Respiratory

Draft – March 15, 2008







NATIONWIDE CHILDREN’S HOSPITAL NICU





PART III: Week 5 - discharge

Guidelines for the Care of the Extremely Premature Infant (0.30 or positive pressure ventilation (CPAP or IPPV) at 36 weeks PMA (Ehrenkranz, 2002).

Therefore, during the time period covered by these guidelines the majority of patients

should be weaning off of IPPV onto bubble CPAP and then to room air. A fair number of

these patients will have BPD, however we anticipate that the majority will have either mild

or moderate BPD – particularly if the first 2 parts of the guidelines were utilized in these

patients care.



Nasal Continuous Positive Airway Pressure (nCPAP): The extremely premature infant cared

for in the NICU will need some form of respiratory support. Currently IPPV and nCPAP

are the modalities available to prematurely born infants cared for in the NICU. It has

been demonstrated that avoiding or minimizing time on IPPV prevents chronic lung disease

in these highly vulnerable patients (Kamper, 1993; De Klerck, 2001; Narenden, 2003).

Therefore, by the time these patients are entering the 5th week of life they should be on

nCPAP, otherwise if they remain on IPPV every effort should be made to extubate to

nCPAP. Premature patients are maintained on nCPAP until they are breathing easily on

room air with little apnea and bradycardia. Thus, the length of nCPAP therapy depends on

each individual patient, although many extremely premature infants may require nCPAP

until ~32 weeks post-conceptual age. When patients are weaned off nCPAP they should

not require supplemental oxygen by nasal cannula. Patients weaned off nCPAP who then

develop an oxygen requirement to maintain SpO2 >85%, and/or increased apnea and

bradycardia need to be placed back on nCPAP.

 Bubble nCPAP is the delivery method for these patients

 Pressures set to 5 – 8 cmH2O

 FiO2 – adjust to keep oxygen saturations (SpO2) per target

guidelines:

 29 weeks PMA – SpO2 85 –93%

 30 – 34 weeks PMA – SpO2 88 – 95%

 >34 weeks PMA – SpO2 90 – 97%

 For cares in some patients may need to increase fiO2 10%

above baseline prior to initiating care

 Need to wean baseline fiO2, i.e. fiO2 when patient “quiet”

 Attempt to wean baseline fiO2 2-5% every 12 hours as

tolerated to maintain guideline oxygen saturations when

patient “quiet”

 Suctioning performed as per protocol (see Appendix I)

 Note: proper technique is imperative

o Should be a 2 person procedure

o Use blow-by oxygen PRN

 Weaning nCPAP





3

Draft – March 15, 2008





 Wean fiO2 to room air

 Once patient is breathing comfortably without significant

apnea and bradycardia episodes place in room air

 Failure of nCPAP weaning

 Supplemental oxygen requirement

 Worsening A&B’s – in terms of character and duration not

necessarily number of episodes

 If fails place back on nCPAP

o Wean fiO2 to 0.21 as tolerated

o When breathing easily without significant A&B’s try

placing in nasal cannula oxygen – wean as tolerated

 Developmental Considerations

 Oral stimulation

 PO feeds if age appropriate

 Note: as with all babies of this gestational age OT should evaluate

the patient prior to initiating oral feeds



Intermittent Positive Pressure Ventilation (IPPV): We anticipate that the majority of

patients who were admitted in the first week of life will be extubated and on nCPAP. We

also anticipate that patients admitted during the 2nd – 4th weeks of life will be extubated

and on nCPAP, and that at least one extubation attempt will have been made. Given that

the only interventions that have been definitively demonstrated to decrease the incidence

of BPD are prevention of premature birth and avoidance of mechanical ventilation (Harris,

1976; Carlo, 2002; DeKlerck, 2001; Kamper, 1993), every effort should be made now that

the patient is entering week 5 of life to extubate these patients to nCPAP.



For the patient that continues to require IPPV at 28 days of age:

 Consider a BPD Service consult, particularly if the patient requires >40% O2

 Optimize conditions and attempt extubation

 nutrition

 maximize caloric intake

 consider fluid restriction

 pulmonary medications

 albuterol

 flovent

 consider lasix course

 at time of extubation shouldn’t be any other issues

 extubation attempts should be controlled

 caffeine dosing should be optimized

 wean to extubation settings as per extubation protocol

 PIP 20 seconds

 Short self-resolved apneas are a normal developmental stage

 Change in number, character or intervention

 Check that nCPAP circuit, prongs and patient’s position are

appropriate

 Suction patient

 Check caffeine dose

 Consider a sepsis work-up

 If refractory to above interventions consider reintubation





5

Draft – March 15, 2008





 If continues consider work-up for other unusual causes of apnea

 Consider weaning off caffeine once >32 - 34 weeks PMA with minimal spells

 There is no role of routine home monitoring in these patients



SKIN: Since the skin begins to keratinize in the first week of life, these patients at 5

weeks of age are now at relatively low risk for skin breakdown and injury (Sedin, 2004).

