Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

It’s the little things. A framework and guidance for programs to care for infants 22–23 weeks’ gestational age

Journal of Perinatology (2025)Cite this article

Subjects

Abstract

Neonatal intensive care units (NICUs) developing a tiny baby program—a clinical approach for care of infants born before 24 weeks’ gestation—have a limited, but growing, body of evidence to guide practice. Infants born 22–23 weeks have more immature organ development and physiology than more mature extremely low birth weight infants. Centers of excellence (CoEs) in the care of tiny babies have evolved integrated approaches to clinical care in which the management of each physiologic system impacts other systems. NICUs may find mentorship and potentially better practices from the CoEs, but must apply them with extreme caution in the context of their local practices. In this article, authors from institutions in the process of developing tiny baby programs propose a framework for developing such programs. The authors summarize both operational and physiologic principles that they have found important for consideration.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on SpringerLink
  • Instant access to the full article PDF.

USD 39.95

Prices may be subject to local taxes which are calculated during checkout

Fig. 1: Clinical considerations for care of infants born before 24 weeks’ gestational age.

Similar content being viewed by others

References

  1. Rysavy MA, Bennett MM, Ahmad KA, Patel RM, Shah ZS, Ellsbury DL, et al. Neonatal intensive care unit resource use for infants at 22 weeks’ gestation in the US, 2008–2021. JAMA Netw Open. 2024;7:e240124.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Ehret DEY, Edwards EM, Greenberg LT, Bernstein IM, Buzas JS, Soll RF, et al. Association of antenatal steroid exposure with survival among infants receiving postnatal life support at 22 to 25 weeks’ gestation. JAMA Netw Open. 2018;1:e183235.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Rysavy MA, Mehler K, Oberthur A, Agren J, Kusuda S, McNamara PJ, et al. An immature science: intensive care for infants born at </=23 weeks of gestation. J Pediatr. 2021;233:16–25.e1.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Backes CH, Rivera BK, Pavlek L, Beer LJ, Ball MK, Zettler ET, et al. Proactive neonatal treatment at 22 weeks of gestation: a systematic review and meta-analysis. Am J Obstet Gynecol. 2021;224:158–74.

    Article  CAS  PubMed  Google Scholar 

  5. Rysavy MA, Li L, Bell EF, Das A, Hintz SR, Stoll BJ, et al. Between-hospital variation in treatment and outcomes in extremely preterm infants. N Engl J Med. 2015;372:1801–11.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Ancel PY, Goffinet F, Group E-W, Kuhn P, Langer B, Matis J, et al. Survival and morbidity of preterm children born at 22 through 34 weeks’ gestation in France in 2011: results of the EPIPAGE-2 cohort study. JAMA Pediatr. 2015;169:230–8.

    Article  PubMed  Google Scholar 

  7. Isayama T. The clinical management and outcomes of extremely preterm infants in Japan: past, present, and future. Transl Pediatr. 2019;8:199–211.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Morgan AS, Zeitlin J, Kallen K, Draper ES, Marsal K, Norman M, et al. Birth outcomes between 22 and 26 weeks’ gestation in national population-based cohorts from Sweden, England and France. Acta Paediatr. 2022;111:59–75.

    Article  PubMed  Google Scholar 

  9. Mehler K, Oberthuer A, Keller T, Becker I, Valter M, Roth B, et al. Survival among infants born at 22 or 23 weeks’ gestation following active prenatal and postnatal care. JAMA Pediatr. 2016;170:671–7.

    Article  PubMed  Google Scholar 

  10. Guillen U, Zupancic JAF, Litt JS, Kaempf J, Fanaroff A, Polin RA, et al. Community considerations for aggressive intensive care therapy for infants <24+0 weeks of gestation. J Pediatr. 2024;268:113948.

    Article  PubMed  Google Scholar 

  11. Yanagisawa T, Nakamura T, Kokubo M. Prognosis of 22- and 23-gestational-week-old infants at our facility: a retrospective cohort study. Am J Perinatol. 2024;41:660–8.

