PREMATURITY

1. PREMATURITY Sue Omel RN, MS, MPH Nursing Program Supervisor; Washington County DHHS; Public Health Division; Field Team

2. PREMATURITY Why Prematurity is an Important Public Health Issue

3. PREMATURITY Public Health focuses on promoting health and preventing disease Primary Prevention Secondary Prevention Tertiary Prevention

4. PREMATURITY Primary Prevention Decreasing the Rate of Preterm Births Determining the Factors that Impact Preterm Birth Social Biologic Environmental

5. PREMATURITY At Risk Populations Low income women Women of color Women younger than 20 and older than 40 Women who were born preterm Women with a history of previous preterm delivery Women with multiple pregnancy Women with uterine/cervical abnormalities

6. PREMATURITY Other Risk Factors Smoking, use of alcohol, other substance use Infection Stress Trauma Unintended pregnancy Chronic health conditions like diabetes or high blood pressure In-vitro conception History of repeated miscarriages or spontaneous abortions

7. PREMATURITY Despite a good understanding of risks, there has been little reduction in the rate of prematurity in the US

8. PREMATURITY Secondary Prevention Improving the Outcome of Premature Infants

9. PREMATURITY Preterm infants are at higher risk for poor health outcomes than infants born at term

10. PREMATURITY Increased Mortality Preterm birth and low birth weight are the leading cause of death in infants younger than one year.

11. PREMATURITY Infants born before 34 weeks are at greatest risk of death and long term morbidities

12. PREMATURITY Increased Morbidity • Respiratory distress and long term respiratory issues; asthma • Delayed brain development/developmental delay • Cerebral palsy • Epilepsy • Cognitive delay • SIDS/SUIDS • Feeding problems • NICU admission and re-hospitalization • Vision and hearing problems • Autism • Behavior and learning problems • Depression, anxiety, and other mental health issues

13. PREMATURITY Late Preterm Infants Mortality Late preterm infants (34-37) weeks are 6 X more likely to die in the first week of life and 3X more likely to die in the first year

14. Prematurity Late Preterm Infants Morbidity • Respiratory distress • Hypothermia • Sepsis • Hypoglycemia • Inadequate feeding/dehydration • Hyperbilirubinemia • Growth and developmental issues • Immature brain

15. Prematurity The fetal brain at 34 weeks weighs only about 65% of that of a full term infant brain

16. PREMATURITY The Costs of Prematurity • Physical/Medical • Developmental • Emotional • Financial • Psychosocial • Educational

17. PREMATURITY Costs According to the Institute of Medicine The annual costs to society are $26.2 billion dollars $51,600 per infant $49,033 to employer The costs are 11 X greater than those of a normal newborn

18. PREMATURITY The average 1st year costs for a preterm infant are 10X than that of a term infant ($32,325 vs $3,235) The average hospital stay is 9 X longer if the infant is born preterm

19. PREMATURITY What is the Role of the Public Health Nurse? • Improve the health and developmental outcomes of the premature infant by identifying the physical, developmental and social/emotional risks • Implement nursing interventions to reduce the risks

20. PREMATURITY • Reduce costs • Reduce disparities The differences in the rates of disease; incidence, prevalence, morbidity, mortality, or survival rates in one population compared to the health of the general population.

21. The CaCoon Nurse’s Role in Providing Services to Preterm Infants Screening Assessment Education/Information Case Management Care Coordination Support/Advocacy Monitoring

22. PREMATURITY What skills do you need to provide services to premature infants and their families? • Know how to adjust for prematurity • An understanding of the growth and development of the pre-term infant • Understand common medical issues and treatments • Understanding of normal vs abnormal course • Understand infant states, cues, and behaviors • Knowledge of community resources • Ability to provide family centered approach to care

23. PREMATURITY Adjusting for Prematurity Determine gestational age in weeks Subtract the gestational age from 40 weeks Subtract the weeks of prematurity from the chronological age Example: JA was born at 32 weeks gestation. Subtract 40-32= 8 weeks premature Today JA is 12 weeks old chronologically 12 weeks (actual age) -8 weeks = 4 weeks adjusted age Adjustment for prematurity should be done until at least 24 months of age

24. PREMATURITY Growth, Nutrition, Feeding The CaCoon Nurse’s Role in Screening, Assessment and Intervention to Identify Risks and Improve Infant Outcomes