However, their skin remains delicate and caution should be used when applying adhesives to

the skin. Although, the rate of transepidermal water loss is dramatically lower now than it

was at birth, and it continues to fall such that by well before discharge these patients can

be cared for in an open crib. However, while the patient remains in an incubator it is

imperative that care be taken to provide adequate humidity to maintain minimal fluid loss

and maintain skin integrity in these rapidly growing infants (Ågren, 1998). Therefore, care

should be taken to provide adequate humidity to maintain fluid loss at a minimum.

 Set humidity at 50% while patient remains in isolette.

 Wean patient from isolette to open crib once patient large enough (usually 1600-

1700 grams) to maintain body temperature while continuing with a good rate of

weight gain

 Reposition with cares

 Tape may be used on the skin, but should be used with caution

 Bath patient

 Use sterile water

 No shampoo

 Patients will not need a bath every day

 Do not use baby wipes until patient is near discharge



CARDIOVASCULAR: The PDA should have been dealt with by week 5 in these patients. If

a patient continues to have a moderate to large PDA then ligation should be considered.

Given the propensity for sepsis in these patients, the blood pressure abnormalities most

likely to be encountered are hypotension and shock (Engle, 2001; Noori and Seri, 2005).

Keep in mind though that as these very premature patients grow older they are at risk for

developing hypertension (Flynn, 2000).

 Normative data – it is not entirely clear what the normal blood pressure values for

an infant born at 80

30 - 36 >90

36 - 48 >100

>48 >110





 If the SBP > 125 mmHg or there is evidence of congestive heart failure (CHF) then

a diagnosis of severe hypertension is made

o Work-up for hypertension

o Check med list (hydrocortisone, other corticosteroids)

o Temperature control

o Pain

o 4 extremity blood pressures

o Echocardiogram



7

Draft – March 15, 2008





o Renal ultrasound, BUN, creatinine and urinalysis

 If any of the above abnormal obtain renal consult

 Treatment

 If considering anti-hypertensive therapy for a patient 125 mmHg

 Hydralazine iv

 Monitor BP q 5 minutes

 If multiple doses necessary consider arterial line

 Renal consult

 Chem-10, urinanalysis, renal ultrasound

 Echocardiogram



Murmurs

o Patient with known PDA >28 days of age

o Get echocardiogram for heart function

o If PDA is symptomatic then ligate

 Symptoms:

 Congestive heart failure (clinical or by echo)

 Persistent oxygen requirement

 Need for fluid restriction or lasix

 Feeding intolerance

 Poor growth

 If asymptomatic then follow expectantly

o Patient with new murmur consider echocardiogram



FLUIDS/NUTRITION: By the start of the fifth week of life most babies that have been

able to follow SBG I and II should be on full enteral feeds. In keeping with the

recommendations of the American Academy of Pediatrics (2005) we strongly encourage

the use of breast milk for all premature infants in whom a specific contraindication is not

present. Indeed, it has been shown that extremely premature infants who are fed breast

milk during their NICU stay have improved neurodevelopmental outcomes at 18 months of

age (Vohr, 2006), an improvement that persists at 30 months of age (Vohr, 2007).

Furthermore, feeding breast milk has been shown in some studies to reduce the incidence

of NEC (Sisk, 2007; Reber, 2004) and infection (Morales, 2007; Furman, 2003). Banked





8

Draft – March 15, 2008





breast milk can be considered for those infants whose mothers cannot provide breast milk.

In these extremely low-birth weight infants breast milk should be fortified to provide

adequate protein, calcium, phosphorus and calories (Schandler, 2001). Remember that

ultimately it is provision of excellent nutrition that will “cure” the extreme premature.

Furthermore, it has been found that in extremely premature patients that those with the

best rate of growth in the NICU had the best neurodevelopmental outcomes at 18 –22

months (Ehrenkranz, 2006).



General

 Normative data – in the time between starting week 5 and discharge the patient will

should grow relatively rapidly (see growth chart next page) such that body weight

at time of discharge should be >2 kg

 Work closely with nutrition – the nutritionist round on the patients weekly

 Remember that even for these VLBW patients that breast milk is best (Vohr, 2006,

Ehrenkranz, 2006)!