    Article  PubMed  Google Scholar 

  12. Morris M. Small baby programs: providing a framework for specialized care. Neonatal Netw. 2021;40:199–200.

    Article  PubMed  Google Scholar 

  13. Morris M, Cleary JP, Soliman A. Small baby unit improves quality and outcomes in extremely low birth weight infants. Pediatrics 2015;136:e1007–15.

    Article  PubMed  Google Scholar 

  14. Pavlek LR, Mueller C, Jebbia MR, Kielt MJ, Nelin LD, Shepherd EG, et al. Perspectives on developing and sustaining a small baby program. Semin Perinatol. 2022;46:151548.

    Article  PubMed  Google Scholar 

  15. Langley GJ, Moen RD, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide. 2nd ed. San Francisco: Jossey-Bass; 2009.

  16. Morisaki N, Isayama T, Samura O, Wada K, Kusuda S. Socioeconomic inequity in survival for deliveries at 22-24 weeks of gestation. Arch Dis Child Fetal Neonatal Ed. 2018;103:F202–F7.

    Article  PubMed  Google Scholar 

  17. Serenius F, Sjors G, Blennow M, Fellman V, Holmstrom G, Marsal K, et al. EXPRESS study shows significant regional differences in 1-year outcome of extremely preterm infants in Sweden. Acta Paediatr. 2014;103:27–37.

    Article  PubMed  Google Scholar 

  18. Silva ER, Shukla VV, Tindal R, Carlo WA, Travers CP. Association of active postnatal care with infant survival among periviable infants in the US. JAMA Netw Open. 2023;6:e2250593.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Boghossian NS, Geraci M, Lorch SA, Phibbs CS, Edwards EM, Horbar JD. Racial and ethnic differences over time in outcomes of infants born less than 30 weeks’ gestation. Pediatrics. 2019;144: e20191106.

  20. Shukla VV, Youngblood EM, Tindal RR, Carlo WA, Travers CP. Persistent disparities in black infant mortality across gestational ages in the United States. J Perinatol. 2024;44:584–6.

    Article  PubMed  Google Scholar 

  21. Travers CP, Carlo WA, McDonald SA, Das A, Ambalavanan N, Bell EF, et al. Racial/ethnic disparities among extremely preterm infants in the United States from 2002 to 2016. JAMA Netw Open. 2020;3:e206757.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Balakrishnan M, Raghavan A, Suresh GK. Eliminating undesirable variation in neonatal practice: balancing standardization and customization. Clin Perinatol. 2017;44:529–40.

    Article  PubMed  Google Scholar 

  23. Wennberg JE. Time to tackle unwarranted variations in practice. BMJ. 2011;342:d1513.

    Article  PubMed  Google Scholar 

  24. Gupta M, Kaplan HC. Improving quality improvement in neonatal-perinatal care. Clin Perinatol. 2017;44:xvii–xix.

    Article  PubMed  Google Scholar 

  25. Kaplan HC, Gupta M. A tipping point for quality improvement in neonatal intensive care. Clin Perinatol. 2023;50:xix–xxi.

    Article  PubMed  Google Scholar 

  26. Kaempf JW, Morris M, Austin J, Steffen E, Wang L, Dunn M. Sustained quality improvement collaboration and composite morbidity reduction in extremely low gestational age newborns. Acta Paediatr. 2019;108:2199–207.

    Article  PubMed  Google Scholar 

  27. Kaempf JW, Gautham K. Do small baby units improve extremely premature infant outcomes? J Perinatol. 2022;42:281–5.

    Article  PubMed  Google Scholar 

  28. Fathi O, Nelin LD, Shepherd EG, Reber KM. Development of a small baby unit to improve outcomes for the extremely premature infant. J Perinatol. 2022;42:157–64.

    Article  PubMed  Google Scholar 

  29. Gadsbøll C, Björklund LJ, Norman M, Abrahamsson T, Domellöf M, Elfvin A, et al. Centralisation of extremely preterm births and decreased early postnatal mortality in Sweden, 2004-2007 versus 2014-2016. Acta Paediatr. 2025;114:319-331.

