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Specialist neonatal respiratory care in preterm babies

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What is covered

This NICE Pathway covers specialist neonatal respiratory care in preterm babies.

Updates

Updates to this NICE Pathway

15 July 2020 Specialist neonatal respiratory care for babies born preterm (NICE quality standard 193) added.

Patient-centred care

Parents and carers have the right to be involved in planning and making decisions about their baby's health and care, and to be given information and support to enable them to do this, as set out in the NHS constitution and summarised in making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on specialist neonatal respiratory care in preterm babies in an interactive flowchart

What is covered

This NICE Pathway covers specialist neonatal respiratory care in preterm babies.

Updates

Updates to this NICE Pathway

15 July 2020 Specialist neonatal respiratory care for babies born preterm (NICE quality standard 193) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.

Quality standards

Specialist neonatal respiratory care for babies born preterm

These quality statements are taken from the specialist neonatal respiratory care for babies born preterm quality standard. The quality standard defines clinical best practice for specialist neonatal respiratory care for babies born preterm and should be read in full.

Quality statements

Respiratory support soon after birth

This quality statement is taken from the specialist neonatal respiratory care for babies born preterm quality standard. The quality standard defines best clinical practice in specialist neonatal respiratory care for babies born preterm and should be read in full.

Quality statement

Preterm babies having respiratory support soon after birth and before admission to the neonatal unit are given continuous positive airways pressure (CPAP), if clinically appropriate, rather than invasive ventilation.

Rationale

Using CPAP, when clinically appropriate, to stabilise preterm babies reduces the use of unnecessary invasive ventilation. It can also reduce mortality before discharge and the incidence of bronchopulmonary dysplasia (BPD) in babies at 36 weeks postmenstrual age. BPD can result in longer hospital stays and readmission after discharge, and can have a significant impact on quality of life for babies and their families and carers.

Quality measures

Structure
a) Evidence of local arrangements to ensure that preterm babies having respiratory support soon after birth and before admission to the neonatal unit are given CPAP where clinically appropriate.
Data source: Local data collection, for example, audits of stabilisation protocols.
b) Evidence of staff training available for neonatal CPAP.
Data source: Local data collection, for example, provision of training courses in neonatal CPAP.
Process
a) Proportion of preterm babies born under 28 weeks of pregnancy who had invasive ventilation in the delivery room.
Numerator – the number in the denominator who had invasive ventilation in the delivery room.
Denominator – the number of preterm babies born under 28 weeks of pregnancy.
Data source: Local data collection, for example, local audit of patient records on BadgerNet neonatal electronic patient record or similar patient records system. For measurement purposes, ‘in the delivery room’ means ‘soon after birth and before admission to the neonatal unit’. In order to use existing data collection invasive ventilation is measured. Numbers are expected to reduce when the quality statement is implemented.
b) Proportion of preterm babies born between 28 weeks and 31 weeks plus 6 days of pregnancy who had invasive ventilation in the delivery room.
Numerator – the number in the denominator who had invasive ventilation in the delivery room.
Denominator – the number of preterm babies born between 28 weeks and 31 weeks plus 6 days of pregnancy.
Data source: Local data collection, for example, local audit of patient records on BadgerNet neonatal electronic patient record or similar patient records system. For measurement purposes, ‘in the delivery room’ means ‘soon after birth and before admission to the neonatal unit’. In order to use existing data collection invasive ventilation is measured. Numbers are expected to reduce when the quality statement is implemented.
c) Proportion of preterm babies born between 32 weeks and 36 weeks plus 6 days of pregnancy who had invasive ventilation in the delivery room.
Numerator – the number in the denominator who had invasive ventilation in the delivery room.
Denominator – the number of preterm babies born between 32 weeks and 36 weeks plus 6 days of pregnancy.
Data source: Local data collection, for example, local audit of patient records on BadgerNet neonatal electronic patient record or similar patient records system. For measurement purposes, ‘in the delivery room’ means ‘soon after birth and before admission to the neonatal unit’. In order to use existing data collection invasive ventilation is measured. Numbers are expected to reduce when the quality statement is implemented.
Outcome
Number of preterm babies with BPD.
Data source: The National Neonatal Audit Programme (NNAP) measures the number of eligible babies alive at 36 weeks with sufficient data to attribute BPD outcome.

