Preterm infant — formative SAQs

SAQ 1 (10)

A 29-week preterm infant is born after spontaneous preterm labour. The mother received one dose of antenatal corticosteroids 18 hours ago. The infant is grunting and cyanosed in the delivery room with a heart rate of 120. [6]

1. Outline your delivery-room stabilisation including oxygen strategy and cord management. (3) [5] [6]
2. State the classification of this infant and the significance of the single corticosteroid dose. (2) [1]
3. Describe your early respiratory management over the first 24 hours. (3) [6] [7]
4. List three complications you will actively screen for during this admission. (2) [11] [12]

Model answer

Delivery-room stabilisation. Dry and warm the infant under a radiant heater with a polyethylene wrap; assess tone, breathing and heart rate; provide gentle CPAP at 5–7 cm water for the grunting infant; start with air or low oxygen (21–30%) and titrate against a pre-ductal saturation nomogram. Since the infant does not need immediate resuscitation, defer cord clamping for 30–60 seconds. [5] [6]

Classification and steroids. This is a very preterm infant (28–31+6 weeks). A single dose of antenatal corticosteroids provides partial benefit; the full course (two doses 24 hours apart) is optimal for accelerating fetal lung maturation and reducing RDS, IVH and mortality. [1]

Early respiratory management. Admit to NICU on CPAP; monitor oxygen targeting 91–95%; give rescue surfactant if oxygen need rises above 30% on CPAP then extubate back to CPAP; start caffeine citrate early for apnoea prevention and extubation readiness; minimise mechanical ventilation. [6] [7]

Screening. Serial cranial ultrasound for IVH/PVL; retinopathy of prematurity screening by GA and birthweight criteria starting around 31–34 weeks PMA; sepsis surveillance with blood cultures before antibiotics. [11] [12]

SAQ 2 (10)

A 30-week preterm infant is now 3 weeks old and tolerating fortified maternal milk feeds. The mother's supply has dropped and there is no donor milk available. [14]

1. Explain the evidence-based nutritional choice when maternal milk is insufficient and donor milk unavailable. (2) [14]
2. Describe the feeding advancement strategy and fortification principles for this infant. (3) [11] [14]
3. Outline how you would recognise and respond to early necrotising enterocolitis. (3) [11]
4. State four discharge-readiness criteria for a preterm infant. (2) [11]

Model answer

Nutritional choice. Maternal milk is first choice; donor human milk is preferred over preterm formula when maternal milk is unavailable because Cochrane evidence shows donor milk reduces necrotising enterocolitis. When donor milk is also unavailable, preterm formula with careful advancement is the alternative, accepting a slightly higher NEC risk. [14]

Feeding advancement. Start with trophic feeds and advance cautiously in very preterm infants; monitor for tolerance (no significant residuals, no distension); fortify human milk to meet protein and energy targets for growth; plot weight, length and head circumference on Fenton charts. [11] [14]

NEC recognition and response. Recognise abdominal distension, increased gastric aspirates, bloody or bilious aspirates, and systemic signs of sepsis. Response: fast the infant immediately, decompress with a replogle tube, start broad-spectrum antibiotics, obtain surgical review and an abdominal radiograph for pneumatosis or free air. Do not delay surgery for imaging if perforation is suspected. [11]

Discharge criteria. Thermally stable in an open cot; full oral feeds with sustained weight gain; no significant apnoea for 5–7 days; immunised on chronological age with a structured follow-up plan. [11]