The Preterm Journey (31–33 weeks)

Take-home

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Where 31–33 weeks sits in the bigger picture

Babies are grouped by gestation at birth:

• Term: 37+0 and later
• Late preterm: 34+0 to 36+6 (see the late preterm journey)
• Moderate preterm: 32+0 to 33+6 weeks
• Very preterm: 28+0 to 31+6 weeks
• Extremely preterm: under 28

A 31–33 week baby spans the boundary between very preterm and moderate preterm. In practice this is the gestation where:

• Babies need the SCN and are not suitable for the postnatal ward
• The baby is mature enough that most will not need long-term ventilation (NICU-level care)
• Antenatal steroids given to mum before birth substantially improve breathing, brain, and survival outcomes
• The first few days are the most active period of care; from there, the focus shifts to feeding and growing

In the private setting (Frances Perry House), 31–33 weeks is the smallest gestation we manage routinely. Babies at the lower end of this range, particularly 31-week babies, sometimes start at the Royal Women’s NICU next door for higher-acuity care in the first hours or days. They then transfer to Frances Perry SCN for the recovery and growing phase. Babies at 32+ weeks who are well at birth usually stay at Frances Perry throughout.

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The first hour after birth

The decisions made in the first hour set the tone for the stay. The standard care for a 31–33 week baby:

Immediate care at birth

• Antenatal corticosteroids given to mum at least 24 hours before delivery if possible, the Cochrane systematic review confirms reduced respiratory distress, intraventricular haemorrhage, neonatal mortality and need for ventilation across the relevant gestation range. Even a partial course helps.
• Delayed cord clamping (at least 30–60 seconds where safe): improves iron stores and lowers transfusion need
• Skilled neonatal team at delivery, paediatrician + nurse for vaginal birth; full team for caesarean or anticipated complications
• Drying and warmth: preterm babies lose heat fast; a warm room and warmed cot are critical, and in some cases a plastic wrap is used to hold temperature
• The ANZCOR newborn life support algorithm guides the next steps:
  • Many babies at 31–33 weeks need positive-pressure breaths to start
  • Many start on CPAP (continuous positive airway pressure): soft prongs in the nose, gentle steady pressure to keep airways open
  • A small minority need intubation and mechanical ventilation (in the NICU)
• First brief skin-to-skin if baby is stable, even for a few minutes
• Vitamin K injection (with consent): see vitamin K

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The first days in the SCN or NICU

Almost all 31–33 week babies are admitted to the SCN (Frances Perry) directly from the birthing room. Some babies need NICU care first: often the Royal Women’s, depending on bed availability at the time. The first 24–48 hours focus on:

• Stabilising breathing: most are on CPAP, some on high-flow oxygen or air via a small set of nasal prongs, a few briefly on a ventilator (in the NICU)
• Temperature control: in a closed isolette (incubator) for the first days to weeks
• IV fluids: typically 10% dextrose for the first hours to days, while feeds establish through the NG tube
• Sepsis screen and prophylactic antibiotics in many cases for the first 36 hours, while blood cultures are awaited
• Initial assessment: head-to-toe examination by the paediatrician within hours of admission
• Cardiorespiratory monitoring (heart rate, breathing, oxygen level): continuous in the early phase
• First brain ultrasound (babies born under 32 weeks): usually within the first week, to look for any bleeding (intraventricular haemorrhage, IVH); see below
• First eye assessment: eye exams for retinopathy of prematurity (ROP) screening start at around 4–6 weeks of age for babies born under 32 weeks or under 1500 g

The bigger picture. A lot happens in parallel in these first days. Most of it settles by the end of the first week, and the focus then shifts to feeding and growing.

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Breathing support

Lung maturity is the biggest determinant of breathing need at this gestation. The progression is fairly predictable:

Stage 1: Most active support (first hours to days)

• CPAP is the most common starting point at 31–33 weeks, about half to two-thirds of babies need this initially
• Surfactant (artificial surfactant given through a brief tube into the lungs, in the NICU): needed in some 31–32 week babies with respiratory distress syndrome (RDS); less commonly at 33 weeks
• Mechanical ventilation (in the NICU): required for a smaller minority, usually those with significant RDS, infection, or congenital lung issues
• Caffeine: given routinely to most babies at this gestation to support the immature breathing centre and reduce apnoea of prematurity (pauses in breathing). Continued until at least 34 weeks corrected, sometimes longer.

