NRP Preterm Infant Resuscitation 1 — Questions and Answers

Question 1: What is the most important intervention for preventing heat loss in a preterm infant less than 32 weeks gestation in the delivery room?

Warm blankets and vigorous drying
Placing the infant in a polyethylene plastic wrap or bag without drying (Correct answer)
Using a radiant warmer set to the highest temperature
Giving the infant directly to the parent for skin-to-skin contact

Correct answer: Placing the infant in a polyethylene plastic wrap or bag without drying

For preterm infants less than 32 weeks, NRP recommends placing the infant immediately (without drying) into a polyethylene wrap or bag under a radiant warmer to minimize evaporative and conductive heat loss.

Preterm infants, especially those under 32 weeks gestation, are highly vulnerable to hypothermia due to their large surface area-to-body weight ratio, thin skin, limited subcutaneous fat, and immature thermoregulatory systems. Evaporative heat loss from wet skin is the most significant cause of heat loss immediately after birth. NRP 8th edition recommends placing infants less than 32 weeks immediately (without drying) into a polyethylene plastic wrap or bag covering the body from the neck down, while placing them under a preheated radiant warmer. The warm and moist microenvironment inside the wrap dramatically reduces evaporative and convective heat loss. The target axillary temperature is 36.5–37.5°C.

Question 2: What initial PEEP (positive end-expiratory pressure) is recommended when providing positive-pressure ventilation to a preterm infant?

0 cmH2O (no PEEP)
5 cmH2O (Correct answer)
10 cmH2O
15 cmH2O

Correct answer: 5 cmH2O

NRP recommends providing PEEP of 5 cmH2O during PPV for preterm infants to maintain alveolar recruitment and functional residual capacity, given their surfactant deficiency and tendency for atelectasis.

Preterm infants with surfactant deficiency are prone to alveolar collapse at end-expiration due to high surface tension. Providing PEEP of 5 cmH2O during PPV helps maintain alveolar recruitment and functional residual capacity between breaths, reducing the work needed to re-open collapsed alveoli with each inspiration. Without PEEP (using a self-inflating bag without a PEEP valve), each breath must start from a lower lung volume, increasing the work of breathing and risk of atelectrauma. T-piece resuscitators and flow-inflating bags with PEEP valves can reliably deliver PEEP; standard self-inflating bags require a separate PEEP valve attachment.

Question 3: When should surfactant therapy be considered for a preterm infant during delivery room management?

For all preterm infants regardless of breathing effort
For intubated preterm infants with respiratory distress syndrome who require ventilatory support (Correct answer)
Only if the infant's SpO2 is below 85% despite PPV
Only after 6 hours of CPAP failure in the NICU

Correct answer: For intubated preterm infants with respiratory distress syndrome who require ventilatory support

Surfactant is indicated for preterm infants with respiratory distress syndrome (RDS) who require intubation and mechanical ventilatory support. NRP supports early surfactant via intubation or LISA/MIST for eligible infants.

Exogenous surfactant replacement therapy significantly reduces the severity of respiratory distress syndrome in preterm infants by restoring surface tension reduction in the alveoli. Indications include preterm infants (typically less than 30–32 weeks or less than 1,500g) who require intubation for respiratory distress. Early (prophylactic or early rescue) surfactant given in the delivery room or within the first 2 hours has been shown to improve outcomes compared to later administration. Less invasive surfactant administration (LISA) or minimally invasive surfactant therapy (MIST) via a thin catheter during spontaneous breathing on CPAP is increasingly preferred to avoid the need for mechanical ventilation. NRP supports but does not mandate surfactant administration in the delivery room setting.

Question 4: What is the target axillary temperature for a preterm infant in the delivery room according to NRP guidelines?

35.0–36.0°C
36.5–37.5°C (Correct answer)
37.5–38.5°C
38.0–39.0°C

Correct answer: 36.5–37.5°C

NRP recommends maintaining the axillary temperature of preterm infants at 36.5–37.5°C to prevent both hypothermia and hyperthermia, as both are associated with adverse outcomes.

Maintaining normothermia (axillary temperature 36.5–37.5°C) in preterm infants is critical because both hypothermia and hyperthermia are associated with adverse outcomes. Hypothermia (below 36.5°C) is linked to increased mortality, hypoglycemia, metabolic acidosis, respiratory distress, IVH, and sepsis. Hyperthermia (above 38°C) is associated with increased mortality, hypotension, and potentially worsening ischemic brain injury. To achieve this target: use a prewarmed (37°C) delivery room, pre-set radiant warmer, polyethylene wrap, warm blankets, and chemical warming mattress for the most premature infants.

Question 5: Why is a preterm infant at increased risk for intraventricular hemorrhage (IVH) during delivery room resuscitation?

Preterm infants have a larger brain volume that is more susceptible to pressure
Preterm infants have fragile germinal matrix vessels that are vulnerable to fluctuations in cerebral blood flow (Correct answer)
Preterm infants receive more medication during resuscitation, which increases bleeding risk
Preterm infants have thinner skull bones that allow external compression during delivery

Correct answer: Preterm infants have fragile germinal matrix vessels that are vulnerable to fluctuations in cerebral blood flow

Preterm infants have a highly vascularized germinal matrix adjacent to the lateral ventricles. These immature vessels lack the structural support and autoregulatory capacity of mature vessels, making them vulnerable to rupture from abrupt changes in cerebral blood flow and pressure.

The germinal matrix is a highly cellular, highly vascularized region located near the caudate nucleus adjacent to the lateral ventricles of the developing brain. It contains a rich network of thin-walled capillaries and venules that lack smooth muscle and are poorly supported by surrounding connective tissue. In preterm infants less than 32 weeks, this matrix is particularly vulnerable to hemorrhage when cerebral blood flow fluctuates — as occurs with rapid changes in blood pressure, PCO2, or volume infusion during resuscitation. Germinal matrix hemorrhage (Grade I–IV IVH) is a major cause of neurodevelopmental impairment in surviving preterm infants. Gentle, careful resuscitation — including avoiding rapid volume boluses, excessive ventilation, and extreme hemodynamic swings — helps reduce IVH risk.

Question 6: Which of the following resuscitation approaches is most appropriate for a spontaneously breathing 28-week preterm infant with mild respiratory distress?

Immediate intubation and surfactant administration
CPAP with 5–6 cmH2O starting pressure and oxygen titrated to SpO2 targets (Correct answer)
PPV with 100% oxygen via mask
Observation only with supplemental oxygen by nasal cannula

Correct answer: CPAP with 5–6 cmH2O starting pressure and oxygen titrated to SpO2 targets

For a spontaneously breathing preterm infant with mild respiratory distress, NRP supports initiating CPAP at 5–6 cmH2O with oxygen titrated to SpO2 targets, reserving intubation for those who fail CPAP.

NRP 8th edition supports a CPAP-first approach for spontaneously breathing preterm infants with mild to moderate respiratory distress syndrome. CPAP at 5–6 cmH2O prevents alveolar collapse, maintains FRC, and reduces work of breathing without the risks associated with intubation (airway trauma, barotrauma, infection, chronic lung disease). Multiple randomized trials (SUPPORT, COIN, CURPAP) have demonstrated that early CPAP with selective surfactant is non-inferior or superior to routine intubation and surfactant for outcomes in preterm infants down to 25–26 weeks. Infants who fail CPAP (worsening respiratory distress, apnea, increasing oxygen needs) should be intubated and given surfactant.

NRP Preterm Infant Resuscitation 1

What is the most important intervention for preventing heat loss in a preterm infant less than 32 weeks gestation in the delivery room?