Recommendations

Parents and carers have the right to be involved in planning and making decisions about their baby's health and care, and to be given information and support to enable them to do this, as set out in the NHS constitution and summarised in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off‑label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Risk factors for bronchopulmonary dysplasia

1.1.1 Be aware that the risk factors for bronchopulmonary dysplasia (BPD) include those in table 1. Note that the risk factors 'treated with surfactant' and 'treated for a patent ductus arteriosus (PDA)' are likely to reflect the severity of the baby's condition. Surfactant should be used, and a PDA should be treated, where clinically appropriate.

The risk factors in table 1 (below) have been identified in large prospective cohort studies, but other gestational ages and other risk factors not listed here might also be associated with an increased risk of bronchopulmonary dysplasia.

Table 1 Identified risk factors for BPD

In babies born before 32 weeks

  • Lower gestational age

  • Lower birthweight

  • Small for gestational age

  • Male sex

  • Core body temperature of less than 35°C on admission to neonatal unit

  • Invasive ventilation begun within 24 hours of birth

  • Clinical sepsis with or without positive blood cultures

  • Feeding with formula milk (exclusively or in addition to breast milk)

  • Treated with surfactant

  • Treated for a patent ductus arteriosus (PDA)

The risk factors of being treated with surfactant and treated for a PDA are likely to reflect the severity of the baby's condition. Surfactant should be used, and a PDA should be treated, where clinically appropriate.

In babies born before 30 weeks

  • Cardiopulmonary resuscitation performed at birth

For a short explanation of why the committee made this recommendation and how it might affect services, see the rationale and impact section on risk factors for BPD.

1.2 Respiratory support for preterm babies

Respiratory support before admission to the neonatal unit

1.2.1 When stabilising preterm babies who need respiratory support soon after birth and before admission to the neonatal unit, use continuous positive airways pressure (CPAP) where clinically appropriate, rather than invasive ventilation.

For a short explanation of why the committee made this recommendation and how it might affect services, see the rationale and impact section on respiratory support before admission to the neonatal unit.

Surfactant

1.2.2 Give surfactant to preterm babies who need invasive ventilation for stabilisation in the early postnatal period.

1.2.3 When giving surfactant to a preterm baby who does not need invasive ventilation, use a minimally invasive administration technique. If this is not possible, for example, in units without the facilities or trained staff to carry out these techniques, use endotracheal intubation to give surfactant, with early extubation afterwards.

In April 2019, this was an off-label use for some brands of surfactant. See NICE's information on prescribing medicines.

For a short explanation of why the committee made these recommendations and how they might affect services, see the rationale and impact section on giving surfactant.

Oxygen

1.2.4 Use nasal cannula or incubator oxygen for preterm babies who need supplemental oxygen.

1.2.5 Humidify oxygen when giving oxygen at higher flow rates, such as 2 litres per minute or more.

For a short explanation of why the committee made these recommendations and how they might affect services, see the rationale and impact section on oxygen.

Non-invasive ventilation techniques in the neonatal unit

1.2.6 For preterm babies who need non-invasive ventilation, consider nasal CPAP or nasal high-flow therapy as the primary mode of respiratory support.

Invasive ventilation techniques in the neonatal unit

1.2.7 For preterm babies who need invasive ventilation, use volume-targeted ventilation (VTV) in combination with synchronised ventilation as the primary mode of respiratory support. If this is not effective, consider high-frequency oscillatory ventilation (HFOV).

1.2.8 For preterm babies who need invasive ventilation but VTV and HFOV are not available or not suitable, consider synchronised intermittent mandatory ventilation (SIMV).

1.2.9 Do not use synchronised pressure-limited ventilation such as assist control (AC), synchronised intermittent positive pressure ventilation (SIPPV), patient-triggered ventilation (PTV), pressure support ventilation (PSV) or synchronised time-cycled pressure-limited ventilation (STCPLV).

For a short explanation of why the committee made these recommendations and how they might affect services, see the rationale and impact section on ventilation techniques.

Nitric oxide

1.2.10 Do not routinely use inhaled nitric oxide for preterm babies who need respiratory support for respiratory distress syndrome (RDS), unless there are other indications such as pulmonary hypoplasia or pulmonary hypertension.

In April 2019, the following uses were off-label: inhaled nitric oxide for pulmonary hypoplasia and inhaled nitric oxide for pulmonary hypertension in babies less than 34 weeks' gestation. See NICE's information on prescribing medicines.