What the quality statement means for different audiences

Service providers (such as maternity and delivery units, and neonatal units, including special care units, local neonatal units and neonatal intensive care units) ensure that systems are in place for preterm babies to be given CPAP, when it is clinically appropriate, if they need respiratory support soon after birth. They ensure that healthcare professionals are trained to provide CPAP and can identify when invasive ventilation is clinically needed.
Healthcare professionals (such as midwives, specialist neonatal nurses, specialist neonatal consultants and other paediatric specialists working with babies born preterm) use CPAP for preterm babies who need respiratory support soon after birth, if clinically appropriate. They are trained to administer CPAP and to identify when invasive ventilation is clinically needed and provide this if necessary.
Commissioners (such as clinical commissioning groups and NHS England) ensure that the services they commission use CPAP for preterm babies who need respiratory support soon after birth, if clinically appropriate.
Preterm babies who need help with their breathing soon after birth are given continuous positive airways pressure (known as CPAP) if it is suitable for them. This is when blended air and oxygen is given through a mask or through tubes into the nose to support breathing. It is preferable to using a ventilator, which has a higher risk of other problems leading to a longer stay in hospital and readmission after discharge.

Source guidance

Definitions of terms used in this quality statement

Bronchopulmonary dysplasia (BPD)
A chronic lung disease that develops in preterm babies. [NICE’s guideline on specialist neonatal respiratory care for babies born preterm, supplement 1: glossary and abbreviations]
Clinically appropriate
It would not, or is unlikely to, be clinically appropriate to use CPAP in the following circumstances:
  • for babies who are persistently not breathing after initial stabilisation
  • for babies with an unstable heart rate, or whose oxygen saturations are not improving, despite high oxygen levels and standard newborn life support
  • for some extremely preterm babies for whom invasive ventilation may be more appropriate.
Clinical judgement should be used to decide whether invasive ventilation with surfactant is more appropriate in the delivery room for babies born very early. Some extremely preterm babies may not have the necessary respiratory drive for CPAP to be effective, and the failure rate of non-invasive ventilation is higher for these babies.
[NICE’s guideline on specialist neonatal respiratory care for babies born preterm, rationale and impact section for recommendation 1.2.1, evidence review on respiratory support, and expert opinion]
Invasive ventilation
Administration of respiratory support via an endotracheal tube or tracheostomy, using a mechanical ventilator. [NICE’s guideline on specialist neonatal respiratory care for babies born preterm, terms used in this guideline section]

Minimally invasive administration of surfactant

This quality statement is taken from the specialist neonatal respiratory care for babies born preterm quality standard. The quality standard defines best clinical practice in specialist neonatal respiratory care for babies born preterm and should be read in full.

Quality statement

Preterm babies who need surfactant are given it using a minimally invasive technique if they do not need invasive ventilation.

Rationale

Surfactant can be given to preterm babies using a minimally invasive technique if they are not on invasive ventilation. Using a minimally invasive technique reduces the risk of bronchopulmonary dysplasia (BPD) and pneumothorax (collapsed lung).

Quality measures

Structure
a) Evidence of local arrangements to ensure that preterm babies who need surfactant receive it using a minimally invasive technique if they do not need invasive ventilation.
Data source: Local data collection, for example, clinical protocols on surfactant administration and clinical governance oversight.
b) Evidence of staff training in a minimally invasive surfactant administration technique.
Data source: Local data collection, for example, the number of staff trained in a minimally invasive surfactant administration technique.
Process
a) Proportion of preterm babies born under 28 weeks of pregnancy who are given surfactant using a minimally invasive technique.
Numerator – the number in the denominator who are given surfactant using a minimally invasive technique.
Denominator – the number of preterm babies born under 28 weeks of pregnancy who are given surfactant.
Data source: Local data collection, for example, local audit of patient records.
b) Proportion of preterm babies born between 28 weeks and 31 weeks plus 6 days of pregnancy who are given surfactant using a minimally invasive technique.
Numerator – the number in the denominator who are given surfactant using a minimally invasive technique.
Denominator – the number of preterm babies born between 28 weeks and 31 weeks plus 6 days of pregnancy who are given surfactant.
Data source: Local data collection, for example, local audit of patient records.
c) Proportion of preterm babies born between 32 weeks and 36 weeks plus 6 days of pregnancy who are given surfactant using a minimally invasive technique.
Numerator – the number in the denominator who are given surfactant using a minimally invasive technique.
Denominator – the number of preterm babies born between 32 weeks and 36 weeks plus 6 days of pregnancy who are given surfactant.
Data source: Local data collection, for example, local audit of patient records.
Outcome
a) Incidence of pneumothorax in preterm babies.
Data source: Local data collection, for example, audits of patient records.
b) Number of preterm babies with BPD.
Data source: The National Neonatal Audit Programme (NNAP) measures the number of eligible babies alive at 36 weeks with sufficient data to attribute BPD outcome.

