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 Table of Contents  
REVIEW ARTICLE
Year : 2016  |  Volume : 5  |  Issue : 4  |  Page : 222-229

The golden hour approach: Practical guidelines of the Saudi neonatology society on managing very low birth weight infants in the first hour of life


1 Department of Pediatrics and Neonatology, Oasis Hospital, Al Ain, United Arab Emirates
2 Department of Pediatrics, Neonatology Section, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
3 Department of Pediatrics, King Abdulaziz Medical City, Riyadh, Saudi Arabia
4 Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
5 Department of Pediatrics, Division of Neonatology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
6 Department of Pediatrics, King Abdulaziz University, Jeddah, Saudi Arabia
7 Department of Pediatrics, Neonatal Division, King Abdulaziz Hospital, Al-Hasa, Saudi Arabia

Date of Web Publication16-Nov-2016

Correspondence Address:
Dr. Zakariya Al-Salam
Department of Pediatrics and Neonatology, Oasis Hospital, Al Ain
United Arab Emirates
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-4847.194178

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  Abstract 

Premature infants are at a high risk of morbidity and mortality. Furthermore, physiologic immaturity renders most very low birth weight infants (VLBWIs) in need of interventions and stabilization immediately following birth. Some of these may trigger deleterious processes that become significant precursors to acute and chronic morbidities. The Kingdom of Saudi Arabia is lacking guidelines that focus on VLBWI, especially on the first hour of life (golden hour). Therefore, the aim of these practice guidelines is to compliment rather than replace clinical judgment. In addition, golden hour approach will enable units to collaborate in providing comprehensive care to VLBWI and thus will improve their chances of survival without pulmonary, neurodevelopmental, and neurosensory morbidities.

Keywords: Golden hour, resuscitation, very low birth weight infants


How to cite this article:
Al-Salam Z, Al-Alaiyan S, Alallah J, Al-Hazzani F, Alfaleh K, Alsaedi S, Al-Abdi SY. The golden hour approach: Practical guidelines of the Saudi neonatology society on managing very low birth weight infants in the first hour of life. J Clin Neonatol 2016;5:222-9

How to cite this URL:
Al-Salam Z, Al-Alaiyan S, Alallah J, Al-Hazzani F, Alfaleh K, Alsaedi S, Al-Abdi SY. The golden hour approach: Practical guidelines of the Saudi neonatology society on managing very low birth weight infants in the first hour of life. J Clin Neonatol [serial online] 2016 [cited 2021 Aug 2];5:222-9. Available from: https://www.jcnonweb.com/text.asp?2016/5/4/222/194178


  Introduction Top


Compared with their term counterparts, premature infants are at a higher risk of morbidity and mortality.[1],[2] Survivors are burdened by complications such as chronic lung disease, neurodevelopmental (cognitive and motor) and neurosensory impairments.[3] Physiologic immaturity and abrupt transition render most very low birth weight infants (VLBWIs) in need of resuscitation and stabilization immediately following birth, subjecting them to multiple interventions. Some of these may trigger deleterious processes at cellular and tissue level that become significant precursors to acute and chronic morbidities.[4]

Energized by a rapidly growing body of evidence, a number of neonatal resuscitation and stabilization guidelines have emerged whose goals are to minimize the rates and effects of some of these complications.[5],[6] These emerging recommendations are not fully incorporated into the practice of neonatology in the Kingdom of Saudi Arabia primarily because the field is largely in its infancy – characterized by a lack of regionalization and inequitable deployment of specialized personnel. As health care develops and neonatal intensive care becomes more readily available, increasing numbers of VLBWI are presented the opportunity to survive. This creates the need for locally relevant practical guidelines to improve the chances of complication-free survival of these infants.

The guidelines we present here address this need by standardizing the resuscitation and stabilization of VLBWI. They are the product of coordinated efforts to search and appraise evidence from the most current literature on practices to improve the outcomes of preterm birth. Cognizant of the local situation in the Kingdom of Saudi Arabia, the practice guidelines are purposed to compliment rather than replace clinical judgment and discretion. We propose that the golden hour approach will enable units to collaborate in providing comprehensive care to VLBWI and thus will improve their chances of survival without pulmonary, neurodevelopmental, and neurosensory morbidities.

