🫀 119.2 Extremely and Very Preterm Infants
Nelson's Textbook of Pediatrics | ELGAN · VLBW/ELBW · Thermal control · Nutrition · Caffeine · IVH/PVL · BPD · ROP · NEC · Outcomes
🔥 Extremely & Very Preterm Infants (119.2) 📊 Definitions Extremely preterm: <28 wk (ELGAN) Very preterm: 28–31 6/7 wk ELBW: <1000 g, VLBW: 1000–1500 g Incidence: 1.5% of births in US (10% preterm overall) ⚠️ Risk Factors Previous preterm birth, multiple gestation Infection (chorioamnionitis), preeclampsia Short interpregnancy interval, uterine anomalies Racial disparities (non-Hispanic Black higher) 🩺 Nursery Care Thermal control: incubator, plastic wrap, exothermic mattress Oxygen targets: SpO2 90-95%, avoid hyperoxia/hypoxia Early nCPAP in delivery room reduces BPD Surfactant via INSURE/LISA for RDS Nutrition: early amino acids (2g/kg), TPN, human milk fortification Caffeine for apnea (20 mg/kg loading) Transfusion thresholds (restrictive: Hgb 7-11 g/dL) Prevention: antenatal steroids (24-34 wk), MgSO4 for neuroprotection ⚠️ Major Morbidities RDS (surfactant deficiency) BPD (chronic lung disease, O2 at 36 wk) IVH grade I-IV (germinal matrix → hemorrhage) PVL (periventricular leukomalacia → spastic diplegia) NEC (pneumatosis, perforation) ROP (retinopathy of prematurity) Late-onset sepsis (CoNS, Candida) PDA (hemodynamically significant) 📈 Survival & Neurodevelopment 22 wk: ~5-30% survival; 24 wk: ~50-60%; 28 wk: >90% Neurodevelopmental impairment (CP, cognitive delay) in ~30-40% of ELBW survivors
🔑 Key: Antenatal steroids, nCPAP, caffeine, early aggressive nutrition, and family-centered care improve outcomes. IVH and PVL are major neurologic risks.
📌 Section 119.2 – Extremely and Very Preterm Infants (Nelson's 22e) Core Summary

1. Definitions & Epidemiology
• Extremely preterm: <28 weeks gestational age (ELGAN). Very preterm: 28–31 6/7 weeks.
• ELBW: birthweight <1000 g; VLBW: 1000–1500 g. Preterm birth rate ~10% in US, with racial/ethnic disparities.
• Survival at 22 weeks ~5-30% (with active management), at 24 weeks ~50-60%, at 28 weeks >90%.

2. Etiology & Risk Factors
• Previous preterm birth, multiple gestation, chorioamnionitis, preeclampsia, short interpregnancy interval, uterine anomalies, genetic predisposition.

3. Assessment of Gestational Age
• Ballard score (neuromuscular + physical maturity) accurate within 2 weeks. Ultrasound crown-rump length at 11-14 wk is most accurate.

4. Nursery Care & Management
• Thermal control: Incubator, plastic wrap, exothermic mattress. Neutral thermal environment (36.5-37.0°C core). Kangaroo care.
• Oxygen administration: Titrate to SpO2 90-95% (lower targets 85-89% increase mortality). Avoid hyperoxia/hypoxia.
• Respiratory support: Early nCPAP reduces BPD and need for intubation. Surfactant via INSURE (intubate-surfactant-extubate) or LISA/MIST for RDS.
• Nutrition: Early IV amino acids (≥2 g/kg within 24h). Human milk (maternal or donor) reduces NEC. Fortification needed for VLBW. Enteral feeding advance 15-30 mL/kg/day.
• Caffeine: For apnea of prematurity: loading 20 mg/kg, maintenance 5-10 mg/kg/day. Also reduces BPD and improves neurodevelopment.
• Transfusion: Restrictive thresholds (Hgb 7-11 g/dL depending on respiratory support and postnatal age) are safe.
• Platelet transfusion: Lower threshold (25,000/µL) better than higher (50,000/µL) to reduce death/bleeding.

5. Major Morbidities
• RDS (surfactant deficiency), BPD (O2 requirement at 36 wk PMA), IVH (grades I-IV, highest risk first 72h), PVL (white matter injury → spastic diplegia), NEC (pneumatosis intestinalis), ROP (retinopathy), late-onset sepsis (CoNS, Candida, gram negatives), PDA.
• Prevention: Antenatal corticosteroids (24-34 wk) reduce RDS, IVH, mortality. Magnesium sulfate for neuroprotection (↓ cerebral palsy). Single course only, rescue course possible.

6. Outcomes & Follow-up
• Neurodevelopmental impairment (cerebral palsy, cognitive delay, hearing/vision loss) occurs in 30-40% of ELBW survivors.
• Post-discharge follow-up using corrected age for at least 2 years. Early intervention services crucial.
• Chronic morbidities: BPD, growth failure, rehospitalization (RSV), learning disabilities, ADHD.

💡 Pearls: Antenatal steroids are the most effective intervention. Caffeine is first-line for apnea and improves neurodevelopmental outcomes. Early nCPAP and gentle ventilation reduce BPD. Human milk prevents NEC.