Background Following delivery, extremely premature infants are vulnerable to rapid development of hypothermia and hypoglycemia. To reduce local rates of these morbidities, a multidisciplinary team developed a protocol standardizing evidence-based care practices during the first hour after birth. Methods Using quality improvement methodology, the Golden Hour protocol was implemented for all inborn infants <27 weeks' gestation. Data were collected (2012-2017) over three phases; pre-protocol (n = 80), Phase I (n = 42), and Phase II (n = 92). Results There were no significant differences in infant characteristics. Improvements in hypothermia (59% vs 26% vs 38%; p = 0.001), hypoglycemia (18% vs 7% vs 4%; p = 0.012), and minutes to completion of stabilization [median (Q1,Q3) 110 (89,138) vs 111 (94,135) vs 92 (74,129); p = 0.0035] were observed. Conclusions Implementation of an evidence-based, Golden Hour protocol is an effective intervention for reducing hypothermia and hypoglycemia in extremely premature infants.

The definition of hypoglycemia in the newborn infant has remained controversial because of lack of significant correlation between plasma glucose concentration, clinical symptoms, and long-term sequelae. A threshold value for plasma glucose at which clinical intervention should be considered is important because of the potential for serious neurological injury. In this review, we have described threshold values for plasma glucose in the newborn infant, based upon available data, at which the clinician should consider close monitoring and therapeutic interventions aimed at increasing the glucose level. In clinically symptomatic infants, plasma glucose concentrations of 45 mg/dL (2.5 mmol/L) or less should be considered as threshold for intervention. In an asymptomatic baby and in those at risk for hypoglycemia, irrespective of gestational and postnatal age, plasma glucose values less than 36 mg/dL (2.0 mmol/L) should be considered as threshold levels. Variances from these criteria, as in breast-fed infants, are discussed. The threshold values described for surveillance and intervention should be separated from the targeted therapeutic values which should be in the range of 72-90 mg/dL (4-5 mmol/L).

The nutritional and immunologic properties of human milk, along with clear evidence of dose-dependent optimal health outcomes for both mothers and infants, provide a compelling rationale to support exclusive breastfeeding. US women increasingly intend to breastfeed exclusively for 6 months. Because establishing lactation can be challenging, exclusivity is often compromised in hopes of preventing feeding-related neonatal complications, potentially affecting the continuation and duration of breastfeeding. Risk factors for impaired lactogenesis are identifiable and common. Clinicians must be able to recognize normative patterns of exclusive breastfeeding in the first week while proactively identifying potential challenges. In this review, we provide new evidence from the past 10 years on the following topics relevant to exclusive breastfeeding: milk production and transfer, neonatal weight and output assessment, management of glucose and bilirubin, immune development and the microbiome, supplementation, and health system factors. We focus on the early days of exclusive breastfeeding in healthy newborns ≥35 weeks’ gestation managed in the routine postpartum unit. With this evidence-based clinical review, we provide detailed guidance in identifying medical indications for early supplementation and can inform best practices for both birthing facilities and providers.

Providing breast milk is challenging for non-nursing mothers of premature infants. Early breast milk expression results in successful and longer lactation in mothers of very low birth weight (VLBW) infants. This quality improvement initiative sought to increase the rate of early milk expression in mothers of VLBW infants and increase the proportion of infants receiving maternal breast milk (MBM) at 28 days of age and at discharge. Phase 1 (n = 45) occurred between April 1, 2012, and August 31, 2012. Phase 2 (n = 58) occurred between September 1, 2012, and February 28, 2013. Pre-phase 2 actions included increased lactation consultant workforce, early lactation consultation, tracking of MBM supply, and physician education. Inborn infants < 1500 grams were eligible. Primary outcomes were the time of first maternal milk expression (TFME) and infant feeding type at 28 days of age and at discharge. The median TFME decreased from 9 (25th, 75th percentile; 6, 16) hours to 6 (5, 11) hours after implementation (P = .06). The proportion of infants receiving exclusive MBM at 28 days and at discharge was 64% and 74%, respectively (P = .40), and the proportion of infants receiving exclusive MBM at discharge increased from 37% to 59% (P = .046). In conclusion, a multidisciplinary initiative aimed at improving the rate of early milk expression was associated with more VLBW infants receiving exclusive MBM at discharge.

ObjectiveTo characterize in-hospital outcomes of premature infants diagnosed with severe bronchopulmonary dysplasia.Study DesignRetrospective cohort study including premature infants with severe bronchopulmonary dysplasia discharged from 348 Pediatrix Medical Group neonatal intensive care units from 1997–2015.ResultThere were 10,752 infants with severe bronchopulmonary dysplasia, and 549/10,752 (5%) died prior to discharge. Infants who died were more likely to be male, small for gestational age, have received more medical interventions, and more frequently diagnosed with surgical necrotizing enterocolitis, culture-proven sepsis, and pulmonary hypertension following 36 weeks postmenstrual age compared to survivors. Approximately 70% of infants with severe bronchopulmonary dysplasia were discharged by 44 weeks postmenstrual age, and 86% were discharged by 48 weeks postmenstrual age.ConclusionA majority of infants diagnosed with severe bronchopulmonary dysplasia were discharged home by 44 weeks postmenstrual age. These results may inform discussions with families regarding the expected hospital course of infants diagnosed with severe bronchopulmonary dysplasia.