Introduction
On November 15, 2022, the World Health Organization (WHO) released some updated recommendations for care of the preterm or low birthweight infant. New up-to-date evidence has emerged regarding the most effective clinical interventions in caring for preterm or low birthweight infants so a group of diverse experts and stakeholders from six different regions were selected and began working on these guidelines back in 2020.
The guidelines developed by the WHO are meant to help end-users or clinicians make informed decisions on whether, when, and how to undertake specific actions such as clinical interventions, diagnostic tests, or public health measures with the aim to achieve the best possible individual or collective health outcomes.
All of the recommendations are evidence-based and they have been reviewed by several committees through several stages to ensure the validity of each one. Some of the recommendations are brand new, like the “hot topic” recommendation of immediate kangaroo care, whereas other recommendations are updated.
As I was reviewing the updated recommendations, I realized that it would be beneficial for all NICU clinicians and parents to learn more about them. Since the entire document is around 137 pages, I will be summarizing and providing cliff notes for all of you in this review. So continue reading and get ready to get empowered as we review the World Health Organization’s recommendations for care of the preterm or low birthweight infant!
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Episode 42
Who is the WHO?
Now, you may be wondering who is the WHO? Sorry, I couldn’t help myself – but rather who is the World Health Organization? The World Health Organization was founded in 1948. It is the United Nations agency that connects nations, partners and people to promote health, serve the vulnerable, and keep the world safe. Their goal is that everyone, everywhere can attain the highest level of health.
The World Health Organization leads global efforts to promote healthier lives through all stages of life, from newborns to the elderly. Their team consists of over 8000 professionals that include the world’s leading public health experts, physicians, epidemiologists, scientists and managers.
Within the World Health Organization, they have different committees. The committees develop global guidelines that ensure the appropriate use of evidence and they contain recommendations for clinical practice. The guidelines developed by the WHO are meant to help end-users or clinicians make informed decisions on whether, when, and how to undertake specific actions such as clinical interventions, diagnostic tests, or public health measures with the aim to achieve the best possible individual or collective health outcomes.
The Guidelines Review Committee ensures that the WHO guidelines are of a high methodological quality and that they are developed through a transparent, evidence-based decision-making process.
For our 42nd podcast episode, we reviewed the World Health Organization’s recommendations for the care of the preterm or low birthweight infant. The Departments of Maternal, Newborn, Child and Adolescent Health and Ageing and Sexual and Reproductive Health and Research previously developed guidelines back in 2011, 2012, and 2015 for improving birth outcomes. Subsequently, new evidence has emerged regarding the most effective clinical interventions in caring for preterm or low birthweight infants.
In 2020, the World Health Organization developed a Steering Group that drafted the initial scope of the guidelines. From there, a Guideline Development Group (GDG) was created that consisted of 25 international experts that examined and interpreted the most up-to-date evidence. After reviewing the evidence from 203 studies from low-, middle- and high income countries, they updated and developed some new recommendations for updated guidance on the care of preterm or low birthweight infants.
The guidelines then went through several additional committees or groups for further review. The final guideline includes 25 recommendations and 1 good practice statement for care of the preterm and low birthweight infant. The recommendations were released on November 15, 2022 and consist of 11 new and 14 updated recommendations. The good practice statement is also new.
Within the recommendations, sixteen are for preventive and promotive care, six are for care of complications and three are for family involvement and support, which I love, of course! The good practice statement was developed for parental leave. And although there was little evidence available to support it, the Guideline Development Group felt that it had obvious benefits.
Grab your FREE PDF of the updated guidelines, so you can easily follow along.
Okay, let’s dive in! Initially, I was hoping to review all of the guidelines in one podcast episode, but with one of the new recommendations, I wanted to discuss it more in depth. Some of the topics we cover today, we have already covered on our previous podcast episodes, so I’ll refer you to the episode as it applies.
Preventive and Promotive Care
A.1a. Kangaroo Mother Care
The recommendation states that kangaroo mother care is recommended as routine care for all preterm or low-birthweight infants. Kangaroo mother care can be initiated in the health-care facility or at home and should be given for 8-24 hours per day or as many hours as possible.
