WHO Recommendations For Care Of The Preterm Or Low Birth Rate Infants-2022

In 2022, the recommendations were revised and now include 25 recommendations (11 new and 14 amended) as well as a good practice statement (evidence varies, but benefits are substantial).

Of them, 14 are conditional, while 11 are strong recommendations. For any preterm or LBW case, strong recommendations are applicable. These are all related to the management of preterm and low birth weight neonates, and conditional recommendations apply to specific preterm and low birth weight newborns.Address three areas: family support and involvement, care for problems, and preventive and promotive care.

A. Preventive And Promotive Care

A1. Related to Kangaroo Mother Care (KMC)

KMC should be started in a medical facility or at home and should be administered for 8 to 24 hours a day (or as many hours as possible) for all preterm or low birth weight infants.

New recommendation

If there are no warning indications, KMC for preterm or low birth weight babies should begin as soon as feasible after delivery. There is strong advice, and the proof is very certain.

A2. Mother’s Own Milk 

It is advised to feed preterm or LBW infants—including extremely preterm infants (less than 1.5 kg)—mother's milk. Even if the data is of poor certainty, the recommendation is strongly suggested.

A3. Donor Human Milk

If the mother's milk is unavailable, preterm or LBW infants, especially very preterm (less than 32 weeks gestation) or very LBW (less than 1.5 kg) infants, may be fed donor human milk. There is evidence of reasonable certainty, however they are conditional suggestions.

A4. Multicomponent Fortification of Human Milk

While multicomponent fortification of human milk is not usually advised for all preterm or low birth weight (LBW) infants, it can be taken into consideration for extremely preterm (less than 32 weeks gestation) or very low birth weight (less than 1.5 kg) infants who are fed donor or mother's milk. The evidence for this conditional recommendation ranges from poor to moderate.

A5. Preterm Formula Milk

 For very preterm (less than 32 weeks gestation) or very low birth weight (less than 1.5 kg) newborns, the nutrient-enriched preterm formula may be considered in the absence of mother's milk or donor human milk. The recommendation is conditional, and there is evidence of low certainty. Data for children older than 32 weeks is lacking.

A6. Early Initiation of Enteral Feeding

Newborns who are capable of breastfeeding should begin doing so as soon as feasible.  Preterm and low birth weight newborns, especially preterm (<32 weeks gestation) and extremely LBW (<1.5 kg) infants, should be fed as soon as possible from the first day after birth. EBM should be given to infants who are unable to nurse. In case the mother's milk is unavailable, donor milk ought to be administered.There is evidence to support the moderate certainty of these strong recommendations.

A7. Responsive and Scheduled Feeding

 For preterm infants delivered before 34 weeks gestation, scheduled feeding may be preferred in medical facilities over responsive feeding until the child is released. There is low certainty evidence and a poor conditional recommendation.

A8. Fast and Slow Advancement of Feeding

If you are increasing the feed everyday by 30 to 40 ml/kg/day, there will be a fast advancement of feeding. If you are increasing the feed by 15 to 25 milliliters per kilogram each day, you may experience slow feeding advancement.

Feed volumes can be raised by up to 30 ml/kg per day in preterm babies or LBW infants, particularly extremely preterm (<32 weeks gestation) or very LBW (1.5 kg) infants, who require an alternative feeding strategy (e.g., gastric tube feeding or cup feeding) in addition to breastfeeding.

A.9 Duration of Exclusive Breastfeeding

Infants who have low birth weight or preterm should only be breastfed for the first six months of their lives. It comes highly recommended, with very little doubt.

A10a. Iron Supplementation

 For preterm or low birth weight babies breastfed with human milk who do not receive iron from another source, intravenous iron supplementation is advised. A daily intake of 2 to 3 mg/kg of elemental iron is advised. There is evidence of moderate certainty and a strong recommendation.

A10b. Zinc Supplementation

 For preterm or low birth weight babies breastfed on human milk who do not receive zinc from another source, enteral zinc supplementation may be taken into consideration. It is advised to take 1-3 mg/kg/d. The recommendation is conditional, and there is evidence of low certainty.

A10c. Vitamin D Supplementation

 Infants fed human milk and born prematurely or with low birth weight who do not receive vitamin D from another source may benefit from intravenous vitamin D supplementation. A daily dose of 400–800 IU is advised. In addition, there is low certainty evidence and the suggestion is conditional.

