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Key messages

  • Tiny babies should be cared for by the most experienced staff.
  • Avoiding hypothermia or cold stress is essential.
  • Infants less than 28 weeks' gestation should be placed immediately after birth in a polyethylene bag or wrap and the body completely covered.
  • Use positive pressure ventilation with bag and mask or via endotracheal tube. Avoid volutrauma and hyperoxaemia.
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    Please note that all guidance is currently under review and some may be out of date. We recommend that you also refer to more contemporaneous evidence in the interim.

    Although more than 90 per cent of babies less than 1,000 grams or < 28 weeks gestation are delivered in tertiary centres, occasionally a tiny baby is delivered in a non-tertiary hospital. Although it is mandatory to transfer these babies ex utero by PIPER Neonatal to a NICU, there is ordinarily some delay between birth and the arrival of the transport team. The following is a guide to the management of the tiny baby pending arrival of PIPER.

    Wherever possible, the most experienced doctors and nurses available should care for these babies. This is particularly important with respect to any procedures.

    It is important to contact PIPER early and maintain communication.

    Antenatal corticosteroids 

    Although the effectiveness on fetal lung maturity of steroids administered to the mother less than 24 hours prior to birth is unclear, there are other benefits, for example, the prevention of intraventricular haemorrhage. Therefore, even if birth is thought to be inevitable, treatment with antenatal steroids should always be considered.


    Refer to resuscitation for general principles.


    Avoiding hypothermia/cold stress is paramount.

    Preferred method to prevent heat loss

    Infants less than 28 weeks' gestation should be placed immediately after birth in a polyethylene bag or wrap and the body completely covered (appropriate size, food grade, heat resistant).

    Place a woollen hat on the infant's head.

    Alternative method - less satisfactory

    A less satisfactory alternative to prevent heat loss is to take the following steps:

    • Avoid evaporative heat loss; dry the infant.
    • Avoid conductive heat loss ensure that wraps are/remain warm (replace if necessary).
    • Reduce radiant heat loss manage baby under a radiant heater.
    • Avoid convective heat loss avoid drafts and keep the baby away from air-conditioning ducts.

    Note: ‘Blanketing’ is ineffective in tiny babies as they are unable to generate enough heat to warm the air between the skin and the blanket. It is preferable to use bubble wrap between the baby and the overhead heater, as it allows transmission of heat and reduces convective heat loss, which is especially important during transfer from birth suite/theatre to special care nursery.

    Endotracheal intubation

    It is extremely likely that the baby will require endotracheal intubation. Please note:

    • See endotracheal intubation.
    • Use a 2.5 mm endotracheal tube.
    • Oral intubation is recommended if:
      • the infant is < 26 weeks' gestation
      • the tube cannot be easily passed through the nose
      • the doctor is inexperienced/is having difficulty with nasotracheal intubation.
    • An oral tube should be tied at 6.5 to 7.0 cm at the lips.
    • A nasal tube should be tied at 7.5 to 8.0 cm at the nares.
    • Alternatively, if using a Portex tube, the tube should be inserted until the black marker ‘disappears’ beyond the vocal cords.
    • An end tidal C02 detector should be used to confirm correct tube position.
    • It may be helpful to check for symmetrical breath sounds.

    After intubation

    Once intubated, most tiny babies respond rapidly to IPPV (or bag and mask ventilation if endotracheal intubation is not possible). Note:

    • IPPV may be provided with
      • a ‘Neopuff’
      • a Laerdal bag
      • an anaesthetic bag attached to a manometer (experienced hands only).
    • Aim for a PEEP of 5 cm H20.
    • Use enough PIP to ensure adequate, but not excessive chest wall movement.
    • Aim to replicate the baby’s endogenous respiratory rate (~ 60 pbm).
    • Where ever possible the infant should be placed onto a mechanical ventilator (the ‘Neopuff’ is an alternative).

    The baby should receive 0.5 mg vitamin K intramuscularly.

    Nursery management

    Procedures should be undertaken under a radiant heater. Once completed, ideally, the baby should be placed in a double walled humidified isolette. However, if this is not available, the baby should remain under a radiant heater (servo controlled, if possible).

