During preterm optimisation week, we should revisit why the optimisation bundle is so important, Dr Alex Cleator, Consultant Neonatologist at Liverpool Women’s Hospital discusses why are we so focused on these (now 9) interventions.

Behind each of these interventions is an established evidence base that demonstrates how outcomes are improved for preterm babies. We’re now familiar with the first 7 interventions; being born in the right place, receiving antenatal steroids, magnesium sulphate and intrapartum antibiotics, normothermia after delivery, deferring the clamping of the cord, and receiving Mum’s breast milk within the first 24 hours. The BAPM perinatal optimisation pathway explores these interventions, building on work from the PERIPrem care bundle from the West and Southwest regions. The big challenge of preterm optimisation remains how do we maximise the number of preterm babies that receive all their eligible interventions during the perinatal period? The answer to this is found in multidisciplinary team working, responding to local data trends and generating appropriate quality improvement.  

Additionally, this year has seen 2 additional measures introduced to the optimisation bundle:

1. All babies <30/40 gestation receive caffeine within 24 hours of birth. 

Caffeine is one of the most prescribed drugs in neonatal medicine. We give it primarily to prevent apnoea of prematurity, but it has different modes of action in the brain, lungs and heart, resulting in lower rates of IVH, BPD and PDA for those preterm babies who receive it. There is also evidence of positive long-term outcomes for neurodevelopment and lung function. Most dosing regimes are based on the caffeine therapy for apnoea of prematurity (CAP) trial published in 2006, but there remains debate about optimal dosage and timing of administration. 

2. In babies <34/40 who need invasive ventilation, use volume-guaranteed ventilation in combination with synchronised ventilation as the primary mode of respiratory support. 

There is a wealth of evidence to tell us that volume-targeted ventilation (VTV) is superior to pressure-limited ventilation (PLV) in neonatal care. The 2017 Cochrane review concludes that VTV reduces death or BPD, BPD alone, pneumothorax, grade 3 or 4 IVH or PVL (or both), mean duration of mechanical ventilation and hypocarbia when compared to PLV. The 2019 NICE guidelines are also very clear and tell us to “use VTV in combination with synchronised ventilation as the primary mode of respiratory support.” “Do not use synchronised pressure-limited ventilation.” Neonatal networks are supporting local neonatal units in making the transition to using VTV.  

These 2 additional interventions will likely be a feature in this year’s preterm optimisation week, with other interventions likely to follow in the future. Regardless of this, the key to successful preterm optimisation remains in multidisciplinary teamwork and a relentless drive towards quality improvement and understanding local data.