 If mom is unable consider donor breast milk



Specific

 Vitamin D

 Once on full feeds consider Vit D source

 When >35 weeks and >2 kg need Vit D

o Poly-vi-sol 0.5 ml PO BID

 Iron

 2 mg/kg/day in premature formula

 Neosure has ~2 mg/kg/day iron

 Breast fed infants need poly-vi-sol with iron

 If utilizing Ross HMF need fer-in-sol

 Nutrition labs

 Screen every month

 Calcium, phosphorus, alkaline phosphatase, albumin

 If stable may check less frequently

 Oral feeds

 Use cue based feeding algorithm (please see appendix)

 Non-nutritive sucking encouraged from the start

 Encourage holding of baby with feeds and non-nutritive sucking

Growth failure

 500 needs more calcium, phosphorus and/or Vitamin

D

 H&H – very low hemoglobin can lead to growth failure

 Direct bilirubin > 2 mg/dL may indicate fat malabsorption



Feeding intolerance

– Please see algorithm next page









11

Draft – March 15, 2008





FEEDING INTOLERANCE ALGORITHM







Gastric residual > ½ of feeding volume at next feed

Abdominal distension > 2 cm increase in 24 hours

Report of clinical instability









Physical Exam









Normal Abnormal









Reduce feeds by 20% Babygram

Consider rectal stim

Followed by glycerin

Advance feeds after 24 h



Normal Abnormal









Hold feeds 12-24

hours ILEUS § PERFORATION§

PNEUMATOSIS

Restart at half Sepsis work-up† Sepsis work-up† Sepsis work-up†

Antibiotics‡ Antibiotics‡

volume NPO

Antibiotics‡

NPO

NPO

Serial¶ X-rays Serial¶ X-rays Serial¶ X-rays

Serial¶ CBC, plts Serial¶ CBC, plts

Surgical consult

Add clindamycin

NPO and antibiotics 48 h Resolution

Slowly restart feeds



†

includes blood and cath urine cultures, consider an LP if clinically stable

‡

Vancomycin and Gentamicin

§

at least 7 – 10 days of NPO and antibiotics

every 6  12 h depending on clinical condition

¶

12

Draft – March 15, 2008







INFECTION: These patients continue to have a poorly developed immune system, and

therefore are extremely susceptible to infections (McGuire, 2004). These patients are

essentially immunocompromised. Therefore, we cannot over-emphasize the need for good

hand washing when contacting these vulnerable patients!

 Central Venous Lines

o Meticulous line care

o Daily discussion of need

o Fill out daily goal sheets

 Daily discussion of change to PO meds

o If patient on full feeds STRONGLY consider discontinuing central line

 Isolation

o If category I do bedside isolation

o For category III or higher move to negative flow isolation room

 Sepsis work-up

o Always consider sepsis for any change in the patient’s condition

o If no “hardware”

 obtain a CBC with differential, platelet count and urinalysis

 If normal follow

 If abnormal do sepsis work-up

o If patient has “hardware”

 Sepsis work-up with any significant change in condition

o Sepsis work-up should include:

 CBC with differential, platelet count and urinalysis

 Blood cultures – peripheral and fungal cultures

 Urine cultures (specimen from either catheter or bladder tap)

 Lumbar puncture if patient stable (remember that up to 33% of

patients with meningitis can have negative blood cultures (Stoll,

2004))

 Consider tracheal aspirate for gram stain and culture if patient on

IPPV

 Start antibiotics with vancomycin and gentamicin

 Check levels is on treatment for >2 days or anuric

 Adjust antibiotics as soon as sensitivities know to narrow

spectrum as much as possible

 STRONGLY consider discontinuing antibiotics if cultures negative at

48 hours

 Consider an ID consult if unusual bacteria, fungus, persistent

septicemia, and/or meningitis

 Note: A CBC should only be obtained when entertaining the diagnosis of sepsis

 CBC parameters consistent with abnormality are leukocytosis, leucopenia, elevated

immature/total neutrophil ratio, and/or a low absolute neutrophil count.





13

Draft – March 15, 2008





 Although fungal infections, including Candida, are a problem in these patients, there

is insufficient data at this point to justify the routine use of fluconazole

prophylaxis in these patients (Manzoni, 2007).



HEMATOLOGIC: In a hemodynamically stable extremely premature infant starting the 5th

week of life, the goals for maintaining hematocrit change. The hematocrit value alone is

probably insufficient grounds for transfusion (Luban, 2002). Remember to limit the

number of blood draws in these relatively stable patients to minimize iatrogenic anemia.

Second, the normal response to birth is for the hematocrit to fall. Most of these patients

are relatively stable and not on mechanical ventilation. These patients will respond to

their physiological fall in hematocrit by demonstrating a reticulocyte response sometime

between 6-8 weeks of age, which reveals that the patient is making new red blood cells.

