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ELBW protocol


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Hi all

There seems to be a wide variation in survival and morbidity  in babies < 26 weeks. The data from Sweden and Japan are much better than the ones from rest of the world.

I would like to know if any one from Sweden or Japan will be willing to share their protocol in the management of Babies < 26 weeks. 



Mike Sukumar MD

Rockville USA

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Hi Mike,

I've been in meetings with the Japanese, and what they do is very simple (but easier said than done):  Always use non-invasive ventilation, and feed early and exclusively with breast milk. Formula is not an option.

Other things they have is excellent prenatal care, almost 100% of antenatal corticosteroids, and adequate staffing of their NICUS...

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Hello, I don't have a good answer but I think there are some things more important than others.

Like Japan we have almost full coverage of antenatal care (free service for all). About 95% of pregnancies are ultrasound-dated, i.e. we have a uniform estimate of gestational age. Obstetric and neonatal services are fairly well "coordinated" and available to all. Level-3 NICU care is centralized to (7?) regional/university hospitals and the vast majority small infants are transferred in utero to their level-3 hospital. And, we have a relatively low proportion of really socially disadvantaged parents.

Apart from that we also have a tradition of non-invasive ventilation (nCPAP) also in tiny infants - I am not sure but it is likely this was a strategy that was developed due to less staffing and budgets initially...

The National Board of Health issued national guidelines recently on some key topics: those are only available in Swe though.... but here they are:


However, I think there is a greater room for improvements in Sweden:

  • we don't use probiotics
  • our transportation services are rather regional "initiatives" than a results of a national strategy
  • there are no national consensus whether 22-weekers should be resuscitated
  • we could still "do less" of things that lack evidence but has potential side-effects
  • we need to combat nosocomial infections better

Most importantly, despite the structure of care/society that enables really large observational studies (we can track /link individual data from birth to death, data in several national registries), we do hardly no intervention research.

Greetings from Sweden :) 

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