Small Baby Guideline
To optimise management of the extremely preterm infant less than 27 weeks the first small baby protocol was introduced in 1997. This was in response to concerns that skin care protocols were not adequate to meet the unique demands of these fragile infants. Changes in care were both, pragmatic and based on research. Over time internal reviews and new research has modified our care practices surrounding the management of these infants.
Figure one. Number of babies admitted and discharged home RPA Newborn Care (RPA NICU).
While the number of infants less than 27 weeks gestation admitted to Newborn Care has not increased in recent years, survival rates to discharge continue to improve with a 73-80% survival during 2007-2008. The nursery management and long term developmental surveillance of these infants remains a resource intensive and challenging aspect of neonatal care.
There are several important elements to the early and effective management of these extremely preterm infants. The aims of the following guideline are to:
1. Prevention of heat loss at resuscitation.
Delivery suites and operating theatres are generally cold environments and cause thermal stress for the newborn which is associated with increased mortality and morbidity 1,2. The four mechanisms of heat loss - evaporation, convection, radiation and conduction 3 can also be used to minimise heat loss during resuscitation and stabilisation. Application of radiant heat, warm wraps, use of plastic wraps to prevent losses through evaporation, convection and conduction 4,5 and warmed and humidified gases to prevent evaporative losses from the respiratory tract are strategies used during resuscitation and transport to the NICU.
A systematic review by 4 reported use of a plastic barrier within the first 10 minutes of life for an extremely preterm/low birth weight infant was beneficial, reducing the incidence of hypothermia whilst allowing accessibility during resuscitation. Some babies managed in this way can become hyperthermic 4,5.
1.1 Clinical management � from birth & transfer to the NICURefer RPA Newborn Care Clinical Practice Guidelines 6
In addition to the routine equipment / procedures for the management of the high risk newborn, resuscitation and stabilisation of the infant less than 27 weeks includes:
2. Management of thermal environment in the NICU
The skin of the extremely preterm infant is immature and the stratum corneum, the outer layer of the epidermis is functionally undeveloped and inefficient as a physical barrier in the first days after birth 7,8,9 - Figure two. As a result, high transepidermal water losses (TEWL) have been well described in this population especially over the abdomen where the skin looks thinner and more transparent 8 and nursery practices have been varied in an attempt to reduce these potentially significant losses 9-13.
Figure two: Stratum corneum at 26 weeks gestation compared with an infant born at term. TEWL decreases with increasing post natal age and while acceleration in the maturation of the stratum corneum occurs after birth, TEWL for infants less than 27 weeks still remains more than twice as high as their term counterparts at four weeks postnatal age 11
Figure three: The relationship of TEWL to gestational & post natal age 11
Early researchers demonstrated significant reduction in TEWL can be achieved by increasing the relative humidity of the infant�s environment 9,12. Although open care systems with overhead radiant warmers allow free procedural access, these systems markedly increase evaporative water losses, increasing the risk of dehydration, electrolyte imbalance and injury to the infant�s skin 15. The results of a systematic review comparing open care with closed care systems 14 do not provide sufficient evidence to guide clinical practice, however due to the increase in evaporative water losses associated with use of radiant heat and its associated risks for extremely preterm babies we nurse these infants in closed care systems.
Figure four: Relationship between TEWL and postnatal age in different levels of ambient humidity 9
2.1 Clinical management of the environment
Refer RPA Newborn Care Clinical Practice Guidelines
Using the available evidence the infant less than 27 weeks gestation is nursed as follows:
A double walled Isolette® (Drager 8000, AirShields 2000 or Isolette® C8000) is used on air (manual) mode.
3. Maintenance of skin integrity:
The stratum corneum is poorly developed and functionally incompetent 8 predisposing the immature and fragile skin to mechanical injury as a result of accidental or iatrogenic damage.