What the quality statement means for different audiences

Service providers (such as neonatal units, including special care units, local neonatal units and neonatal intensive care units) ensure that processes are in place and healthcare professionals are trained to administer surfactant using a minimally invasive technique to preterm babies who do not need invasive ventilation.
Healthcare professionals (such as specialist neonatal nurses, specialist neonatal consultants and other paediatric specialists working with babies born preterm) do not intubate preterm babies to give surfactant to babies who do not need invasive ventilation. They use a minimally invasive technique if surfactant is needed.
Commissioners (NHS England) ensure that they commission services that use minimally invasive techniques to administer surfactant to preterm babies who do not need invasive ventilation.
Preterm babies who need surfactant to help them breathe are given it in a way that has the least risk of problems. This is done through a thin tube into the baby’s nose or mouth and passed into their airway. If the baby needs help with breathing using a ventilation machine with a tube that passes into the windpipe, surfactant is given through the tube that is already in place.

Source guidance

Definitions of terms used in this quality statement

Bronchopulmonary dysplasia (BPD)
A chronic lung disease that develops in preterm babies. [NICE’s guideline on specialist neonatal respiratory care for babies born preterm, supplement 1: glossary and abbreviations]
Invasive ventilation
Administration of respiratory support via an endotracheal tube or tracheostomy, using a mechanical ventilator. [NICE’s guideline on specialist neonatal respiratory care for babies born preterm, terms used in this guideline section]
Minimally invasive technique
Administration of surfactant through a thin endotracheal catheter without insertion of an endotracheal tube or invasive ventilation. Minimally invasive techniques are:
  • minimally invasive surfactant therapy (MIST)
  • less invasive surfactant administration (LISA)
  • avoidance of mechanical ventilation (AMV).
[NICE’s guideline on specialist neonatal respiratory care for babies born preterm, terms used in this guideline section and evidence review on respiratory support]

Invasive ventilation

This quality statement is taken from the specialist neonatal respiratory care for babies born preterm quality standard. The quality standard defines best clinical practice in specialist neonatal respiratory care for babies born preterm and should be read in full.

Quality statement

Preterm babies having invasive ventilation are given volume-targeted ventilation (VTV) in combination with synchronised ventilation.

Rationale

VTV in combination with synchronised ventilation has a lower mortality rate before discharge in preterm babies compared with other invasive ventilation techniques. It also reduces the risk of bronchopulmonary dysplasia (BPD) and pneumothorax (collapsed lung), and the number of days on invasive ventilation.

Quality measures

Structure
Evidence of local arrangements to ensure that preterm babies having invasive ventilation are given VTV in combination with synchronised ventilation.
Data source: Local data collection, for example, clinical protocols.
Process
a) Proportion of preterm babies born under 28 weeks of pregnancy having invasive ventilation who were given VTV in combination with synchronised ventilation.
Numerator – the number in the denominator who were given VTV in combination with synchronised ventilation.
Denominator – the number of preterm babies born under 28 weeks of pregnancy having invasive ventilation.
Data source: Local data collection, for example, local audit of patient records.
b) Proportion of preterm babies born between 28 weeks and 31 weeks plus 6 days of pregnancy having invasive ventilation who were given VTV in combination with synchronised ventilation.
Numerator – the number in the denominator who were given VTV in combination with synchronised ventilation.
Denominator – the number of preterm babies born between 28 weeks and 31 weeks plus 6 days of pregnancy having invasive ventilation.
Data source: Local data collection, for example, local audit of patient records.
c) Proportion of preterm babies born between 32 weeks and 36 weeks plus 6 days of pregnancy having invasive ventilation who were given VTV in combination with synchronised ventilation.
Numerator – the number in the denominator who were given VTV in combination with synchronised ventilation.
Denominator – the number of preterm babies born between 32 weeks and 36 weeks plus 6 days of pregnancy having invasive ventilation.
Data source: Local data collection, for example, local audit of patient records.
Outcome
a) Number of days preterm babies spend on invasive ventilation.
Data source: Local data collection, for example, audits of patient records.
b) Incidence of pneumothorax in preterm babies.
Data source: Local data collection, for example, audits of patient records.
c) Number of preterm babies with BPD.
Data source: The National Neonatal Audit Programme (NNAP) measures the number of eligible babies alive at 36 weeks with sufficient data to attribute BPD outcome.

