pressure

We never try to get umbilical arterial line on aim for measure BP : We use non invasive
methods
Target mean BP will be over the number of gestational age weeks. (AAP guedlines ,Uptodate)

Urination

2-6.5 ml/kg/h

Blood test

Lactate; we often check it as circulatory status.
BNP; we not use for heart failure for congenital heart disease. So we rarely use for ELBW.

Input volume

Day 0; 60-80 ml/kg/day
Day 1; 60 full term, preterm -80 ml/kg
increase next day 10-15 ml/kg/day , depending on patients with warmer table or incubator care
Day 2; 70 ml/kg/d
Day 3; 80-100 ml/kg/d day 4 -120 ml/kg day 5; 6;-..130 …. upto 150 ml/kg

How to diagnose “symptomatic PDA”?
Item

Comment

Echocardiography

Echocardiograms are available on admission if needed. We consult cardiologist forechocardiogram after 72 hours if clinically indicated. Our pediatric cardiologist
recommends if an echocardiogram is needed.
IV Indomethacin is not available us.
We collect the data, LVDD, EF, LA/Ao, Lt PA diastolic flow, DA diameter, DA flow
velocity, DA flow pattern, Cardiologists collect data as needed.

UltrasoundWe also check the flow of anterior cerebral artery and systemic artery (such as renalartery).
No , our radiologists do not routinely measure it . Not any practice yet

Heart rate

Clinical Symptomatic (160-180 per /min )If murmur is auscultated

Urination

2.5-6 ml/kg/min (if urine output is out of normal range)
Check sodium level diuresis and fluid balance/day

How to treat “symptomatic PDA”?
Item

Comment

Medication

We do not have IV indomethacin or Ibuprofen
available to treat PDA
Orally used some symptomatic PDA.

Surgery

Refractory cases for indomethacin and/or ibuprofen
Infants with low renal function
Our pediatric surgeon has performed open chest
ligation on a few preterm cases in babies more than
2000gr,…

How to manage “hypotension”?
Cause

Comment

Hypokinesis

Vasodilators and diuretics
To avoid hypovolemia , keep systemic circulation defending on HF
stages (to evaluate LV and RV function )Dopamin : We use Dopamine and if shock will use Dexamethazone
Dobutamine is available but rarely used.
Hydrocortisone-not yet use it

Hypovolemia Volume expander
Saline and Ringer’s lactate solution , Albumin or RBCs if anemia…

Positioning and Handlingin the first 72 hours.

Positioning
Topics

Details/Comments• Infant’s
positioning• We do and keep neutral midline and head tilt position• During the first 72 h? (supine, side-lying, prone?) : Supine AND
side-lying• A baby in prone or other positions (48 h, 72 h, 7 days?) : Morethan 7 days
• Equipment used to support head/ positioning: Cloth and cottonmaterials are prepared by the nurse based on the newborn’s
weight and used to support the baby’s position• Leveling bed• Degree of head elevation (e.g. 0°, 15-30°, other?)• Mostly recommended 15-30 degrees,Handling
Topics

Details/Comment• Gentle Handling • To avoid much touching and not frequently• Diaper change• Our unit 1 nursing assistant per every nurse shift. She will change
diapers every 3-6 hours before feeding• We avoiding Hip dysplasia, so use special techniques to support the
infant following and during diaper changing• Changing bed
sheet• Every 12-24 hours done by nursing assistant and nurse together (2)• Weigh a baby

• (EENC )After 24 hours. Once a day• All nurse and nurse assistant can do and we weigh at 6 am

• X-ray• We have Xray cassette ports but they are not used by ourtechnician. The cassette size may not be correct for port . Our
radiologists recommend the infants be supine for x-rays.

Handling
Holding or Kangaroo care
• If preterm vital signs and hemodynamic status is stable we do
Kangaroo care if possible.
• It is not done on intubated patients. It is offered if the NICU
nursery is not too busy and staff is available to assist.
• KMC: We start if baby on CPAP or HFNO

New technology• Noninvasive and invasive ventilation
mode (PC/PS ;SIMV, VG/Vt IMV, NIV
HFOV, CPAP, blended oxygen therapy )• Surfactant replacement therapy (LISA)• HFNC-high flow nasal cannula• HFO-Oxygen treatment• PICC-Periperally inserted central line
• HFV-High frequency ventilation• Nasal intubation• Continues sedation after operation• New Standartised Parenteral nutrition
for preterm and term (Numeta G13%E,
Numeta G16%E)-To measured Intra abdominal pressureKapnomonitoring and Nasal intubation

2019-2021
GA< 25-29 wks(n=_217)
Exclusion (n=8)
Chromosomal abnormality (n=_1_)
congenital malformation (n=8)
IVH before birth (n=_2)
Analyzed infants (n=_209)
Inborn (n=_175)
GA _27.0±2.6 wks
BW _877_±199 g