Keep in mind that these patients are rapidly growing and therefore even though their red

blood cell numbers are increasing their plasma volume is also increasing, which may result

in a patient with a seemingly low hematocrit in the face of a brisk reticulocyte count. In

the otherwise stable premature infant a good reticulocyte count suggests an appropriate

increase in red blood cell number and these patients should not be transfused unless there

is a change in their clinical status. Transfusing a neonate with a good reticulocyte count

will result in a decrease in endogenous red blood cell production. In an attempt to

minimize donor exposure the following guidelines should be used in patients who are

hemodynamically stable. (For patients with unstable blood pressure and/or perfusion

please see the cardiovascular section). Furthermore, communication with the blood bank is

necessary to minimize donor exposures (Luban, 2002). Since the use of erythropoietin has

been found to have no effect on the need for transfusions in low birth weight infants

(Ohls, 2001) we do not recommend the routine use of erythropoietin in these patients at

this time.

 Minimize transfusions

 Minimize blood draws

 Check the H&H and reticulocyte count every other week in asymptomatic patients

o The H&H may be checked more frequently if the patient has any of the

following

 Acidosis

 O2 requirement >40%

 Profound desaturation episodes

 If the patient has a reticulocyte response be sure that the patient is receiving

supplemental iron

 If patient is on IPPV and >60% O2, then keep hematocrit >40%

 Consider transfusion

o If patient on nCPAP and >60% O2

o If patient is symptomatic and >40% O2

 If patient is asymptomatic then continue to follow

 To minimize donor exposures when the decision has been made to transfuse





14

Draft – March 15, 2008





o use 15 ml/kg PRBCs

o check hematocrit 4 hours after transfusion complete

o if < 40% then repeat transfusion with 10-15 ml/kg PRBCs



NEUROLOGIC: Extremely premature infants are at high risk for neurological

abnormalities. The presence of intraventricular hemorrhage (IVH) or periventricular

leukomalacia (PVL) increases the risk of neurological abnormalities. IVH usual occurs in

the first week of life (see Small Baby Guidelines for week 1), although patients may be at

risk for extension of the IVH after the 1st week of life (see Small Baby Guidelines for

weeks 2-4). The pathogenesis of white matter injury (PVL) in the developing brain remains

unclear (Jensen, 2006; Folkerth, 2006), it is now the most common form of brain injury in

the premature infant (Back, 2004). PVL should be screened for prior to discharging the

patient. Remember that the patient’s comfort should be a priority, remember to prevent,

limit, or avoid noxious stimuli (i.e. lab draws) (Committee on the Fetus and Newborn, 2000).

 If HUS done in first week of life abnormal, then it should be repeated at 1-2 week

intervals until stable

 If HUS normal in first week of life, then it should be repeated at 36-40 weeks

post-conceptional age (based on AAP/AAN Practice Parameter, see

http://aappolicy.aappublications.org/misc/Neuroimaging_of_the_neonate.dtl)

 If HUS at 36-40 weeks PMA reveals PVL then consider obtaining MRI prior to

discharge

 Head circumference should be checked every week, unless the patient has a Grade

III or Grade IV IVH then the head circumference should be done daily

 If severe IVH and/or post-hemorrhagic hydrocephalus are present consider

neurosurgical consultation



DEVELOPMENTAL: Extremely premature infants are at high risk for developmental

abnormalities, even in the absence of demonstrable pathology on cranial imaging (Broitman,

2007; Laptook, 2005; LeFlore, 2003). It has been shown that these infants have markedly

improved outcomes when stress is reduced in their environment by reducing noxious stimuli

(such as bright light, sound, and traffic) and by promoting proper positioning and handling

(Byers, 2003). Furthermore, developmental care in the NICU should be based on

individualized behavioral structuring and management (Als, 2003; Als, 1994), which

includes a component of family-centered care (Byers, 2003). Although many issues

regarding the effects of developmental care are unresolved, currently available data

suggests benefits of individualized developmental care for these patients without adverse

effects (Lotas, 1996; Byers, 2006).

