ELGAN

Extremely low gestational age newborn

 Guidelines to the management of the
ELGAN
 Perinatal
 Golden Hour
 Respiratory
 Cardiovascular - PDA management
 Infectious Disease
 Nutrition
 Hematology
 Neurology
 Ophthalmology
 Discharge Planning
 Family-centered Care
 Perinatal
 Antenatal steroids
 Perinatal approach to the Periviable Infant
 Use parent handout from policy when consulting on a periviable infant
 www.nichd.nih.gov website has a calculator to calculate an estimate of
mortality and risk for neurodevelopmental delay
 Delayed cord clamping
 Exclusion criteria: unstable condition, Severe maternal illness, Uterine
rupture, uteroplacental insufficiency is suspected, Fetal-maternal
hemorrhage, Twin to twin transfusion, and Severe congenital anomaly
 The Golden Hour

 Review Golden Hour Guideline prior to delivery

 Identified roles for each team member
 Neo, NNP, RN, RT
 Timed interventions from birth to 120 minutes of life
 Each time interval has specific interventions
 Respiratory

 Guidelines to Respiratory Support

 Try to minimize intubation, use non-invasive PPS when possible
 a) If intubation necessary, give surfactant expeditiously for those patients with
RDS
 b)Try to get off vent ASAP to Non-invasive support (NIV-NAVA, Bubble CPAP,
HFNC)
 c)Try to maintain on Non-invasive PPS so long as there is significant risk of
pulmonary alveolar de-recruitment
 2)O2 saturation range: 90-95% (alarm setting at 88 and 96%)
INFANT <26 WKS:
 Early intubation and surfactant administration
 HFV (HFOV or HFJV) as initial support
 Extubation to Non-invasive NAVA
 Transition to Bubble CPAP and then HFNC

INFANT 26-28 WKS:

 Assess for Non-invasive support
 May maintain on ventilator support or INSURE based upon
physician assessment
 Volume or TC/PL ventilation as initial support, and to NAVA if
adequate respiratory drive
 Transition to Bubble CPAP and then HFNC

INFANT >=29 WKS:

 Assess for Non-invasive support
 Initial Non-invasive support: Non-invasive NAVA OR BUBBLE
CPAP
 Consider INSURE first
 Volume or TC/PL ventilation as initial support, and to NAVA if
adequate respiratory drive
 Transition to Bubble CPAP or HFNC
Clinically Significant Cardiopulmonary Events:

• ≥ 20 seconds
Apnea • ≥ 10 sec apnea with HR <70
and/or O2 sat < 85%

Desaturatio • <80% for ≥ 10 sec or any

n cyanosis

Bradycardi • HR <80 for ≥ 10 sec

a

 Applies to Self-resolved events only

 Events occurring exclusively during feeding administration are usually
ignored unless provider documents a reason they are clinically significant
(i.e.. Severe cyanosis, choking)
 Events requiring any stimulation to resolve are Clinically Significant
 Cardiovascular
 Blood Pressure Management
 Delayed cord clamping in the DR
 Aim for MABP > ~ gestational age
 Slow bolus only (10m/kg) over 1 hr.
 UAC flushes – very slowly over 30 sec
 Dopamine /Dobutamine
 Consider Hydrocortisone if pressor resistant

 Medical management of hemodynamically significant PDA

 Prophylactic indomethacin
 Indomethacin is contraindicated in the setting of active
hydrocortisone therapy.
 Gut priming can occur during prophylactic indomethacin
therapy, if clinically appropriate.
 Indication for ECHO
 Echocardiography will be performed at the discretion of Medical
team for infants with clinical symptoms > 6 days ( < 26 weeks –
>mild clinical score or murmur or > 26 weeks moderate to severe
score or murmur )
 Evidence indicates that treatment of moderate or severe ductal shunting
detected at 72 hours of life does not confer a clinical advantage over
treatment at 7 days.

