These three complications share the same root — organs injured while still developing — and several of the same triggers: extreme prematurity, oxygen exposure, fluctuating blood flow, infection, and inflammation.

Bronchopulmonary dysplasia (BPD) — chronic lung disease of prematurity

• The immature lung is injured by mechanical ventilation (volutrauma), oxygen toxicity, infection, and inflammation, and a patent ductus may contribute. The main lesion today is arrested development: fewer, larger alveoli and abnormal pulmonary vessels.
• Definition used in most exam content: oxygen requirement for at least 28 days, with severity graded at 36 weeks postmenstrual age (PMA) for infants born before 32 weeks (mild = room air, moderate = less than 30% oxygen, severe = 30% or more or positive pressure). Newer definitions grade severity by the type of respiratory support at 36 weeks PMA.
• Higher risk with lower gestational age and birth weight, male sex, chorioamnionitis, sepsis, and poor nutrition.

Retinopathy of prematurity (ROP)

• Retinal blood vessels grow from the optic disc toward the periphery and are incomplete in preterm infants. After birth, relatively high oxygen suppresses vessel growth (phase 1). As the avascular retina becomes hypoxic, excess vascular endothelial growth factor (VEGF) drives abnormal new vessel growth into the vitreous (phase 2), which can scar and pull the retina off (detachment).
• Risk factors: very low gestational age and birth weight, hyperoxia and fluctuating oxygen saturation, poor postnatal weight gain, sepsis, transfusions.

International Classification of ROP (ICROP3, 2021)

Intraventricular hemorrhage (IVH)

• Bleeding begins in the germinal matrix, a highly vascular, fragile region next to the lateral ventricles that involutes by about 34 weeks. Preterm infants have poor cerebral autoregulation, so swings in blood pressure and cerebral blood flow (hypoxia, hypercapnia, rapid fluid boluses, pneumothorax, crying, suctioning, seizures) rupture these vessels.
• Most IVH occurs in the first 72 hours of life.
• Papile grading: Grade I — germinal matrix only; Grade II — blood in the ventricle without dilation; Grade III — blood with ventricular dilation; Grade IV — extension into brain tissue (periventricular hemorrhagic infarction). Grades III–IV are "severe."
• Related white-matter injury: periventricular leukomalacia (PVL) — ischemic injury linked to spastic diplegia.

BPD

• Persistent tachypnea, retractions, crackles, wheezing; ongoing oxygen or ventilator dependence
• Poor weight gain, fatigue and desaturation with feeding, oral aversion
• Late: pulmonary hypertension and right heart strain (cor pulmonale) — hepatomegaly, edema, rising oxygen needs

ROP

• No visible signs in early stages — detected only by dilated retinal examination
• Advanced: leukocoria (white pupillary reflex), strabismus, nystagmus, poor visual tracking

IVH

• Often silent — found on screening ultrasound
• Acute large bleed: sudden deterioration, bulging fontanel, falling hematocrit, hypotension, apnea, bradycardia, metabolic acidosis, hypotonia, decreased responsiveness, seizures, abnormal eye movements
• Post-hemorrhagic hydrocephalus: rapidly increasing head circumference, full fontanel, split sutures, "setting-sun" eyes, apnea

BPD

• Prevention: antenatal corticosteroids, early CPAP, less invasive surfactant, gentle ventilation, caffeine, oxygen targeting, human milk, infection prevention.
• Nutrition: high energy needs; fortified human milk or high-calorie formula; moderate fluid limits.
• Diuretics (short-term improvement in lung mechanics):
  • Furosemide — hypokalemia, hyponatremia, hypochloremic metabolic alkalosis, ototoxicity, hypercalciuria/nephrocalcinosis and bone loss.
  • Thiazide with spironolactone — electrolyte loss; spironolactone can cause hyperkalemia (do not add potassium supplements without orders).
• Bronchodilators (albuterol) for reactive airways — tachycardia, tremor, hypokalemia.
• Postnatal corticosteroids (low-dose dexamethasone or hydrocortisone) for ventilator-dependent infants: hyperglycemia, hypertension, infection, GI perforation (especially with indomethacin), growth suppression; early high-dose dexamethasone is linked to cerebral palsy, so use is limited to selected infants after discussing risks.
• Pulmonary hypertension: oxygen to avoid hypoxemia; pulmonary vasodilators (e.g., sildenafil — hypotension, monitor BP) under specialist care.
• Home oxygen with pulse oximetry for some infants.
• RSV prevention: a long-acting monoclonal antibody (nirsevimab or clesrovimab) for infants younger than 8 months born during or entering their first RSV season if the mother did not receive RSV vaccine in pregnancy, her vaccination status is unknown, or the infant was born 14 days or less after maternal vaccination; nirsevimab is also recommended for children with chronic lung disease of prematurity entering their second season (8–19 months) if they needed supplemental oxygen, chronic systemic corticosteroids, or diuretics during the 6 months before that season. Palivizumab is used mainly when these are unavailable. Adverse effects are uncommon (rash, injection-site reactions; rare hypersensitivity).
• Routine vaccines, including live oral rotavirus vaccine, follow chronological age; oxygen therapy is not a contraindication. Annual influenza vaccine from 6 months and for household contacts.

