Infants of <1000 g birthweight are defined as extremely low birthweight (ELBW), and are sometimes referred to as micropremies. These guidelines address the exquisite fragility of these infants with regard to skin integrity, fluid/electrolyte status, ability to regulate stimuli and sheer smallness of body size. Reduction of noxious stimuli is particularly important in the prevention of intraventricular hemorrhage. Remember to check with each attending for approval of micropremie admission orders for each infant.

Most of the guidelines below are included in the EMR order sets. ( * = not in order set)

Interventions to minimize noxious stimulation to which the infant is subjected

1. Weigh on admission, on the fifth day of life (4 days old), and then daily.

2. Nursing physical assessments should be done every 12 h and with obvious changes in status. Vital signs are recorded from the monitors as ordered (every 1-4 hours).

3. Infants who are on ventilators should receive endotracheal suctioning 1-2 hours after surfactant administration and then only as needed.

Interventions to minimize risk of fluid/electrolyte balance

(In the first several days, fluid orders should be assessed q 6-8 hrs.)

The micropremie is at particular risk for hypernatremia, hyperkalemia, hypocalcemia, hypo- or hyperglycemia and hyperbilirubinemia. The need for laboratory monitoring must be balanced

with the need to minimize blood transfusion (which worsens hyperbilirubinemia).

1. 0.45% NaCl (1/2 normal saline) should be used for all intravascular flushes.

2. Continuous calcium infusion from birth (~200 mg/kg/day) will usually prevent the early hypocalcemia, which typically occurs at 24-48 hours.

3. Saran wrap or a protective shield should be placed over infants on open warmers.

4. Arterial blood gases with electrolytes, glucose, and hematocrit (deluxe gas) every 8 hours x 24h

5. Basic metabolic panel, magnesium and phosphorus and bilirubin at 12 hours, then every day for three days.

*While on TPN, obtain BMPs once-twice weekly.

If on PN > 4 weeks, obtain liver function tests (AST, ALT, GGT, bili, protein, albumin) every other week.

6. Prophylactic phototherapy beginning after stabilization at admission.

7. Insulin infusion may be required to control excessive hyperglycemia.

Interventions to protect skin integrity

1. Minimize tape use, particularly in constructing the umbilical vessel catheter bridge, and use baby tape or duoderm.

2.The temp probe cover is cut in quarters and only one quarter is used to secure the temperature probe on the baby.

3. For cardiac monitoring, micro arbo leads or limb leads are used.

4. *In most situations, the UAC or UVC can be used for transfusion of blood and infusion of medications.

5. Protect skin by application of Aquaphor ointment after birth, and continue for 7 days. 

Placement of the umbilical vessel catheters

1. *The catheters should be size 3.5 in infants less than 1500g.

2. *The tip of the UAC should be in the high position (T6-T9) to facilitate monitoring of correct placement and to decrease risk of peripheral embolic phenomenon.

Nutrition Interventions

1. Admission Solution should be started at birth (contains protein, glucose, calcium).

2. If the baby is born before 5 PM, intralipid infusion at 0.5 g/kg/day should be started on the day of birth.

3. TPN should be started on the first or second day of life.

4. Consider using UAC fluid containing acetate (#3), if available. Sodium acetate is among the drugs affected by intermittent nationwide shortages of supply.

5. The baby will usually need help with meconium evacuation. In a step-wide fashion, interventions include:

- glycerin suppository

 - normal saline enema

- serial n-acetylcysteine (Mucomyst) enemas and oral Mucomyst 

(* = not in UTMB EMR order sets)