 PDA Echo Grading Levels

 LEVEL 1: No evidence of ductal flow in 2D or Doppler
 LEVEL 2: Small, non significant PDA
 LEVEL 3: Moderate, hemodynamically significant PDA
 LEVEL 4: Large, hemodynamically significant PDA

 Management – Aim to be more conservative

 Non-pharmacologic intervention vs Pharmacologic Intervention
 Surgical closure
 Infectious Disease
Evaluation of Infants born < 34 weeks gestation for risk for Early Onset Sepsis

Maternal Intrapartum Fever > 100.4 and/or YES

Obstetrical Diagnosis of Chorioamnionitis R/O EOS
NO
Reason for premature birth Maternal Indication

Induction of labor / Cx -without labor and

ROM at incision
Preterm Labor and/or PROM or
non-reassuring fetal testing

YES Infant requiring respiratory or

R/O EOS hemodynamic support

NO

Routine Care No blood culture; CBC

Blood Culture / CBC with diff / +
only if needed to address non-
CRP - Ampicillin/ Gentamicin
infectious concern
 Infectious Disease
 LATE ONSET SEPSIS
 Removing PICC when feeds ~ 120 ml/kg/day
 Promotion of early enteral feeding with breast milk
 Judicious use of antibiotic therapy to reduce the risk of
antibiotic resistance and fungal infection

 Vancomycin reduction protocol for infants with suspected

late-onset sepsis
 Obtain at least 1 mL for blood culture(s) and initiate
empiric nafcillin and gentamicin , if infant has a central
line or infant colonized with MRSA, infant should
receive empiric vancomycin instead of nafcillin.

 Fluconazole prophylaxis: Recommended regimen for

extremely low birth weight neonates is to initiate fluconazole
treatment intravenously during the first 48 to 72 hours after
birth at a dose of 3 mg/kg, and administer it twice a week for
4 to 6 weeks, or until intravenous access no longer is required
for care.
 Nutrition
 Similac Special Care Formulas (20 cal, 24 cal, 24 cal HP): for
preterm babies <2 kg and <36 weeks
 Neosure: for preterm babies >2 k
 Term formula: for baby >36 weeks

 Evaluating adequate growth:

 Optimally, BW should be regained by 2 weeks of life
 Growth velocity goal 15-20 g/kg/day. >35 g/day is
excessive. At discharge, should be gaining >20 gm/day.
 Goal for Length >1 cm/week

 Standardize weaning off of DBM starting at 33 0/7 weeks:

 Day 1: use 1 bottle of SSCF 24 HP
 Day 2: use 1 bottle of SSCF 24 HP / shift
 Day 3: use 2 bottle of SSCF 24 HP / shift
 Day 4: go to ALL of SSCF 24 HP
Feeding Guidelines:
Frequency Advancement

≤ 750 gm q 3 hrs Start 10 ml/kg/day x 3-4 days

 Advance daily by 10 ml/kg/day
751 -999 gm q 3 hrs Start 10 ml/kg/day x 2-3 days
 Advance daily by 10 ml/kg/day
1000-1249 gm q 3 hrs Start 20 ml/kg/day x 2 days
 Advance daily by 20 mL/kg/day
1250-1499 gm q 3 hrs Start 20 mLkg/day x 1 day
 Advance daily by 20 mL/kg/day

Advance at q 12 or q 24 hour intervals. Do not fortify and advance on same day

 At 80-100 ml/kg/day, fortify BM to 22 cal/oz
 At 120 ml/kg/day, fortify BM to 24 cal/oz
 At 100 ml/kg/day, stop IL
 After tolerating 130 ml/kg/day for one full day, pull PICC
 Breast Feeding Guidelines
Test weights for breastfeeding
 If <75 % of calculated feeding volume, give supplement (FPQC)
 If > 75% of calculated feeding volume, skip supplement unless baby still
hungry
 Stop doing test weights when baby has had several feedings of 90% of
calculated need

If not doing test weights with successful breastfeeding

 If infant is actively sucking on breast <5 minutes, gavage all of volume
 If infant is actively sucking on breast 5-10 minutes, gavage 3/4 of feed volume
 If infant is actively sucking on breast 11-15 minutes, gavage ½ of feed volume
 If infant is actively sucking on breast 16-20 minutes, gavage 1/3 of feed
volume
 If infant is actively sucking on breast >20 minutes, do not gavage
 Hematology
 Phototherapy usually started at ½ birth weight

 For pathologic hyperbilirubinemia:

 For sick newborn: Consider Exchange value for weight in kg x 10.
 More conservative approach: Consider Exchange value generally >15
for preterm <1500 grams, and for weight in kg x 10 if >1500 grams.