Death (n=_34_)
IVH (-) (n=_)
IVH 1 (n=__)
IVH 2 (n=_6_)
IVH 3 (n=18)
IVH 4 (n=10)

Discharge (n=175)
IVH (-) (n=_62_)
IVH 1 (n=_33_)
IVH 2 (n=_58_)
IVH 3 (n=_21_)
IVH 4 (n=_1_)

Our Treatment Strategy for ELBW in
the First Few Days in Bangkok, Thailand
Buranee Swatesutipun M.D.
Division of Neonatology
Faculty of Medicine
Ramathibodi Hospital
Mahidol University
Bangkok, Thailand

NICU Introduction• Total 15 NICU beds
• 5 NICU attending staff• 7 Neonatology fellows (2-year training program)• 45 Pediatric residents (3-year training program)• Team composition / 1 rotation: 2 NICU staff, 2-4 fellows, 2-3 residents

Photo Courtesy of T. Surakupt

Management in the Delivery Room (DR)Delivery Room (DR) & Operating room (OR)
LocationManagement• DR are in the same area of OR• Prenatal care: dexamethasone,
MgSO4, tocolytic agents• Both are not located near NICU
(different floor)• DR temperature 23°C

• Average transport time from DR to
NICU is 5-10 min• Use a radiant warmer, plastic
bag/hat to control body temperature• DR management & transport arehandled by the same team using atransport incubator, t-piece
resuscitator & monitors• A warmer mattress is not available

Cord Management• Delay clamping the cord (DCC) at least 30 sec for all preterm infants• A baby is placed at the level of lower abdomen• Contraindications for DCC are§ Placental circulation not intact§ Not vigorous after gentle stimulation or suction by OB providers• We do not provide umbilical cord milking

Steps of Neonatal Resuscitation• Follow the steps of the NRP algorithm(AAP) – ABCD in all cases• Monitor temperature and oxygen saturation• Plan to implement routine ECG monitoringin DR/OR in the near future

Figure of the NRP 8th Edition algorithm from AAP

Respiratory Support in DR/OR• Routinely use a t-piece device when require CPAP or PPV• Give CPAP 5-7 cmH2O with FiO2 0.3 if labored breathing (grunting or
retraction) but HR >100/min• PPV with the initial setting: PIP 20-25/PEEP 5 cmH2O, FiO2 0.3• Surfactant therapy is not given in DR/OR

Respiratory Management in the First 72 Hours

Photo Courtesy of parents and N. Tongsawang

Respiratory Support in NICU
• Use CPAP as a primary mode for spontaneous breathing infants• A flow-driver CPAP with maximum PEEP 7 cmH2O• Administer surfactant (Poractant alfa) with less-invasive technique (prefer
LISA) if require FiO2 >0.3 to keep SpO2 90-95%• Second dose of surfactant is given if require FiO2 >0.3 - 0.4• Intubation if§ Require FiO2 >0.6
§ Increased WOB§ Frequent apnea§ Severe respiratory acidosis• If use MV, always start with VTV (VG) with Pmax 25, VG 5 mL/kg

Respiratory Support in NICU
• Target blood gases§ pH 7.25-7.35, pCO2 45-55, pO2 50-70, BD <-10, and aim to keep lactate <2• Target CXR§ Inspiration: posterior rib 8-9th§ Position of ETT: T1-T2 level (above the carina)• Consider extubation when stable vital signs and§ Has spontaneous breathing§ Require MAP <8, FiO2 <0.4, and back up RR <30/min§ No / minimal sedative drug use• Postnatal corticosteroids§ Consider DART regimen when prolonged intubation >1 week
§ Consider inhaled steroids if high risk to develop BPD• Start inhaled NO if PPHN is diagnosed and OI >15

Circulatory Management in the First 72 Hours

Circulatory Management in NICU
• Acceptable vital signs and urine volume§ HR 100-160, RR 40-60/min§ Mean BP >GA (weeks) and SBP / DBP >3rd percentile§ Urine 1-4 mL/kg/h• Blood tests§ Often check blood gases / lactate§ Use BNP only in research• Fluid volume/day: 60 à 80 à 100 à 120 mL/kg/day, depends on clinicalstatus• NIRS is currently not available

How to diagnose and treat hsPDA
Diagnosis by using clinical status,
CXR and echocardiogram§ Tachycardia, wide PP, low DBP, active
precordium, respiratory acidosis, etc.
§ CXR: cardiomegaly / pulmonary
congestion§ Targeted echo (TnECHO) by NICU
team and/or Full echo by cardiologists§ 1 time/day

