On receiving, the baby was depressed and required active resuscitation. He was intubated after bag and mask ventilation for 2 minutes and in view of severe respiratory distress, was connected to a mechanical ventilator. The chest x-ray showed bilateral “white- out”  lung  fields  suggestive  of  severe  respiratory distress syndrome. Baby received 1 dose of surfactant (survanta) intratracheally and ventilatory parameters were gradually weaned. He was extubated on day 9 of life. Tube feeds were started on day 14 and gradually increased.

Baby also received phototherapy for neonatal hyperbilirubinemia. He had prolonged oxygen requirement for 5 weeks. He received 2 aliquots of packed red cells transfusion for anemia of prematurity. Retinopathy of prematurity screening was started at 4 weeks of age and was followed up subsequently. Other problems during hospital stay included transient hyperkalemia, presumed sepsis, transient circulatory disturbances requiring dopamine support. He was discharged home at 2 months of age and was weighing 1.04 kg at discharge.

The extremely low birth weight neonates (ELBW), birth weight less than 1000 grams, are a unique group of infants characterized by anatomic and functional immaturity of all the organ systems giving rise to a host  of  problems  during  extrauterine  life.  The incidence of LBW babies is 0.3 - 0.6% and survival of these babies in western world ranges between 60- 75%. The major principles of caring for such   tiny infants include prenatal counseling.

PRENATAL COUNSELING
Parents should be explained about survival rates, potential morbidity,   anticipated duration of hospital stay,  finances  and long term outcome.

DELIVERY ROOM CARE
Presence of  experienced neonatologist at time of delivery is helpful. ELBW neonates are at high risk of developing

Careful monitoring
Careful  attention to detailed and frequent clinical and lab monitoring are the basic components of care of ELBW infant.

Respiratory
Most ELBW infants require some form of respiratory support. Conventional ventilation in SIMV mode using lowest possible tidal volumes and avoiding hyperoxia  and  hypocapnia  decreases  morbidity. Surfactant  replacement  therapy  has  markedly improved the survival and decreased the morbidity.

Fluid & Electrolytes
Major problem include increased surface area-body weight ratio, immaturity of skin and kidneys which require careful monitoring of fluid and electrolytes status. Use of  humidified incubators significantly reduces insensible fluid losses. Long term venous access is another major issue and in our unit we routinely use percutaneously inserted central venous catheter (PICV  Neocath Vygon) for such infants.

Nutrition
Most  require  parentral  nutrition .  Adding multivitamins and trace elements to IV fluids prevents nutritional deficiency. Most can be started on EBM tube feeds once clinically stable. Use of EBM reduces infections and necrotizing enterocolitis

Cardiovascular support
Babies may require fluid boluses and dopamine. Stress dose of hydrocortisone may be considered in infants requiring cardiovascular support.

Infection control
Proper  hand-washing,  early  feeding,  minimal handling are the important principles in preventing infection

Blood transfusion
Large phlebotom losses and anemia of prematurity necessitated packed cell transfusion

ROP screening
Should be initiated at 4 weeks of postnatal age and followed up appropriately

Kangaroo mothercare
Improves  feeding,  weight  gain,  mother  infant bonding and thermal control.

Discharge planning
Babies  are discharged  when  showing  appropriate weight gain free from any medical problem, feeding appropriately and mother is confident in caring for the infant.

Long term Followup
Babies are at high risk of  long term medical and neurodevelopmental  handicap.  Appropriate  and regular  neuro-developmental  follow  up,  early stimulation and appropriate remedial measures like physiotherapy  occupational  therapy,  hearing  and visual assessment and support improves long term outcome.