Care of the Tiny Baby [Workshop Session]

NB: We are grateful to the speakers for openly sharing their own unit protocols and day-to-day practices. With so little evidence for babies at 22–23 weeks, describing in detail “how we do it” takes generosity and a certain vulnerability. We hope readers will treat these protocols as a starting point for discussion and shared learning, not as material for judgement. Questions, comparisons with your own practice, and different approaches are all very welcome in the thread below.

This European School of Neonatology workshop covered the babies at the very edge of viability, 22–23 weeks. It had three parts: fluid balance, skin care, and how a whole country (the UK) is learning together about 22-weekers. Two units with long experience (Uppsala and Cologne) gave very practical bedside detail.

1. Fluids (and a little nutrition) at 22–23 weeks

Nima Naseh, Uppsala, Sweden

Physiology first

• Total body water is about 85% of body weight before 24 weeks.

• The early postnatal weight loss is mostly a physiological contraction of the extracellular water. It is larger the more immature the baby is.

• Too much sodium early on disturbs this transition.

• Of all the ways these babies lose water, only two matter clinically: skin (transepidermal) and urine.

Kidneys

• Immature kidneys lose a lot of sodium, and glucose appears in the urine. Infants born at 22–23 weeks still have raised urinary albumin at term.

• AKI is inversely related to gestational age. It was about three times more common at 22–24 weeks than at 25–27 weeks.

• Urine output is high in week 1 and falls during week 2.

Skin

• Transepidermal water loss (TEWL) is very high at birth and is not linearly related to gestational age.

• The barrier matures quickly. By about one week, the differences between gestational ages are much smaller.

• High humidity reduces TEWL, and the effect is biggest in the most immature babies. But there is a trade-off:

  • In animal data, dry conditions sped up barrier recovery.

  • In an RCT of infants at 23–27 weeks randomised to 50% vs 75% humidity from day 7, TEWL fell more slowly at the higher humidity.

  • So high humidity lowers immediate losses but may slow barrier maturation.

• Insensible losses differ between cohorts largely because humidity practice differs (Uppsala uses about 85%).

What to expect

• Weight: across studies, the nadir is around day 3–4 (to day 5), with up to about 15% loss. Birth weight is usually regained at about 2 weeks.

  • In one study, more liberal fluid intake did not change the weight trajectory.

  • At 22 weeks, the median weight loss was about 17%.

• Sodium: it rises over the first days, and hypernatraemia is common around day 3. Hypernatraemia, the weight nadir and hyperglycaemia tend to cluster at about the same time.

Hidden sodium

• With fixed-volume flushes and infusions, the smallest babies get far more sodium per kg.

• In a 500 g baby, these alone can give about 6–7 mmol/kg/day.

• In a 2024 study, saline flushes made up more than 25% of day-1 sodium intake in the smallest infants.

• Serum sodium can look normal despite a high sodium intake. High intake in the first week has been associated with worse outcomes.

The Uppsala approach

• Starting fluid volume depends on humidity. It is calculated to allow about 3–4% weight loss per day, and it counts all fluids: drugs, flushes and line infusions. This keeps practice standardised and makes it comparable between centres.

• Sodium, worked example:

  • Urinary losses are about 8 mmol/kg/day.

  • Allowing for the expected extracellular contraction, they give back about 4 mmol/kg/day, which deliberately leaves a negative balance.

  • In their data, median total sodium intake in week 1, from all sources, was just under 5 mmol/kg/day.

• Monitoring:

  • Weigh every 12 h, then daily once weight, sodium and urine output have stabilised (around day 6–7).

  • Check sodium every 6–12 h, then daily.

  • Expected urine output is roughly 4–5 mL/kg/h.

• Targets:

  • Maximum weight loss of 10–15%, with the nadir on day 3–5.

  • Slow recovery, back to birth weight at about 2 weeks.

  • Sodium below 150 mmol/L. In practice, about 95% of their 22-weekers go above this. Even with a cut-off of 155 mmol/L, they found no link to worse outcomes.