We have termed the guidelines the golden hour both because the majority of procedures and interventions to resuscitate and stabilize VLBWI are performed during the first 60 min of life and because speed is essential to survival beyond the immediate perinatal period. The golden hour approach, therefore, addresses effective teamwork, antenatal care, and perinatal care, with emphasis on optimizing circulatory, respiratory, thermoregulatory, and metabolic support.


  Definitions Top


  • First golden hour: A term used widely in emergency and cardiovascular medicine, and in these guidelines, it refers to the first 60 min from birth
  • VLBWI: A live-born infant of birth weight <1500 g or gestation up to 32 weeks.


Personnel and teamwork

Care of the high-risk fetus and neonate demands close collaboration among medical (neonatologists/pediatricians, obstetricians, and perinatologists), nursing (Neonatal Intensive Care Unit [NICU] nurses, midwives, and transport nurses), and auxiliary (respiratory therapists and clinical pharmacists) personnel. Effective communication is vital to focusing such multidisciplinary efforts on the objective of ensuring complication-free survival of VLBWI, particularly as communication errors have been identified as the root cause of up to 72% of perinatal deaths and injuries.[7],[8]

Each hospital with a maternity service should have a dedicated team responsible for neonatal resuscitation, stabilization, and transfer. The team, drawn from among physicians, nurses, and respiratory therapists, should comprise only members trained and certified in neonatal resuscitation. At least two members of the team, one of whom should be competent in administering advanced life support and performing invasive procedures, should be present at any high-risk delivery including VLBWI. This team should be available 24 h a day.

To enhance readiness and to improve skills, the team should use regular simulation training through the various stages of planning for and performing the resuscitation/stabilization of a high-risk newborn. This must include preparing and checking equipment and supplies, assigning and performing tasks and skills. [Table 1] for the ten behavioral skills during resuscitation], and role-playing in counseling and communication.
Table 1: NRP®'s ten key behavioral skills

Click here to view


The team links the obstetric service, the neonatal service, and the parents; thus demanding an ability to communicate effectively. Its performance should be continuously improved and monitored through briefing, debriefing, feedback, and auditing.

Antenatal care

As most VLBWIs are born either late in the second trimester or early in the third trimester, some of the early antenatal interventions may predate or indeed overlap with the golden hour, thereby directly impacting the condition of the VLBWIs at birth. Therefore, the core functions of antenatal care – screening pregnant women for conditions that adversely affect the fetus and surveillance of maternal and fetal health at regular intervals – should be coupled with anticipation and planning for preterm labor and birth.

Women at risk of preterm birth should be referred to tertiary facilities where antenatal care will include administration of antenatal corticosteroids, treatment of infections, prevention of preterm labor, and counseling and planning for the best and safest mode of delivery.[8],[9],[10] When a woman with inevitable VLBWI delivery presents to a lower level facility, consider in utero transfer to tertiary center if feasible and safe for both the mother and fetus.[8],[11],[12] Antenatal magnesium sulfate confers neuroprotective benefits to the infant and should be considered earlier rather than later.[13]

Delivery room resuscitation and stabilization

Personnel and planning

As part of briefing before delivery, the newborn resuscitation and stabilization team should use checklists to ensure that all the necessary equipment and supplies are available and in good working order [Table 2]. Extra and if needed, more skilled or experienced personnel should be called promptly in case of difficult or complicated resuscitation (e.g., difficult airway) or multiple gestation (there should be a separate team for each infant). To enable prenatal counseling and to enhance golden hour practice, the neonatologist on call, the NICU, and the high-risk newborn resuscitation team should all be alerted whenever a high-risk pregnant mother is admitted to the hospital.
Table 2: Equipment list adopted from NRP® guidelines

Click here to view


Delayed cord clamping

It is quite likely that the benefits of delayed cord clamping (DCC) – improved cardiovascular stability, reduced requirement for inotropes, and reduced requirement for transfusion with blood products [14] – are mediated by its effect on circulatory transition. To reduce risk and minimize harm in VLBWIs, the practice of DCC for the recommended 30–60 s should be carefully planned and coordinated with the obstetric team and should be limited only to those who do not require immediate resuscitation.[14],[15],[16]