    The baby should be covered directly with bubble wrap or indirectly with cling wrap, preferably in a humidified (60-80 per cent) environment see section on thermoregulation above.

    Mechanical ventilator settings

    If the baby is placed on a neonatal mechanical ventilator, the following settings are recommended:

    Inspiratory time 0.35 seconds
    Expiratory time 0.65 seconds
    Respiratory rate 60 breaths per minute
    PEEP 5 cm H2O
    PIP (Ensure adequate, but not excessive chest movement) 20-25 cm H2O

    Monitoring guidelines

    The following monitoring guidelines are recommended:

    • FiO2 this should be altered to maintain percutaneous SaO2 between 91 and 95 per cent with alarms set at 88-96 per cent (high saturations may increase the risk of retinopathy of prematurity).
    • Transcutaneous electrodes should be used with caution (for example, heated to 43 not 44 degrees) as they can strip the immature epidermis.
    • The skin is extremely fragile and liable to break down the following products help to avoid this trauma, but if they are not availableremember that it is better to use all available monitoring equipment and standard probe attachments in order to avoid excessive handling of the infant.
      • Hydrogel products should be used for all electrodes and temperature probe placement.
      • Hydrocolloid products (for example, Comfeel Coloplast) should be applied under all taping.
      • A non-adhesive tape should be used to secure pulse oximeter probes and peripheral cannulas.

    Chest x-ray

    A chest x-ray should be organised to ensure correct position of the endotracheal tube and assess the type/severity of lung disease.

    Venous access

    Venous access should be obtained via:

    Fluids and feeding

    Points to note:

    • Fluids should be commenced at 80 mL/kg/day of 10 per cent dextrose. Blood glucose should be checked within one hour of commencement.
    • Saline bolus of 10 mL/kg may be given for cardiovascular compromise or poor perfusion.
    • The baby should not be fed. Early expressing of EBM should be encouraged to accompany infant when transferred.
    • Document urine output and stool.

    Blood tests

    If possible, the following blood tests should be performed (to facilitate discussion with PIPER Neonatal):

    • blood glucose level
    • blood gas
    • blood culture.

    IV antibiotics and other medications

    Because of the high risk of perinatal sepsis, even if a blood culture cannot be taken, intravenous antibiotics should be given (even though many babies may not eventually prove to be septic or have a ‘set up’ for perinatal sepsis). Medication and dosage: 

    • penicillin 60 mg/kg
    • gentamicin 5 mg/kg.

    Following discussion with PIPER, particularly if the retrieval is to be delayed, and the baby is in experienced hands, the baby may be given an exogenous surfactant.

    If there are concerns about poor perfusion, then volume expansion in the form of 10 mL/kg 0.9  per cent normal saline should be considered

    The baby may require inotropic support, although this should follow discussion with PIPER.

    Blood pressure

    Blood pressure should be measured every 30 minutes.

    Areas of uncertainty in clinical practice

    The role of limiting tidal volume rather than just pressure in the resuscitation of the tiny infant.

    More information



    • Crowley P. Prophylactic corticosteroids for preterm birth. The Cochrane Library 2001 Issue 2
    • Donoghue D, Cust A. Report of the Australian & New Zealand Neonatal Network: 1999. University of Sydney
    • Harpin V, Rutter N. Humidity of incubators. Arch Dis Child 1985;60:219-224
    • Flenady VJ, Woodgate PG. Radiant warmers versus incubators for regulating body temperature in newborn infants. The Cochrane Library 2001 Issue 2
    • Bucher H, Fanconi S, Baeckert P, Duc G. Hyperoxaemia in newborn infants: detection by pulse oximetry. Paediatrics 1989;84:226-30
    • Sorm K, Jenson T. Skin care of preterm infants: strategies to minimise potential damage. Journal of Neonatal Nursing 1999;5:13-5

    Get in touch

    Centre of Clinical Excellence - Women and Children
    Safer Care Victoria

    Version history

    First published: January 2014

    Last reviewed: October 2018

    Review by: January 2021


    Page last updated: 17 Feb 2021

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