Introduction
On our last episode, I continued to summarize the updated recommendations for care of the preterm and low birthweight infant from the World Health Organization (WHO) that were just released on November 15th of this year, 2022. The recommendations are directed at a large target audience and are beneficial for national policy makers, supervisors, managers, NICU clinicians plus more! I think it’s extremely important for anyone who works with the preterm and low birthweight population to be aware of the updated recommendations by the World Health Organization. I also believe that it is important that parents of preterm or low birthweight infants have some idea of what the recommendations entail and how it may impact the care given to your infant. On this episode, I finished discussing the recommendations by spotlighting the most pertinent points.
So stay tuned and get ready to get empowered as we continue to review the World Health Organization’s recommendations for care of the preterm or low birthweight infant!
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Episode 44
Who is the WHO?
The World Health Organization was founded in 1948. They are 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.
On our last podcast, we discussed the World Health Organization, who they are and what their goals are in detail. We then started to discuss each of the WHO’s recommendations that they developed and released on November, 15, 2022. If you have not already, I encourage you to go and listen to our 42nd podcast episode: A Review of the WHO Recommendations for the Care of Preterm or Low-Birth-weight Infant and our 43rd podcast episode: A Review of the WHO Recommendations for the Care of Preterm or Low-Birth-weight Infant – Part III
Today we are going to continue our review of the World Health Organization’s recommendations for the care of the preterm or low birthweight infant. The guidelines went through several committees or groups for a thorough 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.
We developed a guide so you can follow along easily as we review the recommendations. Grab your FREE PDF of the updated guidelines, so you can easily follow along.
Preventive and Promotive Care
A.11 Probiotics
Probiotics may be considered for human-milk fed very preterm infants (<32 weeks’ gestation). This is a new recommendation by the Guideline Development Group (GDG)and they stated that only probiotics especially formulated for preterm or low birthweight infants that meet regulatory standards should be used, and clear instructions for safe use should be given to health workers. The group did not make specific recommendations on which species or strain should be used as well as which formulation is preferred whether it be powder or drops. The GDG was also unable to make specific recommendations on the dose, timing and duration of probiotic use as there was insufficient evidence and the decision should be based upon clinical judgment.
It is likely that you have heard of probiotic use in adults, but perhaps not in the neonatal population. Probiotics are formulations given by the enteral route that contain bacteria, bifidobacterium, lactobacillus or fungi like Saccharomyces. Probiotic supplements are available over-the-counter with a variety of formulations. Probiotics work by colonizing the mucosal surface of the gastrointestinal tract. Colonizing means that there is the presence of bacteria on a body surface, but it does not cause a disease in the person. Probiotics also modulate the intestinal microbiome and promote mucosal barrier functions.
The studies that specifically reviewed probiotic use in the preterm and low birthweight population over the last 10 years have shown varying effects including reductions in sepsis and necrotizing enterocolitis (NEC), but they have also shown an increase in bacteraemia and fungaemia.
According to recent reports from large collaborative databases in the United States, approximately 10% of extremely low gestational age neonates receive a probiotic preparation during their stay in the NICU, but there remains to be a wide variation of practice amongst units. Large meta-analyses of these trials have demonstrated the efficacy of multiple-strain probiotics in reducing necrotizing enterocolitis and all-cause mortality.
According to the American Academy of Pediatrics, due to the lack of FDA regulated pharmaceutical-grade products in the United States, as well as conflicting data on safety and efficacy, and potential for harm in a highly vulnerable population, current evidence does not support the routine, universal administration of probiotics to preterm infants, particularly those with a birth weight of less than 1000 g. Centers who decide to administer probiotics to select preterm infants should discuss the potential risks and benefits of this therapy with parents prior to starting.
A.12 Emollients
This is also a new recommendation and it states that application of topical oils to the body of preterm or low birthweight infants may be considered. Emollients are moisturizing treatments applied topically or directly to the skin including ointments, creams, and natural vegetable or plant topical oils like sunflower or coconut oils.
The skin of preterm infants is structurally and developmental different than that of a term infant which makes them more prone to skin injury and trauma. Skin trauma can lead to serious consequences for infants in the NICU including problems with thermoregulation, fluid and electrolyte balance, diversion of calories for tissue repair, discomfort, potential toxicity from absorbed substances, and an increased risk for infection.
