Fax +41 61 306 12 34 E-Mail karger@karger.ch www.karger.com Review Neonatology 2009;95:286–298 DOI: 10.1159/000178770 The First Golden Minutes of the Extremely-Low-Gestational-Age Neonate: A Gentle Approach Máximo Vento a Po-Yin Cheung c Marta Aguar b a Neonatal Research Unit, Division of Neonatology, Hospital Universitario La Fe, and b Research Foundation Hospital La Fe, Valencia, Spain; c Departments of Paediatrics and Pharmacology, Neonatal Sciences Laboratory, University of Alberta, Edmonton, Alta., Canada Morbidity and Mortality of Extremely-Low- Gestational-Age Neonates In the last decade, improvement in the survival of in- fants born with gestational ages at or less than 28 weeks has been widely documented [1–10]: survival of infants born at 24 and 25 weeks’ gestation rose from 25 and 50% in the early 90s to 40 and 60% 10 years thereafter in Eu- rope and North America, respectively [3–10]. Of note, a similar improvement has also taken place in less devel- oped countries, although the actual mortality rate is higher than that in developed countries [11]. The decrease in mortality rate has been attributed to a constellation of factors, and among them regionalization has been identi- fied as one of the most relevant. Hence, volume of high- risk pregnancies and thus volume of patients admitted into the neonatal intensive care unit (NICU) have been underscored as determining factors to improved perina- tal and neonatal care and the increasing survival [12–15]. Moreover, Phibbs et al. [15] predicted that up to 21% of the deaths of very-low-birth-weight infants in the year 2000 would have been potentially preventable if these in- fants had been born in a tertiary care regional medical centre. Notwithstanding, improvement in mortality seems not to be correlated to changes in the obstetric practice or neonatal resuscitation of the extremely-low- gestational-age neonates (ELGANs, defined as less than Key Words Prematurity  Fetal to neonatal transition  Resuscitation  Noninvasive ventilation  Continuous positive airway pressure  Oxidative stress  Inflammation Abstract An increasing body of evidence has revealed that interven- tions performed during resuscitation of extremely-low-ges- tational-age neonates (ELGANs) may have a direct influence on the immediate survival and also on long-term morbidity. It has been proposed that interventions in the delivery room and/or hypothermia could trigger changes constitutive of chronic lung disease. New approaches in the first minutes of life using more gentle parameters of intervention are being studied. Thus, titrating inspiratory fraction of oxygen, the use of non-invasive ventilation to reduce trauma to the lung, the use of polyethylene/polyurethane wrapping to avoid hy- pothermia and delaying cord clamping altogether consti- tute promising initiatives. The first minutes of life are a valu- able window for intervention. However, whilst these practice changes make sense and there are emerging data to support them, further evidence including long-term follow up is needed to definitively change resuscitation procedures in ELGANs. Copyright © 2008 S. Karger AG, Basel Published online: December 2, 2008 formerly Biology of the Neonate Prof. Máximo Vento, PhD, MD Director of the Neonatal Research Unit, Division of Neonatology Hospital Universitario La Fe, Avenida de Campanar, 21 ES–46009 Valencia (Spain) Tel. +34 963 862 791, Fax +34 961 973 408, E-Mail maximo.vento@uv.es © 2008 S. Karger AG, Basel 1661–7800/09/0954–0286$26.00/0 Accessible online at: www.karger.com/neo