WHO Recommendations for Care of the Preterm or Low-Birth-Weight Infant

Overview

This new Guidelines summary covers the World Health Organization (WHO)’s recommendations for care of infants who are born preterm or with a low birth weight (LBW). 

Refer to the full guideline for explanatory remarks and recommendations on parental leave and entitlements and care for complications of preterm birth and LBW, including continuous positive airway pressure and methylxanthines, as well as information on implementation, applicability issues, research implications, and dissemination. The WHO has developed several other guidelines that these recommendations are intended to complement:

• Guidelines on optimal feeding of low-birth-weight infants in low- and middle-income countries
• WHO recommendations on interventions to improve preterm birth outcomes
• Recommendations for management of common childhood conditions
• WHO recommendations on antenatal care for a positive pregnancy experience
• WHO recommendations: intrapartum care for a positive childbirth experience.

Reflecting on your Learnings

Preventive and Promotive Care

For recommendations on responsive and scheduled feeding and fast and slow advancement of feeding for infants, refer to the full guideline.

Kangaroo Mother Care

• Kangaroo mother care (KMC) is defined by the WHO as early, continuous, and prolonged skin-to-skin contact between the mother (or other caregiver) and the baby, and exclusive breastfeeding
• Any KMC: KMC is recommended as routine care for all preterm or LBW infants. KMC can be initiated in the healthcare facility or at home and should be given for 8–24 hours per day (as many hours as possible)
  • KMC can be given at home or at the healthcare facility
  • infants who receive KMC should be secured firmly to the mother’s chest with a binder that ensures a patent airway
  • whenever possible, the mother should provide KMC. If the mother is not available, fathers, partners, and other family members can also provide KMC 
  • infants who need intensive care should be managed in special units, where mothers, fathers, partners, and other family members can be with their preterm or LBW infants 24 hours a day
• Immediate KMC: KMC for preterm or LBW infants should be started as soon as possible after birth
  • at home, immediate KMC should be given to infants who have no danger signs 
  • at healthcare facilities, immediate KMC can be initiated before the infant is clinically stable unless the infant is unable to breathe spontaneously after resuscitation, is in shock, or needs mechanical ventilation
  • the infant’s clinical condition (including heart rate, breathing, colour, temperature, and oxygen saturation, where possible) must be monitored.

Mother’s Own Milk

• Mother’s own milk is recommended for feeding of preterm or LBW infants, including very preterm (<32 weeks’ gestation) or very LBW (<1.5 kg) infants.^[A]

Donor Human Milk

• When mother’s own milk is not available, donor human milk may be considered for feeding of preterm or LBW infants, including very preterm (<32 weeks’ gestation) or very LBW (<1.5 kg) infants^[A],[B]
  • the WHO’s Guideline Development Group (GDG) was not able to make a recommendation on the use of unpasteurised milk
  • safe and affordable milk banking facilities are needed for the provision of donor human milk.

Multicomponent Fortification of Human Milk

• Multicomponent fortification of human milk is not routinely recommended for all preterm or LBW infants but may be considered for very preterm (<32 weeks’ gestation) or very LBW (<1.5 kg) infants who are fed mother’s own milk or donor human milk^[A],[B]
  • the GDG decided not to routinely recommend multicomponent fortifier for all preterm or LBW infants and suggested that fortification may be considered for very preterm or very LBW infants
  • the GDG suggests that commercially available multicomponent fortifiers specifically formulated for preterm infants may be considered
  • the GDG suggests that the initiation and duration of multicomponent fortification should be based on clinical judgement.

Preterm Formula

• When mother’s own milk and donor human milk are not available, nutrient-enriched preterm formula may be considered for very preterm (<32 weeks’ gestation) or very LBW infants^[A],[B]
  • the GDG was not able to recommend a particular type of preterm formula. Based on most trials included in the evidence review, the GDG suggests that commercially available nutrient-enriched formulas specifically formulated for preterm infants may be considered
  • for infants who were born at 32–36 weeks’ gestation or with birth weight of 1.5–2.4 kg, the GDG considered that standard-term formula or nutrient-enriched preterm formula may be considered, depending on clinical judgement
  • the GDG suggests initiation and duration should be based on clinical judgement.

