The impact of early management changes on growth and morbidity in <1000 g neonates

The efforts to implement evidence-based practices in neonatal intensive care units largely improved clinical outcomes. In order to further verify the impact of implementing evidence-based practices into an early management protocol for neonates, an American group have conducted a retrospective analysis on an historical cohort of extremely low birth weight (ELBW) infants. These early management practice changes (EMPC) included: (1) changing from a respiratory strategy of prophylactic surfactant administration followed by synchronized intermittent mandatory ventilation to a strategy of surfactant administration followed by immediate extubation to nasal continuous positive airway pressure (CPAP) in the delivery room; (2) lowering the goals for oxygen saturation from >95% to 90 to 95% and decreasing the initial FiO2 from 60 to 40% and (3) starting early amino-acid supplementation on the first day of life compared to the previous practice of dextrose and electrolyte containing solutions followed by a 4 to 6 day advance of amino acids.
Infants with a birth weight (BW) =1000 g, to whom resuscitation was offered, appropriately sized for gestational age, imborn and without congenital malformations were included in the study. Neonates born before the introduction of EMPC (pre-EMPC group; n=87) were compared with those born after the introduction of EMPC (post-EMPC group; n=76). The impact of these EMPC on extra-uterine growth restriction (EUGR), defined as growth less than the 10th percentile for postmenstrual age (PMA), on growth parameters and on the incidence of morbidities associated with poor long-term outcomes was investigated.
Results showed that infants in the post-EMPC cohort regained BW faster (16±5.8 vs 12±4.5 days) and maintained appropriate size for weight at 36 weeks PMA more (2166±408 vs 1928±321 g) than pre-EMPC neonates. The introduction of EMPC was also associated to a reduction in EUGR at 36 weeks PMA or discharge (18% vs 42%, in post-EMPC and pre-EMPC groups, respectively). Statistical analysis revealed that predictors of EUGR included BW <750 g and surgical necrotizing enterocolitis. Noteworthy, the post-EMPC cohort had only 49% of infants with mortality or conditions at high risk for morbidities compared to 72% in the pre-EMPC cohort.
The etiology of EUGR is multifactorial and effective treatment likely requires multiple approaches that reduce illness and injury in addition to supplying appropriate nutritional support. The results of this analysis may suggest that early management strategies aimed at (1) reducing barotrauma and volutrauma, (2) decreasing oxidant injury and (3) increasing early parenteral amino-acid support significantly could reduce the incidence of EUGR and overall neonatal morbidities. Even if these findings should be further evaluated in prospective, ad-hoc studies, it is possible to preliminarily observe that the introduction of surfactant at delivery followed by immediate extubation to CPAP, decreased oxygen exposure and early parenteral amino acids in ELBW infants is possible, safe and associated with improvements in growth and morbidity.

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