The recommendation is labeled as a strong recommendation with a high-certainty of evidence. If you are unsure what kangaroo mother care is otherwise referred to as “kangaroo care” or “skin-to-skin care”, it is when the infant is held in an upright position with only a diaper and hat in place against their parent’s bare chest.
We have covered kangaroo care or skin-to-skin care in several of our podcast episodes. Mostly, because it is a key component of neonatal care and highly recommended. But also, after my personal NICU experience with my son William, I am incredibly passionate and believe in it and all of its benefits even more now! For the full podcast episodes on kangaroo care, go back and listen to Episode 14: Kangaroo Care in the NICU: How Does it Benefit the Infant and the Parents?
Back on this particular episode, I reviewed the multitude of benefits that kangaroo care offers not just for the infant, but the parents as well. To follow that episode up, for episode 15, we focused on some of the common barriers that prevent daily kangaroo care, how to assess for readiness as well as guidelines to safely transfer the infant. So if you have not already, go and listen to: Kangaroo Care in the NICU: How to Address the Barriers, Assess for Readiness, and Transfer the Infant Safely
As if that wasn’t enough, I also did a literature review of the positive effects of kangaroo care for our 30th podcast episode….I told you I was a fan, so you can listen and learn about some of the most recent pieces of research on kangaroo care with the episode: The Positive Effects of Kangaroo Care: A Literature Review
So, I will briefly review some of the benefits since the first two recommendations in the updated guideline are all about kangaroo mother care! Kangaroo care has been associated with decreased mortality as well as physiological benefits with temperature regulation and cardiorespiratory stability. Kangaroo care is also associated with behavioral benefits including improvement in sleep cycles, breastfeeding duration and exclusivity as well as an effective therapy to relieve procedural pain. And the benefits are not just for the infant, kangaroo care is associated with improved breastmilk production and improved mood for both parents.
For the recommendations provided by the World Health Organization, they reviewed 27 random control trials between 1994 to 2021 that included 11,956 infants. The studies were conducted in low and high income countries and everything in between! Their review confirmed that when kangaroo mother care was compared to conventional newborn care, there was a decrease in mortality, a decrease in severe infection or sepsis, and an improvement in hypothermia. Additional outcomes revealed an increase in exclusive and any breastfeeding at discharge and at 1-3 months as well as a decrease in the hospital length of stay.
I strongly support, encourage, and believe in this recommendation. I did kangaroo care with my son in the NICU starting on his 5th day of life and almost everyday thereafter. Initially my husband and I would take turns. But once our son was a little more stable, we would both hold him skin-to-skin daily and I typically did for around 6 hours a day. I truly believe our daily skin-to-skin care is a huge component of his success!
A.1b. Immediate Kangaroo Mother Care (KMC)
The recommendation states that kangaroo mother care for preterm or low birthweight infants should be started as soon as possible after birth. For this recommendation, the experts reviewed four random-control trials for a total of 3603 infants from both high-income and low-income countries. Kangaroo mother care was started as soon after birth as possible in all studies.
Part of this recommendation came from a systematic review about what matters to families. They learned that families want to be involved in caring for their infant and they would like to take an active role in decision-making including, skin-to-skin care and feeding. This is music to my ears! I love hearing that parents are speaking up and confidently saying that they want to be involved!
According to this recommendation, kangaroo mother care should be initiated immediately after birth, or after initial resuscitation if that is needed. If the mother is not available for immediate skin-to-skin care, other family members should be identified prior to the delivery and provide kangaroo care. What is different with this recommendation than the previous, is that the World Health Organization also recommends that preterm and and low birthweight infants should also receive kangaroo mother care as soon as possible after birth unless the infant is unable to breathe spontaneously after resuscitation, is in shock, or needs mechanical ventilation.
How will this be implemented?
Now that these new recommendations have come out, each institution will need to implement their own practices regarding how to approach the new guidelines. Since these recommendations are very new, it does take some time clinically to develop institutional guidelines that everyone is comfortable with, but most importantly, we want to change practice in the hospital setting systematically and in a way that is safe and most beneficial for the infant and family. As neonatal providers, we always want to ensure that the infant receives the care and resuscitation that they need and in a timely manner.