Stage 2: Stepping down (days)

• From CPAP or high-flow nasal prongs → off support, once baby shows they don’t need it
• Most babies are off respiratory support within 2–5 days

Stage 3: Watching (weeks)

• Some babies have brief pauses in breathing called apnoeas: usually short and self-correcting, monitored continuously while in SCN, and gradually resolving as the baby matures
• Apnoeas typically settle by 34 weeks corrected
• It is rare at this gestation for a baby to still need oxygen support past 36 weeks corrected (chronic lung disease)

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Temperature and the isolette

31–33 week babies have less body fat and proportionally larger surface area than term babies, so they lose heat fast. The closed isolette (incubator) is the standard environment for the first few weeks:

• Heat and humidity controlled to keep baby’s body temperature in a normal range
• Easier monitoring: clear walls, hand ports, continuous observation
• Cot graduation, moving from isolette to open cot, typically happens at 34–35 weeks corrected age, once baby can hold their own temperature and is generally over 1.8 kg

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Family-centred and developmental care

The principles in plain English:

What developmental care means in practice

Early and frequent skin-to-skin (kangaroo care)

• We aim to support the first skin-to-skin contact within the first hours wherever your baby’s clinical condition allows
• Daily skin-to-skin sessions of an hour or more are encouraged once you and baby are comfortable
• Strong evidence for benefit: better temperature stability, fewer apnoeas, faster weight gain, better breastfeeding outcomes, reduced parental stress and anxiety, stronger bonding
• Both parents are encouraged, kangaroo care isn’t just for mum

Cue-based, infant-led care

• Care routines (feeding, nappies, observations, examinations) are clustered and timed to baby’s cues, when they are awake, alert and ready, rather than the clock
• Watching and learning your baby’s cues (alert eyes, hands to mouth, calm body) builds your confidence and reduces stress for baby
• Painful procedures are minimised, grouped, and where possible delivered with comfort positioning, sucrose or breast milk on a pacifier, and parental presence

Minimal handling and rest

• Preterm babies need long stretches of undisturbed sleep to grow brain and body
• The team batches cares together so there are predictable, longer rest windows
• We avoid unnecessary handling, lifting, and repeated examinations

Positioning

• Babies are nested in soft boundaries (a positioning aid that gives the womb-like containment baby’s nervous system expects)
• Position is changed regularly to support both sides of the body, prevent flattening of the head and chest, and encourage normal motor development
• This carries through to discharge, your MCH nurse can demonstrate good supported positioning at home

The environment

• Light: kept dim during sleep, with day-night cycling once baby is more mature; bright procedural light only when needed
• Noise: kept low; conversations, alarms, and equipment noise are managed actively because the immature cochlea is more sensitive to noise than an adult’s
• Smell and taste: colostrum on a cotton bud near the nose, or for oral cares, gives early sensory comfort

Practical things you can do

• Visit as often as you can: there is no “wrong” amount; even short visits matter
• Talk and sing softly to your baby, your voices are recognised from the womb and are uniquely soothing
• Offer skin-to-skin before each feed once baby is stable
• Be involved in cares: nappy changes, temperature checks, mouth care, oral colostrum
• Read the cues: when baby is calm and alert, that’s the moment to engage
• Take breaks: burnout is real; the team will care for your baby while you rest

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Feeding: the longest part of the stay

Feeding is the rate-limiting step for most 31–33 week babies. The progression has clear phases:

For the full step-by-step picture, the bottle regimen (1 suck + 2 NG → alternate → 2 suck + 1 NG → all sucks 3-hourly → 4-hourly → home), the parallel breastfeeding pathway with NG top-ups, why quality of suck feeds matters more than quantity, and the role of breast contact and expressing, see our dedicated guide on establishing feeds for preterm babies.

Stage 1: IV glucose. For the first 24-72 hours most babies have a short course of 10% dextrose through a small IV cannula, while feeds establish through the NG tube. This keeps blood sugars steady through the early days. Some babies don’t need an IV and can start feeds straight away.

Stage 2: Trophic feeds (gut wake-up). Tiny milk volumes (1-2 mL every 2-3 hours) start in the first day; larger, more stable babies often move to larger volumes from the start. Expressed colostrum and breast milk are the first choice; preterm formula otherwise. The goal here is to wake up the gut rather than provide calories; the calories come later as feeds build up. Given via an NG (nasogastric) tube: soft, comfortable, leaves the mouth free for skin-to-skin and pacifier sucking.

Stage 3: Feed advancement. Volumes increase by 20-30 mL/kg/day as tolerated. Most babies reach full milk feeds within a week and no longer need the cannula. Babies under 1.5 kg feed smaller amounts more frequently (every 2 hours).