Thermoregulation

To prevent the adverse effects of hypothermia, the skin temperature should be kept in the range of 36.3°C–37.5°C.[17] Several interventions are required to achieve this. The delivery room temperature should be set at 25°C–26°C.[18] The radiant warmer (and linen) should prewarmed at full power. The infant should immediately be transferred to the radiant warmer and wrapped in a polyethylene sheet, exposing only the head, which should be dried with a warm towel before putting a warm cap on. Do not use additional towels on top of the polyethylene wrap as they will absorb the radiant heat preventing it from reaching the infant. Adding, chemically activated warming pads must be used with caution as they can cause hyperthermia.[19] If resuscitation is expected to exceed 10 min, attach the temperature probe to the infant and switch the warmer to servo-controlled mode.[20]

Cardiorespiratory resuscitation

Resuscitate VLBWIs according to the most current Neonatal Resuscitation Program (NRP ®) guidelines for the resuscitation of premature infants.[21]

Oxygen supplementation

In term newborns, it takes approximately 5 min for saturations (SpO2) to rise to 80%[22] and this may take longer in the preterm. Visual assessment of color is not a reliable indicator of oxygenation, therefore all infants should be monitored with pulse oximetry.[23] When attached in the following sequence, the pulse oximeter sensor is likely to detect and display the pulse earlier: first switch on the monitor before connecting the sensor, then attach the sensor to the right wrist or hand (preductal), and then connect the sensor cable to the monitor.[24] If required, give blended oxygen starting at a concentration (FiO2) of 0.3–0.4 and titrate to the targeted age-specific preductal SpO2[Table 3].[25],[26] Increase FiO2 to 1.0 when initiating chest compressions.
Table 3: Targeted preductal percutaneous oxygen saturation (SpO2)

Click here to view


Continuous positive airway pressure

Evidence has demonstrated that delivery room continuous positive airway pressure (CPAP) is a safe and effective alternative to intubation/ventilation and early administration of surfactant.[27] If used, CPAP of 6 cm of H2O is recommended and only in infants with spontaneous breathing. The most frequently used CPAP devices are the T-piece, bubble CPAP, and positive end expiratory pressure (PEEP) valve.[28] Choice of device depends on the condition of the newborn, the availability of equipment, and the experience of personnel in using each device. Surfactant should ideally be administered soon after endotracheal intubation but no later than the first hour of life.[29]

Intermittent positive pressure ventilation

A T-piece or pressure-limited device should be used to provide intermittent positive pressure ventilation (IPPV) with mask, starting with a peak pressure of 20 cmH2O and PEEP of 5–6 cmH2O.[30],[31] Chest rise does not accurately estimate tidal volume, and in VLBWIs, it may be a sign of overinflation; thus a manometer or pressure gauge should always be attached – this will prevent excessive pressures and consequent volutrauma.[32],[33] The most useful sign of adequate ventilation is a rising heart rate, followed by SpO2. If there is no response to IPPV, the following corrective steps (acronym MRSOPA) should be taken immediately: Ensure adequate seal with appropriate size Mask, Reposition the head into the “sniffing” position, Suction the mouth and nose, use airway Opening maneuvers, apply appropriate level Pressure (increase gradually to 25 and maximum of 30 cmH2O as necessary), and consider an Alternative airway (e.g., endotracheal tube).[21]

Family (parents)

Before transfer to NICU, the most experienced/senior member of the team should update the parent(s) about the newborn's condition. Further updates should follow after admission to the NICU.

Transfer

Except for the short journey between delivery room and NICU, the transport incubator should always be connected to a power source. In anticipation of delivery, the incubator should be set at appropriate air temperature to provide a thermo-neutral interior. Secure all tubes and lines placed during resuscitation/stabilization prior to transfer. Once stabilized, transfer the infant to NICU in the prewarmed transport incubator and avoid opening the ports during transfer as this can drop the air and infant's temperature precipitously.

Admission to Neonatal Intensive Care Unit

Thermoregulation

Upon arrival in NICU, remove the polyethylene bag/sheet immediately and transfer the patient to a prewarmed closed incubator with humidity. Set humidity at 80% for patients with more mature-appearing skin and 90% for less mature skin. All thermoregulation measures initiated in the delivery room should continue. Additional heating should be used during procedures that require opening the incubator, such as umbilical catheterization. Continue in the servo-controlled mode and use only heated, humidified medical gases for respiratory support.