Importance of Neonatal Resuscitation Program (NRP)
At delivery, resuscitation for newborns is guided by the Neonatal Resuscitation Program (NRP). For any infant that does not respond to the initial resuscitation steps with stimulation, inflation and ventilation of the lungs become the priority in newly born infants who need support after birth. Successful neonatal resuscitation efforts depend on critical actions that must occur in rapid succession to maximize the chances of survival. A large observational study found if there is a delay in positive pressure ventilation or inflation of the lungs, it increases the risk of death and prolonged hospitalization.
With all of that said, I strongly believe in immediate kangaroo mother care. I personally and professionally encourage it today and practice it as long as the baby does not need resuscitation beyond stimulation – even in late preterm infants. Oftentimes, if an infant is taking a bit longer to transition, but is overall stable, I encourage skin-to-skin care because that is often what positively turns them around clinically. But we as providers and NICU clinicians want to make sure that if further resuscitation steps are needed, that they are not delayed as it may potentially affect the outcomes.
The World Health Organization also encourages that if the infant needs to be transported to a special or intensive care unit, that the infant should be transported safely in kangaroo mother care with the mother if possible, or another family member. Implementation of this practice will vary between institutions, but for its success, there will need to be appropriate equipment for the transport and it would need to be discussed prior to the transfer to ensure the safety and proper securement of pulse oximeters, oxygen cannulas, and any additional equipment needed for the infant.
The recommendations also touch on the importance of the infant receiving kangaroo mother care once they are in the special or intensive care units, which I completely agree with. But again, each infant and their clinical condition will be different, so this is ultimately up to the NICU care team. But, once your infant is stable, I strongly recommend daily kangaroo care, as the guide suggests for 8-24 hours per day if possible. Part of the success of consistent kangaroo mother care will require NICUs to follow zero separation. Meaning, the infants in the NICU should not be separated from their mothers, especially due to shift report, pandemics, or for any other reason! This necessary change may require some policy changes amongst leadership and governance, but it is desperately needed moving forward.
Some units are shifting to couplet-care where the dyad of the ill or prematurely born infant and the mother, needing medical care of her own, are cared for together, in the same room, from the birth of the baby to its discharge.
And lastly, NICUs need to have the space and equipment that supports prolonged kangaroo mother care to support the mother’s comfort and ensure its success with reclining beds and/or chairs.
A.2. Mother’s own milk
The recommendation says that mother’s own milk is recommended for feeding preterm or low birthweight infants including very preterm, or those infants less than 32 weeks’ gestation or very low birthweight or infants less than 1.5 kg. Now, I am not going to spend a lot of time on this one, because I believe we all know the multitude of benefits that maternal milk provides to infants, but even more so with our vulnerable preterm population.
The Guideline Development Group (GDG) considers mothers providing their own milk as the standard of care across all countries. Maternal milk confers important immune and nutritional advantages for all infants, but especially preterm and low birthweight infants. Formulas do not contain the antibodies and protective properties that are present in human milk that protect the immature gastrointestinal tract. Maternal milk should be provided through direct breastfeeding whenever possible, otherwise expressed maternal breastmilk should be given.
Most institutions have certified lactation consultants that will support mothers and families with education and supplies. Believe me, as a mother who pumped breastmilk for almost a year, it is a commitment and not always easy, but so beneficial for infants. But with the proper support and supplies, it increases the rate of success and length of time that mothers provide breastmilk.
A.3. Donor Human Milk
The recommendation states that when mother’s own milk is not available, donor human milk may be considered for feeding of preterm or low birthweight infants. The recommendation is conditional based on shared-decision making and consent by the parents. Due to the potential harm of necrotizing enterocolitis or NEC from infant formula, the group considered this recommendation more clinically important than the benefit of increased growth. As growth in premature infants can be slightly less with human milk when compared with formula.