Treatment• In the past
§ IV Indomethacin / oral
ibuprofen• Now§ IV paracetamol as a first
choice• PDA ligation§ Usually perform at DOL 1-2§ Refractory cases§ TnECHO: DA flow diameter, DA
flow pattern, LA/Ao, EF§ Has contraindications to use
NSAID such as renal failure*hsPDA, hemodynamically significant PDA

How to manage hypotension• Depends on the cause• Hypovolemia§ NSS§ Blood products• Cardiogenic shock§ Dobutamine / Dopamine• Septic shock§ NSS§ Epinephrine / Norepinephrine / Dopamine§ Hydrocortisone§ Blood productsPositioning and Handling in the First 72 Hours

Photo Courtesy of parents and N. Tongsawang

Positioning• Infant’s positioning§ 0-72 h: neutral / midline and supine§ >72 h: side-lying is allowed§ >7 d: prone is allowed• Equipment used to support head and position§ Nest, clothes, gloves• Levelling bed§ Head elevation 15-30°

Photo Courtesy of parents and N. Tongsawang

Handling• Gentle, minimal handling and cluster of care
• Diaper change (no special technique)§ Use 1-2 persons to change a diaper during the first 3 days

• Bed sheet change§ Use 2 persons to change a sheet during the first 3-7 days

• Weigh a baby: 1-2 times / day§ Use 2 persons to weigh a baby during the first 3-7 days

• X-ray§ Incubators with an X-ray cassette tray port are not always available• Kangaroo care
§ Is allowed for stable infants aged >3 days

Problems in these tiny babies

Photo Courtesy of T. Surakupt

Problems in NICU• CPAP belly, abdominal distension• Feeding problem / meconium obstruction• Displacement of ETT• Air leak (rarely pneumothorax)• Lung Collapse / atelectasis• InfectionNICU guidelines and protocols• Abdominal distension / Feeding Problems /CPAP belly§ Use donor human milk
§ Adjust feedings per feeding protocol & gastricresidual volume guideline management§ Mini-volume gavage feeding• Meconium related ileus§ Rectal irrigation with NSS if no passing stool>48-72 h§ Diluted glycerin enema in some cases

NICU guidelines and protocols

NICU guidelines and protocols• VAP and CLABSIIVH Result in Ramathibodi Hospital
Total cases, N = 72
No IVH, 35%
Severe IVH, 12.5%

Year 2019 – 2021
GA 240/7 – 276/7 wk
N = 74
Analyzed infants, N = 72
[Inborn, N = 66 (91.6%)]
GA 26.3 + 1.1 wk
BW 823.9 + 161.7 g

Death, N = 10 (12.3%)
No IVH, N = 0
IVH gr I, N = 3
IVH gr II, N = 2
IVH gr III, N = 2
IVH gr IV, N = 3

Exclusion, N = 2
Chromosome defect, N = 0
Critical anomalies, N = 2
IVH before birth, N = 0

Discharge, N = 62
No IVH, N = 25
IVH gr I, N = 28
IVH gr II, N = 5
IVH gr III, N = 3
IVH gr IV, N = 1

Thank youKeralaINDIA
TrivandrumDifferences and Diversity!

Management of Extreme preterm neonatesOur policies and practices
Dr Femitha Pournami
MBBS, MD Pediatrics, DM Neonatology
Senior Consultant and Academic Coordinator, Neonatology
KIMS Health, Trivandrum
India

Our NICU:
Level IIIB (accredited by National Neonatology Forum, India)
Parameter

NumberBeds

33

Consultants

6

Senior residents

10

Nurse manager

3

Staff nurses

33

Patient care assistants

5

Housekeeping

4

High risk follow up ‒ development team 2

Management in the delivery
room (DR)Delivery room and transport to NICU
Parameter

Specifications

Temperature control in DR

Radiant warmer (Open care)
Plastic wrap
Isothermal mattress

Distance of DR from NICU
Time taken for transport

2-3 minutes

Mode of temperature support

Isothermal mattress
Plastic wrap

Cord management• Delayed cord clamping is attempted• Not done if non vigorous at birth• Compliance is 9% for extreme preterm• No cord milking• No skin to skin immediately after birthInitial steps and monitoring• Policy revised in 2023
• Active management of 22-23 weeks initiated• Skip initial steps for <=24 weeks (intubation)

Respiratory support at delivery room
• T-piece resuscitator (in the DR and during transport)• CPAP prophylactic for <=28 weeks• Early rescue surfactant (<2 hours of life)- CPAP trial (30% O2, 6 cm H2O CPAP)- NIMV trial (usually for larger babies)- ET surfactant (beractant/ Bovine Lung lavage)Respiratory managementin the first 72 hours.