  30. Cahill AG, Kaimal AJ, Kuller JA, Turrentine MA, American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine. Use of Antenatal Corticosteroids at 22 Weeks of Gestation. Practice Advisory [Internet]. 2021. Available from: https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2021/09/use-of-antenatal-corticosteroids-at-22-weeks-of-gestation#.

  31. Croop SEW, Thoyre SM, Aliaga S, McCaffrey MJ, Peter-Wohl S. The Golden Hour: a quality improvement initiative for extremely premature infants in the neonatal intensive care unit. J Perinatol. 2020;40:530–9.

    Article  PubMed  Google Scholar 

  32. Lamary M, Bertoni CB, Schwabenbauer K, Ibrahim J. Neonatal Golden Hour: a review of current best practices and available evidence. Curr Opin Pediatr. 2023;35:209–17.

    Article  PubMed  Google Scholar 

  33. Berger JN, Elgin TG, Dagle JM, Klein JM, Colaizy TT. Survival and short-term respiratory outcomes of <750 g infants initially intubated with 2.0 mm vs. 2.5 mm endotracheal tubes. J Perinatol. 2022;42:202–8.

    Article  PubMed  Google Scholar 

  34. Geraghty LE, Dunne EA, Ni Chathasaigh CM, Vellinga A, Adams NC, O’Currain EM, et al. Video versus direct laryngoscopy for urgent intubation of newborn infants. N Engl J Med. 2024;390:1885–94.

    Article  PubMed  Google Scholar 

  35. Pereira SS, Raja EA, Satas S. Weight-based guide overestimates endotracheal tube tip position in extremely preterm infants. Am J Perinatol. 2019;36:1498–503.

    Article  PubMed  Google Scholar 

  36. Sotiropoulos JX, Oei JL, Schmölzer GM, Libesman S, Hunter KE, Williams JG, et al. Initial Oxygen Concentration for the Resuscitation of Infants Born at Less Than 32 Weeks' Gestation: A Systematic Review and Individual Participant Data Network Meta-Analysis. JAMA Pediatr. 2024;178:774–783.

  37. Oei JL, Saugstad OD, Lui K, Wright IM, Smyth JP, Craven P, et al. Targeted oxygen in the resuscitation of preterm infants, a randomized clinical trial. Pediatrics. 2017;139:e20161452.

  38. Sotiropoulos JX, Oei JL, Schmolzer GM, Libesman S, Hunter KE, Williams JG, et al. Initial oxygen concentration for the resuscitation of infants born at less than 32 weeks’ gestation: a systematic review and individual participant data network meta-analysis. JAMA Pediatr. 2024.

  39. Herting E, Hartel C, Gopel W. Less invasive surfactant administration (LISA): chances and limitations. Arch Dis Child Fetal Neonatal Ed. 2019;104:F655–F9.

    Article  PubMed  Google Scholar 

  40. Mehler K, Grimme J, Abele J, Huenseler C, Roth B, Kribs A. Outcome of extremely low gestational age newborns after introduction of a revised protocol to assist preterm infants in their transition to extrauterine life. Acta Paediatr. 2012;101:1232–9.

    Article  PubMed  Google Scholar 

  41. Norman M, Jonsson B, Wallstrom L, Sindelar R. Respiratory support of infants born at 22-24 weeks of gestational age. Semin Fetal Neonatal Med. 2022;27:101328.

    Article  PubMed  Google Scholar 

  42. Katz LA, Klein JM. Repeat surfactant therapy for postsurfactant slump. J Perinatol. 2006;26:414–22.

    Article  CAS  PubMed  Google Scholar 

  43. Keszler M, Abubakar MK. Volume-targeted ventilation. Semin Perinatol. 2024;48:151886.

    Article  PubMed  Google Scholar 

  44. Thibeault DW, Mabry SM, Ekekezie II, Truog WE. Lung elastic tissue maturation and perturbations during the evolution of chronic lung disease. Pediatrics 2000;106:1452–9.

    Article  CAS  PubMed  Google Scholar 

  45. Goldsmith LS, Greenspan JS, Rubenstein SD, Wolfson MR, Shaffer TH. Immediate improvement in lung volume after exogenous surfactant: alveolar recruitment versus increased distention. J Pediatr. 1991;119:424–8.

