In response to the growing number of extremely preterm infants born in Arizona, Phoenix Children’s and Dignity Health St. Joseph’s Hospital and Medical Center together created a protocol for small baby care to focus on improving outcomes among this particularly vulnerable population.
Physicians, nurses and other providers within the multidisciplinary team provide uniform, evidence-based care to babies born before 28 weeks of gestation. This includes very low birth weight (VLBW) babies – those weighing less than 1,500 grams – and extremely low birth weight (ELBW) babies weighing less than 1,000 grams.
Since starting in January 2022, the team’s efforts to standardize small baby care have paid off: data show these patients have lower complication rates and better overall survival rates compared to the national averages.
Improving Outcomes by Reducing Variability
Amy Brown, MD
Despite modern advances in neonatal care that have dramatically improved survival rates among all preterm infants, the mortality rate for ELBW babies still hovers around 30%. These patients also have a much higher risk of complications like intraventricular hemorrhage (IVH) and bronchopulmonary dysplasia (BPD).
One of the factors impacting these morbidity and mortality rates is the inconsistency among hospitals in treating babies born near the limit of viability.
A 2015 study reported wide variation in practices for initiating or forgoing resuscitation and active, potentially lifesaving treatment among babies born between 22-24 weeks. It found that the differences in each hospital’s rates of active treatment explained most of the variation in hospital rates of survival (and survival without severe impairment). Further, it found that hospitals where active treatment was initiated more frequently had higher rates of risk-adjusted survival – with and without impairment – than hospitals where active treatment was initiated less frequently.
“Decreasing treatment variability is key to decreasing mortality and complication rates among extremely preterm infants,” said neonatologist Amy Brown, MD, Director of Small Baby Care at Phoenix Children’s. “Two years after implementing our dedicated small baby care protocol for infants as young as 22 weeks and 0 days, data show we’re improving short- and long-term outcomes.”
Specialized and Standardized Neonatal Care
For Dr. Brown and her colleagues, treatment planning for infants who may need small baby care often begins before birth.
“When it’s clear a baby will be born near the limit of viability, we initiate periviable counseling with the family,” she said. “This includes educating them about resuscitation, including whether to offer comfort care, limited resuscitation with only airway and respiratory support or full resuscitation. With this counseling, the families can make informed decisions.”
Whenever possible, the team arranges early maternal transport to St. Joseph’s, a hospital where Phoenix Children’s provides neonatology services and first implemented the small baby care protocol. They aim to deliver all extremely preterm infants at St. Joseph’s as the hospital offers specialized high-risk perinatal care services.
Care team members – including neonatologists, pharmacists, nutritionists, speech-language pathologists, neonatal nurses, neonatal nurse practitioners and physician assistants, and neonatology fellows – hold pre-delivery huddles to review all maternal-fetal data and assign roles. Then, immediately after each birth, they follow standardized protocols in several key areas:
-
The Golden Hour
The team follows a strict regimen during the first 60 minutes after delivery. This includes delayed cord clamping for up to 60 seconds, immediate initiation of neonatal resuscitation, and transfer to the neonatal intensive care unit (NICU) within 20 minutes. For the rest of the golden hour, they set up respiratory support, prep umbilical lines, administer surfactant and/or antibiotics and place their patients in isolettes.
-
Respiratory Care
To reduce the risk of adverse effects associated with traditional mechanical ventilation, especially among babies in the canalicular stages of lung development, the team uses high-frequency jet ventilation for all intubated infants less than 26 weeks. They also use graded, gestational age-specific oxygen saturation targets to reduce the risk of retinopathy of prematurity (ROP). For example, the target saturation for infants less than 24 weeks is 83-94%, while the target for infants older than 32 weeks is 92-98%.
-
Skin Care
The stratum corneum is structurally immature in ELBW babies. Compared to full-term infants born with around 15 layers of stratum corneum, 28-week infants may have only 2-3 layers, and 22-week infants may not have any. This deficiency can cause insensible water loss, poor thermoregulation and electrolyte imbalances. To that end, the team monitors isolette humidity and follows guidelines for which protective skin creams and dressings to use, when to initiate bathing, how often to bathe and what to bathe with.
-
Cardiovascular Care
Because of their immature circulation, extremely preterm infants have a high risk of hemodynamic compromise. Providers follow specific hypotension guidelines for administering vasoactive medications and obtaining an echocardiogram to evaluate for other cardiac diagnoses that would impact management.
-
Neurodevelopmental Care
To optimize cognitive development – and reduce the risk of IVH – the team follows specific guidelines related to positioning and environmental stimulation. For example, they provide cluster care no more than every six hours, and use midline, neutral positioning for the first seven days of life. Babies are admitted to private areas within the NICU which are located away from bright lights, noise and foot traffic.
Early Outcomes Indicate Success
To ensure continuous process and quality improvement, clinicians from the multi-disciplinary team began tracking outcomes on day one. They report their data to – and benchmark them against – independent organizations.
During the first six months, the small baby care team treated 22 infants ranging in age from 22 weeks and 4 days to 27 weeks and 5 days. Their survival rate for babies under 24 weeks was 58%; this was higher than the national average at that time, which was 37%. And for babies born between 24-27 weeks, the survival rate was 87% (compared to the national average of 85%).
“Most of our outcomes during the second six months were even better than the first half of the year,” Dr. Brown said. “While our patient volume decreased and overall survival rate dipped slightly, from 75% to 72.2%, we had fewer complications. For example, the number of patients with spontaneous intestinal perforation or necrotizing enterocolitis (NEC) fell from 2 to 1 and 3 to 1, respectively. Also, while we had five patients with a grade 3 or 4 IVH during the first half of the year, we didn’t have any during the second half.”
Thus far, Phoenix Children’s outcomes show higher-than-expected rates of chronic lung disease, which contributes to its higher-than-expected morbidity rate. However, Phoenix Children’s performed better than expected in all other areas, including lower-than-average rates of mortality, late-onset infection, NEC, pneumothorax, cystic periventricular leukomalacia and severe ROP.
“Being able to benchmark against third-party data helps us decide which guidelines need to be updated or refined,” added Dr. Brown. “For example, we’re planning to revise our small baby hypotension guidelines and assess our use of postnatal steroids in BPD prevention. By continuously monitoring and improving the care we provide, we’re giving these vulnerable patients a better chance of surviving – and thriving.”
Standardized small baby care is offered at all NICU locations staffed by Phoenix Children’s neonatologists.
To learn more about Phoenix Chilren's Small Baby Care, email fetalcarecenter@phoenxichildrens.com.