Virtually Always / Category 2 Practices
Virtually Never / Category 3 Practices
Apply Thoughtfully, Sometimes / Category 4 Practices
Unknown Efficacy and Safety
Chronic
Lung Disease / Antenatal corticosteroids
NCPAP before mechanical
ventilation to avoid MV*
Surfactant for significantly
worsening or severe RDS*
Caffeine Day 1*
Saturation Targets87-93%*
Alarm limits 84% and 96%*
Resuscitation FiO2 21-30%*
Avoidhypocarbia PCO240 with
assisted ventilation
VAP prevention bundle*
Minimizetime off NCPAP during
maintenance care / Early corticosteroids (<7 days
old)
Routine surfactant for mild
RDS
Routine diuretics / Gentle ventilation TV 4-5 cc/kg,
permissive PCO2 ~45-69 mm Hg*
PDAmanagement guidelines*
High flow nasal cannula*
NIPPV*
High frequency ventilationb/c ELGAN
Late corticosteroids (>/=7-14
days old)*
Late surfactant
Vitamin A
TranscutaneousPCO2 Monitor* / Ventilator weaning protocols
NCPAP weaning protocols to room air,
high flow cannula, or low flow nasal
cannula
Surfactant type, # of doses, optimal
delivery route
Fluid restriction
Gastric reflux management
Anti-oxidants
Omega 3 fatty acids
Any Late
Infection / Hand hygiene every encounter
Breast milk
Central line care bundle*
36 hour hardstop for ATBx in
rule out sepsis work-ups
Pharmacy sterile prep procedures
Minimize postnatal
corticosteroids
Appropriatepre-incision
antibiotics
Antibiotic stewardship* / Prolonged or broad spectrum
antibiotic courses without a
specific indication.
Routine antacids
Intravenous immune globulin
for suspected or proven sepsis
Granulocyte colony stimulating
factor / Reduce blood draws and
venipunctures
Skin integrity protocols*
VAP prevention*
Probiotics*
Debriefing nosocomial infections
Isolation for specific pathogens
Placental blood draw for admission
labs*
Humidified isolette* / Lactoferrin
Gown and glove protocols
De-colonizationprocedures for specific
pathogens
Grade 3-4
Intracranial
Hemorrhage / Antenatal corticosteroids
Timed umbilical cord clamping,
or cord milking* / Routine sedation, airway
suctioning, NaHCO3, fluid
boluses, and/or pro-
coagulants
Routine fluid boluses or
pressors for low blood
pressure / Small Baby Guidelines – head and
bodypositioning, pain, light, and
soundstimuli reduction*
Cardiovascular(CV) instability –
treatment of significant
hypotension and poor perfusion
Push/pullUAC blood draw guidelines* / Cesarean section v. vaginal delivery
Prophylactic PSI
Synchronized ventilation
Optimal sedation
Optimal airway suctioning
Highfrequency ventilation
Optimal management of CV instability
Periventricular
Leukomalacia / Avoidhypocarbia PCO2 <35 with
assisted ventilation / CV instability - treatment of
hypotension, poor perfusion
Minimize hypoxic episodes / Anti-inflammatory agents
Early delivery for prolonged ruptured
membranes
Stage 3-4
Retinopathy
Of Prematurity / Saturation targets 87-93%*
Alarm limits 84% and 96%* / 100% FiO2 for resuscitation
Saturation >98% while
receiving supplemental oxygen / Vitamin E
Breast milk
Insulin-like growth factor- 1
Hyperglycemia/insulin use reduction
Bevacizumab
Omega-3 fatty acids / Optimal saturation target and range
Light shield
Erythropoietin
Penicillamine
Omega3 fatty acids, inositol, statins
Necrotizing
Enterocolitis / Antenatal corticosteroids
Breast milk*
Donor breast milk instead of
cow’s milk formula*
Human milk only before 33 wks*
Probiotics*
Our feeding guideline*
Human milk based fortifier
(Prolacta) for high risk of
necrotizing enterocolitis* / Milk thickeners
Prolonged or broad spectrum
antibiotic courseswithout a
specificindication
Routine antacids
Routine cow’s milk formula / Optimalfeeding guideline
Red blood cell transfusions
Withholding all cow’s milk products
Gastric residualmanagement
PSI use
Lactoferrin, growth factors, EPO,
Omega-3 fatty acids
Umbilical line placement and duration
Hyperosmolar feeds
Optimal PSI use
Gastrointestinal
Perforation / Early and/or concurrent use of
indomethacin and
corticosteroids / Trophic breast milk feeds* / Optimal PSI use
Enteral sterile water
Umbilical line placement and duration
Patent
Ductus Arteriosus / Antenatal corticosteroids / Indomethacin or any
prostaglandin synthase
inhibitor for an
asymptomatic or early PDA
Not treating a large,
persistent, symptomatic PDA / PDA guidelines*
Indomethacin or acetaminophen or
ibuprofen or a combination of drugs
Oral vs. intravenous PSIs
Humidity in isolette* / Timing and selection of surgical ligation
candidates
Optimal respiratory support
Fluid restriction
Diuretics
Drugs that may increase PDA incidence
Discharge
Weight
< 10th pctl
Head Circumference
<10th pctl / Day 1 TPN and IL*
Early breast milk feeds (donor or
own mother’s milk) <24-48
hours old*
Fortifiers added per guideline*
Intravenous and enteral kcal and
proteingoals* / Improper feeding pump and
tubing use* / TPN calculator
Insulin for hyperglycemia* / Nutrition laboratory monitoring*
Optimal growth rate and growth chart
Optimal fortifier
Optimal protein and calorie intake
Prokinetics
Q2h v. Q3h v. continuous feeds
BRF v. bottle feed %’s at discharge
Category 1 Practice - ALWAYS - This should be done virtually every time for every VLBW infant in the appropriate scenario. Strong published evidence exists to support its effectiveness and safety.
Category 2 Practice - NEVER - This should virtually never be done, strong evidence suggests it is ineffective, unsafe, and/or wasteful.
Category 3 Practice - SOMETIMES - This may be effective in certain VLBW infants in particular clinical situations. More studies and evidence are needed before we adopt, refine, or reject this as a therapy. Because there is questionable and variable overall effectiveness and safety, these practices should be thoughtfully applied with careful measurement and review of its application.
Category 4 Practice - UNKNOWN - There is insufficient evidence to determine whether this is helpful or ineffective, safe or harmful. Optimal use is unknown, we should generally minimize use, and when employed measure and review its application.
* Detailed guidelines and explanation accessible at the Providence St. Vincent Medical Center NICU intranet website.
BRF – breast feeding, EPO - erythropoietin, ELGAN – extremely low gestational age infant, IL - Intralipid, MV – mechanical ventilation, NCPAP – nasal continuous positive airway pressure, NIPPV – noninvasive positive pressure ventilation, PDA – patent ductus arteriosus, PSI – prostaglandin synthase inhibitor, RDS – respiratory distress syndrome, TPN – total parenteral nutrition, UAC – umbilical arterial catheter, VAP – ventilator associated pneumonia, VLBW – very low birth weight
Supplemental Table 1. Updated 2016-2017 Antifragility Potentially Better Practices Schema to improve outcomes inVery Low Birth Weight infants.