25. PREMATURITY Screening Growth Height, weight, head circumference, and height/weight ratio Development Use standardized tools Other standardized screening

26. PREMATURITY Nursing Systems ASSESSMENT • Cardiovascular • Respiratory • Gastrointestinal • Urinary • Neuro-motor

27. PREMATURITY Risk Assessment • Feeding and Nutrition • Infection • Unintentional Injury • Intentional Injury • Exposure to toxins (second hand smoke) • Dental • Attachment and Bonding • Parenting • Coping • Basic Needs

28. PREMATURITY Case management Helping the family access and utilize other services

29. PREMATURITY Referral and Follow Up • Well Child Care and Immunizations • Early Intervention • Head Start/Early Head Start • Healthy Start • WIC • Speciality Services ie, OT, PT, Developmental Clinics • Community Services to meet basic needs • Services for family ie, counseling, primary care, etc • Services to provide financial support, ie SSI • Respite care

30. PREMATURITY Care Coordination • Primary care provider • Vision-ophthalmologist • Hearing-audiologist/ENT • Cardiologist • Pulmonologist • Gastroenterologist • Neurologist • Home Health • Equipment supplier

31. PREMATURITY Family Support • Understanding family’s experience and needs • Provide opportunity for family to share feelings • Identification of support systems • Role model and support advocacy efforts • Encourage healthy coping strategies

32. PREMATURITY Monitoring Constantly re-evaluating • Repeating screening and assessment • Trying new interventions • Gathering outcome data

33. PREMATURITY Development The Cacoon Nurse’s Role in Screening, Assessment and Intervention to Identify Risks and Improve Infant Outcomes

34. PREMATURITY Screening for Physical Development Standardized screening tools—must look at all areas of development RDSI ASQ CAT/CLAMS Adjust for Prematurity!

35. PREMATURITY Gross motor risks in early screening Looking at more than milestones Use the Infant Motor Screen • Symmetry • Presence or absence of reflexes • Tone • Protective responses • Vestibular responses

36. PREMATURITY Interventions Education/Information Case Management Care Coordination Support Monitoring

37. PREMATURITY Education and Information Current development and what to expect next –normal progression of development Activities to foster development Modifying activities based on infants needs, behaviors, and cues

38. PREMATURITY Case Management Identify and remove barriers Referrals to EI, SSI, OT/PT, Speech, Developmental clinics or pediatricians Community services Infant massage, infant sign language, library programs, swimming classes

39. PREMATURITY Care Coordination Educational staff, medical, neurologist, ophthalmologist, audiologist, developmental disabilities

40. PREMATURITY Support Family’s understanding of developmental issues Family resources and strengths

41. PREMATURITY Social Emotional Development Preterm infants are at significant risk for later relationship issues. These risks are related to: Maternal/family experience Infant’s experience in the NICU Financial impact Infant cues and behaviors Ongoing stress when infant transitions to the home

42. PREMATURITY Maternal Experience Interrupted pregnancy leads to crisis birth Crisis leads to anxiety and fear May also experience feelings of guilt, grief or loss Attachment behaviors are developed in a technical environment that doesn’t foster nurturing Infant is probably less socially responsive and harder to soothe

43. PREMATURITY Maternal outcomes • Depression • Disengagement • Symptoms similar to PTSD • Over-involved and protective

44. PREMATURITY Infant’s Experience Immature brain and nervous system NICU environment Unusual stimulation and pain Cues and behavior patterns may be difficult for caregiver to understand

45. PREMATURITY Infant Outcomes Insecure attachment Anxiety Internalizing problems Difficulty developing social relationships Increased risk for abuse and neglect

46. PREMATURITY The longer the NICU stay, the higher the likelihood of issues related to maternal infant interaction

47. PREMATURITY Interverventions Screening ASQ-SE; screening for maternal depression; screening for attachment issues Assessment Maternal infant interaction; parents knowledge of cues, behaviors, infant state

48. PREMATURITY Education Improve Parent Understanding • Cues • Behaviors • Infant states • Temperament

49. PREMATURITY Variations in behavior, sleep states, and cues should guide all parent interactions. The parent’s role is to meet the infant’s needs. Parents who are empathetic and responsive foster a sense of trust which strengthens the infant’s attachment and sense of security.

50. PREMATURITY Modifying the Environment Help the parent learn to respond sensitively to the infant’s ability to handle various levels of light, noise, and activity and adjust the infant’s environment as needed for the infant