Respiratory system

If not already administered in the delivery room, the intubated VLBWI should receive the first dose of surfactant soon after admission to NICU. Those who require endotracheal intubation for ventilation subsequent to NICU admission should receive surfactant immediately after intubation using the INtubation-SURfactant-Extubation technique.[34]

If doing well on CPAP, this therapy should be continued at the same pressure initiated in the delivery room. For conventional ventilation, we recommend volume-targeted ventilation with tidal volume of 4–5 ml/kg. Decisions regarding initiation, type, weaning, or cessation of respiratory support must be guided by continuous and careful respiratory monitoring (using pulse oximetry, capnography, and blood gas analysis).

The FiO2 should be adjusted to maintain preductal SpO2 of 90%–95%.[35] Although it results in higher rates of retinopathy of prematurity, this range of SpO2 is associated with higher survival rates and lower risk of necrotizing enterocolitis.

Cardiovascular system and vascular access

If indicated, arterial and venous umbilical catheters should be inserted by experienced staff and confirmed urgently by radiography. In the hypotensive infant (mean blood pressure less than gestational age) with signs of impaired tissue perfusion and clinical signs of hypovolemia, administer an appropriate volume expander – such as normal saline (10 ml/kg) or packed red blood cell in case of hemorrhage. Volume-refractory cases should be treated with vasopressors starting with dobutamine, followed by dopamine and then epinephrine, in that sequence, if required. Hydrocortisone (1 mg/kg/dose for every 8 h) may be considered if the hypotension does not respond to volume and maximum dose of the first vasopressor.[36]

Fluids and metabolic

To prevent hypoglycemia and the catabolic state, a dextrose-amino acid solution is recommended immediately after birth,[37] starting at 60–90 ml/kg/day. Blood sugar should be checked frequently until normal and stable, and initial serum electrolytes and bilirubin should be checked at the age of 6–12 h.

Infection control and sepsis

Perform a septic screen and initiate empiric antibiotic therapy with ampicillin and gentamicin within the first hour. Antibiotic treatment should not be delayed because of delayed cultures. Empiric antibiotic treatment is continued pending blood culture reports at 48–72 h of age.

Perform all invasive procedures under aseptic conditions with careful attention to hand hygiene and infection control. Use chlorhexidine 0.5%–1% for cleaning and use minimal amount of adhesive on the skin.

Neuroprotection

When appropriately managed and optimized, all the systemic interventions in these guidelines – such as avoiding excessive pressures during ventilation, adjusting inspired oxygen to maintain targeted SpO2, and avoiding fluctuations in blood pressure – contribute to neuroprotection. Other interventions useful for this goal are gentle handling and positioning the head and the body in midline and supine at 30° for the first 72 h of age. Prophylactic indomethacin is associated with a lower risk of severe intraventricular hemorrhage, patent ductus arteriosus ligation, and pulmonary hemorrhage, but has no long-term effect on neurosensory outcomes.[38],[39] For newborns weighing up to 1000 g, we recommend prophylactic indomethacin to prevent intraventricular hemorrhage and advocate close attention to fluid balance and low threshold for suspecting spontaneous intestinal perforation when indomethacin is given at the same time as hydrocortisone.[40]

Miscellaneous

Avoid heel pricks and peripheral intravenous cannulation in infants <26 weeks if possible, and consider procedural analgesia for all VLBWIs.

Parents

This period is very stressful and parents may not be able to understand all details right from the start. It is very important that the most senior/experienced staff responsible for the care of the patient should regularly update the parents.


  Auditing the Golden Hour Practices Top


We have included a tool that we recommend for use to monitor golden hour practices in institutions that adopt these guidelines [Table 4]. The aim of the tool is to facilitate continuous quality improvement and patient safety.
Table 4: Audit form for the first golden hour practice

Click here to view


Summary Guidelines

  1. Personnel and communication

    1.1. Hospitals should establish means for open and effective inter-departmental communication regarding women with high-risk pregnancies