We dedicated an entire podcast episode to why preterm infants are at increased risk for skin injury and followed it up with skin care guidelines for the NICU on our 34th and 35th podcast which if you have not already, I recommend that you go and listen!
Topical emollients can improve skin integrity and they offer protective barrier functions, but studies have shown that daily application of topical ointments increases the risk for hospital-acquired infections. Therefore, it is not recommended to use prophylactic application of topical ointments, they should be exclusively used in cases of severe skin dryness, cracking of the skin and/or if the infant has a fissure.
Studies have shown that the use of vegetable oils rich in linoleic acid like in sunflower oil and coconut oil have been shown to improve the barrier function and hydration. Therefore, the GDG suggested that sunflower or coconut oil may be used and that the initiation and duration of use should be based on clinical judgment. During the application process, the oils should be applied gently to avoid any disruptions of the skin integrity.
Care for Complications
B.1 CPAP for Respiratory Distress Syndrome
Continuous positive airway pressure (CPAP) therapy is recommended in preterm infants with clinical signs of respiratory distress syndrome. This particular guideline is labeled as a strong recommendation with a moderate certainty of evidence.
Respiratory distress syndrome (RDS) is very common in premature infants and a major cause of morbidity and mortality. To learn more about the pathophysiology behind respiratory distress syndrome, we covered it in great detail back on on episode 8: Take a Deep Breath – Diving into Respiratory Distress in Newborns.
Continuous positive airway pressure, (CPAP) has been the standard of neonatal respiratory care in the NICU for decades. It was first introduced by Gregory and colleagues back in 1971. Continuous Positive Airway Pressure (CPAP) delivers a constant level of positive end expiratory pressure (PEEP) to the baby’s alveoli, or air sacs which prevent the alveoli from collapsing, it maintains functional residual capacity (FRC), it facilitates gas exchange, improves lung compliance and airway resistance. We also covered non-invasive ventilation, including CPAP back on episode 11: Non-Invasive Ventilation in the NICU – A Review of NIPPV, CPAP, HFNC, and LFNC too
Although CPAP has been around for years, it continues to be used routinely in infants with respiratory distress in many healthcare facilities globally. The GDG did note that there was limited data on the timing of initiation and duration of CPAP. Based on the majority of the trials reviewed, the GDG suggests that CPAP may be considered as soon as the diagnosis of RDS is clinically suspected, and the duration of use, should be based on clinical judgement. They also recommended that the implementation of CPAP must be done with skilled staff, quality equipment, and humidified blended oxygen. It should be provided when its use can be monitored well at a minimum of a Level II intensive care unit.
B.2 CPAP immediately after birth
CPAP therapy may be considered immediately after birth for very preterm infants (<32 weeks’ gestation), with or without respiratory distress.
Some NICUs administer CPAP immediately after birth for infants at risk, or those born prematurely, regardless of their respiratory status rather than waiting and assessing for clinical symptoms of respiratory distress. A 2020 study by Lam et al., found that in stable preterm infants, early CPAP use may be a nonpharmacologic and safe therapeutic strategy to stimulate lung growth. The use of early CPAP may not only benefit the preterm lung by minimizing injury, but clinical and animal data indicate that the mechanical stretch of the lung with CPAP may actually stimulate lung growth.
One of the NICUs I have worked in, continue the infant on CPAP regardless of their clinical respiratory status until the infant is 32 weeks’ gestation to promote lung growth, but again each institution and their practices will vary.
B.3 CPAP pressure source (bubble CPAP)
For preterm infants who need continuous positive airway pressure (CPAP) therapy, bubble CPAP may be considered rather than other pressure sources (e.g. ventilator CPAP).
As you may know, and we discussed in more detail back on the 11th episode of our podcast, CPAP can be delivered via different apparatuses including water-seal otherwise known as bubble, or via a ventilator, or Infant Flow Driven (IFD) CPAP. This recommendation is based on evidence from trials that compared bubble CPAP with ventilator CPAP or Infant Flow Driven CPAP. Despite this recommendation, it is important to say that each institution will have their own practices or protocols in place regarding their preferred method for delivering CPAP so it will be unit-dependent.