What the quality statement means for different audiences

Service providers (such as neonatal units, including special care units, local neonatal units and neonatal intensive care units) ensure that systems are in place for preterm babies to be given VTV with synchronised ventilation if they are having invasive ventilation. Most units have flow sensors for triggered ventilation and the same sensor can be used for VTV.
Healthcare professionals (such as specialist neonatal nurses, specialist neonatal consultants and other paediatric specialists working with babies born preterm) ensure that they use VTV with synchronised ventilation for preterm babies who are having invasive ventilation.
Commissioners (NHS England) ensure that the services they commission provide VTV with synchronised ventilation to preterm babies having invasive ventilation.
Preterm babies using a ventilation machine to help them breathe are given a type of ventilation that lets healthcare professionals control and maintain the volume of gas the baby receives per breath. This may reduce the risk of other problems and the number of days they need to spend in hospital.

Source guidance

Definitions of terms used in this quality statement

Bronchopulmonary dysplasia (BPD)
A chronic lung disease that develops in preterm babies. [NICE’s guideline on specialist neonatal respiratory care for babies born preterm, supplement 1: glossary and abbreviations]
Invasive ventilation
Administration of respiratory support via an endotracheal tube or tracheostomy, using a mechanical ventilator. [NICE’s guideline on specialist neonatal respiratory care for babies born preterm, terms used in this guideline section]

Oxygen saturation

This quality statement is taken from the specialist neonatal respiratory care for babies born preterm quality standard. The quality standard defines best clinical practice in specialist neonatal respiratory care for babies born preterm and should be read in full.

Quality statement

Preterm babies have a target oxygen saturation of 91% to 95% after stabilisation.

Rationale

Aiming for an oxygen saturation level of between 91% and 95% can reduce mortality, particularly in babies born very preterm (between 28 weeks and 31 weeks plus 6 days) and extremely preterm (under 28 weeks). Setting a target oxygen saturation level of less than 91% increases the risk of mortality and morbidity.

Quality measures

Structure
Evidence of local arrangements to ensure that preterm babies have a target oxygen saturation of 91% to 95% after stabilisation.
Data source: Local data collection, for example, audits of oxygen administration protocols.
Process
Proportion of preterm babies who have a target oxygen saturation set at between 91% and 95% after stabilisation.
Numerator – the number in the denominator who have a target oxygen saturation between 91% and 95%.
Denominator – the number of preterm babies receiving oxygen after stabilisation.
Data source: Local data collection, for example, audits of patient records.
Outcome
Mortality rates in preterm babies.
Data source: Local data collection, for example, audits of neonatal mortality rates. The National Neonatal Audit Programme (NNAP) collects data on mortality in preterm babies, which will be published by local neonatal networks from 2020.

What the quality statement means for different audiences

Service providers (such as neonatal units, including special care units, local neonatal units and neonatal intensive care units) ensure that systems are in place for preterm babies to have a target saturation level of 91% to 95%. They ensure that healthcare professionals are aware of this target.
Healthcare professionals (such as specialist neonatal nurses, specialist neonatal consultants and other paediatric specialists working with babies born preterm) ensure that oxygen saturation targets for preterm babies are between 91% and 95%. They monitor this using continuous pulse oximetry, supplemented by arterial sampling if clinically indicated.
Commissioners (NHS England) ensure that they commission services that specify target oxygen saturation levels of 91% to 95% in preterm babies.
Preterm babies have the amount of oxygen in their blood (oxygen saturation) monitored, with the aim of achieving a safe level (between 91% and 95%).