 Lighting (Figueiro, 2006)

o When patient reaches ~32 weeks PMA begin cyclical lighting

 12 hours per day

 10-600 lux (check with light meter)

 Consider opening blinds to allow for natural light





15

Draft – March 15, 2008





o Once tolerating cyclical lighting transition from heavy to thin blanket cover

o ~34 weeks PMA remove isolette cover

o NOTE: it is better to cover the isolette than to cover the face

o Avoid direct lighting

 Noise

o Turn off alarms quickly

o Set tone and/or volume to be less disturbing

o Utilize a noise meter to check levels randomly to remind all to maintain low

noise levels

o At term add music and mobiles

o Encourage the parents talking to their babies

o No conversations over the patient’s isolette or crib

o Don’t slam isolette doors or tap on the top of the isolette

 Visual

o Black and white cards are NOT to be used

o NO television

 Positioning

o Swaddle

o Head in midline once per shift in supine position

o Prone positioning use a roll until 34 weeks

o Change the orientation of the bed weekly

o Bed should be flat unless on IPPV or nCPAP (in which case head up will allow

for full diaphragmatic excursion)

o Removing positioning aids when nipple feeding, but no later than 2 weeks

prior to discharge or 37 weeks PMA

o Portable scale weights should be done with patient in side lying

o Encourage swaddle bathing

o Bathe twice a week (or following a unit soccer match)

 Kangaroo care preferred until 32 weeks PMA

 As patient approaches term try to link cares with patient’s state – particularly at

night

 Ensure that OT and PT have been consulted



FAMILY ISSUES: Remember that infants born near the threshold of viability continue to

present complex and unique social and ethical problems throughout their hospitalization.

Although, the patient is entering a more stable phase of development, the families

continue to need not only honest and timely updates regarding the patient’s condition, but

also a great deal of emotional support. Every family has unique needs and responses, thus

as healthcare providers we must provide individualized parental support in an honest and

forthright manner, with as positive an attitude as possible. Remember as the patient

nears discharge, as evidenced by weight gain, ability to wean out of an isolette, and ability

to take PO feeds, to encourage family involvement and to initiate discharge planning. As





16

Draft – March 15, 2008





the patient reaches milestones remind the parents that the patient is nearer to discharge

and that appropriate planning on their part should be underway (i.e. getting the nursery at

home ready, arranging grandparental visits, talking to extended family, talking to

employers, etc). Remember these patients will have been in hospital for several months,

don’t walk into the room on the day of discharge and say that the patient is going home

today; discharge must be a planned and scheduled activity.

 Keep the parents informed

o Honest and timely communication is imperative.

o The attending should continue to communicate with the family frequently.

o Any changes in clinical condition must be communicated to the family ASAP.

o Even in this relatively stable phase, the parents must be kept updated with

prognosis and how clinical events impact the patient’s prognosis.

 Plan of Care (McDonald, 2002)

o Decisions regarding the care plan require that the parents be well informed.

o Discussions must include the multi-disciplinary care team present in the

NICU.

o Plans of care must be discussed and updated frequently even in this

relatively stable phase of development for most of these patients.

o Families should be given the opportunity to have regularly scheduled

multidisciplinary care conferences.

o Family decisions will be unique and widely variable, but in all cases these

decisions must be respected within the limits of medical feasibility and

social appropriateness.

o If conflicts arise between the healthcare providers and the family then the

following resources should be considered:

 The ethics committee

 Religious leaders

 Other family members

 Patient ombudsman

 As the patient develops and grows their clinical status will continue to improve, the

family should be encouraged to be more and more involved with the patient’s care

o Encourage kangaroo care

o When the patient begins to take PO encourage breast feeding

o If mom is not breast feeding then encourage the parents to feed the baby

o Baths

o Positioning

o Changing diapers

o Holding the baby

o Reading to the baby

o Parents should be encouraged to bring things in from home for the baby

(blankets, clothes, mobiles, toys, etc.)

o Encourage sibling visitation





17

Draft – March 15, 2008





o Other medically indicated activities which are appropriate for family

involvement

 Allowing the family to assume a larger role in care will facilitate discharge planning

 Ensure that social work has been consulted

 Encourage involvement in a family support group

 Discharge planning on the majority of patients should include:

 Advancement to all PO feeds

 Weaning to open crib

 Maintaining growth

 Maintaining temperature

 Initiate home going “safe sleep” positions

 Minimize or simplify home going medication schedules

 Make sure immunizations are up-to-date

 Remember all of these patients meet criteria for synagis™ if

discharged during RSV season

 Appropriate teaching

 CPR

 Teaching/modeling of appropriate newborn care

o Well baby teaching

o SIDS teaching

 Required videos

 Any home going medications

 Formula teaching

 OT/PT teaching

 Any special concerns (i.e. tube feedings, oxygen, medical

equipment, etc.)