 May also use

 AAP recommendations: www.PediTools.org
 Stanford guidelines: https://pbr.stanfordchildrens.org

 PRBC transfusions:
 We generally hold feeds for some period of time (6-24 hours) during a
transfusion; trophic feeds are not routinely stopped for transfusions.
 Neurology
 Indomethacin for IVH prophylaxis
 IVH calculator - https://sites.google.com/a/neoqic.org/neoqic-
public-1/sivhcalculator
 Consider most strongly if risk 15% or greater
 Routine CUS screening:
 All infants less than or equal to 1.5 kilogram OR less than 32
weeks gestation
< 26 weeks – performed at:
 3 days of life
 7 days of life
 4 weeks chronological age
 36 weeks corrected gestation age
>26 –30 weeks – performed at:
 7 days of life
 4 weeks chronological age
 36 weeks corrected gestation age
30 - < 32weeks – performed at:
 7 days of life
 36 weeks corrected gestation age
Follow-up of Identified Intracranial Hemorrhage

 All patients will have weekly head circumferences plotted on a

growth chart

 If no or Grade 1 hemorrhage, remain on routine screening

schedule

 Grade 2 hemorrhage:
 Repeat in 1 Week
 If stable hemorrhage, return to routine

 Be aware that infants >31 weeks may still be at-risk for ICH
 For the infant who is >31 weeks, consider a screening
Cranial ultrasound for risk factors including decreased
OFC; ventilator support; asphyxia
Potentially Better Practices for Neurodevelopment
Potentially Better Practice Bundle #1: (Implement for ALL NICU
Admissions, as early as 23 weeks gestation
 Containment and body flexion
 Oral Stimulation/ Non-nutritive suck
 Gentle touch, hand grasping/ facial stimulation
 Decrease painful/ negative stimulation
 Exposure to mother’s scent
 Minimize exposure to noxious odors
 Noise abatement
 Minimize ambient light exposure
 Avoid direct light exposure
 Minimize exposure to narcotics and other medications that disrupt or
disturb sleep cycles

Potentially Better Practice Bundle #2: (Implementation by 31-32 weeks gestation):

Infant massage/ diurnal implementation
 Skin to Skin care: all NICU babies are candidates (see STS policy)
 Exposure to audible maternal voice/ diurnal implementation
 Cycled lighting (Auditory/Visual/Sleep): minimum of 1-2 hours
 Provide more complex visual stimulation: after 37 wks
 Opthalmology
SCREENING /MANAGEMENT FOR ROP:
 For all newborns born less than or equal to 1500 grams or less than or
equal to 30 weeks gestation, the initial screening fundoscopic exam is at
31 weeks corrected gestational age or 4 weeks chronologic age,
whichever is later.
 We routinely hold feeds around the time of the exam (when infant’s are
given cholinergic drops): If feeds are given within ½ hour of the
procedure, it will be held or withdrawn, and then feeds are not resumed
for about 2 hours after the procedure.
 The role of Avastin and Laser is still evolving. Dr. Kovarik will initiate
Avastin for Zone I disease, and Zone II posterior disease. Otherwise, she
will still consider Laser as first line therapy.
 Laser surgery: This will be done in the NICU. Neonatologist will
provide sedation. Dr. Kovarik will prefer non-invasive support, although
airway management will be determined on a case-by-case basis.

OXYGEN TARGETING:
 Avoid hyperoxia and hypoxemia/ wide swings in oxygen saturation
 Infant < 32 weeks and on supplemental oxygen: 90-95 %
 ELGAN Guidelines in EPIC
 ELGAN Guidelines - Available in Sidebar reports:
 For physicians – the NICU vitals report, scroll to index links
 For nursing – on the hospital course report look for “NEO
course” (bottom of the report)

 Hospital Course for nursing– Look for “NEO Course”

 How to set the Hospital Course report as one of your default
sidebar reports: