Core Principle
- ELGAN care should be treated as a structured injury-prevention bundle, not as routine preterm care with smaller doses.
- The most important priorities: avoid hypothermia, avoid volutrauma, avoid hypocarbia/hypercarbia swings, avoid unnecessary stimulation, avoid rapid volume shifts, avoid unnecessary phlebotomy, and avoid routine PDA prophylaxis without a clear indication.
1. Definitions
| Term | Practical Meaning |
|---|
| Preterm | Birth before 37 completed weeks' gestation. |
| ELBW | Birth weight <1000 g. |
| ELGAN | Usually used for infants born <28 weeks' gestation; this chapter focuses on <28 weeks, especially 22–23 weeks. |
| Highest-risk ELGAN | 22+0 to 23+6 weeks, where evidence is limited and care must be individualized. |
Scope: This chapter covers specialized care for ELGANs, especially infants born <28 weeks' gestation, with a separate emphasis on the highest-risk group born at 22+0 to 23+6 weeks. The goal is to reduce avoidable injury during the first hours and days by using senior-led stabilization, gentle ventilation, thermoregulation, humidity, minimal handling, careful fluid balance, neuroprotective care, and evidence-based use of medications.
2. First 72 Hours: ELGAN Bedside Bundle
| Domain | Recommended Approach | Why It Matters |
|---|
| Team preparation |
Use senior neonatology/NNP/RT/nursing leadership for delivery-room and early NICU stabilization. |
Extremely preterm infants should be stabilized by the most experienced available team because small errors in ventilation, temperature, lines, and blood pressure can cause major harm. |
| Temperature |
Target normothermia; use plastic wrap/bag, prewarmed incubator, servo control, and humidity. |
Hypothermia and hyperthermia are both associated with adverse neonatal outcomes. Target range: 36.5–37.5°C. |
| Humidity |
For 22–23 week infants, use high humidity (~80%) for the first 5 days, then wean per local protocol (50% until ~DOL 12). |
High humidity reduces insensible water loss through immature skin and stabilizes temperature and fluid balance. |
| Handling |
Clustered care q6h when stable; minimal suctioning; monitor-derived vitals; avoid unnecessary cuff BPs if UAC present. |
Every unnecessary stimulation can destabilize the smallest infants — postpone daily weights, avoid four-extremity cuff BPs when UAC is present. |
| Respiratory support |
Start CPAP when breathing spontaneously; intubate and give surfactant if inadequate ventilation, severe RDS, or noninvasive failure. |
AHA/AAP 2025 supports CPAP for spontaneously breathing preterm infants needing support, with oxygen titration by pulse oximetry. |
| Ventilation target |
Avoid excessive tidal volume; target stable CO₂ — pCO₂ 40–55 mmHg in the first week if clinically appropriate. |
Frequent gases until target pCO₂ is achieved (Baylor 22–23 week pathway). Rapid swings in CO₂ increase IVH risk. |
| Fluids |
Avoid unnecessary volume boluses; use volume only for clear hypovolemia or blood loss; infuse slowly (over 30–60 min for NS, 1–2 hours for PRBCs). |
Rapid volume shifts cause hemodynamic instability and increase IVH risk in ELGAN infants. |
| PDA prophylaxis |
Do not use routine prophylactic indomethacin solely to prevent symptomatic PDA. |
AAP 2025: prophylactic medical PDA treatment is not recommended at any gestational age or birth weight. |
| Neuroprotection |
Minimize blood pressure swings, venous congestion, airway obstruction, unnecessary suctioning, heel sticks, and stimulation. |
BP fluctuation and venous congestion are key modifiable IVH risk factors in ELGANs. |
3. Specialized Pathway for 22+0 to 23+6 Weeks
Framework Principles
- Infants born at 22+0 to 23+6 weeks need a separate bedside pathway because they are at the border of viability and evidence is limited.
- Before delivery: the plan should be individualized after joint counseling by obstetrics/MFM and neonatology, with documentation of parental goals, prognostic factors, and the expected initial approach.
- After birth: the plan may change based on the infant's condition, response to stabilization, and best-interest assessment.
- The 2026 BAPM framework emphasizes updated survival and neurodevelopmental outcome data, joint maternity-neonatal counseling, and comfort care for babies assessed to be at extremely high risk of dying.
Prognostic Factors to Include in Counseling
- Gestational age (days matter at this threshold)
- Estimated weight and sex (female and higher weight are associated with improved outcomes)
- Singleton vs. multiple
- Antenatal corticosteroid status
- Fetal growth restriction and placental insufficiency
- Congenital anomalies and infection risk
- Parental values, goals, and informed preferences
4. Respiratory Management
| Situation | Bedside Action |
|---|
| Spontaneously breathing ELGAN | Start CPAP early if there is respiratory effort but increased work of breathing or oxygen need. |
| Poor respiratory effort, bradycardia, or failed mask ventilation | Intubate, confirm effective ventilation, and give surfactant when indicated. |
| 22–23 weeks requiring invasive ventilation | Baylor recommends HFJV as the primary ventilation strategy for this subgroup. |
| Initial HFJV settings (22–23 weeks) | Jet rate 360 bpm, jet PIP 22–24, jet IT 0.02 sec, IMV PEEP 5, IMV PIP = PEEP+6 to 8, IMV rate 0, IMV Ti 0.4 sec. |
| Gas monitoring after admission | Check gases q1–2h until target pCO₂ reached → q8h in first 24h → q12h on DOL 1–2 → q24h when stable. |
| After surfactant | Watch closely for rapid lung compliance improvement; reduce PIP, tidal volume, and FiO₂ promptly to avoid volutrauma and air leak. |
5. Extubation Readiness
Extubation should be strongly considered once the infant is clinically stable and ventilator settings are low enough, although the decision must be individualized in the most immature infants.
| Mode | Minimal Support Suggesting Readiness for Extubation |
|---|
| Conventional VG (Volume-Guaranteed) | Vt 4–5 mL/kg · PIP ≤25 cm H₂O · PEEP 5–6 cm H₂O · Rate <30 · FiO₂ ≤0.40 |
| HFJV | Jet PIP <20 · PEEP <7–8 · FiO₂ ≤0.40 |
| HFOV | MAP <10 · Amplitude <25 · ΔP <10 · Hz 12–15 · FiO₂ ≤0.40 |
6. Fluids, Nutrition, and GI Care
Baylor 22–23 Week Nutrition Pathway
- Total fluids: start ~120–140 mL/kg/day with starter TPN; begin intralipids early per local dosing protocol.
- Breast/donor milk introduction: 1 mL q6h via OG for 3 days → 1 mL q3h for 3 days → slow advancement by ~10 mL/kg/day (or 1 mL/feed daily) as tolerated.
- Fortification: may be added when feed volume reaches a defined unit threshold; Baylor lists Prolacta +6 kcal/oz at 60 mL/kg/day in its 22–23 week pathway.
- Avoid large or rapid fluid boluses; any necessary volume should be infused over 30–60 minutes (NS) or 1–2 hours (PRBCs).
7. Cardiovascular Management
Patent Ductus Arteriosus (PDA)
Routine Prophylactic Indomethacin: Not Recommended
- AAP 2025 PDA guidance: prophylactic medical treatment is not recommended at any gestational age or birth weight.
- Early closure before 14 days has not been shown to improve outcomes.
- Cochrane data: prophylactic indomethacin reduces symptomatic PDA, PDA ligation, and severe IVH — but does not reduce mortality or improve long-term neurodevelopmental outcomes.
- Baylor's ELGAN pathway does not use routine prophylactic indomethacin for 22–23 week infants.
Hydrocortisone for Hypotension / Adrenal Insufficiency
Baylor Hydrocortisone Protocol
- Consider for adrenal insufficiency or early hypotension in ELGAN infants.
- Loading dose: 1 mg/kg IV once
- Maintenance: 0.5 mg/kg IV q8h, starting 8 hours after loading dose
- Wean as tolerated based on hemodynamic response.
- Confirm dose and indication with neonatal consultant and local formulary.
8. Caffeine
Caffeine for Apnea of Prematurity
- Indication: All infants ≤1250 g should receive caffeine citrate unless contraindicated.
- Loading dose: 20 mg/kg IV/PO
- Maintenance: 5–10 mg/kg/day IV/PO
- A 2024 systematic review found caffeine reduced apnea and BPD in preterm infants; the optimal dose remains under investigation.
- Confirm dose and timing with local formulary and consultant.
9. Postnatal Steroids for Evolving BPD
DART Therapy — Selective Use Only
- Low-dose dexamethasone (DART) should be considered for selected ELGANs with prolonged ventilation and high predicted risk of BPD or death — not given routinely.
- AAP and CPS support selective low-dose systemic corticosteroids for high-risk ventilator-dependent preterm infants while discouraging routine early dexamethasone or inhaled steroid use.
| DART Criteria (Baylor) | Details |
|---|
| Gestational age | 24+0 to 27+6 weeks |
| Day of life | DOL 14–42 |
| Duration of ventilation | Mechanically ventilated ≥14 days |
| Risk threshold | Combined risk of grade 2/3 BPD plus death ≥60% using the NICHD BPD estimator |
| Regimen | 10-day taper with cumulative dexamethasone exposure of 0.89 mg/kg |
| Caution | Not recommended for routine use in all ELGANs; discuss risk/benefit with family and consultant before initiating. |
10. Neuroprotection and Minimal Handling
Cluster care and reduce unnecessary stimulation.
Use monitor-derived vitals when reliable (pulse oximetry, arterial line).
Use UAC/UVC to reduce heel sticks and peripheral IV trauma.
Watch continuously for ETT obstruction, malposition, or air leak.
Maintain normothermia and eucapnia throughout.
Routine suctioning during the first 24–48 hours unless clinically needed.
Repeated cuff blood pressures if a UAC is present and functioning.
Rapid boluses without clear hypovolemia or blood loss.
Large swings in oxygen, CO₂, blood pressure, or ventilation pressure.
Unnecessary phlebotomy — cluster labs and keep daily draw volume within a small fraction of blood volume.
Baylor Ch 2.2 — The 22–23 Week Protocol and ELGAN Specifics
22 0/7 – 23 6/7 weeks: general care
- Cares every 6 hours, daily weights postponed, and no four-extremity or cuff blood pressures while a UAC is in place — every touch counts.
- Humidity 80% for 5 days, then weaned to 50% by protocol and stopped on day 12.
- Baylor notes openly that evidence at this gestation is thin — these are best practices from centres of excellence rather than trial-driven rules.
| System | 22 0/7 – 23 6/7 week protocol |
|---|
| Respiratory |
- High-frequency jet ventilation is the primary mode (Watkins 2020).
- Initial settings: jet rate 360/min, jet PIP 22–24, jet inspiratory time 0.02 s; conventional PEEP 5, conventional PIP = PEEP + 6–8, conventional rate 0, inspiratory time 0.4 s.
- Gases every 1–2 h after admission until pCO₂ is 40–55 mmHg (the target for the first 7 days), then every 8 h for the first day, every 12 h on days 1–2, and daily once stable.
- Lowest settings used: jet rate 240, jet PIP 14, inspiratory time 0.02 s.
|
| Cardiovascular |
- Do not give prophylactic indomethacin at 22–23 weeks (Mitra 2022).
- Hydrocortisone for adrenal insufficiency and as first line for early hypotension: load 1 mg/kg IV once, then 0.5 mg/kg IV every 8 h starting 8 h after the load, weaning as tolerated.
|
| Fluids and feeds |
- Total fluids 120–140 mL/kg/day. Start D5 starter PN at 100 mL/kg/day (or D10 at 80 mL/kg/day if indicated) and lipid at 0.1 mL/h for 12 h.
- Fortify with human-milk-based fortifier (+6 kcal/oz) once feeds reach 60 mL/kg/day.
- Feeding ladder: 1 mL every 6 h by gastric tube for 3 days → 1 mL every 3 h for 3 days → advance by 10 mL/kg/day divided every 3 h, or by 1 mL per feed daily, to a goal of 130–160 mL/kg/day.
|
ELGAN below 28 weeks
- Volume expanders: avoid them. If one is given, infuse over 30–60 min; transfuse blood over 1–2 h. For non-specific hypotension without anemia or blood loss, a pressor such as dopamine is preferable to volume.
- Respiratory: a vigorous infant with good effort goes straight onto nasal CPAP; give early selective surfactant if distress develops, by LISA, InSurE or tube — individualized. Confirm tube position and lung inflation before dosing, or the surfactant distributes unevenly.
- Volume guarantee is the preferred conventional mode above 24 0/7 weeks because it self-weans pressure as compliance improves — which can happen fast after surfactant, so watch chest rise and cut PIP and FiO₂ promptly.
- Extubate once minimal settings are reached unless something else prevents it — and an attempt from higher settings is still legitimate.
| Minimal support for extubation (Baylor Table 2-4) | Conventional | High-frequency jet | Oscillator |
|---|
| Pressure / volume | Tidal volume 4–5 mL/kg; PIP ≤25 | PIP <20; ΔP <10 | Mean airway pressure <10; amplitude <25 |
| PEEP / frequency | PEEP 5–6; rate <30 | PEEP 7–8 | 12–15 Hz |
| Oxygen | FiO₂ ≤0.40 |
DART dexamethasone for BPD prevention
- Who: 24 0/7 – 27 6/7 weeks, 14–42 days old, still ventilated at ≥14 days, with a combined risk of grade 2–3 BPD or death ≥60% on the NICHD outcome estimator (moderate certainty, strong recommendation).
- Regimen (10 days, cumulative 0.89 mg/kg), every 12 h: 0.075 mg/kg × 6 doses → 0.05 × 6 → 0.025 × 4 → 0.01 × 4.
- Do not start during a sepsis evaluation or active infection under treatment, or with clinical concern for a haemodynamically significant PDA — consider an echo first.
- While running it: watch glucose and blood pressure closely, take gases every 6–8 h, and wean the ventilator toward extubation. If settings will not come down by day 5–6, consider stopping.
- Consider weaning or stopping hydrocortisone first, resuming afterwards if adrenal insufficiency is a concern. A second course needs a multidisciplinary discussion — the evidence for benefit is weak.
- Tell parents the trade: extubation and lower risk of death, chronic lung disease and neurodevelopmental impairment, against hyperglycemia and hypertension.
Prophylactic indomethacin — no longer recommended at any gestation
- Cochrane 2022 found less symptomatic PDA, less surgical ligation and, to a lesser degree, less severe IVH (moderate certainty), but no mortality benefit and no difference in cerebral palsy. In the subgroup below 28 weeks or 1000 g it did not improve mortality or severe IVH at all.
- The AAP's 2025 clinical report goes further: prophylactic medical treatment — given without knowing PDA status — is not recommended at any gestational age or birth weight, since it does not change mortality, BPD or neurodevelopmental outcome (high certainty).
- What does help: early fluid restriction in the first weeks may reduce PDA (high certainty).
Keeping blood pressure and venous return steady
- Weigh on the in-bed scale, and weigh infants on CPAP with the CPAP in place so functional residual capacity is preserved.
- Take vital signs from the monitor, not by disturbing the infant.
- Routine suctioning is usually unnecessary in the first 24–48 h.