 Car seat test – to equal length of time for ride home or at least 1

hour whichever is greater

 Selection of a primary care doctor for the baby

 patient should see primary care doctor within 2-3 days of

discharge

 Schedule home nursing visit for day after discharge if possible

 Sign up for Help Me Grow

 Make any required follow-up appointments

 Remember to check and schedule follow-up with ophthalmology

o Emphasize the importance of continued vision f/u

 Remember to schedule neonatal follow-up clinic appointment

o Schedule for 3-4 months corrected age

o Emphasize that all of these patients are at increased

risk for neurodevelopmental delay even in the absence

of complications of prematurity

 Schedule any additional follow-up appointments as needed





18

Draft – March 15, 2008





o If on oxygen patient needs a BPD clinic appointment in

~2 weeks

 Schedule any previously ordered outpatient procedures/tests









These Guidelines were drafted by the Small Baby Sub-committee III (Beth Martin, Leif

Nelin, Kim Samson, Emily Brinkman, Patty Luzader, Michele Crane, Leslie Thomas, Susan

Frazier, Michele Grosser, Sarah Knouff, Brandon Kuehne, Tria Shadeed, Diana Hinton,

Edward Shepherd, Craig Nankervis, Lori Alexander, Robbie Wilkowski, Michael Stenger,

Debbie Dunn) August, 2007 – March, 2008.



Special thanks to the entire neonatal PT/OT department, Dr Dennis Cunningham (Pediatric

Infectious Diseases), and Dr Andrew Schwaderer (Pediatric Nephrology). We would also

like to thank Pat Black for arranging meeting times, locations and refreshments!







REFERENCES



Ågren J, Sjörs G, Sedin G. Transepidermal water loss in infants born at 24 and 25 weeks of gestation. Acta

Pædiatr 87: 1185-1190, 1998.

Als H, Lawhon G, Duffy FH, McAnulty GB, Giles-Grossman R, Blickman JG. Individualized developmental care

for the very low-birth-weight preterm infant: Medical and neurofunctional effects. JAMA 272: 853-858,

1994.

Als H, Gilkerson L, Duffy FH, McAnulty GB, Bruehler DM, Vandenberg K, Sweet N, Sell E, Parad RB, Ringer SA,

Butler SC, Blickman JG, Jones KJ. A three-center, randomized, controlled trial of individualized

developmental care for very low birth weight preterm infants: medical, neurodevelopmental, parenting, and

caregiving effects. J Dev Behav Pediatr 24: 399-408, 2003.

American Academy of Pediatrics. Breastfeeding and the use of human milk. Pediatrics 115: 496-506, 2005.

Back SA, Rivkees SA. Emerging concepts in periventricular white matter injury. Semin Perinatol 28: 405-414,

2004.

Bancalari E, Claure N, Gonzalez A. Patent ductus arterious and respiratory outcome in premature infants. Biol

Neonate 88: 192-201, 2005.

Berseth CL, Bisquera JA, Paje VU. Prolonging small feeding volumes early in life decreases the incidence of

necrotizing enterocolitis in very low birth weight infants. Pediatrics 111: 529-534, 2003.

Broitman E, Ambalavanan N, Higgins RD, Vohr BR, Das A, Bhasker B, Murray K, Hintz SR, Carlo WA, NICHD

Neonatal Network. Clinical data predict neurodevelopmental outcome better than head ultrasound in

extremely low birth weight infants. J Pediatr 151: 500-505, 2007.

Brooks JM, Travadi JN, Patole SK, Doherty DA, Simmer K. Is surgical ligation of patent ductus arteriosus

necessary? The Western Australian experience of conservative management. Arch Dis Child Fetal

Neonatal 90: F235-9, 2005.

Byers JF. Components of developmental care and the evidence fur their use in the NICU. MCN: Am J Maten

Child Nurs 28: 174-181, 2003.

Byers JF, Lowman LB, Francis J, Kaigle L, Lutz NH, Waddell T, Diaz AL. A quasi-experimental trial of

individualized, developmentally supportative family-centered care. J Obstet Gynecol Neonatal Nurs 35:

105-115, 2006.









19

Draft – March 15, 2008



Carlo WA, Stark AR, Wright LL, Tyson JE, Papile LA, Shankaran S, Donovan EF, Oh W, Bauer CR, Saha S, Poole

WK, Stoll B. Minimal ventilation to prevent bronchopulmonary dysplasia in extremely-low-birth-weight

infants. J Pediatr 141:370-4, 2002.

Davis PG, Henderson-Smart DJ. Nasal continuous positive airways pressure immediately after extubation for

preventing morbidity in preterm infants. Cochrane Database Sys Rev CD000143, 2003

De Klerck AM and De Klerck RK. Nasal continuous positive airway pressure and outcomes of preterm infants. J

Paediatr Child Health 37:161-7, 2001.

Engle WD. Blood pressure in the very low birth weight neonate. Early Hum Dev 62: 97-130, 2001.