Source guidance

Definitions of terms used in this quality statement

Stabilisation
Facilitating and supporting a smooth transition from fetal to neonatal life. The process involves careful assessment of heart rate, colour (oxygenation) and breathing, and providing appropriate interventions where indicated. [NICE’s guideline on specialist neonatal respiratory care for babies born preterm, terms used in this guideline section]

Involving parents and carers

This quality statement is taken from the specialist neonatal respiratory care for babies born preterm quality standard. The quality standard defines best clinical practice in specialist neonatal respiratory care for babies born preterm and should be read in full.

Quality statement

Parents and carers of preterm babies who are having respiratory support are helped to care for their baby.

Rationale

Involving parents and carers in planning and delivering day-to-day care for their preterm baby while in hospital, for example feeding and nappy changing, can help to support parent and carer mental health and attachment, and improve confidence. If parents and carers are confident to manage their baby’s condition and able to use specialist equipment safely at home, their baby may be able to come home earlier. Poor mental health can affect bonding between parents and carers and their baby, so access to psychological support can be beneficial.

Quality measures

Structure
a) Evidence of local arrangements to ensure that parents and carers of preterm babies having respiratory support are involved in discussions and decisions about their baby during ward rounds.
Data source: Local data collection, for example, protocols to involve parents and carers during ward rounds. The National Neonatal Audit Programme (NNAP) measures the proportion of admissions where parents were present on a consultant ward round on at least 1 occasion during their baby’s stay.
b) Evidence of local arrangements to ensure that parents and carers of preterm babies having respiratory support have 24-hour access to their baby.
Data source: Local data collection, for example, protocols on parent and carer access to preterm babies while in a neonatal unit.
c) Evidence of local arrangements to ensure parents and carers of preterm babies having respiratory support are involved in their baby’s day-to-day care and are able to use specialist equipment on discharge.
Data source: Local data collection, for example, protocols to involve parents and carers of preterm babies having respiratory support in their baby’s care.
d) Evidence of local arrangements to ensure that parents and carers of preterm babies having respiratory support are offered psychological support while their baby is on respiratory support.
Data source: Local data collection, for example, availability of professionals trained to deliver psychological support to parents and carers of preterm babies.
Process
a) Proportion of parents and carers of preterm babies having respiratory support who are involved in discussions and decisions about their baby during ward rounds.
Numerator – the number in the denominator who are involved in discussions and decisions about their baby during ward rounds.
Denominator – the number of parents and carers of preterm babies having respiratory support.
Data source: Local data collection, for example, audits of patient records of the frequency that parents and carers participated in ward rounds during their baby’s admission.
b) Proportion of parents and carers of preterm babies having respiratory support who have 24-hour access to their baby.
Numerator – the number in the denominator who have 24-hour access to their baby.
Denominator – the number of parents and carers of preterm babies having respiratory support.
Data source: Local data collection, for example, audits of patient records and surveys of parents’ and carers’ experience.
c) Proportion of parents and carers of preterm babies having respiratory support who are involved in providing their baby's day-to-day care.
Numerator – the number in the denominator who are involved in providing their baby's day-to-day care.
Denominator – the number of parents and carers of preterm babies having respiratory support.
Data source: Local data collection, for example, audits of patient records.
d) Proportion of parents and carers of preterm babies who will need respiratory support following discharge who receive training to use specialist equipment before their baby is discharged.
Numerator – the number in the denominator who receive training to use specialist equipment before their baby is discharged.
Denominator – the number of parents and carers of preterm babies who will need respiratory support following discharge.
Data source: Local data collection, for example, audits of parent training logs and patient records.
e) Proportion of parents and carers of preterm babies having respiratory support who can access psychological support while their baby is on the neonatal unit.
Numerator – the number in the denominator who can access psychological support.
Denominator – the number of parents and carers of preterm babies having respiratory support on the neonatal unit.
Data source: Local data collection, for example, audits of patient records.
Outcome
Proportion of parents and carers of preterm babies who had respiratory support who feel confident to care for their preterm baby at home.
Numerator – the number in the denominator who feel confident to care for their preterm baby at home.
Denominator – the number of parents and carers of preterm babies who had respiratory support.
Data source: Local data collection, for example, surveys of parents’ and carers’ experience.