For a short explanation of why the committee made this recommendation and how it might affect services, see the rationale and impact section on nitric oxide.

1.3 Managing respiratory disorders

Corticosteroids

1.3.1 Consider dexamethasone to reduce the risk of BPD for preterm babies who are 8 days or older and still need invasive ventilation for respiratory disease. When considering whether to use dexamethasone in these babies:

1.3.2 For preterm babies who are younger than 8 days old, be aware that dexamethasone increases the risk of gastrointestinal perforation.

1.3.3 Do not use dexamethasone with non-steroidal anti-inflammatory drugs (NSAIDs).

1.3.4 Monitor the blood pressure of babies who receive dexamethasone, because of the risk of hypertension.

Table 2 Benefits and harms of dexamethasone in preterm babies 8 days or older

Outcome

Benefit or harm for preterm babies 8 days or older

Notes

Mortality before discharge

There is no difference in mortality before discharge in babies who receive dexamethasone compared with babies who do not receive dexamethasone.

There was evidence demonstrating this lack of difference.

BPD at 36 weeks' postmenstrual age

  • Babies who receive dexamethasone are less likely to develop BPD compared with babies who do not receive dexamethasone.

On average:

  • without dexamethasone treatment, 63 babies per 100 would develop BPD (and 37 would not)

  • with dexamethasone treatment, 47 babies per 100 would develop BPD (and 53 would not).

There was evidence demonstrating this difference.

Cerebral palsy

There is no difference in the incidence of cerebral palsy in babies who receive dexamethasone compared with babies who do not receive dexamethasone.

Although there was evidence demonstrating this lack of difference, there is uncertainty about the risk, so the possibility of cerebral palsy occurring cannot be excluded.

Other neurodevelopmental outcomes (neurodevelopmental delay and neurosensory impairment)

There is no difference in neurodevelopmental outcomes in babies who receive dexamethasone compared with babies who do not receive dexamethasone.

Although there was evidence demonstrating this lack of difference, there is uncertainty about the risk of neurodevelopmental delay and neurosensory impairment because the studies reported neurodevelopmental assessments at different timepoints.

Days on invasive ventilation

Babies who receive dexamethasone have fewer days on invasive ventilation compared with babies who do not receive dexamethasone.

Although there was evidence demonstrating this difference, there is uncertainty about the difference in the number of days on invasive ventilation because of the different ways the studies reported it.

Gastrointestinal perforation

There is no difference in gastrointestinal perforation in babies who receive dexamethasone compared with babies who do not receive dexamethasone.

Although there was evidence demonstrating this lack of difference, there is uncertainty about the risk, so the possibility of gastrointestinal perforation occurring cannot be excluded.

Hypertension

Babies who receive dexamethasone are more likely to develop hypertension compared with babies who do not receive dexamethasone.

On average:

  • without dexamethasone treatment, 3 preterm babies per 100 would develop hypertension (and 97 would not)

  • with dexamethasone treatment, 11 babies per 100 would develop hypertension (and 89 would not).

There was evidence demonstrating this difference.

Full details of the evidence for the benefits and harms of dexamethasone for preterm babies 8 days or older are in evidence review C: managing respiratory disorders.

For a short explanation of why the committee made these recommendations and how they might affect services, see the rationale and impact section on dexamethasone.

Diuretics

For a short explanation of why the committee did not make a recommendation, see the rationale on diuretics.

Caffeine citrate

1.3.5 Use caffeine citrate routinely in preterm babies born at or before 30 weeks, starting it as early as possible and ideally before 3 days of age.

1.3.6 Consider stopping caffeine citrate at 33 to 35 weeks' corrected gestational age if the baby is clinically stable.

1.3.7 Consider caffeine citrate for any preterm baby with apnoea.

Give a loading dose of 20 mg/kg of caffeine citrate, followed 24 hours later by a maintenance dosage of 5 mg/kg once daily, increasing up to 20 mg/kg daily if episodes of apnoea persist.

In April 2019, this dosage was an off-label use of caffeine citrate. See NICE's information on prescribing medicines.

1.3.8 Consider a maintenance dosage higher than 20 mg/kg daily if therapeutic efficacy is not achieved, while ensuring that a safe plasma level is maintained.

In April 2019, this dosage was an off-label use of caffeine citrate. See NICE's information on prescribing medicines.

When measuring plasma levels, prescribers should use the local laboratory's reference ranges. See the British National Formulary for Children for further information about caffeine citrate.

