Outcome of periviable neonates after implementation of the Tiny Baby Protocol: a prospective study from India

Outcomes of periviable gestations in low- and middle-income countries (LMICs) depend on perinatal practices and tailored care strategies. The unit implemented a revised "Tiny Baby Protocol" (TBP) in 2023 for neonates born at periviable gestations (23-25 weeks). This prospective study compared survival and short-term outcomes in 23-25 weeks gestation neonates who received care by TBP (preferred proactive approach to perinatal care, elective intubation, respiratory care practices including volume guarantee and high frequency ventilation, inhaled nitric oxide, sedation, skin care practices, transpyloric feeding, rectal wash-outs, and targeted management of perfusion and patent ductus arteriosus) to those from a previous epoch who had received intensive care before TBP was implemented. Thirty-one periviable (23-25 weeks) neonates received care by TBP, of whom 58.1% survived, compared to 35.2% before TBP. Survivors (with TBP) required median (interquartile range) of 22 (14-32) days of ventilation, 9 (8-10) days of parenteral nutrition, and 104 (95-121) days of hospital stay, compared to 19 (13-42), 7 (6-12), and 95 (86-108) days of each respectively in the previous epoch. Changes in survival rates were observed after implementation of the TBP; from 0% to 60% at 23 weeks, 37.5% to 50% at 24 weeks, and 50% to 71.4% at 25 weeks. Implementation of a revised TBP policy for periviable neonates was associated with improved survival when compared to previous epoch of intensive care given in a neonatal intensive care unit in the South Kerala region in India. Wide-scale implementation of such protocols needs to be studied to examine if survival increases in other LMICs.