Stage 4: Suck feeding. Coordinated suck-swallow-breathe usually emerges around 34 weeks corrected age: that’s the developmental milestone full feeding rides on. Practice sucking at the breast or bottle is offered once or twice a day from earlier, with whatever isn’t taken by suck given by NG. The NG tube is removed when all feeds are taken by suck consistently and weight is gaining well, which is typically around 35-37 weeks corrected age.

Necrotising enterocolitis (NEC)

NEC is a serious bowel inflammation that mainly affects very preterm babies. At 31–33 weeks, it is uncommon (much less than 1%) but always considered, which is why feeds are introduced gradually and breast milk is preferred. Signs (abdominal distension, blood in stool, bilious vomiting, baby unwell) are watched for actively. Treatment, when needed, involves stopping feeds, antibiotics, and occasionally surgery.

Breastfeeding: protect the supply now

Breastfeeding a 31–33 week baby takes weeks of patience but is achievable for most mothers who want it:

• Hand-express colostrum in the first hours after delivery, even if your baby is in the SCN, this colostrum is given via NG
• Pump every 3 hours, including at least once between midnight and 6 am, for the first 2 weeks. This builds and protects supply.
• Skin-to-skin (kangaroo care) even on CPAP is the single most useful thing for milk supply and bonding
• Practice feeds at the breast once your baby reaches around 33–34 weeks corrected
• Lactation consultants are a core part of the team

See breastfeeding support for more detail.

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Brain and eye monitoring

Two important screening exams during the stay:

Cranial ultrasound

For babies born under 32 weeks, a bedside ultrasound of the brain is done in the first week and again at around 4 weeks of age; babies born at 32–33 weeks don’t need one routinely. It looks for:

• Intraventricular haemorrhage (IVH): bleeding into the fluid-filled spaces of the brain. Small bleeds (grade I–II) usually don’t cause problems; larger bleeds (grade III–IV) need closer follow-up. At 31–33 weeks, severe IVH is uncommon (well under 5%) thanks to antenatal steroids and modern delivery practice.
• Periventricular leukomalacia (PVL): damage to the white matter; rare at this gestation, but checked for

The vast majority of cranial ultrasounds at 31–33 weeks are completely normal or show only minor findings.

Eye examination: retinopathy of prematurity (ROP)

ROP is a problem of the developing retinal blood vessels. Routine eye screens are done for babies born under 32 weeks or under 1500 g. The first exam is usually at 4–6 weeks of age, and exams continue every 1–2 weeks until the retina is mature.

• Most 31–33 week babies have no ROP at all or very mild changes that resolve without treatment
• A small minority need treatment, laser, anti-VEGF injection, or rarely surgery
• All ROP-screened babies need a follow-up eye check at 6–12 months by a paediatric ophthalmologist

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Jaundice

Jaundice is very common at 31–33 weeks, almost all babies have some degree of jaundice in the first week, and most need phototherapy for several days. Treatment thresholds are lower than for term babies because the immature brain is more sensitive to bilirubin.

• Transcutaneous meter + serum bilirubin (SBR) blood test to track levels
• Overhead phototherapy or fibre-optic blanket, usually 2–7 days
• Eye protection during phototherapy
• Prolonged jaundice (still present at 3 weeks) is reviewed routinely in preterm babies

See neonatal jaundice.

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Hypoglycaemia, sepsis, and other monitoring

Other routine monitoring during the stay

• Hypoglycaemia: universal monitoring with pre-feed heel-prick sugars; treatment with feed advancement, glucose gel, or IV glucose. See hypoglycaemia management.
• Sepsis screening: blood test + antibiotics for 36 hours in many cases at the start of the stay, with further screens if any concern arises
• Patent ductus arteriosus (PDA): the connection between the two main heart arteries that should close after birth. Stays open in some preterm babies and usually closes on its own with time. At 31–33 weeks this is less common than at very early gestations but possible.
• Anaemia of prematurity: preterm babies often have low red blood cells; sometimes a blood transfusion is given if levels drop or baby is symptomatic
• Weight every second day; length and head circumference charted weekly
• Vitamin D from day 5, and iron from a few weeks of age
• Hearing screen (AABR) before discharge, see hearing screen
• Newborn bloodspot screen (heel-prick): usually at day 3, sometimes repeated at 1 week
• Hip examination: done routinely; ultrasound at 6 weeks corrected age for risk groups (see hip dysplasia screening)

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Length of stay

Length of stay varies, but expect weeks rather than days. The range below is a broad ballpark for 31–33 week babies in private practice; many fall within it, some sit outside.