B.4 Methylxanthines for treatment of apnea
Caffeine is recommended for the treatment of apnea in preterm infants. This particular recommendation was considered a strong recommendation with a moderate-certainty of evidence. Apnea, or the cessation of breathing is common in preterm infants with the incidence being inversely related to gestational age. Apnea is known to occur in almost all extremely preterm infants or those born prior to 28 weeks’ gestation. Although apneic events are common, intermittent hypoxic episodes in the first two months of life are associated with an increased risk of chronic conditions including retinopathy of prematurity (ROP) and adverse neurodevelopmental outcomes, so it is important to minimize the occurrence of apneic episodes as much as possible.
Administration of theophylline, aminophylline, and caffeine have been used to manage apnea for over 50 years. Methylxanthines are available in either intravenous (IV) or oral formulations. Caffeine is given once a day whereas theophylline and Aminophylline are given 3 times a day. The justification of this recommendation stems from evidence of moderate benefits including decreased incidence of death and bronchopulmonary dysplasia (BPD), decreased need for mechanical ventilation, and decreased neurodevelopmental disability.
B.5 Methylxanthines for extubation
Caffeine is recommended for the extubation of preterm infants born before 34 weeks’ gestation. This a strong recommendation with a moderate-certainty of evidence.
The evidence for this recommendation only stems from studies of infants less than 34 weeks’ gestation, but it does suggest that Caffeine or other methylxanthines should also be considered for extubation of preterm infants born at or after 34 weeks’ gestation and before 37 weeks, but it should be based on clinical judgement.
The GDG suggested the dose of Caffeine should be given 24 hours before the planned extubation. If there is an unplanned extubation, Caffeine should be given as soon as possible after the extubation, but with the goal for it to be given within 6 hours of the extubation and the infant should continue to receive it for six days. Although there was limited data on the dosage, based on the largest trials, the GDG suggested a 20 mg/kg loading dose and a maintenance dose of 5 mg/kg for six days.
B.6 Methylxanthines for prevention of apnea
Caffeine may be considered for the prevention of apnea in preterm infants born before 34 weeks’ gestation. Although the GDG noted that there was limited data on the dose, timing of initiation, and duration of administration, they suggested a loading dose of 20 mg/kg followed by a daily maintenance dose of 5 mg/kg. The duration of Caffeine administration should be based on clinical judgement since every infant in the NICU and their clinical course is different, some infants may require the use of Caffeine for longer durations than others.
Family Involvement and Support
C.1 Family Involvement
This new recommendations states that family involvement in the routine care of preterm or low birthweight infants in healthcare facilities is recommended. The guideline is strongly recommended with a low to moderate certainty of evidence.
Based simply on the title of our podcast, but especially if you have listened to this podcast before, you know that I could spend the entire episode plus more speaking on this topic, but I will try to be succinct and keep it brief.
It has been widely accepted throughout literature that family involvement is not only beneficial for the infant and parents, but it is actually a critical key component in the overall outcomes for the entire family unit. Parents of infants who have been admitted to the NICU undergo a large amount of stress. They are physically separated from their infant, exposed to an unfamiliar environment where healthcare workers are caring for their infant, and they often lose their identity as parents which can negatively impact their ability to bond with their baby. Parent-infant attachment is crucial and if not fostered well, it can negatively impact the infant’s long-term trajectory.
Each healthcare facility has their own policies regading parental involvement, but the trend is to encourage family-centered or family-integrated care where parents are involved with guided instruction on helping to care for their infant, to participate in skin-to-skin care, and be involved in medical-decision making.
The trials reviewed by the GDG varied widely in the intervention content, but they all showed consistent and similar effects. Therefore, the GDG recommended that simple family involvement interventions such as the delivery of direct bedside care and involvement in medical-decision making could be implemented in all settings. The GDG noted that family involvement strategies reduced the length of hospital stay, improved breastfeeding and reduced parental anxiety and stress. Not only that, with the review, parents reported wanting to be involved and they would like to take an active role in deciding what interventions are given to their infants.
The beauty in applying family-integrated care in NICUs is that there is not a special infrastructure needed to implement it in regards to special equipment or supplies. Although, adequate room and comfortable, reclining chairs or beds should be available to promote skin-to-skin care. But, moreso, some units need a shift in their practice and structure to fully embrace parents as active care partners to successfully implement family-integrated care.
C.2 Family Support
Families of preterm or low birthweight infants should be given extra support to care for their infants, starting in healthcare facilities from birth, and continued during follow-up post-discharge. The support may include education, counseling and discharge preparation by health workers, and peer support.