A10d. Vitamin A Supplementation

 For human milk-fed infants who are very preterm (less than 32 weeks gestation) or very low birth weight (less than 1.5 kg), and who do not receive vitamin A from another source, enteral vitamin A supplementation may be considered. A daily dosage of 1000–5000 IU is advised. The recommendation is conditional, and there is evidence of low certainty.

A11. Probiotics

Very preterm newborns (less than 32 weeks gestation) given human milk may benefit from taking probiotics. The recommendation is conditional, and there is evidence of moderate certainty. There is no proof that kids born before 32 weeks or after are premature.

A12. Emollients

 Applying topical oil to preterm or low birth weight infants' bodies could be taken into consideration. The recommendation is conditional, and there is evidence of low certainty.

Also Read: Fungal Infections In Neonates

B. Care for Complications

B1. CPAP for Respiratory Distress Syndrome

 For preterm newborns exhibiting clinical indications of respiratory distress syndrome, continuous positive airway pressure (CPAP) therapy is advised. There is intermediate certainty data to support this strong recommendation.

B2. CPAP Immediately after Birth

For extremely preterm newborns (less than 32 weeks gestation), whether or not they are experiencing respiratory distress, continuous positive airway pressure (CPAP) therapy may be investigated right away after birth. The recommendation is conditional, and there is evidence of low certainty. This suggestion is fresh.

B3. CPAP Pressure Source (Bubble CPAP)

 Bubble continuous positive airway pressure (CPAP) therapy may be a better option than alternative pressure sources (such as ventilator CPAP) for preterm infants who require CPAP therapy. There is minimal certainty and a conditional recommendation.

B4. Methylxanthines for Treatment of APNEA

 There is strong recommendation and intermediate certainty evidence supporting the use of caffeine in the treatment of apnea in preterm newborns.

B5. Methylxanthines for Extubation

There is substantial evidence to support the suggestion that caffeine be used for the extubation of preterm infants born before 34 weeks gestation.

B6. Methylxanthines for Prevention of APNEA

Coffee might be taken into consideration to help premature babies born before 34 weeks gestation avoid apnea. There is little evidence to support this conditional advice.

Also Read : Temperature Control In Neonates

C. Family Involvement and Support

C1. Family Involvement

It is advised that families be included in the routine care of infants who are preterm or have low birth weights at healthcare institutions. It is strongly advised, and the level of evidence is low to moderate certainty.

C2. Family Support

Preterm or low birth weight (LBW) families should receive additional assistance in caring for their babies, beginning in medical facilities at the time of birth and continuing through follow-up care after ischarge.Health professionals may provide education, counseling, and help with discharge planning, in addition to peer support. The assistance is conditional, and the evidence is of extremely low certainty.

C3. Home Visits

 There is intermediate certainty evidence and a strong recommendation for home visits by qualified health workers to assist families in caring for their preterm or low birth weight infant.

C4. Parental Leave and Entitlements

 The specific requirements of mothers, dads, and other primary caregivers of preterm or low birth weight infants should be taken into consideration when determining parental leave and entitlements.
The statement "there is little evidence but significant benefits" is a good practice.

Also Read: Skull Fractures And Traumatic Intracranial Hemorrhage

Plain Language Summary 

KMC, lasting 8 to 24 hours, in all preterm and LBW patients.
The best milk is that from the mother, next donor human milk, and finally preterm formula milk (for neonates under 32 weeks old and VLBW babies)..  For newborns under 32 weeks old and VLBW, multicomponent fortification of human milk may be taken into consideration.

For infants under 34 weeks old, scheduled feeding is preferable to responsive feeding.  Feeds are being advanced at a rate of 30 ml/kg each day.  EBF for a 6-month-old.               

Although enteral zinc and vitamin D supplements may be used, enteral iron supplementation is highly advised.  In newborns that are VLBW and fed human milk, enteral vitamin A is evaluated at <32 weeks.
Probiotics could be taken into consideration for newborns under 32 weeks old.  Emollients may be taken into consideration for preterm and LBW newborns.  If respiratory stress persists for fewer than 32 weeks, with or without distress, CPAP may be taken into consideration. The best CPAP is bubble.  In addition to being suggested for apnea therapy and extubation, caffeine may also be taken into account for apnea prevention.

Also Read: Hearing Loss in Nicu Graduates

Hope you found this blog helpful for your NEET SS Pediatrics Neonatology Preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.