What the quality statement means for different audiences

Service providers (such as neonatal units, including special care units, local neonatal units and neonatal intensive care units) ensure that systems are in place for parents and carers to be supported to be involved in their baby’s care. This can be through participation in ward rounds, providing day-to-day care and, if their baby is being discharged on respiratory support, understanding how to use specialist equipment at home. They also ensure that parents and carers have access to their baby 24 hours a day and that psychological support is available while their baby is on the unit.
Healthcare professionals (such as specialist neonatal nurses, specialist neonatal consultants, allied health professionals and other paediatric specialists working with babies born preterm) engage with parents and carers to ensure they are provided with all the necessary information to help them understand their baby’s condition and management, and to make informed decisions about their baby’s care. This includes providing support and guidance for parents and carers, making them aware of psychological support that is available, providing constructive and supportive feedback about how to care for their baby and, if their baby is being discharged on respiratory support, support to use specialist equipment at home.
Commissioners (NHS England) ensure that they commission services that help parents and carers to be involved in their baby’s care.
Parents and carers of preterm babies having help with their breathing in hospital are supported by their healthcare professionals to care for their baby. They have access to their baby 24 hours a day and are involved in ward rounds and in the planning of their baby’s care. They are helped to be confident to provide their baby’s day-to-day care, for example feeding and nappy changing, and if their baby is being discharged on respiratory support, they are supported to use specialist equipment at home. They are also made aware of the psychological support that is available to them.

Source guidance

Definitions of terms used in this quality statement

Help to care for their baby
Parents and carers are involved in planning and providing their baby’s day-to-day care, for example, feeding and nappy changing. They are encouraged and supported to participate in discussions and decisions about their baby during ward rounds, providing input into planning care. They are given constructive and supportive feedback about how to care for their baby and, if their baby is being discharged on respiratory support, how to use specialist equipment at home. [NICE’s guideline on specialist neonatal respiratory care for babies born preterm, recommendations 1.6.5 and 1.7.4 and expert opinion]
Respiratory support
This includes invasive ventilation, non-invasive ventilation or oxygen therapy. [Adapted from NICE’s guideline on specialist neonatal respiratory care for babies born preterm, supplement 1: glossary and abbreviations and expert opinion]

Equality and diversity considerations

Parents and carers should have access to an interpreter or advocate if needed.
Parents and carers who are very young or who have a learning difficulty may need additional support when their baby is being cared for. Healthcare professionals should discuss what support they need with them, for example, involving other members of their family or their social and support workers.
It may be difficult for some parents and carers to visit every day and be involved in their baby’s care, for example, because of the costs of travel, accommodation and subsistence. Parents and carers should be advised of any support available to them on admission to the neonatal unit, including the availability of accommodation and support with subsistence costs. This may be available directly through the neonatal unit or through charities. Healthcare professionals should continue to involve parents and carers in their baby’s care as much as possible.

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Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Patient-centred care

Parents and carers have the right to be involved in planning and making decisions about their baby's health and care, and to be given information and support to enable them to do this, as set out in the NHS constitution and summarised in making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Benefits and harms of dexamethasone in preterm babies 8 days or older
Outcome
Benefit or harm for preterm babies 8 days or older
Notes
Mortality before discharge
There is no difference in mortality before discharge in babies who receive dexamethasone compared with babies who do not receive dexamethasone.
There was evidence demonstrating this lack of difference.
BPD at 36 weeks' postmenstrual age
Babies who receive dexamethasone are less likely to develop BPD compared with babies who do not receive dexamethasone.
On average:
  • without dexamethasone treatment, 63 babies per 100 would develop BPD (and 37 would not)
  • with dexamethasone treatment, 47 babies per 100 would develop BPD (and 53 would not).
There was evidence demonstrating this difference.
Cerebral palsy
There is no difference in the incidence of cerebral palsy in babies who receive dexamethasone compared with babies who do not receive dexamethasone.
Although there was evidence demonstrating this lack of difference, there is uncertainty about the risk, so the possibility of cerebral palsy occurring could not be excluded.
Other neurodevelopmental outcomes (neurodevelopmental delay and neurosensory impairment)1
There is no difference in neurodevelopmental outcomes in babies who receive dexamethasone compared with babies who do not receive dexamethasone.
Although there was evidence demonstrating this lack of difference, there is uncertainty about the risk of neurodevelopmental delay and neurosensory impairment because the studies reported neurodevelopmental assessments at different timepoints.
Days on invasive ventilation
Babies who receive dexamethasone have fewer days on invasive ventilation compared with babies who do not receive dexamethasone.
Although there was evidence demonstrating this difference, there is uncertainty about the difference in the number of days on invasive ventilation because of the different ways the studies reported it.
Gastrointestinal perforation
There is no difference in gastrointestinal perforation in babies who receive dexamethasone compared with babies who do not receive dexamethasone.
Although there was evidence demonstrating this lack of difference, there is uncertainty about the risk, so the possibility of gastrointestinal perforation occurring cannot be excluded.
Hypertension
Babies who receive dexamethasone are more likely to develop hypertension compared with babies who do not receive dexamethasone.
On average:
  • without dexamethasone treatment, 3 preterm babies per 100 would develop hypertension (and 97 would not)
  • with dexamethasone treatment, 11 babies per 100 would develop hypertension (and 89 would not).
There was evidence demonstrating this difference.
Full details of the evidence for the benefits and harms of dexamethasone for preterm babies 8 days or older are in evidence review C: managing respiratory disorders.
1 In this NICE Pathway, neurodevelopmental outcomes at 18 months or older have been defined as:
  • cerebral palsy (reported as presence or absence of condition, not severity)
  • neurodevelopmental delay (reported as dichotomous outcomes, not continuous outcomes such as mean change in score)
    • severe (score of more than 2 SD below normal on validated assessment scales, or a score of less than 70 on the Bayley II scale of infant development MDI or PDI, or complete inability to assign score because of cerebral palsy or severe cognitive delay)
    • moderate (score of 1 to 2 SD below normal on validated assessment scales, or a score of 70 to 84 on the Bayley II scale of infant development MDI or PDI)
  • neurosensory impairment (reported as presence or absence of condition, not severity):
    • severe hearing impairment (for example, deaf)
    • severe visual impairment (for example, blind).