Supporting NICU families to care for their infant is a basic and integral component of any health system. Unfortunately, NICU families still feel ill-equipped to care for their preterm or low birtweight infant upon discharge.
The GDG noted that education, counseling, and discharge preparation had important effects on improving parent-to-infant interaction, improving breastfeeding and decreasing parental anxiety, stress, and depression. Due to preterm and low birthweight infants often needing care from multiple disciplines, careful coordination of care is needed post-discharge. The GDG also recommended peer groups for families to support their mental well-being. Any parent that has brought an infant home from the NICU could speak on the stress and anxiety that goes along with it. It is imperative that while the infant is in the NICU, parents are involved and that education and preparation for home start from the beginning so parents feel confident in caring for their infant when it is time to bring them home.
C.3 Home visits
Home visits by trained health workers are recommended to support families to care for their preterm or low birthweight infant. This is a new, strong recommendation with a moderate certainty of evidence.
Studies over the last 10 years in high-, middle-, and low-income countries have shown that home visits done both antenatally and postnatally can reduce maternal and newborn mortality. The GDG noted that trained health workers can include nurses, midwives, doctors, and community health workers. They recommended that extra home visits should be made for preterm and low birthweight infants in addition to the routine scheduled follow-ups, but the frequency should be based on clinical judgement. Home visits have shown an increase in exclusive breastfeeding rates, immunization visits, parental-infant attachment, and they decreased parental stress.
C.4 Parental leave and entitlements
Parental leave and entitlements should address the special needs of mothers, fathers and other primary caregivers of preterm or low birthweight infants.
The GDG made this good practice statement in recognition of the costs and burdens to parents and families of preterm and low birthweight infants. Families of preterm and low birthweight infants have increased financial responsibilities, stress, anxiety, and depression. Leave time is meant to help families care for the infant and families may also need financial support for transportation, to assist them in caring for their other children, as well as the costs of the hospitalization.
Based on the studies in the review, the GDG recommend that parental leave and entitlements should include additional days of excused leave from work and additional financial payments. They noted that parental leave and entitlements are in place in some countries, but they recommend that they should be expanded globally.
I love this good practice statement. For myself and so many other NICU parents, we have had to carefully manage our time while our infant is ill in the NICU for several months while also trying to save some time for when they are able to come home. It is very stressful and a struggle for many NICU parents, especially mothers. To add to it, so many mothers, like myself, also had to take some time off prior to the delivery due to pregnancy complications, so it is a common issue that needs some additional attention to better support NICU families.
Closing
I hope you found some value in hearing these global recommendations developed by the World Health Organization. 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.
Whether you are a policy maker, supervisor, 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. The recommendations are meant to help guide clinicians so the most optimal care for preterm and low birthweight infants is provided globally. And since NICU Parents are often thrown into a world without any basis of knowledge, we hope this review is beneficial. We at Empowering NICU Parents want to help provide you with appropriate, evidence-based education so you feel more confident in caring for and advocating for your infant.
Next time, we will complete our review of the recommendations from the World Health Organization 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
Gardner, S., Carter, B., Enzman-Hines, M., & Niermeyer, S. (2021). Merenstein & Garner’s Handbook of Neonatal Intensive Care Nursing: An Interprofessional Approach, Ninth Edition. Elsevier.
Gomella, T., Eyal, F., & Bany-Mohammed, F. (2020). Gomella’s Neonatology: Management, Procedures, On-Call Problems, Diseases, and Drugs, 8th Edition. McGraw-Hill.
Gray, K., Messina, J., Cortina, C., Owens, T., Fowler, M., Foster, M., Gbadegesin, S., Clark, R., Benjamin Jr., D., Zimmerman, K., & Greenberg, R. (2020). Probiotic use and safety in the neonatal intensive care unit: A matched cohort study. Journal of Pediatrics, 222, 59-64.
Lam, R., Schilling, D., Scottoline, B., Platteau, A., Niederhausen, M., Lund, K., Schelonka, R., MacDonald, K., & McEvoy, C. (2020). The effect of extended continuous positive airway pressure on changes in lung volumes in stable premature infants: A randomized controlled trial. Journal of Pediatrics, 217, 66-72.
Poindexter, B. (2021). Use of probiotics in preterm infants. American Academy of Pediatrics, 147(6), https://doi.org/10.1542/peds.2021-051485
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