For a short explanation of why the committee made these recommendations and how they might affect services, see the rationale and impact section on caffeine citrate.

Patent ductus arteriosus

1.3.9 Do not treat a PDA in a preterm baby unless the PDA causes a significant clinical problem, for example, difficulty weaning the baby from a ventilator.

For a short explanation of why the committee made this recommendation and how it might affect services, see the rationale and impact section on PDA.

1.4 Monitoring

Oxygen

1.4.1 Use continuous pulse oximetry to measure oxygen saturation in preterm babies, supplemented by arterial sampling if clinically indicated.

1.4.2 After initial stabilisation, aim for an oxygen saturation of 91% to 95% in preterm babies.

1.4.3 For preterm babies on invasive ventilation who are clinically unstable, consider transcutaneous oxygen monitoring.

For a short explanation of why the committee made these recommendations and how they might affect services, see the rationale and impact section on oxygen monitoring.

Carbon dioxide

1.4.4 For preterm babies on invasive ventilation, aim for a carbon dioxide partial pressure (PCO2) of:

  • 4.5 kPa to 8.5 kPa on days 1 to 3 and

  • 4.5 kPa to 10 kPa from day 4 onwards.

1.4.5 Reduce minute ventilation without delay in preterm babies with a low PCO2, and check the PCO2 within an hour of the low measurement being identified.

For a short explanation of why the committee made these recommendations and how they might affect services, see the rationale and impact section on carbon dioxide monitoring.

Blood pressure

1.4.6 Do not treat preterm babies for hypotension based solely on specific blood pressure thresholds, but take into account other factors, such as evidence of poor tissue perfusion. The aim of treatment should be to improve perfusion.

For a short explanation of why the committee made this recommendation and how it might affect services, see the rationale and impact section on blood pressure.

1.5 Sedation and analgesia

Morphine

1.5.1 Do not routinely use morphine for preterm babies on respiratory support.

1.5.2 Consider morphine if the baby is in pain. Assess the baby's pain using locally agreed protocols or guidelines.

In April 2019, the following uses were off-label: intravenous morphine for children under 12 years and oral morphine for children under 1 year. See NICE's information on prescribing medicines.

1.5.3 Regularly reassess babies on morphine to ensure that it is stopped as soon as possible.

For a short explanation of why the committee made these recommendations and how they might affect services, see the rationale and impact section on morphine.

Premedication before intubation

1.5.4 Consider premedication before elective non-urgent intubation in preterm babies.

1.5.5 If giving premedication, consider either:

  • an opioid analgesic (for example, morphine or fentanyl), combined with a neuromuscular blocking agent (for example, suxamethonium) or

  • propofol alone.

    In April 2019, the following uses were off-label: intravenous morphine for children under 12 years, oral morphine for children under 1 year, fentanyl for children under 2 years, and propofol for children under 1 month. See NICE's information on prescribing medicines.

For a short explanation of why the committee made these recommendations and how they might affect services, see the rationale and impact section on premedication for intubation.

1.6 Involving, supporting and informing parents and carers

NICE has produced a guideline on babies, children and young people's experience of healthcare.

Involving parents and carers while their preterm baby is on respiratory support

1.6.1 Explain to the parents and carers of preterm babies on respiratory support that non-nutritive sucking (using a dummy) during periods when the baby is awake is beneficial because:

  • it can help soothe the baby between feeds and

  • in babies fed by a nasogastric tube, dummy use can reduce the length of the baby's hospital stay.

1.6.2 Tell parents and carers about the benefits of using touch, for example, through skin-to-skin contact, to communicate with their baby.

1.6.3 Consider providing the Newborn individualized developmental care and assessment program (NIDCAP®) to improve cognitive development in babies born at less than 27 weeks.

For a short explanation of why the committee made these recommendations and how they might affect services, see the rationale and impact section on involving parents and carers.

Supporting parents and carers while their preterm baby is on respiratory support

1.6.4 Recognise parents and carers as partners in their baby's care, and support them in this role.

1.6.5 Encourage and support parents and carers to:

  • be involved in planning and providing their baby's day-to-day care, for example, feeding and nappy changing

  • participate in discussions and decisions about their baby during ward rounds, providing input into planning and providing care.

1.6.6 Provide regular opportunities and time for parents and carers to discuss their baby's care, ask questions about the information they have been given, and discuss concerns.