• Why “slow” matters:

  • Weight loss by day 3 has a U-shaped association with mortality and severe brain injury: both too much and too little are bad.

  • Faster regain of birth weight was linked to poorer developmental scores.

• Later on:

  • Losses continue and sodium needs go up. The decision to start supplementing is based on weight and sodium trends together.

  • If the baby is well and growing, they supplement “blind” rather than add extra blood tests just to check sodium.

Take-home: Less sodium early, more later, because the losses continue. Keep weighing and follow the trend. Keep nutrition steady and adjust fluids separately. Use clear targets.

2. Skin care at 22–23 weeks – two views

Cologne (Eva Heine, pre-recorded)

At 22–23 weeks, the skin is essentially in functional organ failure: it is thin and translucent, with almost no stratum corneum. The task is to support it, protect it and connect through it.

Warm and humid

• They start at 85–90% humidity.

• Very high humidity carries an infection risk; they showed a case of cutaneous aspergillosis that began in the diaper area.

• They use the skin (servo) mode of new-generation incubators. Humidity then adjusts automatically and sometimes drops to about 70% while temperature stays in range.

• She was clear that small studies have not recommended skin mode, and that this is experience-based, not evidence-based.

Protect the barrier

• Minimal handling.

• No adhesives where avoidable.

• Sterile water or saline only; no antiseptics, which can cause burns.

• No ECG electrodes; pulse oximetry only.

Connect – skin-to-skin is protection, not a threat

• Evidence that SSC is safe:

  • A Swedish register study (~2,500 infants) found early SSC was not linked to more IVH or sepsis.

  • EPIPAGE-2 (~3,400 infants) found no association with late-onset sepsis.

• Evidence that SSC helps:

  • SSC may reduce pain.

  • Attachment is modifiable: maternal sensitivity predicted attachment security, not prematurity.

• The gap between evidence and practice:

  • In Sweden, SSC started at a median of about 88 h.

  • Only about 5% of infants had SSC on day 1.

• DAISY RCT (25–30 weeks): 60 min of SSC vs 5 min of visual contact in the delivery room, after stabilisation.

  • There were no adverse events.

  • Parent–infant interaction at 6 months was better.

  • Parental mental health improved in the short term; long-term effects are unclear.

Delivery-room SSC at 22–23 weeks
It is feasible when the whole team treats it as the goal, not the exception. Their checklist:

• Prepare the parents in advance.

• Secure lines and airway before the transfer.

• Preheat the room.

• Do a two-person transfer, with a neonatologist and the bedside nurse present.

• Monitor continuously; keep the room dark and quiet; give the parents privacy.

• Foil over the baby, not between mother and baby.

• Prewarm the mother’s skin. Use a hat, heated and humidified gas, warm towels and warm packs. Monitor temperature.

• Aim for at least 30, ideally 60, minutes undisturbed.

• Transfer to the ward with the baby still on the mother’s chest.

Uppsala (Victoria Karlsson)

She was honest that there is no evidence base, so she shared the Uppsala protocol. Their NICU has about 20 babies at 22–23 weeks each year, aims for parental presence 24/7, and has a parent bed at every care space.

Key concept: by the second week of life, TEWL in extremely preterm infants approaches term values. The dry, flaky skin seen after a week or two is normal maturation, not “skin breakdown”, so there is nothing to fix.

Care environment by week

Practical details

• Lines and tubes:

  • Babies start in a plastic bag, which is removed after the first X-ray.

  • A hydrocolloid goes under all tape, including for the ETT and feeding tube.

  • Umbilical lines are sutured, with no tape on the skin.

  • Saturation probes are non-adhesive.

  • Vitamin K is given IV.

• Day 1:

  • Cares every 6 h, with a parent present.

  • No other interventions or examinations.

  • All blood samples from umbilical lines; no capillary sampling.

  • Diaper left open; no servo skin probe.

• No skin-breaking procedures in the first two weeks: the UAC stays until the end of week 1 and the UVC until the end of week 2. After that, sampling is venous, never by heel prick, ideally during SSC.

• Parents are key: they change the very first diaper. The incubator hood is raised from day 1 to allow closeness.