    Article  CAS  PubMed  Google Scholar 

  46. Elgin TG, Stanford AH, Klein JM. First intention high-frequency jet ventilation for periviable infants. Curr Opin Pediatr. 2022;34:165–9.

    Article  PubMed  Google Scholar 

  47. Mullaly R, El-Khuffash AF. Haemodynamic assessment and management of hypotension in the preterm. Arch Dis Child Fetal Neonatal Ed. 2024;109:120–7.

    Article  PubMed  Google Scholar 

  48. Baud O, Trousson C, Biran V, Leroy E, Mohamed D, Alberti C, et al. Two-year neurodevelopmental outcomes of extremely preterm infants treated with early hydrocortisone: treatment effect according to gestational age at birth. Arch Dis Child Fetal Neonatal Ed. 2019;104:F30–F5.

    Article  PubMed  Google Scholar 

  49. Onland W, Cools F, Kroon A, Rademaker K, Merkus MP, Dijk PH, et al. Effect of hydrocortisone therapy initiated 7 to 14 days after birth on mortality or bronchopulmonary dysplasia among very preterm infants receiving mechanical ventilation: a randomized clinical trial. JAMA 2019;321:354–63.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  50. Masumoto K, Kusuda S, Aoyagi H, Tamura Y, Obonai T, Yamasaki C, et al. Comparison of serum cortisol concentrations in preterm infants with or without late-onset circulatory collapse due to adrenal insufficiency of prematurity. Pediatr Res. 2008;63:686–90.

    Article  CAS  PubMed  Google Scholar 

  51. Ishimoto H, Jaffe RB. Development and function of the human fetal adrenal cortex: a key component in the feto-placental unit. Endocr Rev. 2011;32:317–55.

    Article  CAS  PubMed  Google Scholar 

  52. Shaffer ML, Baud O, Lacaze-Masmonteil T, Peltoniemi OM, Bonsante F, Watterberg KL. Effect of prophylaxis for early adrenal insufficiency using low-dose hydrocortisone in very preterm infants: an individual patient data meta-analysis. J Pediatr. 2019;207:136–42.e5.

    Article  CAS  PubMed  Google Scholar 

  53. Barrington KJ, Finer N, Pennaforte T. Inhaled nitric oxide for respiratory failure in preterm infants. Cochrane Database Syst Rev. 2017;1:CD000509.

    PubMed  Google Scholar 

  54. Nakanishi H, Suenaga H, Uchiyama A, Kusuda S, Neonatal Research Network J. Persistent pulmonary hypertension of the newborn in extremely preterm infants: a Japanese cohort study. Arch Dis Child Fetal Neonatal Ed. 2018;103:F554–F61.

    Article  PubMed  Google Scholar 

  55. Shaul PW. Ontogeny of nitric oxide in the pulmonary vasculature. Semin Perinatol. 1997;21:381–92.

    Article  CAS  PubMed  Google Scholar 

  56. Shiraishi J, Kusuda S, Cho K, Nakao A, Hiroma T, Sugiura H, et al. Standardization of nitric oxide inhalation in extremely preterm infants in Japan. Pediatr Int. 2019;61:152–7.

    Article  CAS  PubMed  Google Scholar 

  57. Boly TJ, Dagle JM, Klein JM, Rios DR, McNamara PJ, Giesinger RE. Response categorization and outcomes in extremely premature infants born at 22-26 weeks gestation that received inhaled nitric oxide for hypoxic respiratory failure. J Perinatol. 2023;43:324–31.

    Article  CAS  PubMed  Google Scholar 

  58. Pavlek LR, Rivera BK, Smith CV, Randle J, Hanlon C, Small K, et al. Eligibility criteria and representativeness of randomized clinical trials that include infants born extremely premature: a systematic review. J Pediatr. 2021;235:63–74.e12.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Giesinger RE, Hobson AA, Bischoff AR, Klein JM, McNamara PJ. Impact of early screening echocardiography and targeted PDA treatment on neonatal outcomes in “22-23” week and “24-26” infants. Semin Perinatol. 2023;47:151721.

