Comprehensive

Management of ELBW
Rinawati Rohsiswatmo
TERMINOLOGY - WHO
• ELBW: one with a birth weight of
less than 1000 g, usually born at
27 weeks' gestational age or
younger
 Incidence Rate of LBW, VLBW, ELBW
in Cipto Mangunkusumo Hospital 2016
50

45
43.7
40 40 39.1
38.6
36.6
35 34.8 35
33.1 31.9
31.6 30.9 31
30
LBW
25
VLBW
20 ELBW
15 15.8
14.2
12.6
10 10.5 9.8 10.8
9.5
7.6 7.2 8 7.7
6.2 6.6
5 5.1 4.1 4.2
2.1 2 2.1 3.1 2.9
1.8
0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
100.00% 2014
2016
90.00%
80.00%
Approximately 0.5% of births occur at ≤27 weeks
but they account for almost 50% of infant
70.00%
mortality in US
60.00%
50.00% Survival
40.00% - 20 and 21 weeks- 0%
- 22 weeks – 6%
30.00%
- 23 weeks - 26%
20.00% - 24 weeks – 50%
10.00% - 25 weeks – 72%
0.00%
ELBW VLBW LBW
2014 8.92% 49.03% 83.90% Post-discharge mortality – 2%
2016 15.71% 64.73% 96.03%

Survival Rate Of ELBW, VLBW, LBW

in Cipto Mangunkusumo Hospital 2016
 Prenatal care for ELBW
1. Aggressive and proper resuscitation > 25 weeks of gestation
 22-25 weeks gestation age infants still debating
2. Antenatal steroid: increased survival and decrease complication
3. Magnesium sulfate 48 h prior to delivery
• Neuroprotective effects of prenatal maternal
• Decrease the incidence of Cerebral palsy and gross motor disfunction at 28-30 mo (NNT
63)
4. Routine use of broad spectrum antibiotics does not prolong pregnancy
or improve outcome unless PPROM
5. No data support that the tocolisys in preterm labour with suspected
chorioamnionitis could improve outcome
6. Mode of delivery should depend on the risk of the mother and baby
Management of the ELBW
• Delivery room (DR) management
1. Preparation
2. Cord clamping
3. Prevention of heat loss
4. Asessment of heart rate and oxygenation
5. Respiratory management
• Transport to the NICU
• Initial NICU Management
 Preparation prior to arrival
Team consist of : 1 neonatologist & experienced nurse

Sveinsdottir et al. J Neonato. 2017

Delivery room management
Prevent Heat Loss
Cord Clamping • Maintain 36.5-37.5 C o

• Hypothermia associated with IVH,

• More 30 seconds (1-3 min) apnea, hypoglycemia and metabolic
• Less need for transfusions acidosis
• Higher blood pressure • Pre-heated delivery room/surgical
• Less IVH of any grade suite to 24-26’C
• Wrap with plastic bag without drying,
• Less NEC
put a cap on its head
Neonatal resuscitation: 2015 American Heart Miller et al. J Perinatol: Off J Calif Perinat Assoc.
Association guidelines 2011;31
update for cardiopulmonary resuscitation and Suppl 1:S49–56.
emergency cardiovascular care.
Delivery room management
Respiratory management
Assess heart rate and
oxygenation • T-piece resuscitator
• Using ECG rather than • Blend of air and oxygen
stethoscope • Targeting O2
• Pulse oxymetry

Neonatal resuscitation: 2015 American Heart Miller et al. J Perinatol: Off J Calif Perinat Assoc.
Association guidelines 2011;31
update for cardiopulmonary resuscitation and Suppl 1:S49–56.
emergency cardiovascular care.
Newborn Resuscitation
Surfactant
administration Focusing on respiratory and
circulation
IPPV

Intubation
“BRING NICU TO
DELIVERY ROOM”
Is it possible also
to monitor brain
Anaemia in the DR ?
Current routine monitoring using SpO2 and heart rate does not provide information about
cerebral oxygenation or perfusion or brain activity
Finn D, et al. Frontiers in Pediatrics. (2016) 4: 30.
 An observational study…

