Care of premature infants with birth weights between 1000 and 1500 g has become almost routine in most neonatal intensive care units (NICUs) in the United States. The most recent challenge in neonatology is the care of ELBW infants (birth weight < 1000 g). Although they represent a small percentage of overall births and NICU admissions, ELBW infants are often the most critically ill and at the highest risk for mortality and long-term morbidity of any NICU patient. They remain hospitalized for long periods of time, suffer the most acute and long-term complications of neonatal intensive care, and consume a disproportionate number of hospital days. The purpose of this chapter is to provide an overview of topics related to care of the ELBW infant. Detailed information on resuscitation, thermoregulation, ventilation, and fluids and electrolytes can be found in those specific chapters.

B. Preterm–related causes of death together accounted for 35% of all infant deaths in 2008, more than any other single cause. Preterm birth is also a leading cause of long-term neurologic disabilities in children.

B. In 2009, nearly half of all infants 501 to 1500 g and 89% of those weighing 501 to 750 g either died or survived after experiencing ≥ 1 major morbidity during their initial hospital stay, highlighting the continuing challenges facing these vulnerable patients, their families, and the health professionals who care for them.

C. There has been a dramatic increase in the number of multiple births in the United States over the past two decades, largely due to artificial reproductive technology and fertility–inducing drugs.

D. Perinatal risks that may be associated with assisted reproductive therapy include high–order multiple pregnancy, prematurity, low birth weight, small for gestational age, perinatal mortality, cesarean delivery, placenta previa, placental abruption, preeclampsia, and birth defects.

B. Whenever possible, data specific to the age, weight, and gender of the fetus should be used to aid management decisions made by obstetricians and parents of fetuses at risk of preterm delivery before 26 completed weeks of gestation. This information may be developed by each institution and should indicate the population used in determining estimates of survivability.

B. A single course of antenatal corticosteroids should be administered to women with premature rupture of membranes (PROM) before 32 weeks of gestation to reduce the risks of respiratory distress syndrome, perinatal mortality, and other morbidities.

C. The efficacy of corticosteroid use at 32 to 33 completed weeks of gestation for preterm PROM is unclear, but treatment may be beneficial, particularly if pulmonary immaturity is documented. Sparse data exist on the efficacy of corticosteroid use before fetal age of viability, and such use is not recommended.

D. A single rescue course of antenatal corticosteroids may be considered if the antecedent treatment was given more than 2 weeks prior, the gestational age is less than 32^6/7 weeks, and the woman is judged by the physician to be likely to give birth within the next week. However, regularly scheduled repeat courses or multiple courses (more than two) are not recommended.

B. The single most important clinical benefit for preterm infants is the possibility for a nearly 50% reduction of intraventricular hemorrhage (IVH). It is important to note that the timing of umbilical cord clamping should not be altered for the purpose of collecting umbilical cord blood for banking.

B. The infant’s temperature must be monitored closely because overheating has been described when plastic wrap is used in combination with an exothermic mattress. The goal should be an axillary temperature of approximately 36.5° C (97.7° F).

2. Because many babies born at less than 32 weeks of gestation will not reach target saturations when resuscitated with air, blended oxygen may be used. If blended oxygen is not available, resuscitation should be initiated with air.

2. Because of the high transepidermal fluid losses in these infants, intravenous (IV) fluids containing 5% to 10% dextrose should be started as quickly as possible after admission and efforts should be made to reduce evaporative water losses by increasing the relative humidity surrounding the infant.

B. Ambient humidity.

2. 70% or higher humidity in the first week of life is needed to affect a difference in TEWL.

C. Oxygen saturation range.

C. Percutaneous central venous catheter.

2. A variety of devices are now available for use: synchronized intermittent mandatory ventilation (SIMV), assist–control ventilation, volume-controlled ventilation, high-frequency jet ventilation (HFJV), and high-frequency oscillatory ventilation (HFOV).

C. Methylxanthines.

B. All infants have a physiologic weight loss that is a reduction in extracellular water. In very premature infants, the loss of extracellular fluid can be 15%.

C. Fluid requirements.