UPMC Newborn Medicine Program Develops Small Baby Program for Extremely Premature Infants

Caring for extremely premature infants, those born at less than 29 weeks gestation, is one of the most medically complex and challenging endeavors that face neonatal care teams. Fortunately, the combined resources of the UPMC Newborn Medicine Program and the Obstetrics and Labor and Delivery care teams at UPMC Magee-Womens Hospital excel at managing these most fragile infants.

The UPMC Newborn Medicine program began resuscitating and caring for babies born as early as 23 weeks gestation nearly a decade ago as technological advances in the field and evidence-based care protocols successfully increased the odds of survival at this early birth time. And, beginning a year ago, in June 2022, the UPMC Newborn Medicine Program and its collaborators extended their care efforts to deal with babies born at just 22- and zero weeks gestation. Approximately 120 babies with a gestational age less than 29 weeks were born at UPMC Magee in 2022.

This recent advance in extending care to infants born at 22 weeks precipitated the team’s review and development of new guidelines, protocols, and standards of care for extremely premature infants that reflect the current care landscape and the most current evidence-based approaches and standards of care. This work has been rolled into an effort dubbed the Small Baby Program.

Michelle Lamary, MPAS, PA-C, from the UPMC Newborn Medicine Program, has been leading the development of the new program, which is being rolled out in phases as each of the areas of the program becomes fully operational.

"When dealing with extremely premature infants, those born at less than 29 weeks, and in particular down to the ones at 22 or 23 weeks, it becomes such a complex care dynamic to navigate," says Ms. Lamary. "The size of the baby, their physical characteristics at these ages, and the complications that can arise, along with the systemic support they need to survive these peri-viable periods, all lead to care challenges that can only be successfully executed through a systems-based approach to care and one that is without a doubt multidisciplinary in nature."

Revising and Creating New Care Protocols for the Small Baby Program

With such early births, there isn't an aspect of care, anatomical component, or organ system that doesn't need specialized care focus and vigilance for possible complications, which, as one would expect with such early births, can be numerous.

The Small Baby Program consists of multiple breakout groups, each working on reviewing and revising standards of care for extremely premature babies. This includes focus groups dedicated to:

• Skin care and thermoregulation (led by Amy Parish, MSN, CRNP, NNP-BC)
• Neurodevelopmental care and support (led by fellow Anusha Chinthaparthi, MD)
• Fluids and nutrition (led by Brian C. King, MD, and fellow Darren Bodkin, MBBS)
• Hematology and hyperbilirubinemia (led by Mary Ann Compomizzi, CRNP, BC)
• Respiratory care (led by Amanda Monteverde, MSN, CRNP, NNP-BC)
• Cardiovascular care and infectious disease (Paris Ekeke, MD, MS)

“The interesting and difficult thing about optimizing care for extremely premature infants across all these care dynamics is that the available evidence and literature can be thin, and randomized trials in this patient population even more so, so our teams have plowed through what exists, in addition to our own experiences and what has worked, what has worked at other centers, what has been derived from the trials that exist to help us shape our practices and guidelines,” says Ms. Lamary.

Each breakout group is tasked with developing recommendations for care for their specific area. Then the findings and plan are presented to the entire Newborn Medicine division for comment and suggestions or concerns before the new standards take effect and are communicated broadly to all care components of the Newborn Medicine Program.

"We also emphasize supportive care and counseling for parents," says Ms. Lamary. "Christine Bishop, MD, our division’s director of Perinatal Supportive Care, is leading these efforts along with Kate Ramey, one of our neonatal supportive care nurse practitioners. We have also instituted a standard order for a consult for any baby born 24 weeks or under."

Examples of Care Needs and Work Group Solutions

Take, for example, this patient population's skincare and thermal regulation needs. Some of the earliest babies' skin is incredibly delicate, almost transparent, and gelatinous in nature, and prone to infection or breakdown.

“So, our workgroup has been devising ways to prevent these possible complications, but also working on solutions for how to get things to stick or adhere to the skin, when necessary, for example, when securing IV lines," says Ms. Lamary. "What works in full-term babies, children, or adults does not apply to these babies, so we must develop optimized solutions."

The workgroup dedicated to hematology and hyperbilirubinemia must deal with both limited quantities of blood available for testing, how to minimize blood loss, and the need for transfusions.

"And how do we effectively treat hyperbilirubinemia appropriately, but at the same time, not over-treat it? These are some of the complexities our teams are grappling with," says Ms. Lamary.

Quality Improvement as an Integral Component of the Small Baby Program

Aside from the overt clinical care aspects of the program, an overall goal of the Small Baby Program is developing a series of coordinated QI projects to monitor the progress of the program, intercede with evolutions or changes in care practices when warranted, and measure long-term outcomes of this patient population across a variety of metrics.

“Another important aspect of our ongoing QI work within the program will be staff education, particularly for our outstanding NICU nursing staff,” says Ms. Lamary.

QI initiatives and outcomes tracking in the Small Baby Program will cover several common areas or potential complications that may significantly affect the long-term outcomes trajectories of these extremely premature babies as they grow. Many outcomes are currently tracked for this population, and QI programs will include additional outcome measures, including:

• Patent ductus arteriosus, a prevalent complication seen in premature babies
• Bronchopulmonary dysplasia, another common complication of prematurity affecting lung function and respiratory ability, and initial ventilatory modes
• Neurodevelopmental outcomes measures, including ventricular hemorrhage and periventricular leukomalacia
• Sepsis and fungal infection
• Number of blood transfusions
• Time to full feedings

Learn more about the UPMC Newborn Medicine Program.

Read a related story on the UPMC Newborn Medicine Program’s recent development of the Golden Hour Program for extremely premature neonates.