• 31 weeks at birth: 6 to 10+ weeks in hospital, typically going home somewhere between 38 weeks corrected and a few weeks past your due date
• 32–33 weeks at birth: 4 to 8 weeks, typically home between 37 and 40 weeks corrected

The upper end, staying past your due date, is uncommon but not unusual, especially for 31-weekers slow with feeds.

The team won’t hurry discharge; they also won’t hold a baby longer than necessary. The decision is jointly made by the paediatrician and the family.

Going-home criteria

Babies are discharged home when:

• They take all feeds by suck (breast and/or bottle), without an NG tube
• They are gaining weight reliably for at least a week, with weight comfortably above 2 kg
• They have had no significant apnoeas for the nursery’s observation period (usually about a week), with caffeine stopped
• They can stay warm in an open cot, dressed normally
• They have completed hearing and bloodspot screens (and ROP screen, if indicated, with a follow-up plan)
• The family feels confident in feeding, bathing, and basic care
• A paediatric and developmental follow-up is arranged

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Going home

When discharge approaches, the team will go through:

• Discharge examination (the newborn check), done during the stay, at the latest the day before going home
• Feeding plan: volumes, intervals, what to look for, who to call
• Vaccinations, hepatitis B (if not already given); the rest of the immunisation schedule starts at 6–8 weeks chronological age (not corrected age, see below). See immunisations.
• Vitamin D: recommended in all babies for 1 year
• Iron supplementation: often continued until 6–12 months
• Discharge summary to GP and MCH nurse
• First paediatric review: book for 6 weeks after discharge (book early, appointments can take a few weeks)
• Preterm follow-up clinic referral: see below
• MCH home visit arranged through your local council
• Car seat fitted correctly: a properly fitted capsule, reclined as the manufacturer directs; a professional fitting check is worthwhile for small babies
• RSV protection: a plan for the first RSV season, the maternal vaccine in pregnancy and/or nirsevimab for the baby; we’ll confirm what applies

Corrected age: for the first 2 years

For the next 2 years, your baby’s development is judged against corrected age (chronological age minus weeks born early). A 6-month-old born at 32 weeks is really 4 months corrected, and is expected to do what a 4-month-old does, not a 6-month-old. The Centre of Research Excellence in Newborn Medicine (CRE) NHMRC-approved guideline recommends corrected age until at least 2 years for very preterm babies. See neurodevelopmental milestones.

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Follow-up after discharge

Follow-up depends on gestation at birth. The structured schedule from the CRE Newborn Medicine 2024 guideline applies to babies born before 32 weeks; babies born at 32–33 weeks follow a simpler pathway.

Born before 32 weeks — the CRE 2024 schedule

• 1–2 weeks after discharge: weight and feeding review (usually the MCH nurse)
• 6 weeks after discharge: paediatric review with us: weight, feeding, growth, any leftover concerns (book early, appointments can take a few weeks)
• 6–8 weeks chronological age: GP for first immunisations
• 4 months corrected: paediatric review
• General Movements Assessment (GMA): video-based assessment around 3–5 months corrected age
• Hammersmith Infant Neurological Examination (HINE): structured neuro exam at around 6–9 months corrected
• Developmental assessment at 2 years corrected age: Bayley scales or equivalent
• Hearing follow-up if any concerns at the newborn screen
• Eye review at 6–12 months for any baby who had ROP screening
• MCH visits as per the universal Victorian schedule (use corrected age until 2 years)
• Ongoing immunisations at the chronological-age schedule

Born at 32–33 weeks

• 1–2 weeks after discharge: weight and feeding review (usually the MCH nurse)
• 6 weeks after discharge: paediatric review with us (book early, appointments can take a few weeks)
• 4 months corrected age: paediatric review
• Hearing review: as arranged after the newborn screen
• Developmental review at around 18 months
• MCH visits as per the universal Victorian schedule, and immunisations at the chronological-age schedule

This sounds like a lot, but most of it is built into routine care. The point is that structured follow-up helps pick up concerns sooner and arrange support when it’s needed. The NDIS Early Childhood approach is available without a formal diagnosis if support is needed. See neurodevelopmental milestones for the full picture.