Invasive ventilation

Administration of respiratory support via an endotracheal tube or tracheostomy, using a mechanical ventilator – see the table for a summary of the definitions of invasive ventilation modes.
Identified risk factors for bronchopulmonary dysplasiaa
In babies born before 32 weeks
  • lower gestational age
  • Lower birthweight
  • Small for gestational age
  • Male sex
  • Core body temperature of less than 35°C on admission to neonatal unit
  • Invasive ventilation begun within 24 hours of birth
  • Clinical sepsis with or without positive blood cultures
  • Feeding with formula milk (exclusively or in addition to breast milk)
  • Treated with surfactantb
  • Treated for a PDAb
In babies born before 30 weeks
  • Cardiopulmonary resuscitation performed at birth
a These risk factors have been identified in large prospective cohort studies, but other gestational ages and other risk factors not listed here might also be associated with an increased risk of bronchopulmonary dysplasia.
b These risk factors are likely to reflect the severity of the baby's condition. Surfactant should be used, and a PDA should be treated, where clinically appropriate.

Glossary

assist control
bronchopulmonary dysplasia
continuous positive airways pressure
high-frequency oscillatory ventilation
mental developmental index
non-steroidal anti-inflammatory drugs
carbon dioxide partial pressure
psychomotor developmental index
patent ductus arteriosus
pressure support ventilation
patient-triggered ventilation
respiratory distress syndrome
synchronised intermittent mandatory ventilation
synchronised intermittent positive pressure ventilation
synchronised time-cycled pressure-limited ventilation
volume-targeted ventilation
(administration of surfactant through a thin endotracheal catheter without insertion of an endotracheal tube or invasive ventilation)
(the tidal volume of each breath in millilitres [ml] multiplied by the number of breaths per minute gives the minute ventilation in ml/min (usually expressed as ml/kg/min, which is achieved by dividing by the baby's weight in kg))
(sounds, characteristics of movements including facial expressions and physiological parameters such as heart rate, breathing patterns and skin tone that reflect the baby's current level of sensitivity or wellbeing, and reveal their current developmental stage)
(administration of respiratory support using a ventilator or flow driver, but not via an endotracheal tube or tracheostomy)
(in this guidance, the perinatal period is defined as the period of time from 48 hours before birth up until 7 completed days after birth)
standard deviation
(holding a naked baby, or a baby wearing only a nappy, on the skin of a parent or carer, usually on the chest)
(facilitating and supporting a smooth transition from fetal to neonatal life; involves careful assessment of heart rate, colour [oxygenation] and breathing, with provision of appropriate interventions where indicated)

Paths in this pathway

Pathway created: April 2019 Last updated: July 2020

© NICE 2020. All rights reserved. Subject to Notice of rights.

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