What is common practice for respiratory supports
in NICU?
Item

Comment

Primary mode if spontaneous
respiratory efforts are good

CPAP
Synchronization in non-invasive modes (NIMV) not available

Thresholds for intubation andearly rescue surfactant

Need of FiO2 >30-40%

Methods of surfactant
administration

We try INSURE for >25 weeks when respiratory efforts are goodMode of ventilation on first
0-3 days

SIPPV or SIMV VG, HFO as rescue mode

Second dose surfactant>30-40% O2 need 4-6 hours after first dose surfactant

The first 72 hours…
Targets in Blood gases(day 0-3)

pH >7.2
Lactate <4 mmol/L
pCO2 up to 50 mm Hg

Target X ray findings

Posterior rib spaces 7 to 8
No collapse lung regions
ETT position T1-T2 vertebra

When is extubation first considered?

<=25 weeks: Up to 5-7 days electively
26 weeks onwards: if comfortable; as early as possible

When is postnatal steroid considered?

Only after 14 days of life
DART regimen if ventilator dependent
No active signs of infection

Inhaled nitric oxide in preterm infants

Not routinely used
Sildenafil if refractory hypoxia in <26 weeks

Often encountered complications/ adverse
events ?
Item

Comment

ET tube position changes

Hydrocolloid base adhesive, Elastic plaster above that

Pneumothorax

8 Fr trocar ICD, fixation with Hydrocolloid base dressing

CPAP “Belly”

Standard feed regimen
Rectal saline wash outs if feed intolerance and not passed stools

Spontaneous intestinal
perforation

Suspected if acute abdominal distension
X ray: free intraperitoneal air

VAP

Care bundles
Nurse: patient ratios = we try 1:1 for 22-23 weeks
Minimum experience of nurse allocated to ELBW: 6 months in NICUCirculatory managementin the first 72 hours.

What is your routine for circulatory management ?
Item

Comment

Heart rate

Acceptable range 100 - 160

SpO2

Acceptable range 85-95.
We do not aim at SpO2 >95 with oxygen.

Blood pressure

We try to get umbilical arterial line <=25 weeks
Target mean BP will be over the number of gestational week.

Urination>1 ml/kg/hour

Blood test

LactateBNP: we rarely use for ELBW

Input volume

Day 0: in incubator 50-60 ml/kg/day
Increase based on Serum Sodium, Circulatory status

NIRS

Not available

How to diagnose “symptomatic PDA”?
Item

Comment

Echocardiography

If symptomatic
For 22-24 weeks, we try to do daily
LVDD, EF, LA/Ao, Lt PA diastolic flow, DA diameter, DA flow velocity, DA
flow pattern,

UltrasoundNot routinely done for PDA related changes in systemic circulation

How to treat “symptomatic PDA”?
Item

Comment

Medication

IV Indomethacin and IV Ibuprofen are not available in India
IV Paracetomol is available
Ibuprofen enteral diluted: if on at least >20 -30 ml/kg/day feed (more thanminimal enteral nutrition )Surgery

Done only for chronic / persistent PDA with failure
Not done in first few weeks of life

How to manage “hypotension”?
Cause

Comment

Hypokinesis

Inotropes: Dobutamine, Adrenaline

Hypotension
No hypokinesis

Vasoconstrictors- Dopamine- Adrenaline

Hypovolemia

Volume expander: cautious use-Saline-RBC

Positioning and Handlingin the first 72 hours.

Positioning
Topics

Details/Comments• Infant’s
positioning• Head in midline• Supine, left-up and right-up positions• Prone after extubation• Equipment used to support head/ positioning: nest: cloth roll

• Leveling bed• Degree of head elevation: 30 degree

Handling
Topics

Details/Comment• Gentle Handling••• Nurse-patient ratios 1:1 when possible. 1 nurse usually

Diaper change

Routinely use minimal and gentle handling rules• Changing bed sheet•

2 people when intubated/ CPAP

• Weigh a baby••

After 72 hours only usually
1-2 people• X-ray•

Incubators with an X-ray cassette tray port : Yes• Parent participation••

Early, as soon as possible
KMC started: when on HFNC

IVH result

2018-2021
GA<28w(n=106)

Analyzed infants (n=101)
GA (Median IQR)
27 (26,28) weeks
BW(Median IQR)
860 (660,1090) g

Death (n=9)
IVH (-) (n=0)
IVH 1 (n=0)
IVH 2 (n=3)
IVH 3 (n=1)
IVH 4 (n=5)

Exclusion (n=5)
Congenital Ventriculomegaly=1
Absent corpus callosum=1
Post meningitis hydrocephalus=1
Brain Abscess=2

Discharge (n=92)
IVH (-) (n=64)
IVH 1 (n=22)
IVH 2 (n=1)
IVH 3 (n=4)
IVH 4 (n=1)