There is a discussion in our neonatal ward of the positioning of the ELBW (< 1000g) in the first three days of life. We think about the risk of cerebral bleeding in prone position, on the other hand prone may be better for breathing. Perhaps there is a differnce between a preterm with bubble-CPAP and invasive respirtory support.?

Do you have a protocol for positioning in your ward?

Our facility has a protocol called "Golden Hour" where we have specific research-based protocols during the first hour of life then position the infant supine in a neutral position for 72hrs. We have a certain temp in the delivery suite, resuscitate in an adjoining stabilization room, place temp probe on and servo control, give minimal oxygen and have pulse oximeter in place, use a neopuffer instead of bag and mask ventilation, place on prewarmed chemical mattress, place 2 hats on infant, give surfactant, take infant to the nicu in transport isolette with ventilator or nasal cpap. We dont' hand "bag" the infant. Once in the unit we are hands off after lines are placed. We don't measure infant or take manual blood pressures (get BP's off arterial lines);we dont use ekg leads, just HR off the pulse oximeter. We dont do capillary sticks or venipunctures if lines are placed. The giraffe isolette cover is closed within 2 hrs of arrival and antibiotics started within 30 min. All of these measures are to decrease IVH's among other things. We have the infant "minimal stimulation" for 72 hr or longer depending on condition. This means no touching, vitals taken hands on every twelve hours and vs off monitor every hr. OUr IVH rate has dramatically decreased since this protocol. you can read the article published inthe National Assoc Neonatal Nurses Journal this past month called "golden hour"

Our facility has a protocol called "Golden Hour" where we have specific research-based protocols during the first hour of life then position the infant supine in a neutral position for 72hrs. We have a certain temp in the delivery suite, resuscitate in an adjoining stabilization room, place temp probe on and servo control, give minimal oxygen and have pulse oximeter in place, use a neopuffer instead of bag and mask ventilation, place on prewarmed chemical mattress, place 2 hats on infant, give surfactant, take infant to the nicu in transport isolette with ventilator or nasal cpap. We dont' hand "bag" the infant. Once in the unit we are hands off after lines are placed. We don't measure infant or take manual blood pressures (get BP's off arterial lines);we dont use ekg leads, just HR off the pulse oximeter. We dont do capillary sticks or venipunctures if lines are placed. The giraffe isolette cover is closed within 2 hrs of arrival and antibiotics started within 30 min. All of these measures are to decrease IVH's among other things. We have the infant "minimal stimulation" for 72 hr or longer depending on condition. This means no touching, vitals taken hands on every twelve hours and vs off monitor every hr. OUr IVH rate has dramatically decreased since this protocol. you can read the article published inthe National Assoc Neonatal Nurses Journal this past month called "golden hour"

I am very impressed with your protocol and would like to institute it in our NICU. I am curious as to how often diapers are changed, do you use mostly CPAP or invasive ventilator support.

Edited September 23, 201015 yr by JACK

Hi, we don't have a policy as such but our practice is very similar to yours. Minimal handling is so important for these tiny babies.

We do diaper changes 8 - 12 hourly depending on need - once the baby starts to diurese it is sometimes necessary to change more frequently. If the baby is nursed in a humidified isolette it is really important that the linen is changed regularly - it can become very wet from the humidification and this will cause the skin to break down. Most of our babies go straight onto CPAP but the very small or very sick still require ventilator support. We have a low IVH rate also.

Could you send me info. on where I can find a protocol like this? I'm trying to do something similar in our NICU and would love your input. Feel free to message me too! Thanks!

The risk of cerebral bleeding in the first days of the ELBW (talking about the positioning) is related with the rotation of the head in extreme positions (90 degrees), because of the collapsing of the neck vessels and the aumentaion of the cerebral blood volume (cerebral extasis).

The first days of life it´s probably that the ELBW has some kind of umbilical catheter so the prone position sould be contraindicated.

We use frecuently the supine position with the head in neutral position and a neck pillow, or the lateral position with the head in neutral position.

Itñs important avoid the extension of the neck and the excesive rotation.