1.6.7 Give parents and carers the time, support and encouragement they need to become confident in caring effectively for their baby.

1.6.8 Offer parents and carers psychological support from a professional who is trained to deliver this type of help and advice.

Providing information to parents and carers while their preterm baby is on respiratory support

1.6.9 Ask parents and carers about how and when they would like to receive information about their baby's treatment and progress, and how they would prefer to be contacted when they are away from the neonatal unit.

1.6.10 Support discussions with parents and carers using written information. Ensure that information is up to date, relevant, appropriate to the parents' and carers' needs and preferences, and consistent between healthcare professionals. For more guidance on communication (including different formats and languages), providing information, and shared decision making, see the NICE guidelines on patient experience in adult NHS services and shared decision making.

1.6.11 Ensure that information for parents and carers is delivered by an appropriate healthcare professional, and information for hospitalised mothers who cannot visit their baby is delivered by a senior healthcare professional, for example, a neonatologist or specialist registrar, face-to-face whenever possible.

1.6.12 Be sensitive about the timing of discussions with parents and carers. In particular, discuss significant perinatal events without delay, providing the mother has sufficiently recovered from the birth.

1.6.13 Provide information for parents and carers that includes:

  • explanations and regular updates about their baby's condition and treatment, especially if there are any changes

  • what happens in the neonatal unit, and the equipment being used to support their baby

  • what respiratory support is being provided for their baby

  • how to get involved in their baby's day-to-day care, interact with their baby and interpret the baby's neurobehavioural cues

  • the roles and responsibilities of different members of their baby's healthcare team, and key contacts

  • information about caring for a premature baby to share with family and friends, and practical suggestions about how to get help and support from family and friends

  • opportunities for peer support from neonatal unit graduate parents or parent buddies

  • details of local support groups, online forums and national charities, and how to get in touch with them.

For a short explanation of why the committee made these recommendations and how they might affect services, see the rationale and impact section on supporting and providing information to parents and carers.

Neonatal services for preterm babies on respiratory support

1.6.14 Those responsible for planning and delivering neonatal services should ensure that neonatal units:

  • are welcoming and friendly

  • foster positive and supportive relationships by providing parents and carers with 24‑hour access to their baby

  • provide privacy for skin-to-skin contact and feeding

  • have private areas for difficult conversations

  • have comfortable furniture and provide a relaxing environment for families.

1.6.15 Ensure that healthcare professionals in neonatal units can support parents and carers by being competent in:

  • communicating complex and sensitive information clearly

  • tailoring information and support to the person's individual needs and circumstances.

For a short explanation of why the committee made these recommendations and how they might affect services, see the rationale and impact section on neonatal services.

1.7 Discharge planning

Planning safe discharge from the neonatal unit for preterm babies on respiratory support

1.7.1 Neonatal units should consider appointing a member of staff as a designated neonatal discharge coordinator to discuss the following with parents and carers:

1.7.2 When planning to discharge a preterm baby on respiratory support from the neonatal unit:

  • follow the principles in the NICE guideline on postnatal care

  • consider early referral to, and regular contact with, community and continuing healthcare teams

  • consider an interim discharge placement to, for example, a hospice, alternative family member's home, step-down unit, transitional care unit, or alternative suitable accommodation, where appropriate.

For a short explanation of why the committee made these recommendations and how they might affect services, see the rationale and impact section on planning safe discharge.

Supporting and providing information to parents and carers of preterm babies on respiratory support – preparing for discharge

1.7.3 Recognise parents and carers as partners in the discharge planning process. Answer their questions and concerns as they arise, and support them in making joint decisions with the discharge team.

1.7.4 Throughout the baby's neonatal admission, provide support and guidance for parents and carers with constructive and supportive feedback about how to care for their baby and how to use specialist equipment. Use a formal competency-based assessment tool to evaluate the safe use of specialist equipment.

1.7.5 Discuss any modifications that parents and carers might need to make to their home as soon as possible.

1.7.6 Educate parents and carers about possible emergencies that may arise, how to deal with them and who to contact for help and advice. This should include how to carry out cardiopulmonary resuscitation, and what to do if there are problems with any specialist equipment.

1.7.7 Provide parents and carers with opportunities to care for their baby overnight.

1.7.8 Provide information for parents and carers to help them care for their baby safely and confidently after discharge. Follow the principles in the section on communication and information-giving in this guideline, and also see the NICE guideline on postnatal care. Information should include:

  • how to recognise signs of illness in their baby, and what to do

  • how to adapt routines such as feeding and sleeping after discharge, and information about safe sleep guidance

  • how to make follow‑up appointments and timing of immunisations

  • who to contact after discharge, as well as a list of useful medical contacts.