    Article  CAS  PubMed  Google Scholar 

  60. Sathanandam S, McNamara P, Pedra C, Toyoshima K, Malekzadeh-Milani S, Patkai J, et al. A global perspective on PDA management in the extremely premature: shifting trend toward transcatheter closure. J Soc Cardiovascular Angiography Intervent. 2023;2:100968.

  61. Wada M, Kusuda S, Takahashi N, Nishida H. Fluid and electrolyte balance in extremely preterm infants <24 weeks of gestation in the first week of life. Pediatr Int. 2008;50:331–6.

    Article  CAS  PubMed  Google Scholar 

  62. Segar DE, Segar EK, Harshman LA, Dagle JM, Carlson SJ, Segar JL. Physiological approach to sodium supplementation in preterm infants. Am J Perinatol. 2018;35:994–1000.

    Article  PubMed  PubMed Central  Google Scholar 

  63. Hartnoll G, Betremieux P, Modi N. Randomised controlled trial of postnatal sodium supplementation on body composition in 25 to 30 week gestational age infants. Arch Dis Child Fetal Neonatal Ed. 2000;82:F24–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  64. Costarino AT Jr., Gruskay JA, Corcoran L, Polin RA, Baumgart S. Sodium restriction versus daily maintenance replacement in very low birth weight premature neonates: a randomized, blind therapeutic trial. J Pediatr. 1992;120:99–106.

    Article  PubMed  Google Scholar 

  65. Araya BR, Ziegler AA, Grobe CC, Grobe JL, Segar JL. Sodium and growth in preterm infants: a review. Newborn (Clarksville). 2023;2:142–7.

    Article  PubMed  Google Scholar 

  66. Chiou YB, Blume-Peytavi U. Stratum corneum maturation. A review of neonatal skin function. Ski Pharm Physiol. 2004;17:57–66.

    Article  CAS  Google Scholar 

  67. Agren J, Sjors G, Sedin G. Ambient humidity influences the rate of skin barrier maturation in extremely preterm infants. J Pediatr. 2006;148:613–7.

    Article  PubMed  Google Scholar 

  68. Puopolo KM, Benitz WE, Zaoutis TE, Committee On F, Newborn, Committee On Infectious D. Management of neonates born at </=34 6/7 weeks’ gestation with suspected or proven early-onset bacterial sepsis. Pediatrics 2018;142:e20182896.

    Article  PubMed  Google Scholar 

  69. Visscher MO, McKeown K, Nurre M, Strange R, Mahan T, Kinnett M, et al. Skin care for the extremely low-birthweight infant. Neoreviews. 2023;24:e229–e42.

    Article  PubMed  Google Scholar 

  70. Lund CH, Osborne JW. Validity and reliability of the neonatal skin condition score. J Obstet Gynecol Neonatal Nurs. 2004;33:320–7.

    Article  PubMed  Google Scholar 

  71. Indrio F, Neu J, Pettoello-Mantovani M, Marchese F, Martini S, Salatto A, et al. Development of the gastrointestinal tract in newborns as a challenge for an appropriate nutrition: a narrative review. Nutrients. 2022;14:1405.

  72. Konnikova Y, Zaman MM, Makda M, D’Onofrio D, Freedman SD, Martin CR. Late enteral feedings are associated with intestinal inflammation and adverse neonatal outcomes. PLoS One. 2015;10:e0132924.

    Article  PubMed  PubMed Central  Google Scholar 

  73. Siddiqui MM, Drewett M, Burge DM. Meconium obstruction of prematurity. Arch Dis Child Fetal Neonatal Ed. 2012;97:F147–50.

    Article  CAS  PubMed  Google Scholar 

  74. Kubota A, Shiraishi J, Kawahara H, Okuyama H, Yoneda A, Nakai H, et al. Meconium-related ileus in extremely low-birthweight neonates: etiological considerations from histology and radiology. Pediatr Int. 2011;53:887–91.