Brain oxygenation monitoring in the DR

Fuchs H et al. Journal of Perinatology (2012) 32, 356–362

Cerebral hypoxia was defined by crSO <10th percentile using the
2
neonatal sensor

crSO during the first 15 minutes after birth. Dotted line

2
represents the 10th percentile of crSO . *P < .05; †P < .1
2

Infants <34 weeks were randomized in the DR

either to cerebral NIRS and SpO2 monitoring or
SpO2 monitoring alone to guide titration of
oxygen therapy

Gerhard P et al. J Pediatr 2016;170:73-8

Transport to the NICU
• Pre-heated incubator : 36-37’C
• Respiratory support with T-piece device
• Oxygen should be blend with air
• Monitor oxygenation with pulse oxymeter
Limited facilities

+ plastic
if needed
Ideally
Causes of neonatal mortality among
transported neonates

Indian Journal of Public Health. 2013

What care should be given during transport?
• Temperature maintenance
• Airway and breathing
• Circulation
• Check oxygenation
• Communication
• Feeds

NNF Clinical Practice Guidelines

What should be done in case the neonate
deteriorates during transport?
• Evidence: Evidence regarding the most appropriate action for the patient
who deteriorates during transport is scanty. The most appropriate action
depends on the level of skills of transport team in resuscitation, space and
equipments available in the ambulance, and the distance from the
receiving hospital.

• Recommendation: The two major strategies can be used in case of acute

deterioration are:
• Stop the vehicle and resuscitate: If skills and space is available stop the vehicle and
resuscitate (ET intubation or chest tube insertion for pneumothorax).
• Don’t perform procedure in a moving vehicle; get to the nearest hospital, stabilize,
before proceeding.

NNF Clinical Practice Guidelines

 Potential Complications Transporting
the Sick Neonate Intra and
Interfacility

Nancy Young, Transporting the Sick Neonate Intrafacility & Interfacility

Initial NICU Management
• Maintaining the temperature
• Inserting cathethers, umbilical vein and artery are preferred (easy and pain free)
• Humidification up to 70-80% for the first two weeks
• Commence a proper skin care
• Avoid hypoglycemia with commencing aggressive TPN
• GIR 4-6 mg/kg/min in one hour of life
• Amino acid 2-2.5 g/kg/d in one hour of life
• Lipid 0.5-1 g/kg/d – from day 1
• Early enteral feeding with fresh MOM (mother’s own milk)/colostrum, 0,5 ml
within 6 hs
• Encourage mother to pump her breast ASAP
Newborn skin care, why?
Newborn skin care, how?
 Golden hour check list

Brenda Wallingford, DNP, APRN-NP, NNP-BC; Lori Rubarth, PhD,

APRN-NP, NNP-BC; Amy Abbott, PhD, RN; Linda J. Miers, DSN, RN,
APRN-CNS; NAINR. 2012;12(2):86-96.
Newborn positioning – developmental care
Initial NICU Management
• Initial total fluid 80-100 ml/kg/d
• Total fluid administration should be adjusted by sodium plasma level
• Avoid overly aggressive ventilation
• Consider non invasive ventilation
• Intubation and surfactant if necessary
• Rapid extubation and early caffeine
• Avoiding unnecessary disturbances, minimal handling
• Monitoring acid-base balance, blood gases and blood pressure
• Antibiotics are only warranted if there is a clinical suspicion of infection and
discontinued if blood culture is negative
 KEY FACTORS INFLUENCING SURVIVAL OF
“MIRACLE BABIES”
 Special small baby units?
 Aggressive nutritional support
 Colostrum
 I.V protein starting day 1
 Minimal enteral nutrition
 Human milk
 Prevent infection
 Prevent intracranial hemorrhage
 KEY FACTORS INFLUENCING SURVIVAL OF
“MIRACLE BABIES”
• PREVENT BILIRUBIN ENCEPHALOPATHY
• CONSERVATIVE APPROACH TO BILIRUBIN
• MINIMIZE MAJOR MORBIDITIES INCLUDING: BPD;IVH;NEC;ROP
• MINIMIZE PROCEDURES AND PROVIDE HUMAN PAIN RELIEF
• AVOID MULTIPLE SURGERIES REQUIRING GENERAL ANESTHESIA
• STIMULATE BABY AND ENCOURAGE INVOLVEMENT OF FAMILY KANGOROO
CARE; NIDCAP; ETC
• CLOSE FOLLOW UP WITH STRONG FAMILY SUPPORT
Terima Kasih