1.7.9 Tell parents and carers about sources of support after discharge, for example:

For a short explanation of why the committee made these recommendations and how they might affect services, see the rationale and impact section on supporting and providing information to parents as part of discharge planning.

Terms used in this guideline

Automated oxygen titration

A control system that measures the oxygen saturation and automatically adjusts the oxygen flow to maintain oxygen saturation within a predefined target range.

Invasive ventilation

Administration of respiratory support via an endotracheal tube or tracheostomy, using a mechanical ventilator. The definitions of invasive ventilation modes are summarised in table 3.

Table 3 Definitions and groupings for analysis of invasive ventilation modes

Volume-targeted ventilation (VTV)

Volume guarantee ventilation (VGV)

Target tidal volume (TTV)

Pressure regulated volume control (PRVC) ventilation (PRVCV)

Volume-limited ventilation (VLV)

Volume assured pressure support (VAPS)

Any synchronised pressure-limited ventilation (SPLV) plus VTV

Synchronised intermittent mandatory ventilation (SIMV) plus VTV

Synchronised pressure-limited ventilation (SPLV)

Assist control ventilation (AC)

Synchronised intermittent positive pressure ventilation (SIPPV)

Patient-triggered ventilation (PTV)

Pressure support ventilation (PSV)

Synchronised time-cycled pressure-limited ventilation (STCPL)

Synchronised Intermittent Mandatory Ventilation (SIMV)

Non-synchronised pressure-limited ventilation (NSPLV)

Conventional mandatory ventilation (CMV)

Non-triggered/unsynchronised time-cycled pressure-limited ventilation (TCPL)

Intermittent mandatory ventilation (IMV)

High-frequency ventilation (HFV)

High-frequency oscillatory ventilation (HFOV)

High-frequency flow interruption (HFFI)

Minimally invasive administration technique

Administration of surfactant through a thin endotracheal catheter without insertion of an endotracheal tube or invasive ventilation.

Minute ventilation

The tidal volume of each breath in millilitres (ml) multiplied by the number of breaths per minute gives the minute ventilation in ml/minute (usually expressed as ml/kg/minute, which is achieved by dividing by the baby's weight in kg).

Neurobehavioural cues

Sounds, characteristics of movements including facial expressions and physiological parameters such as heart rate, breathing patterns and skin tone that reflect the baby's current level of sensitivity or wellbeing, and reveal their current developmental stage.

Neurodevelopmental outcomes

In this guideline, neurodevelopmental outcomes at 18 months or older have been defined as:

  • cerebral palsy (reported as presence or absence of condition, not severity)

  • neurodevelopmental delay (reported as dichotomous outcomes, not continuous outcomes such as mean change in score):

    • severe (score of more than 2 standard deviations [SD] below normal on validated assessment scales, or a score of less than 70 on the Bayley II scale of infant development mental developmental index [MDI] or psychomotor developmental index [PDI], or complete inability to assign score because of cerebral palsy or severe cognitive delay)

    • moderate (score of 1 to 2 SD below normal on validated assessment scales, or a score of 70 to 84 on the Bayley II scale of infant development MDI or PDI)

  • neurosensory impairment (reported as presence or absence of condition, not severity):

    • severe hearing impairment (for example, deaf)

    • severe visual impairment (for example, blind).

Non-invasive ventilation

Administration of respiratory support using a ventilator or flow driver, but not via an endotracheal tube or tracheostomy.

Perinatal

In this guideline, the perinatal period is defined as the period of time from 48 hours before birth up until 7 completed days after birth.

Preterm

A baby born before 37 weeks. This can be subdivided further:

  • extremely preterm: babies born at less than 28 weeks

  • very preterm: babies born at between 28 and 31+6 weeks

  • moderate to late preterm: babies born at between 32 and 36+6 weeks.

Skin-to-skin contact

Holding a naked baby, or a baby wearing only a nappy, on the skin of a parent or carer, usually on the chest.

Stabilisation

Facilitating and supporting a smooth transition from fetal to neonatal life. The process involves careful assessment of heart rate, colour (oxygenation) and breathing, with provision of appropriate interventions where indicated.

  • National Institute for Health and Care Excellence (NICE)