    Article  PubMed  Google Scholar 

  75. Koshinaga T, Inoue M, Ohashi K, Sugito K, Ikeda T, Tomita R. Therapeutic strategies of meconium obstruction of the small bowel in very-low-birthweight neonates. Pediatr Int. 2011;53:338–44.

    Article  PubMed  Google Scholar 

  76. Flannery DD, Edwards EM, Puopolo KM, Horbar JD. Early-onset sepsis among very preterm infants. Pediatrics. 2021;148:e2022059058.

  77. Kaufman D, Boyle R, Hazen KC, Patrie JT, Robinson M, Donowitz LG. Fluconazole prophylaxis against fungal colonization and infection in preterm infants. N. Engl J Med. 2001;345:1660–6.

    Article  CAS  PubMed  Google Scholar 

  78. Benjamin DK Jr, Hudak ML, Duara S, Randolph DA, Bidegain M, Mundakel GT, et al. Effect of fluconazole prophylaxis on candidiasis and mortality in premature infants: a randomized clinical trial. JAMA 2014;311:1742–9.

    Article  PubMed  PubMed Central  Google Scholar 

  79. Flannery DD, Edwards EM, Coggins SA, Horbar JD, Puopolo KM. Late-onset sepsis among very preterm infants. Pediatrics. 2022;150:e2022058813.

  80. Back SA, Miller SP. Brain injury in premature neonates: A primary cerebral dysmaturation disorder? Ann Neurol. 2014;75:469–86.

    Article  PubMed  PubMed Central  Google Scholar 

  81. Molloy EJ, El-Dib M, Soul J, Juul S, Gunn AJ, Bender M, et al. Neuroprotective therapies in the NICU in preterm infants: present and future (Neonatal Neurocritical Care Series). Pediatr Res. 2024;95:1224–36.

    Article  PubMed  Google Scholar 

  82. Volpe JJ. Dysmaturation of premature brain: importance, cellular mechanisms, and potential interventions. Pediatr Neurol. 2019;95:42–66.

    Article  PubMed  Google Scholar 

  83. Wheater ENW, Galdi P, McCartney DL, Blesa M, Sullivan G, Stoye DQ, et al. DNA methylation in relation to gestational age and brain dysmaturation in preterm infants. Brain Commun. 2022;4:fcac056.

    Article  PubMed  PubMed Central  Google Scholar 

  84. Liebowitz M, Kramer KP, Rogers EE. All care is brain care: neuro-focused quality improvement in the neonatal intensive care unit. Clin Perinatol. 2023;50:399–420.

    Article  PubMed  Google Scholar 

  85. Vinall J, Grunau RE. Impact of repeated procedural pain-related stress in infants born very preterm. Pediatr Res. 2014;75:584–7.

    Article  PubMed  PubMed Central  Google Scholar 

  86. Selvanathan T, Miller SP. Brain health in preterm infants: importance of early-life pain and analgesia exposure. Pediatr Res. 2024;96:1397–1403.

  87. Ryan M, Lacaze-Masmonteil T, Mohammad K. Neuroprotection from acute brain injury in preterm infants. Paediatr Child Health. 2019;24:276–90.

    Article  PubMed  PubMed Central  Google Scholar 

  88. Charpak N, Tessier R, Ruiz JG, Hernandez JT, Uriza F, Villegas J, et al. Twenty-year follow-up of kangaroo mother care versus traditional care. Pediatrics. 2017;139:e20162063.

  89. Franck LS, Axelin A, Van Veenendaal NR, Bacchini F. Improving neonatal intensive care unit quality and safety with family-centered care. Clin Perinatol. 2023;50:449–72.

    Article  PubMed  Google Scholar 

  90. Church PT, Banihani R, Litt JS, Msall M. Reimagining Neonatal Follow-Up: An Equitable Model of Care Emphasizing Family and Child Function. Pediatr Clin North Am. 2025;72:93–109.

  91. Litt JS, Halfon N, Msall ME, Russ SA, Hintz SR. Ensuring optimal outcomes for preterm infants after NICU discharge: a life course health development approach to high-risk infant follow-up. Children (Basel). 2024;11:146.