- Minimize peripheral IVs and heel sticks: run glucose and PN through the UVC, infuse saline or sodium acetate through the UAC, and draw gases, labs and glucose from the UAC.
- Watch continuously for tube displacement or obstruction — and use a humidified convertible incubator.
11. Monitoring Schedule
| Time | Key Monitoring |
|---|
| Admission | Glucose at 30 minutes; blood gas if indicated; CBC/platelets if indicated; blood culture if sepsis evaluation needed; blood type/Rh/Coombs; early electrolytes/renal function depending on stability. |
| First 24–72 hours | Electrolytes, glucose, BUN/creatinine every 12–24 hours depending on size and metabolic stability; Ca/Mg/Phos and bilirubin per risk and TPN status. |
| Respiratory instability | Frequent blood gases after admission, especially q1–2h until pCO₂ target is reached in 22–23 week infants. |
| Neuroimaging | Cranial ultrasound around DOL 7; follow-up based on IVH severity; term/discharge imaging to assess PVL. |
| ROP | Screen infants by birth weight, gestational age, or unstable clinical course using AAP-based criteria; ensure follow-up before discharge or transfer. |
12. Common Mistakes
| Mistake | Better Approach |
|---|
| Treating a 22–23 week infant like a routine VLBW infant | Use a dedicated micropreemie pathway with high humidity, q6h care, senior review, and minimal handling. |
| Continuing high ventilator pressures after surfactant | Anticipate rapid compliance improvement and wean PIP/Vt/FiO₂ promptly to avoid volutrauma and air leak. |
| Using routine prophylactic indomethacin for PDA prevention | Avoid routine PINDO; current evidence does not show improved mortality or neurodevelopmental benefit. |
| Giving fast volume boluses for nonspecific hypotension | Avoid volume unless hypovolemia or blood loss is likely; consider vasopressor or hydrocortisone strategy depending on physiology. |
| Frequent unnecessary labs | Cluster labs and limit phlebotomy; keep daily blood draw volume within a small fraction of blood volume when possible. |
13. Parent Communication
Key Points for Parents
- The first hours focus on breathing, temperature, lines, glucose, blood pressure, infection evaluation, nutrition, and brain-protective care.
- The plan may change as the infant's response to stabilization, gases, ventilation, blood pressure, ultrasound findings, infection status, and overall stability become clearer.
- For 22–23 week infants: counseling should be honest that evidence is limited, outcomes vary by gestational age and prognostic factors, and active care versus comfort-focused care must be individualized.
14. Teaching Points
High-Yield Teaching Points
- ELGAN care is injury prevention from minute one. The bundle matters more than any single intervention.
- The first 72 hours should be quiet, warm, humidified, senior-led, and protocolized.
- Ventilation should prioritize lung recruitment without volutrauma and avoid rapid CO₂ swings.
- Routine prophylactic indomethacin for PDA prevention is no longer recommended as a default strategy.
- DART is for selected high-risk ventilated infants, not for routine use in all ELGANs.
- Every handling event should have a reason — stimulation itself can destabilize the smallest infants.
15. Key Takeaways
High-Yield Summary
- Bundle approach: Normothermia · High humidity · Gentle ventilation · Minimal handling · Careful fluids · Caffeine · Senior-led care.
- pCO₂ target: 40–55 mmHg in the first week; check gases q1–2h until stable in 22–23 week infants.
- After surfactant: wean promptly — rapid compliance improvement is expected.
- PDA: No routine prophylactic indomethacin; treat symptomatic PDA guided by clinical assessment and cardiology input.
- DART: Selected ventilator-dependent ELGANs with ≥60% risk of BPD/death on NICHD estimator (DOL 14–42, ≥14 days ventilated, 24–27+6 weeks).
- Caffeine citrate: All ≤1250 g; 20 mg/kg load → 5–10 mg/kg/day maintenance.
- 22–23 weeks: Individualized plan, joint counseling, separate micropreemie pathway, reassess frequently.
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