ROP

• Prevention: avoid hyperoxia and wide saturation swings; titrate oxygen to targets; promote growth.
• Laser photocoagulation of the avascular peripheral retina for treatment-requiring ROP (type 1). Can reduce peripheral vision; associated with myopia.
• Intravitreal anti-VEGF injection (bevacizumab and ranibizumab are off-label in the US; aflibercept was FDA-approved for ROP in 2023). Faster and useful for Zone I and aggressive disease, but ROP can reactivate weeks to months later, so screening must continue longer. Possible systemic VEGF suppression is a concern.
• Scleral buckle or vitrectomy for Stage 4–5 detachment.
• Cryotherapy is largely historical. Oral corticosteroids are not a treatment for ROP.

IVH

• Prevention: antenatal corticosteroids, delayed cord clamping, delivery at a center with a NICU, avoid hypothermia and hypercapnia, avoid rapid infusions and hyperosmolar solutions, careful blood pressure management, and prophylactic indomethacin in selected extremely preterm infants (reduces severe IVH and PDA). Indomethacin safety: reduced urine output, rising creatinine, GI bleeding/perforation, platelet dysfunction; avoid with active bleeding, thrombocytopenia, NEC, or concurrent steroids; monitor urine output, creatinine, and platelets.
• Treatment: supportive (ventilation, blood pressure, platelets and correction of coagulopathy, seizure control).
• Post-hemorrhagic hydrocephalus: temporizing measures (serial lumbar punctures, ventricular access reservoir, or ventriculosubgaleal shunt), then a ventriculoperitoneal (VP) shunt if hydrocephalus persists once the infant is large enough and CSF protein falls. Diuretics are not effective long-term.

Listed in priority order.

1. Oxygenation
   • Keep SpO₂ within the ordered target range (about 90–95% for most preterm infants); set alarms and respond to both low and high values; avoid "chasing" saturations with large FiO₂ changes
   • Continuous monitoring of respiratory rate, work of breathing, and apnea; watch for fatigue during feeds
2. Neuroprotective care (first 72 hours especially)
   • Head in midline, body aligned, head of bed slightly elevated per unit protocol; avoid head-down positions
   • Minimal handling, clustered care, two-person turns moving head and body together
   • Suction only when needed, with appropriate pressure; avoid prolonged crying and pain (use sucrose, containment)
   • Slow, controlled infusions; report hypotension or sudden changes
3. Neurologic monitoring — fontanel, sutures, tone, activity, seizures; measure head circumference as ordered (at least weekly; daily after IVH)
4. Fluid and electrolyte monitoring on diuretics — daily weight, intake and output, potassium, sodium, chloride, calcium
5. Nutrition — fortified feeds; small frequent or gavage feeds; energy conservation; weekly growth plotting
6. ROP examinations
   • Give dilating eye drops as ordered; watch for tachycardia, hypertension, apnea, bradycardia, feeding intolerance afterward
   • Pain relief during the exam (sucrose, swaddling, pacifier); monitor vital signs and SpO₂
   • Ensure no screening exam is missed at transfer or discharge
7. Infection prevention — hand hygiene; limit sick contacts; RSV prophylaxis before discharge
8. Family support — honest information about prognosis; teach home oxygen, medications, and warning signs

BPD / home oxygen

• Correct flow and equipment use; no smoking or open flames near oxygen; backup supply
• Signs of respiratory distress: faster breathing, retractions, color change, poor feeding
• Avoid crowds and sick contacts during the respiratory virus season; hand hygiene
• Keep all vaccines up to date; ask about RSV antibody protection
• Diuretics: give exactly as prescribed; do not add salt or potassium unless ordered

ROP

• Keep every eye appointment — missing one can mean missing the window for treatment
• Long-term risks: myopia, strabismus, amblyopia, glaucoma, and later retinal detachment — yearly or more frequent eye checks; report a white pupil, eye turning, or not following objects

IVH / hydrocephalus

• Developmental follow-up and early intervention services
• Shunt: report vomiting, irritability, lethargy, bulging fontanel, rapid head growth, or fever (malfunction or infection)

• BPD = oxygen need at 28 days, graded at 36 weeks PMA; causes: oxygen, ventilation, infection, inflammation
• BPD care: high-calorie nutrition, diuretics (watch potassium), bronchodilators, limited steroids, RSV prevention
• ROP: abnormal retinal vessel growth driven by VEGF, triggered by hyperoxia and oxygen swings
• ROP screening: ≤ 1,500 g or ≤ 30 weeks; first exam at 31 weeks PMA or 4 weeks after birth, whichever is later
• Zone I = most posterior and most serious; Stage 3 = neovascularization; Stage 5 = total detachment
• ROP treatment: laser or anti-VEGF injection (needs longer follow-up for reactivation)
• IVH starts in the germinal matrix, mostly in the first 72 hours; screen with cranial ultrasound
• Papile Grade III = ventricular dilation; Grade IV = parenchymal involvement
• Prevent IVH: midline head, minimal handling, no head-down position, avoid pressure swings
• Hydrocephalus after IVH → track head circumference; VP shunt when persistent