Early Initiation of Enteral Feeding

• Preterm and LBW infants, including very preterm (<32 weeks’ gestation) and very LBW (<1.5 kg) infants, should be fed as early as possible from the first day after birth. Infants who are able to breastfeed should be put to the breast as soon as possible after birth. Infants who are unable to breastfeed should be given expressed mother’s own milk as soon as it becomes available. If mother’s own milk is not available, donor human milk should be given wherever possible
  • enteral feeding includes direct breastfeeding and feeding by cups, naso-, or orogastric tubes
  • careful consideration is needed in applying these recommendations to unstable babies. The GDG considers that initiation of enteral feeding in unstable babies should be based on clinical judgement
  • infants should be given mother’s own milk wherever possible. The provision of colostrum is especially important. If mother’s own milk is not available, then donor human milk should be given wherever possible. If human milk is not available, infants can be fed formula as this is preferable to delayed initiation of enteral feeding and the use of parenteral nutrition
  • a recommendation was not made on restricting the volume of feed.

Duration of Exclusive Breastfeeding

• Preterm or LBW infants should be exclusively breastfed until 6 months of age.^[B]

Micronutrient Supplementation

• Enteral iron supplementation is recommended for human-milk-fed preterm or LBW infants who are not receiving iron from another source
  • the GDG suggests a daily dose of 2–4 mg/kg per day of elemental iron may be initiated when enteral feeds are well established, and may be continued until the infant receives iron from another source
• Enteral zinc supplementation may be considered for human-milk-fed preterm or LBW infants who are not receiving zinc from another source^[B]
  • the GDG suggests a daily dose of 1–3 mg/kg per day of elemental zinc. The GDG also suggests that zinc may be initiated when enteral feeds are well established, and may be continued until the infant receives zinc from another source
• Enteral vitamin D supplementation may be considered for human-milk-fed preterm or LBW infants who are not receiving vitamin D from another source^[B]
  • based on most trials included in the evidence review, the GDG suggests a daily dose of 400–800 IU may be initiated when enteral feeds are well established, and may be continued until the infant receives vitamin D from another source
• Enteral vitamin A supplementation may be considered for human-milk-fed very preterm (<32 weeks’ gestation) or very LBW (<1.5 kg) infants who are not receiving vitamin A from another source^[B]
  • based on most trials included in the evidence review, the GDG suggests a daily dose of 1000–5000 IU may be initiated when enteral feeds are well established, and may be continued until the infant receives vitamin A from another source
• The GDG decided not to make a recommendation on calcium or phosphorous supplementation as there was little evidence of benefits or harms on any critical outcome
• The GDG decided not to make a recommendation on multiple micronutrient supplementation as there was no evidence of benefits or harms on any critical outcome.

Probiotics

• Probiotics may be considered for human-milk-fed very preterm infants (<32 weeks’ gestation)^[B]
  • the GDG considered that only probiotics especially formulated for preterm or LBW infants that meet regulatory standards should be used, and clear instructions for safe use should be given to health workers
  • the GDG did not make a recommendation for infants born after 32 weeks’ gestation because the data were insufficient
  • the GDG considered that type, formulation, dose, timing, and duration should be based on clinical judgement.

Emollients

• Application of topical oils to the body of preterm or LBW infants may be considered^[B]
  • the GDG suggested that sunflower or coconut oils may be used and that initiation and duration of use may be based on clinical judgement. The GDG also felt that application of oils should be done gently to avoid disrupting skin integrity
  • the GDG decided not to make a recommendation on the use of ointments or creams.

Family Involvement and Support

Family Involvement in Routine Care

• Family involvement in the routine care of preterm or LBW infants in healthcare facilities is recommended.

Family Support

• Families of preterm or LBW infants should be given extra support to care for their infants, starting in healthcare facilities from birth, and continued during follow-up post-discharge. The support may include education, counselling, and discharge preparation by health workers, and peer support^[B]
  • preterm and LBW infants often require care from multiple health workers so the GDG also noted that careful coordination of care is needed post-discharge.

Home Visits

• Home visits by trained health workers are recommended to support families to care for their preterm or LBW infant
  • trained health workers can include nurses, midwives, doctors, and community health workers
  • the GDG recommended that extra home visits (that is, additional to the routine scheduled postnatal contacts for all infants) should be made, and that their content, frequency, duration, and intensity should be based on clinical judgement.

Footnotes

[A] Mothers should also be encouraged and supported before and after birth to provide their own breastmilk (including colostrum) for their infants.

[B] The recommendation is conditional on shared decision-making with parents; this includes informing parents about the benefits and risks and the need for further research.