Ehrenkranz RA, Dusick AM, Vohr BR, Wright LL, Wrage LA, Poole WK. Growth in the neonatal intensive care

unit influences neurodevelopmental and growth outcomes of extremely low birth weight infants. Pediatrics

117:1253-61, 2006.

Fenton TR. A new growth chart for preterm babies: Babson and Benda’s updated with recent data and a new

format. BMC Pediatrics 3: 13-23, 2003.

Fernandez E, Schrader R, Watterberg K. Prevalence of low cortisol values in term and near-term infants with

vasopressor-resistant hypotension. J Perinatol 25: 114-118, 2005.

Figueiro MG, Appleman K, Bullough JD, Rea MS. A discussion of recommended standards for lighting in the

newborn intensive care unit. J Perinatol 26: S19-S26, 2006.

Flynn JT. Neonatal hypertension: diagnosis and management. Pediatr Nephrol 14: 332-341, 2000.

Folkerth RD. Periventricular leukomalacia: overview and recent findings. Pediatr Dev Pathol 9: 3-13, 2006.

Furman L, Taylor G, Minich N, Hack M. The effect of maternal milk on neonatal morbidity of very low-birth-

weight infants. Arch Pediatr Adolesc Med 157:66-71, 2003.

Harris H, Wilson S, Brans Y, Wirtschafter D, Cassady G. Nasal continuous positive airway pressure.

Improvement in arterial oxygenation in hyaline membrane disease. Biol Neonate 29:231-7, 1976.

Heckmann M, Hartmann MF, Kampschulte B, Gack H, Bödeker RH, Gortner L, Wudy SA. Cortisol production

rates in preterm infants in relation to growth and illness: A noninvasive prospective study using gas

chromatography-mass spectrometry. J Clin Endocrinol Metab 90: 5737-5742, 2005.

Henderson-Smart DJ, Davis PG. Prophylactic methylxanthine for extubation in preterm infants. Cochrane

Database Syst Rev CD000139, 2003.

Hintz SM, Poole WK, Wright LL, Fanaroff AA, Kendrick DE, Laptook AR, Goldberg R, Duara S, Stoll BJ, Oh W,

NICHD Neonatal Research Network. Changes in mortalities and morbities among infants born at less than

25 weeks during the post-surfactant era. Arch Dis Child Fetal Neonatal Ed 90: 128-133, 2005.

Jensen FF. Developmental factors regulating the susceptibility to perinatal brain injury and seizures. Curr Opin

Pediatr 18: 628-33, 2006.

Jobe AH and Ikegami M. Mechanisms initiating lung injury in the preterm. Early Human Dev 53: 81-93, 1998.

Johnston AM, Bullock CE, Graham JE, Reilly MC, Rocha C, Hoopes RD Jr, Van der Meid V, Gutierrez S,

Abraham MR. Implementation and case-study results of potentially better practices for family-centered

care: the family-centered care map. Pediatrics 118:S108-14, 2006.

Kamper J, Wolff K, Larsen C, Lindequist S. Early treatment with nasal continuous positive airway pressure in

very low-birth-weight infants. Acta Pædiatr 82: 193-7, 1993.

Keller RL, Clyman RI. Persistent Doppler flow predicts lack of response to multiple courses of indomethacin in

premature infants with recurrent patent ductus arteriosus. Pediatrics 112: 583-587, 2003.

Kirchner L, Weninger M, Unterasinger L, Birnbacher R, Hayde M, Krepler R, Pollak A. Is the use of early nasal

CPAP associated with lower rates of chronic lung disease and retinopathy of prematurity? Nine years of

experience with the Vermont Oxford Neonatal Network. J Perinat Med 33: 60-6, 2005.

Laptook AR, O’Shea TM, Shankaran S, Bhaskar B, NICHD Neonatal Network. Adverse neurodevelopmental

outcomes among extremely low birth weight infants with a normal head ultrasound: prevalence and

antecedents. Pediatrics 115: 673-680, 2005.

LeFlore JL, Broyles RS, Pritchard MA, Engle WD. Value of neurosonography in predicting subsequent cognitive

and motor development in extremely low birth weight neonates. J Perinatol 23: 629-634, 2003.

Lotas MJ, Walden M. Individualized developmental care for very low-birth-weight infants: a critical review. J

Obstet Gynecol Neonatal Nurs 25: 681-687, 1996.







20

Draft – March 15, 2008



Luban NL. Neonatal red blood cell transfusions. Curr Opin Hematol 9: 533-536, 2002.

Lucey JF, Rowan CA, Shiono P, Wilkinson AR, Kilpatrick S, Payne NR, Horbar J, Carpenter J, Rogowski J, Soll

RF. Fetal infants: the fate of 4172 infants with birth weights of 401 to 500 grams--the Vermont Oxford

Network experience (1996-2000). Pediatrics 113:1559-66, 2004.