    1.2. Assemble newborn resuscitation, stabilization, and transport teams comprising NRP ®-certified personnel only

    1.3. Ensure readiness of the team by regular simulation exercises, debriefing, audit, and feedback.
  2. Antenatal

    2.1. Refer all high-risk pregnant women to centers with tertiary neonatal care

    2.2. Promote safe maternal–fetal transfers to tertiary centers

    2.3. Treat confirmed or suspected maternal infections with appropriate antibiotics

    2.4. Administer antenatal corticosteroids

    2.5. Administer magnesium sulfate

    2.6. Delay preterm delivery if possible

    2.7. Prenatal counseling regarding preterm birth, method of delivery, and likely outcomes

    2.8. Regular multidisciplinary high-risk maternal–fetal unit meetings.

  3. Delivery room

    3.1. Team briefing using checklist for roles, equipment, and supplies

    3.2. Alert neonatologist on call and NICU

    3.3. Turn radiant warmer to full power and prewarm transport incubator, delivery room temperature at 25°C–26°C

    3.4. Plan for DCC 30–60 s, but assess need for urgent resuscitation at birth

    3.5. Dry the head and wrap the newborn with the polyethylene sheet up to the neck under radiant warmer. Cover the head with a woolen cap

    3.6. Attach the pulse oximeter probe to the right (preductal) hand/wrist and then connect it to the pulse oximeter

    3.7. If required, supplement oxygen with FiO2 0.30–0.40 and titrate slowly to targeted preductal SpO2 in the first 10 min of life

    3.8. If required, provide intermittent positive pressure ventilation using T-piece with pressure monitoring if the infant lacks effective breathing and do corrective measures if ventilation is not effective (assessed by rising heart rate)

    3.9. Start with continuous positive airway pressure (CPAP) of 6 cmH2O in spontaneously breathing infants of gestational age of 28 weeks or older

    3.10. Intubate and administer surfactant immediately to infants of gestational age of 27 weeks or less or those older than 27 weeks without spontaneous respirations or not responding to CPAP. Follow the recommendations of the NRP ® for resuscitating premature infants

    3.11. Debrief

    3.12. Update the parents before you leave the delivery room and invite them to the NICU.d

  4. NICU

    4.1. Use preadmission checklist to prepare supplies and equipment for admission of very low birth weight infant. Set incubator thermo-neutral temperature for gestational age, with 80%–90% humidity

    4.2. When the patient arrives, remove the polyethylene sheet/bag and immediately weigh and measure the length and head circumference if the condition permits

    4.3. If the infant is intubated:

    4.3.1. Set up the initial ventilator settings at volume guarantee of 4–5 ml/kg, rate at 40–60/min, and Ti of 0.3 s

    4.3.2. Adjust settings according to the clinical situation and blood gas results. Acceptable good gas parameters are: pH: 7.30–7.40, PaCO2: 45–65, and HCO 3: 18–22. Avoid NaHCO3 boluses.

    4.4. If the infant is not intubated, maintain the CPAP

    4.5. Intubate and administer surfactant if FiO2 increases to more than 0.3 or work of breathing increases or if there is recurrent apnea

    4.6. Accept SpO2 of 90%–95%

    4.7. Insert umbilical arterial and venous catheters

    4.8. Baseline blood tests include full blood count, random blood sugar, blood gas, blood group, and blood culture. Serum electrolytes and bilirubin can be done at the age of 6–12 h

    4.9. Use chlorhexidine 0.5%–1% solution for procedures requiring antiseptic technique and avoid iodine and adhesives

    4.10. Start ampicillin and gentamicin. Consider the maternal cultures and risk of maternal infection and treat accordingly

    4.11. Start dextrose + amino acid solution immediately after insertion of the venous line

    4.12. Monitor blood pressure continuously using arterial line

    4.13. If mean blood pressure is less than gestational age, give 10 ml/kg normal saline

    4.14. If hypotension persists, start dobutamine infusion and add dopamine and epinephrine accordingly

    4.15. Hydrocortisone 1 mg/kg/dose for every 8 h can be started after the first inotrope reaches maximum without appropriate response

    4.16. After stabilization, start prophylactic indomethacin if infant birth weight is <1000 g or gestation is 27 weeks or less

    4.17. Monitor fluid balance meticulously for electrolyte disturbances (hyperkalemia and hypernatremia)

    4.18. Avoid rapid intravenous boluses of fluids and medications

    4.19. Practice caution and gentle handling of infants. Position the head and body at supine and 30° for the first 72 h of age

    4.20. Update parents and provide detailed information about the status of the infant when time permits.


Acknowledgments

The authors thank Sameh Abozaid, Abbas Alomran, Abudlrahman Alzahrani, Khalid Alhussien, Mahasen Azzouz, and Aziza Alharbi for their contribution to the guidelines. The authors would also thank Dumisani Kamwana for his editorial support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


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