Historical data has demonstrated systemic absorption of toxic agents such as aniline dyes, topical steroids, hexachlorophene and iodine 19. Chemical burns have also been reported with the application of alcohol based solutions previously used for topical antisepsis. Epidermal stripping can occur with use of transcutaneous oxygen monitoring and application of adhesives.
Preservation of skin integrity is therefore essential for the optimal management of the extremely preterm infant. Breakdown of the epidermis will increase the risk of nosocomial infection, compromise temperature regulation, increase TEWL and cause pain and discomfort for the infant. Damage to the skin will also increase anxiety for parents and may cause long term scarring or disfigurement for the infant.
In addition to reducing TEWL and heat loss, a secondary benefit of topical emollient is markedly improved skin condition 17,18,20. This has been observed in our practice along with a noticeable reduction in the use of adhesives applied to the skin.
However in a systematic review by Conner et al 21 more sepsis from coagulase negative staphylococcal was reported in infants receiving topical emollient compared with those infants who did not. When infections from coagulase negative staphylococcal were excluded from the analysis no differences was seen in rates of sepsis from other causative organisms 21.
3.1 Clinical management � Maintenance of skin integrityRefer RPA Newborn Care Clinical Practice Guidelines
On review of the data and the demonstrated benefits to skin integrity 17,18,20,22 we have made a pragmatic decision to continue use of Eucerin� (Beiersdorf Australia) with the following precautions.
Eucerin (Beiersdorf Australia) is the emollient of choice as it is a preservative free wool alcohol with a high molecular weight (minimal absorption). Use a new tube for each infant and discard after use.
Use is limited to one week and is applied after stabilisation and insertion of umbilical lines, usually within 2 hours of birth
Ensure the endo tracheal tube and umbilical lines are secure before each application
Eucerin is ordered on a medication chart and applied BD using a single coat and signed by two RNs.
Eucerin is not applied to the head, face, or abdominal area immediately surrounding the umbilical tapes or the anterior aspect of the thighs that may come in contact with umbilical line tapes.
Umbilical cord should be observed - if soiled clean with water. Ensure the area is dry and clean � report any inflammation or migration of lines. Remove linen tape around stump at 12 hours of age when there is no evidence of ooze.
Eucerin should not be used on a limb where a PIC line is inserted � the PIC dressing should be kept clean and intact. Medipore (3M) a special adhesive white tape should be used to secure the edges of the Tegaderm� (3M). Do not encircle the limb with tape.
Eucerin may be used under phototherapy � ensure infant does not over heat. Avoid use of the MicroLite® (Hill-Rom) if possible as the tungsten halogen bulbs can cause hyperthermia for infants nursed in incubators.
Application of Eucerin does not mean routine removal of cardiac leads � for some infants loss of contact and frequent alarms can be problematic. There are situations however where a continuous rhythm is necessary and chest leads should be left on or reapplied eg. hyperkalaemia.
Possible complications associated with use of Eucerin include dislodgement of endotracheal tube, lines, lifting of PIC line dressings, hyperthermia and difficulty in handling infant when first applied.
4. Additional Considerations
5. Management of fluid and electrolytes
Infants less than 27 weeks gestation have increased TEWL due to immature epidermis and greater surface area to body mass which significantly increases the difficulties associated with fluid and sodium management 33.
Considerations for infants less than 27 weeks gestation
A systematic review on restricted versus liberal water intake in preterm infants recommends careful water restriction 34. If dehydration is prevented this restriction of fluids could reduce the risk of patent ductus arteriosus and necrotising enterocolitis and perhaps overall risk of death. Because of the complex nature of fluid and electrolyte management in these infants fluid balance is individualised. RNs are not to grade up total fluid requirements and must discuss all fluid and electrolyte management issues with registrar.
5.1 Clinical Management � fluids and electrolytes
Refer RPA Newborn Care Clinical Practice Guidelines
To optimise fluid balance aim for
Initial fluid requirements when < 27 weeks and / or 750 grammes
Ongoing fluid balance and nutrition
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Revised: April 2010