Martin RJ and Abu-Shaweesh JM. Control of breathing and neonatal apnea. Biol Neonate 87: 288-295, 2005.

MacDonald HG, the Committee on the Fetus and Newborn. Perinatal care at the threshold of viability.

Pediatrics 110: 1024- 1027, 2002.

McGuire W, Clerihew L, Fowlie PW. Infection in the preterm infant. BMJ 329: 1277-1280, 2004.

Morales Y, Schanler RJ. Human milk and clinical outcomes in VLBW infants: how compelling is the evidence of

benefit? Semin Perinatol 31:83-8, 2007.

Narenden V, Donovan EF, Hoath SB, Akinbi HT, Steichen JJ, Jobe AH. Early bubble CPAP and outcomes in

ELBW preterm infants. J Perinatol 23: 195-9, 2003.

Ng PC, Lee CH, Lam CWK, Ma KC, Fok TF, Chan IHS, Wong E. Transient adrenocortical insufficiency of

prematurity and systemic hypotension in very low birthweight infants. Arch Dis Child Fetal Neonatal 89:

F119-F126, 2004.

Noori S, Seri I. Pathophysiology of newborn hypotension outside the transitional period. Early Hum Dev 81:

399-404, 2005.

Northway WH, Rosan RC, Porter DY. Pulmonary disease following respirator therapy of hyaline-membrane

disease, Bronchopulmonary dysplasia. N Engl J Med 276:357-68, 1967.

Ohls RK, Ehrenkranz RA, Wright LL, Lemons JA, Korones SB, Stoll BJ, Stark AR, Shankaran S, Donovan EF,

Close NC, Das A. Effects of early erythropoietin therapy on the transfusion requirements of preterm

infants below 1250 grams birthweight: a multicenter, randomized, control trial. Pediatrics 108: 934-942,

2001.

Pejovic B, Peco-Antic A, Marinkovic-Erik J. Blood pressure in non-critically ill preterm and full-term neonates.

Pediatr Nephrol 22: 249-257, 2007.

Pellicer A, Valverde E, Elorza MD, Madero R, Gayá F, Quero J, Cabañas F. Cardiovascular support for low birth

weight infants and cerebral hemodynamics: a randomized, blinded, clinical trial. Pediatrics 115: 1501-1512,

2005.

Reber KM and Nankervis CA. Necrotizing enterocolitis: Preventative strategies. Clin Perinatol 31: 157-167,

2004.

Robinson RF, Nahatam C, Batisky DC, Mahan JD. Pharmacologic treatment of chronic pediatric hypertension.

Pediatr Drugs 7: 27-40, 2006.

Schandler RJ. The use of human milk for premature infants. Pediatr Clinics North Am 48: 207-219, 2001.

Sedin G. Physics and physiology of human neonatal incubation. In: Polin R, Fox W editor. Fetal and Neonatal

Physiology. Philadelphia: W B Saunders Company; 2004.

Seri I, Tan R, Evans J. Cardiovascular effects of hydrocortisone in preterm infants with pressor-resistant

hypotension. Pediatrics 107: 1070-1074, 2001.

Sisk PM, Lovelady CA, Dillard RG, Gruber KJ, O'Shea TM. Early human milk feeding is associated with a lower

risk of necrotizing enterocolitis in very low birth weight infants. J Perinatol 27:428-33, 2007.

Stokowski LA. A primer on apnea of prematurity. Adv Neonatal Care 5:155-170, 2005.

Stoll BJ, Hansen N, Fanaroff AA, Wright LL, Carlo WA, Ehrenkranz RA, Lemons JA, Donovan EF, Stark AR,

Tyson JE, Oh W, Bauer CR, Korones SB, Shankaran S, Laptook AR, Stevenson DK, Papile LA, Poole WK. To

tap or not to tap: high likelihood of meningitis without sepsis among very low birth weight infants.

Pediatrics 113: 1181-1186, 2004.

Vohr BR, Poindexter BB, Dusick AM, McKinley LT, Wright LL, Langer JC, Poole WK, NICHD Neonatal Research

Network. Beneficial effects of breast milk in the neonatal intensive care unit on the developmental

outcome of extremely low birth weight infants at 18 months of age. Pediatrics 118:e115-23, 2006.

Vohr BR, Poindexter BB, Dusick AM, McKinley LT, Higgins RD, Langer JC, Poole WK, NICHD National Research

Network. Persistent beneficial effects of breast milk ingested in the neonatal intensive care unit on

outcomes of extremely low birth weight infants at 30 months of age. Pediatrics 120:e953-9, 2007.









21