Guideline sources The following summarized guidelines for the evaluation and management of preterm infant are prepared by our editorial team based on guidelines from the World Health Organization (WHO 2022; 2015), the International Liaison Committee on Resuscitation (ILCOR 2022), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2022), the American Heart Association (AHA 2020), the American College of Obstetricians and Gynecologists (ACOG 2020), the American Gastroenterological Association (AGA 2020), the Canadian Paediatric Society (CPS 2018), and the American Academy of Pediatrics (AAP 2014). 1 2 3 4 5 6 7 8 9 10 Guidelines 1. Diagnostic investigations Heart rate assessment: Consider obtaining an ECG for the rapid and accurate measurement of the HR during resuscitation of preterm infants. C Consider obtaining an ECG for the rapid and accurate assessment of the HR during chest compressions. B https://web.pathway.md/diseases/recfhonthEZ9uftQT 1/6 6/29/23, 11:27 PM Preterm infant Pathway 2. Respiratory support Noninvasive positive pressure ventilation: As per ILCOR 2022 guidelines, insufficient evidence to recommend for or against the routine use of CPAP in spontaneously breathing late preterm infants with respiratory distress in the delivery room. Show 2 more As per WHO 2022 guidelines, initiate CPAP therapy in preterm infants with clinical signs of respiratory distress syndrome. B Show 2 more As per AHA 2020 guidelines, initiate positive pressure ventilation without delay in newly born infants gasping or apneic within 60 seconds after birth or persistently bradycardic (HR < 100/minute) despite appropriate initial actions (including tactile stimulation). B Show 7 more Supplemental oxygen: consider initiating oxygen supplementation at 21% concentration in late preterm infants receiving respiratory support at birth. C Show 2 more 3. Medical management Surfactant replacement therapy: As per WHO 2015 guidelines, initiate surfactant replacement therapy in intubated and ventilated infants with respiratory distress syndrome. B Show 3 more As per AAP 2014 guidelines, initiate surfactant therapy after initial stabilization of preterm infants born at < 30 weeks of gestation requiring mechanical ventilation because of severe respiratory distress syndrome. A Show 7 more Inhaled nitric oxide: do not use rescue or routine inhaled nitric oxide in preterm infants with respiratory failure to improve survival or to prevent/ameliorate bronchopulmonary dysplasia, severe intraventricular hemorrhage, or other neonatal morbidities. D Show 2 more Caffeine: administer caffeine for the treatment of apnea in preterm infants. B Show 2 more Probiotics: As per WHO 2022 guidelines, consider administering probiotics in human-milk-fed very preterm infants (< 32 weeks of gestation). C As per AGA 2020 guidelines, consider administering the following strains of probiotics in preterm (< 37 weeks of gestation), low-birth-weight infants: a combination of Lactobacillus rhamnosus ATCC 53103 and Bifidobacterium longum subsp. infantis a combination of Lactobacillus casei and Bifidobacterium breve https://web.pathway.md/diseases/recfhonthEZ9uftQT 2/6 6/29/23, 11:27 PM Preterm infant Pathway a combination of Lactobacillus rhamnosus, Lactobacillus acidophilus, Lactobacillus casei, Bifidobacterium longum subsp. infantis, Bifidobacterium bifidum, and Bifidobacterium longum subsp. longum a combination of Lactobacillus acidophilus and Bifidobacterium longum subsp. infantis a combination of Lactobacillus acidophilus and Bifidobacterium bifidum a combination of Lactobacillus rhamnosus ATCC 53103 and Bifidobacterium longum Reuter ATCC BAA-999 a combination of Lactobacillus acidophilus, Bifidobacterium bifidum, Bifidobacterium animalis subsp. lactis, and B longum subsp. longum bifidobacterium animalis subsp. lactis (including DSM 15954) lactobacillus reuteri (DSM 17938 or ATCC 55730) lactobacillus rhamnosus (ATCC 53103 or ATC A07FA or LCR 35). B Emollients: consider applying topical oil to the body of preterm or low-birth-weight infants. C 4. Nonpharmacologic interventions Kangaroo mother care: Implement Kangaroo mother care as routine care in all preterm or low-birth-weight infants and initiate as soon as possible after birth. A Consider initiating Kangaroo mother care in the healthcare facility or at home and provide for 8-24 hours/day (as many hours as possible). B Temperature management: As per ILCOR 2022 guidelines, consider maintaining the room temperature of 23 C at birth in order to maintain a normal temperature in late preterm infants. C Show 3 more As per AHA 2020 guidelines, consider using radiant warmers, plastic bags and wraps (with a cap), increased room temperature, and warmed humidified inspired gases to prevent hypothermia in preterm infants in the delivery room. C Show 2 more Feeding: advise using mothers own milk for feeding in preterm or low-birth-weight infants, including very preterm (< 32 weeks gestation) or very low-birth-weight (< 1.5 kg) infants. B Show 7 more Vitamin and microelement supplementation: initiate enteral iron, B zinc, vitamin D, and vitamin A supplementation in human milk-fed preterm or low-birth-weight