• Timing of SSC at the end of week 1 is guided by the weight and sodium trends from talk 1.

• Hygiene:

  • No sterile gloves or linen; short nails, no nail polish or jewellery.

  • Staff wear gloves for diaper changes; parents do not.

  • Sterile gloves are used only for IV procedures.

• Cleaning: water only in the early weeks, pressing a wet compress rather than wiping.

• Disinfection: chlorhexidine in the first two weeks, chlorhexidine with alcohol later.

• If the skin is damaged:

  • Cavilon (silicone-based barrier cream) for diaper-area redness or frequent stools, because the aim is dry skin even at 85% humidity.

  • An absorbent dressing for exudative skin folds; it heals within a day or two.

  • Pain relief.

• A recent paper (45 infants <26 weeks, 20 of them at 22–23 weeks) showed that early SSC maintained body temperature.

• Evidence is coming: large multicentre humidity RCTs are ongoing in the US and in Australia.

Take-home (both units): Keep babies warm and humid, but don’t forget that humidity has costs. Avoid adhesives and skin-breaking procedures. Put parents at the centre: from the first diaper and from the delivery room.

3. Improving care at 22 weeks through national collaboration: the UK approach

Cheryl Battersby, Imperial College London / BAPM

A very different talk: not “what we do at the bedside” but how a country with modest 22-week outcomes is learning systematically.

Context and caution

• Single-centre results from places like Cologne, Uppsala, Iowa and Japan are impressive.

• Those centres work in very different systems: centralised care, outreach teams, and (in Japan) almost all births in tertiary centres.

• Don’t copy them without accounting for your own system.

The UK situation

• Many units each see very few 22-weekers; the median is about one per unit.

• Up to 40% of births are transferred.

• Survival is about 2–3 in 10.

• The NHS structure makes national, population-based learning possible.

The UK journey

• 2019: the BAPM framework moved from no active care at 22 weeks to a risk-based assessment.

• National data (BMJ Medicine) then showed a threefold increase in active care.

• Survival did not improve, partly because babies with very unfavourable risk profiles were being admitted.

• Framework revision:

  • Chorioamnionitis and prolonged rupture of membranes were added as very unfavourable features. Where the chance of a poor outcome is >90%, comfort-focused care is advised.

  • The wording changed from parents “choosing” management to professionals explaining the recommended management, so parents don’t carry the burden of an impossible decision.

  • Babies born outside a tertiary centre without antenatal steroids should not be transferred postnatally (>90% of them died).

• Her personal view: a country should not start offering care at 22 weeks until outcomes at 23 weeks are good.

• A new BAPM 22-week group, with representatives from every network plus parents, dietitians and psychologists. It runs national “roadshows” so units can share experience.

Recurring themes from the roadshows

• Perinatal optimisation and birth in the right place (with maternity colleagues).

• Capacity and transfer responsibility.

• Counselling support for non-tertiary units.

• Very intense first hours.

• Equipment not sized for these babies.

• Wide practice variation and reluctance to write guidelines without evidence.

• A strong need for psychological support for staff as well as families: when most 22-weekers die, moral injury is real.

The UK 22-week study

• A national observational study (England, Wales, Scotland, Northern Ireland) in nearly all tertiary centres since last June.

• Run without individual consent: parents receive an information sheet in five languages, with parent-group support.

• Data collected daily for the first 7 days, then weekly, in REDCap. Definitions are aligned with the US Tiny Baby Collaborative.

• Led on the ground by trainees.

• About 100 babies so far.

• She also showed very preliminary, exploratory results. These are not reported here; we’ll wait for the published data.

Overall take-home: Care at 22–23 weeks is still largely experience-based. The units with the best results share an attention to detail: counting every millilitre and millimole, protecting the skin, and putting parents at the centre. The way forward is pooled data and the RCTs that are now underway.

Disclosure: This is an AI-assisted summary of the session, generated from a recording made by our team in attendance. We believe it is as accurate as our own notes would be, but please refer to the speakers’ original work before applying anything in clinical practice.