Many hospitals are already providing donor breastmilk, especially in preterm neonates, but also for term infants to bridge the gap until the mother’s milk comes in, specifically with certain medical conditions like hypoglycemia or hyperbilirubinemia.
Donor milk is provided through human milk banks or places where the human milk is collected, treated, and/or distributed. Although donor milk has a different immune composition compared to the mother’s own milk, it is still preferred over formula due to infants tolerating it more and the decreased risk of NEC.
A.4. Multicomponent fortification of milk
Fortification is not routinely recommended for all preterm infants, but it is recommended for very preterm infants, or those less than 32 weeks and less than 1.5 kg who are receiving their mother’s own milk or donor human milk. Milk fortifiers are clinically important for weight, length, and head circumference. The Guideline Development Group (GDG) noted that there was limited data on the type of fortifier to use, the timing of initiation, and duration of fortification use. The group added that those decisions should be based on clinical judgment and each institution’s preferences. Fortifiers can be human or animal protein based and contain carbohydrate, fat, protein, multivitamins, iron, zinc, calcium, and phosphorus in varying amounts.
A.5. or Preterm formula
The recommendation states that when mother’s own milk and donor milk are not available, nutrient-enriched preterm formula may be considered for preterm and/or low birthweight infants. The Guideline Development Group was not able to recommend a particular type of preterm formula. Preterm formula has higher energy content and protein content when compared to term formula. Specifically, preterm formula is defined as having both an energy content over 72 kcal/100 ml and protein content of over 1.7 mg/100ml.
Closing
So there you have it, the first few recommendations from the updated World Health Organization’s care of the preterm or low birthweight infant. I hope you found some value in hearing these global recommendations. As I mentioned, all of the recommendations are evidence-based and they have been reviewed by several committees through several stages to ensure the validity of each one. They are based on evidence from multiple studies. The target audience for the recommendations range from national policy-makers, to implementers, supervisors, managers, to neonatologists, advanced-practice nurses and nurses. The recommendations are to help guide and provide the most optimal care for preterm and low birthweight infants.
Whether you are a NICU parent or a NICU clinician, I think it is important to know what the global recommendations are for the care of the preterm and low birthweight infant. Next time, we will continue to review more of the World Health Organization’s recommendations so you can stay up-to-date on what is best for the preterm and low birthweight neonatal population.
Remember to grab your free PDF of these recommendations if you have not already!
References
Aziz, K., Lee, H., Escobedo, M., Hoover, A., Kamath-Rayne, B., Kapadia, V., Magid, D., Niermeyer, S., Schmolzer, G., Szyld, E., Weiner, G., Wyckoff, M., Yamada, N., & Zaichkin, J. (2020). Part 5: Neonatal Resuscitation, 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 142 (suppl 2), S524-S550.
Campbell-Yeo, M., Disher, T., Benoit, B., & Johnston, C. (2015). Understanding kangaroo care and its benefits to preterm infants. Pediatric Health, Medicine and Therapeutics, 6, 15-32.
Ersdal HL, Mduma E, Svensen E, Perlman JM. Early initiation of basic resuscitation interventions including face mask ventilation may reduce birth asphyxia related mortality in low-income countries: a prospective descriptive observational study. Resuscitation. 2012;83:869–873. doi: 10.1016/j.resuscitation.2011.12.011 Crossref. PubMed.
Hardin, J., Jones, N., Mize, K., & Platt, M. (2020). Parent-Training with Kangaroo Care Impacts Infant Neurophysiologic Development & Mother-Infant Neuroendocrine Activity. Infant Behavior and Development, 58, https://doi.org/10.1016/j.infbeh.2019.101416
Vittner, D. Butler, S., Smith, K., Makris, N., Brownell, E., Sara, H., & McGrath, J. (2018). Parent Engagement Correlates With Parent and Preterm Infant Oxytocin Release During Skin-to-Skin Contact.
Advances in Neonatal Care, 19(1), 73-79.
World Health Organization. (2022, November). WHO recommendations for care of the preterm or low-birth-weight infant. World Health Organization. https://apps.who.int/iris/bitstream/handle/10665/363697/9789240058262-eng.pdf