infants not receiving these micronutrients from other sources. B 5. Therapeutic procedures Umbilical cord clamping: As per SOGC 2022 guidelines, delay cord clamping for 60-120 seconds in both preterm (< 37 weeks) and extremely preterm (< 28 weeks) singletons because it decreases newborn mortality and morbidity and improves hematological outcomes after the neonatal period. https://web.pathway.md/diseases/recfhonthEZ9uftQT 3/6 6/29/23, 11:27 PM Preterm infant Pathway Delay cord clamping for at least 30 seconds over clamping immediately when cord clamping cannot be deferred for a full 60-120 seconds. Delay cord clamping with the infant at or below the level of the introitus or at the level of the Cesarean incision. A Show 11 more As per ACOG 2020 guidelines, perform delayed umbilical cord clamping in preterm infants as it is associated with significant neonatal benefits, including improved transitional circulation, better establishment of RBC volume, decreased need for blood transfusion and lower incidence of necrotizing enterocolitis and intraventricular hemorrhage. E Show 2 more As per AHA 2020 guidelines: Consider delaying cord clamping for > 30 seconds in preterm infants not requiring resuscitation at birth. C Insufficient evidence to recommend early versus delayed cord clamping in preterm infants requiring resuscitation at birth. I 6. Patient education Family involvement: involve family in the routine care of preterm or low-birth-weight infants in healthcare facilities. B Show 3 more 7. Preventative measures Vitamin K prophylaxis: Administer IM vitamin K prophylaxis in all preterm infants. E Insufficient evidence to support the routine use of IV vitamin K administration in preterm infants. I Clinical findings Past medical history Past obstetric history Apnea of prematurity Premature labor Bronchopulmonary dysplasia Respiratory exam Necrotizing enterocolitis Neonatal hyperbilirubinemia Grunting Neonatal respiratory distress syndrome Retractions Patent ductus arteriosus Lab findings Retinopathy of prematurity Hyperglycemia Sepsis serum creatinine Vital signs Tachypnea https://web.pathway.md/diseases/recfhonthEZ9uftQT 4/6 6/29/23, 11:27 PM Preterm infant Pathway O2 saturation Integument exam Cyanosis Jaundice Imaging findings Intraventricular hemorrhage Studies 2017 APTS In fetuses from women who were expected to deliver before 30 weeks of gestation, delayed cord clamping was not superior to immediate cord clamping with respect to death or major morbidity at 36 weeks of postmenstrual age. William Tarnow-Mordi et al. N Engl J Med. 2017 Dec 21. References 1. No authors listed. WHO recommendations for care of the preterm or low-birth-weight infant. Geneva: World Health Organization; 2022. Open 2. Ng E, Loewy AD. Guidelines for vitamin K prophylaxis in newborns: A joint statement of the Canadian Paediatric Society and the College of Family Physicians of Canada. Can Fam Physician. 2018 Oct;64 10 736 739. Open 3. Khalid Aziz, Henry C Lee, Marilyn B Escobedo et al. Part 5 Neonatal Resuscitation: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020 Oct 20;142 16_suppl_2 S524 S550. Open 4. Myra H Wyckoff, Robert Greif, Peter T Morley et al. 2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Resuscitation. 2022 Oct 29;S0300 9572 22 00684 0. Open 5. No authors listed. WHO Recommendations on Interventions to Improve Preterm Birth Outcomes. Geneva: World Health Organization; 2015. Open 6. No authors listed. Delayed Umbilical Cord Clamping After Birth: ACOG Committee Opinion Summary, Number 814. Obstet Gynecol. 2020 Dec;136 6 1238 1239. Open 7. Grace L Su, Cynthia W Ko, Premysl Bercik et al. AGA Clinical Practice Guidelines on the Role of Probiotics in the Management of Gastrointestinal Disorders. Gastroenterology. 2020 Aug;159 2 697 705. Open 8. Sarah D McDonald, Michael Narvey, William Ehman et al. Guideline No. 424 Umbilical Cord Management in Preterm and Term Infants. J Obstet Gynaecol Can. 2022 Mar;44 3 313 322.e1. Open https://web.pathway.md/diseases/recfhonthEZ9uftQT 5/6 6/29/23, 11:27 PM Preterm infant Pathway 9. Praveen Kumar, Committee on Fetus and Newborn, American Academy of Pediatrics. Use of inhaled nitric oxide in preterm infants. Pediatrics. 2014 Jan;133 1 164 70. Open 10. Richard A Polin, Waldemar A Carlo, Committee on Fetus and Newborn et al. Surfactant replacement therapy for preterm and term neonates with respiratory distress. Pediatrics. 2014 Jan;133 1 156 63. Open 11. American College of Obstetricians and Gynecologists' Committee on Practice Bulletins Obstetrics. Prediction and Prevention of Spontaneous Preterm Birth: ACOG Practice Bulletin, Number 234. Obstet Gynecol. 2021 Aug 1;138 2):e65-e90. Open 12. William Tarnow-Mordi, Jonathan Morris, Adrienne Kirby et al. Delayed versus Immediate Cord Clamping in Preterm Infants. N Engl J Med. 2017 Dec 21;377 25 2445 2455. Open 13. Nicholas David Embleton, Sissel Jennifer Moltu, Alexandre Lapillonne et al. Enteral Nutrition in Preterm Infants 2022 A Position Paper From the ESPGHAN Committee on Nutrition and Invited Experts. J Pediatr Gastroenterol Nutr. 2023 Feb 1;76 2 248 268. Open https://web.pathway.md/diseases/recfhonthEZ9uftQT 6/6