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Long-term outlook

The reassuring picture for 31–33 weeks:

• Survival is high at this gestation with modern care, antenatal steroids and tertiary delivery
• Growth typically catches up by 2 years of corrected age
• Cerebral palsy rate is elevated relative to term but much lower than at very early gestations (current birth prevalence overall is ~1.5/1000); risk decreases steeply between 28 and 34 weeks
• Neurodevelopmental concerns (delays in movement, language, learning or attention) run at about twice the background rate seen in term-born babies. Because that background rate is low, most children born at 31–33 weeks still have no moderate or severe difficulty
• Asthma and respiratory infections are slightly more common in the first few years
• Most babies do well, with follow-up used to pick up concerns early

See understanding the risks for the gestation-by-risk picture and outcome chart.

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Common questions

“How long will my baby be in hospital?”

Plan for weeks rather than days: most go home somewhere between a few weeks before the due date and sometimes a few weeks after it. Feeding maturity is the rate-limiting step. The team will give you a personalised expected discharge window during the stay; expect it to evolve.

“Does my time in the nursery make a difference?”

Yes, a real one. Your presence, voice, touch, and skin-to-skin time during the stay have measurable effects on later development. Spend as much time as you can; ask the team how to help with cares. (And no, your baby won’t remember the nursery itself: there’s no episodic memory at this age, but the comfort registers.)

“How much breast milk do I need to express?”

Aim for 8 expressing sessions every 24 hours, including at least one between midnight and 6 am, for the first 2–3 weeks. This protects supply during the long slow-feeding phase. Volumes vary widely; consistency matters more than amount.

“Will my baby need a transfer?”

At 31–33 weeks in private practice, some babies need a brief stay at a public NICU, such as the Royal Women’s, for higher-acuity care (extra breathing support, surfactant, parenteral nutrition) before transferring to the Frances Perry SCN; sometimes a baby may need transfer to another Melbourne NICU. This is coordinated through the Victorian PIPER transport network. Other babies stay at Frances Perry throughout. The decision is made on the day based on how well your baby is doing.

“When can my baby come home with me from the postnatal ward?”

Almost never at 31–33 weeks, these babies are too immature to share the postnatal ward safely. The SCN provides the right environment for the early days. Once your baby has matured enough, going home directly to your home is the next step.

“Will my baby catch up?”

Yes, for the great majority. Use corrected age as the developmental yardstick until 2 years for 31–33 week babies, and review at MCH and paediatric visits. A small number will need extra help with feeding, language or learning later, and that’s exactly what the structured follow-up schedule is for.

“When can we have visitors?”

While in the SCN, visitor policy is set by the unit, usually limited to immediate family for infection-control and noise reasons. After discharge, limit visits in the first 4–6 weeks, especially during winter / RSV season, and exclude anyone with cold symptoms. Hand hygiene matters. See bronchiolitis.

“Do regular vaccines start late because my baby was preterm?”

No: vaccines are dosed by chronological age for preterm babies. The 6-week immunisations are given at 6 weeks chronological age, even if your baby is still in hospital. See immunisations.

“What about RSV protection?”

We’ll confirm what applies to your baby. Many mothers have the RSV vaccine (Abrysvo) during pregnancy, which passes protection to the baby for the first months. If mum wasn’t vaccinated in time, the baby can have nirsevimab (a single antibody injection) before their first RSV season. Babies born before 32 weeks are eligible for nirsevimab either way, usually before leaving hospital. The program runs each winter and the rules change year to year, so we’ll confirm what your baby needs.

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Related reading

What you’ll meet during the stay

• The late preterm journey (34–36+6 weeks), for an older preterm gestation
• Hypoglycaemia (low blood sugar)
• Neonatal jaundice
• Transient tachypnoea (fast breathing)
• Common newborn findings
• Breastfeeding support
• Tongue tie
• Vitamin K
• Newborn bloodspot screening
• Newborn hearing screening
• Hip dysplasia screening

Going home

• Safe sleep
• Tummy time
• Cord care
• The unsettled baby (crying peak)
• Fever in babies
• Choking & infant CPR

Looking ahead

• Neurodevelopmental milestones & early CP detection
• Immunisation schedule
• Bronchiolitis, the biggest first-winter risk
• Understanding the risks, the gestation curve

External

• Centre of Research Excellence in Newborn Medicine — Preterm Follow-Up Guideline (PDF)
• Safer Care Victoria — Neonatal eHandbook
• Royal Women’s Hospital — Newborn Intensive and Special Care
• Raising Children Network — Premature babies

Antenatal consultation for anticipated preterm birth

An antenatal paediatric consult covers what to expect at your gestation, the SCN/NICU plan, the feeding journey, and follow-up.