Care of the Late-Preterm Infant

1. Care of the Late-Preterm Infant Constance Hymas CDR, NC, USN RNC-NIC, MN, MSHS, NNP-BC

2. The AWHONN Initiative • June 2005, AWHONN launched the Late Preterm Infant (formerly “Near-Term” Infant) initiative . • The population is defined as those born between 34 and 37 weeks gestation

3. The AWHONN Initiative • The initiative is designed to • Raise awareness of the unique needs of the LPI • Emphasizes the need for research • Encourages development of evidence based-guidelines in caring for this population • Provide clinical resources for care and parent education • Foster collaboration with other health care stakeholders to enhance awareness of impact on the health care system and families

4. The Late Preterm Infant • 8.9% of all births in the U.S. • 71% of all preterm births • Greatest proportional increase in the last decade • Increase accounts for almost all of the 30% increase in preterm births in the last 10 years • Birthweight generally between 2-2.5 kg • Given their size, initial stability and relatively mature physical appearance • often cared for in the well newborn nursery

5. The Late Preterm Infant • Mortality rate for infants 32-36 weeks rose from 8.9-9.2 per 100,000 live births (2002) • Mortality rate for term infants remained stable at 2.5 / 100,000 live births ( 2002) • These infants can be 3-8 weeks less mature than full term infants

6. The Late Preterm Infant • Retrospective chart review study of 90 full term and 95 Late-Preterm Infants • No significant difference in Apgar scores • Temp instability ( 10% vs. 0%) • Hypoglycemia (15.6% vs. 5.3 %) • Need for IV infusions ( 26.7% vs. 5%) • Respiratory distress ( 28.9 % vs. 4.2 %) • Apnea and bradycardia (4.4 % vs. 0 %) • Sepsis evaluation (36.7% vs. 12.6%) • Clinical jaundice ( 54.4% vs. 37.9%) • Wang, et. Al., 2004

7. Physiology of Fetal Development • Third Trimester Fetal Development • Surfactant production • Neurological maturity • Maturation of the regulation of breathing • Coordination of sucking/swallowing/breathing • Increased glycogen stores • Increased brown fat stores

8. Clinical Risks Associated with the Late Preterm Infant • The risks should not be underestimated • Clinical protocols, policies and procedures for full term infants may not be appropriate • Even “well” Late Preterm Infants with a normal hospital course are at increased risk for hospital re-admittance

9. Care of the Late Preterm Infant • Thermoregulation • Minimize heat loss • Supply heat as needed, promote skins to skin contact • Assess alertness, muscle tone, and activity • If irritable, infant may be attempting to increase muscle activity to generate heat • Tachypnea and respiratory distress • Increased respiratory rate increases evaporative heat loss • Heat and humidify oxygen asap • Ensure thermal stability prior to discharge

10. Care of the Late Preterm Infant • Hypoglycemia • 10-15% in LPI • Glucose needed for cerebral outcome, linked to neurodevelopmental outcome (it’s all about the brain cells) • Frequent monitoring and assessment • Early, frequent feeding, especially in the first 24 hours

11. Care of the Late Preterm Infant • Jaundice • 2.4x more likely to develop significant hyperbilirubinemia; 25% require photo tx • Peak is at 5-7 days • Immature liver function, infective albumin binding decreases conjugation of bilirubin • Frequent feeding and assessment critical • bilitool.org

12. Care of the Late Preterm Infant • Feeding • Suck/ swallow coordination develops at 36-38 weeks gestation • Fewer sucks, lower pressure • Little empirical data on feeding protocols for the Late Preterm Infant • an excellent research opportunity for you future grad students

13. Care of the Late Preterm Infant • Feeding protocol • Feed within first hour, skin to skin contact • Provide lactation support • Provide test weights • Skin to skin contact 30 minutes per day increases milk volume • Frequent feedings • State assessment- teach parents

14. The Environment: The AWHONN Initiative • Matching the needs of the Late Preterm Infant with appropriate care environment • NICU and well-baby nurseries often fail to meet the needs of this population • Need to develop practice guidelines and a standard of care for the environment • Lack of widespread recognition threatens delivery of optimal care

15. Family Role: The AWHONN Initiative • The Late Preterm Infant may not be mature enough to provide adequate cues to assist the family in meeting care needs • The expectation to perform like their full term counterpart can lead to parental frustration and sense of inadequacy • Lack of evidence-based information

16. Parent-Education for Late Preterm Infants • Feeding • Feed slower and need to be fed more often • Less volume • Feed often to prevent jaundice • If baby refusing feedings, contact provider • May have problems initiating or maintaining breastfeeding

17. Parent-Education for Late-Preterm Infants • Sleeping • May be sleepier than term infants and may sleep through feedings • Need to awakened for feeds every 3 or 4 hours • All infants, including LPI’s, should be placed on their backs to sleep

18. Parent-Education for Late-Preterm Infants • Breathing • Greater risk for respiratory distress • Any symptoms or trouble, call their provider • Remind parents to look at their lips and mucus membranes for color changes

19. Parent-Education for Late-Preterm Infants • Temperature • Have less body fat • May be less able to regulate their own body temperature • Should be kept away from drafts • Do not need to be overdressed

20. Parent-Education for Late-Preterm Infants • Jaundice • These infants are more likely to develop jaundice that can lead to severe neurological damage if not identified and treated • Should be screened for jaundice prior to discharge • Should see provider within 24-48 hours of discharge, and any time skin appears yellow or infant not feeding well

21. Parent-Education for Late-Preterm Infants • Infections • May have immature immune system • Watch for signs for illness or infection such as: • temp instability • difficulty breathing

22. Questions Parents of Late Preterm Infant’s Should Ask Their Provider • How often should I bring my baby in for examinations? • What is the minimum number of times I should feed him or her each day? • What is the longest period of time I should let him or her go without eating? • What sorts of things should I be watching out for in terms of behavior or appearance? • How will I know if I should call you and how do I reach you? • When should my baby have a test for jaundice? (This list is available for print/ download at awhonn.org)

23. Bibliography • American Academy of Pediatrics (2004) Clinical Practice Guideline “Management of Hyperbilirubinemia in the newborn 35 or more weeks gestation”, aap.org. • Cockley, C. (2005) focus on the Near-tem infant) , AWHONN Lifelines, 9, (4). • “Emerging Issues in Late Preterm ( near-term) Infant Care” AWHONN Lifelines, 9, (10) • Medoff-Cooper, et.al. “The AWHONN Near-Term Initiative”, JOGGN, 34, 667-671. • Near-Term Initiative: www.awhonn.org • ‘Near-term’ unease grows: www.usatoday.com/news/health/2005-10-09-babies-birth_x.htm?POE=click-refer • Wang, M.L., Dorer, D.J., et al (2004) Clinical Outcomes of Near-Term Infants. Pediatrics 114: 372-376 • Wright, Gretchen (2005) “What the Parents of Near-Term Infants Need to Know”. AWHONN.Org