Download references

Acknowledgements

We would like to acknowledge the contributions of those who have provided mentorship and feedback on this manuscript: Dr. Munish Gupta for his expert input around neonatal quality improvement; Dr. Dara Brodsky for her mentorship in program and curriculum development; and Drs. Elizabeth Flanigan and Elisa Abdulhayoglu for their leadership and mentorship in development of a Small Baby Program at Brigham and Women’s Hospital.

Author information

Author notes

  1. These authors contributed equally: Laura B. Bernardini, Helen Healy.

Authors and Affiliations

  1. Brigham and Women’s Hospital, Boston, MA, USA

    Laura B. Bernardini & Elizabeth Brennick

  2. Beth Israel Deaconess Medical Center, Boston, MA, USA

    Helen Healy & Paige Church

  3. University of Alabama at Birmingham, Birmingham, AL, USA

    Ashley N. Battarbee, Colm Travers & Ashley N. Battarbee

  4. Nationwide Children’s, Columbus, Columbus, OH, USA

    Leeann R. Pavlek & Carl H. Backes

  5. MemorialCare Miller Children’s, Long Beach, CA, USA

    Thea Tagliaferro

  6. Parent Representative, Ames, IA, USA

    Kourtney Vier

  7. The Royal Women’s Hospital, Parkville, VIC, Australia

    Jennifer Walsh

  8. University of Texas Houston, Houston, TX, USA

    Matthew A. Rysavy & Matthew A. Rysavy

  9. University of Cologne, Köln, Germany

    Angela Kribs

  10. University of Iowa, Iowa City, IA, USA

    Edward F. Bell

  11. Kyorin University, Tokyo, Japan

    Satoshi Kusuda

  12. Duke University Hospital, Durham, NC, USA

    Noelle Younge

  13. Uppsala University, Uppsala, Sweden

    Johan Ågren

Authors
  1. Laura B. Bernardini
    View author publications

    Search author on:PubMed Google Scholar

  2. Helen Healy
    View author publications

    Search author on:PubMed Google Scholar

  3. Ashley N. Battarbee
    View author publications

    Search author on:PubMed Google Scholar

  4. Elizabeth Brennick
    View author publications

    Search author on:PubMed Google Scholar

  5. Paige Church
    View author publications

    Search author on:PubMed Google Scholar

  6. Leeann R. Pavlek
    View author publications

    Search author on:PubMed Google Scholar

  7. Thea Tagliaferro
    View author publications

    Search author on:PubMed Google Scholar

  8. Colm Travers
    View author publications

    Search author on:PubMed Google Scholar

  9. Kourtney Vier
    View author publications

    Search author on:PubMed Google Scholar

  10. Jennifer Walsh
    View author publications

    Search author on:PubMed Google Scholar

  11. Matthew A. Rysavy
    View author publications

    Search author on:PubMed Google Scholar

Consortia

the Tiny Baby Collaborative Steering Committee

  • Matthew A. Rysavy
  • , Angela Kribs
  • , Edward F. Bell
  • , Satoshi Kusuda
  • , Noelle Younge
  • , Johan Ågren
  • , Ashley N. Battarbee
  • , Kourtney Vier
  •  & Carl H. Backes

Contributions

LBB and HH participated in conceptualization of article content and manuscript revisions. ANB, PC, LRP, TT, CT, JW participated in drafting the manuscript and provided subject expertise. EB, RN contributed content expertise in the area of neonatal nursing and skin care. KV provided expertise regarding the lived experience of parents and family centered care. Members of the Tiny Baby Collaborative Steering Committee contributed to conceptualization of this article and reviewed the content of the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Corresponding author

Correspondence to Helen Healy.

Ethics declarations

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Bernardini, L.B., Healy, H., Battarbee, A.N. et al. It’s the little things. A framework and guidance for programs to care for infants 22–23 weeks’ gestational age. J Perinatol (2025). https://doi.org/10.1038/s41372-025-02252-x

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Version of record:

  • DOI: https://doi.org/10.1038/s41372-025-02252-x

Search

Advanced search

Quick links