PRENATAL CARE

RECOMMENDATIONS

1. Mothers at high risk of preterm birth < 28–30 weeks’ gestation should be transferred to perinatal centres with experience in management of RDS (C1).
2. Clinicians should offer a single course of prenatal corticosteroids to all women at risk of preterm delivery from when pregnancy is considered potentially viable until 34 weeks’ gestation ideally at least 24 h before birth (A1).
3. A single repeat course of steroids may be given in threatened preterm birth before 32 weeks’ gestation if the first course was administered at least 1–2 weeks earlier (A2).
4. MgSO₄ should be administered to women in imminent labour before 32 weeks’ gestation (A2).
5. In women with symptoms of preterm labour, cervical length and fibronectin measurements should be considered to prevent unnecessary use of tocolytic drugs and/or antenatal steroids (B2).
6. Clinicians should consider short-term use of tocolytic drugs in very preterm pregnancies to allow completion of a course of corticosteroids and/or in utero transfer to a perinatal centre (B1).

DELIVERY ROOM STABILIZATION

RECOMMENDATIONS

1. Delay clamping the umbilical cord for at least 60 s to promote placento-fetal transfusion (A1).
2. In spontaneously breathing babies, stabilise with CPAP of at least 6 cm H₂O via mask or nasal prongs (B1). Do not use SI as there is no long-term benefit (B1). Gentle positive pressure lung inflations with 20–25 cm H_O peak inspiratory pressure (PIP) should be used for persistently apnoeic or bradycardic infants.
3. Oxygen for resuscitation should be controlled using a blender. Use an initial FiO₂ of 0.30 for babies < 28 weeks’ gestation and 0.21–0.30 for those 28–31 weeks, 0.21 for 32 weeks’ gestation and above. FiO₂ adjustments up or down should be guided by pulse oximetry (B2).
4. For infants < 32 weeks’ gestation, SpO2 of 80% or more (and heart rate > 100/min) should be achieved within 5 min (C2).
5. Intubation should be reserved for babies not responding to positive pressure ventilation via face mask or nasal prongs (A1). Babies who require intubation for stabilisation should be given surfactant (B1).

SURFACTANT THERAPY

RECOMMENDATIONS

1. Babies with RDS should be given an animal-derived surfactant preparation (A1).
2. A policy of early rescue surfactant should be standard (A1), but there are occasions when surfactant should be given in the delivery suite, such as when intubation is needed for stabilization (A1).
3. Babies with RDS should be given rescue surfactant early in the course of the disease. A suggested protocol would be to treat babies who are worsening when FiO₂ > 0.30 on CPAP pressure of at least 6 cm H₂O (B2).
4. Poractant alfa at an initial dose of 200 mg/kg is better than 100 mg/kg of poractant alfa or 100 mg/kg of beractant for rescue therapy (A1).
5. LISA is the preferred mode of surfactant administration for spontaneously breathing babies on CPAP, provided that clinicians are experienced with this technique (B2).
6. A second and occasionally a third dose of surfactant should be given if there is ongoing evidence of RDS such as persistent high oxygen requirement and other problems have been excluded (A1).

OXYGEN SUPPLEMENTATION BEYOND STABILIZATION THERAPY

RECOMMENDATIONS

1. In preterm babies receiving oxygen, the saturation target should be between 90 and 94% (B2).
2. Alarm limits should be set to 89 and 95% (D2).

NON-INVASIVE RESPIRATORY SUPPORT

RECOMMENDATIONS

1. CPAP should be started from birth in all babies at risk of RDS, such as those < 30 weeks’ gestation who do not need intubation for stabilisation (A1).
2. The system delivering CPAP is of little importance; however, the interface should be short binasal prongs or mask with a tarting pressure of about 6–8 cm H₂O (A2). Positive end-expiratory pressure (PEEP) can then be individualised depending on clinical condition, oxygenation and perfusion (D2).
3. CPAP with early rescue surfactant is considered optimal management for babies with RDS (A1).
4. Synchronised NIPPV, if delivered through a ventilator rather than BIPAP device, can reduce extubation failure but may not confer long-term advantages such as reduction in BPD (B2).
5. During weaning, HFNC can be used as an alternative to CPAP for some babies with the advantage of less nasal trauma (B2).

MECHANICAL VENTILATION STRATEGIES

RECOMMENDATIONS

1. After stabilisation, MV should be used in babies with RDS when other methods of respiratory support have failed (A1). Duration of MV should be minimised (B2).
2. The primary choice of ventilation mode is at discretion of clinical team; however, if conventional MV is used, targeted tidal volume ventilation should be employed (A1).
3. When weaning from MV, it is reasonable to tolerate a modest degree of hypercarbia provided the pH remains above 7.22 (B2).
4. Caffeine should be used to facilitate weaning from MV (A1). Early caffeine should be considered for babies at high risk of needing MV such as those on non-invasive respiratory support (C1).
5. A short tapering course of low dose or very low dexamethasone should be considered to facilitate extubation in babies who remain on MV after 1–2 weeks (A2).
6. Inhaled budesonide can be considered for infants at very high risk of BPD (A2).
7. Opioids should be used selectively when indicated by clinical judgment and evaluation of pain indicators (D1). The routine use of morphine or midazolam infusions in ventilated preterm infants is not recommended (A1).

MONITORING AND SUPPORTIVE CARE

RECOMMENDATIONS

1. Core temperature should be maintained between 36.5 and 37.5 ° C at all times (C1).
2. Most babies should be started on intravenous fluids of 70–80 mL/kg/day in a humidified incubator, although some very immature babies may need more (C2). Fluids must be tailored individually according to serum sodium levels, urine output and weight loss (D1).
3. Parenteral nutrition should be started from birth. Amino acids 1–2 g/kg/day should be started from day one and quickly built up to 2.5–3.5 g/kg/day (C2). Lipids should be started from day one and built up to a maximum of 4.0 g/kg/day if tolerated (C2).
4. Enteral feeding with mother’s milk should be started from the first day if the baby is haemodynamically stable (B2).

MANAGING BLOOD PRESSURE AND PERFUSION

RECOMMENDATIONS

1. Treatment of hypotension is recommended when it is confirmed by evidence of poor tissue perfusion such as oliguria, acidosis and poor capillary return rather than purely on numerical values (C2).
2. If a decision is made to attempt therapeutic closure of the PDA then indomethacin, ibuprofen or paracetamol can be used (A2).
3. Haemoglobin (Hb) concentration should be maintained within acceptable limits. Hb thresholds for infants with severe cardiopulmonary disease are 12 g/dL (HCT 36%), 11 g/dL (HCT 30%) for those who are oxygen dependent and 7 g/dL (HCT 25%) for stable infants beyond 2 weeks of age (C2).

MISCELLANEOUS AND PERFUSION

RECOMMENDATIONS

1. Surfactant can be used for RDS complicated by congenital pneumonia (C2).
2. Surfactant therapy can be used to improve oxygenation following pulmonary haemorrhage (C1).
3. Use of iNO in preterm babies should be used with caution and limited to those in clinical studies or as a therapeutic trial when there is severe documented pulmonary hypertension (D2).

REPRESENTATIONS OF QUALITY OF EVIDENCE AND STRENGTH OF RECOMMENDATIONS AND PERFUSION