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Optimizing Health for the Late Preterm Infant

Optimizing Health for the Late Preterm Infant. The AWHONN Initiative Presented by: Bette T. Johnson, CRNP St. Charles Medical Center Bend, OR. Objectives. Discuss the definition, incidence and contributing factors of late preterm birth

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Optimizing Health for the Late Preterm Infant

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  1. Optimizing Health for the Late Preterm Infant The AWHONN Initiative Presented by: Bette T. Johnson, CRNP St. Charles Medical Center Bend, OR

  2. Objectives • Discuss the definition, incidence and contributing factors of late preterm birth • Identify the mortality and morbidity issues associated with late preterm birth • Describe AWHONN’s Late Preterm Infant Inititatives • Discuss risks for and etiology of respiratory distress in the late preterm newborn • Describe the clinical presentation, diagnostic evaluation and management of transient tachypnea versus respiratory distress

  3. Objectives • Indentify methods of heat loss and gain • Recognize symptoms of hypo/hyperthermia • Describe the increased risk for, evaluation and management of hyperbilirubinemia • Understand how immaturity increases the risk of hypoglycemia and feeding difficulties • Articulate and nursing care plan for parent education

  4. Definition of the Late Preterm Infant • Infants born between 34 and 36 completed weeks of gestation • Terminology changed in literature 2006 • Late preterm is synonymous with near-term

  5. Scope and Significance of Late Preterm Issues • Incidence Increasing incidence of late preterm births Late preterm infants makeup > 70% of all births • Morbidity: full risk not clear • Mortality: some explained by medical reasons for early delivery

  6. Importance of the Third Trimester • Vital period of maturation Lung development Brain maturation Liver maturation • Vital period of growth Body mass increases Fat stores increase

  7. Late Preterm Complications • Respiratory Distress • Temperature instability • Hyperbilirubinemia • Feeding challenges

  8. AWHONN’s Late Preterm Infant Initiative • Raise awareness of unique needs of late preterm infants • Emphasize need for research • Encourage development and adoption of evidence-based guidelines for late preterm care • Provide resources for systematic clinical assessment and parent education • Foster collaboration among other health care providers

  9. Physiological Functional Status The late preterm infant’s physiologic and functional well-being is influenced by many factors: • Postmenstrual age • Maternal and fetal health and history • Timing and method of birth • Transition to extrauterine life • Location and quality of care provided

  10. Contributing Factors • Advanced Maternal Age • Birth rate for women >35 has been rising while rates for women between 20-24 have declined • Increased incidence of pregnancy induced hypertension and subsequent IUGR • AMA associated with chromosomal abnormalities, gestational disorders, chronic health disorders, the use of assisted reproductive technologies (ART), multiple births and c-sections

  11. Contributing Factors Assisted Reproductive Techniques (ART) • Associated with delayed childbearing and AMA and increased numbers of multiple births • 2004 CDC reported 128,000 ART procedures resulting in 50,000 infants – 50% were multiples. Increasing risk of preterm deliveries

  12. Contributing Factors Multiple births • 2003- 67% increase in twins and 500% in triplets and other higher-order multiples since 1980. • Average age of twins is 35.3 weeks, triplets 32.2 weeks. • Complications that may cause late preterm birth- gestational diabetes, preeclampsia, abruptio placenta, maternal hemorrhage

  13. Contributing Factors C-Section • 2004 US Vital Statistics showed that c-section rates rose to 29 % Preterm Premature Rupture of Membranes • PPROM is responsible for 1/3 of all preterm deliveries. High association with intrauterine infections. Other known causes- smoking, STD’s, prior cervical surgery, abnormal placentas

  14. Contributing Factors Human Papillomavirus (HPV) • Most common STD in US • Associated with high incidence of cervical cancer • Surgical treatment is cone biopsy which removes portion of cervix • Cryosurgery and LEEP (loop electrosurgical excision procedure • Treatments may increase risk of preterm deliveries

  15. Contributing Factors Stillbirth Prevention and Medical Legal Concerns • Stillbirth rate has dropped from 14% in 1970 to 6.7/1,000 births in 1998. • Advances in OB care and fetal monitoring detect problems early and allows for early delivery when indicated

  16. Assessment of Risk Factors • Respiratory Distress • Temperature instability • Hyperbilirubinemia • Feeding issues

  17. Respiratory Distress Incidence: • 35-36 week infants: 28.9% respiratory distress at birth compared to 4.2% of term infants • 35-36 week ventilated infants: 62% with RDS

  18. Respiratory Distress in the Late Preterm Infant • Distinguish difficult transition to extra-uterine life from significant respiratory distress • Differential diagnosis TTN RDS Sepsis PPHN Congenital anomalies

  19. Transient Tachypnea of the Newborn • TTN occurs due to delayed re-absorption of lung fluid • Onset: 2-6 hours of life • Risk Factors – c/s without labor, precipitous delivery, polyhydramnios • Clinical presentation – tachypnea 80-120 bpm, grunting, flaring and retractions

  20. Transient Tachypnea • Diagnostic studies Blood gases- mild, mixed acidosis Chest xray – peri-hilar streaking, fluid, over-inflated CBC, blood culture – r/o sepsis screen • Management Supportive care- oxygen, NPO, IV’s, antibiotics • Outcome: usually self-limiting

  21. Respiratory Distress: Risk Factors • Elective C-section without labor • Maternal complications • Gestational diabetes, hypertension • Placental abnormalities • Premature rupture of membranes

  22. Respiratory Distress: Risk Factors • Fetal Factors • Male sex • Prematurity • Intrauterine growth retardation • Fetal distress

  23. Respiratory Distress Syndrome • RDS occurs due to a deficiency in amount of surfactant • Onset: within minutes to hours of birth • Risk Factors for RDS: late preterm birth, male, IDM, pre/natal or perinatal stress, traumatic delivery

  24. RDS: Clinical Presentation • Tachypnea up to 120 bpm • Grunting, flaring and retractions • Pallor or cyanosis with increasing hypoxemia • Decreased breath sounds/fine rales • Hypotension, decreased perfusion, tachycardia

  25. RDS Diagnosis • Arterial blood gases PaO2 < 50-60 mm Hg with FiO2 > 60% Severe Hypercapnia (PaCo2 > 55-65 mm Hg with pH < 7.20-7.25) • Chest xray: characteristic granular pattern with air bronchograms • Rule out sepsis

  26. RDS: Management • Lung expansion NCPAP, mechanical ventilation if needed • Neutral thermal environment • Oxygen • Surfactant replacement therapy • 100mg/kg in 2-4 aliquots per the ETT as early as possible q 6-12 hours for 2 – 3 doses

  27. RDS: Management • Fluid restriction – NPO • Monitor serum electrolytes • Minimal stimulation • Blood pressure support • Alkali therapy

  28. RDS: Outcome • Morbidity and mortality of RDS directly related to birth weight and gestational age • Affected by prenatal glucocorticoid treatment and surfactant replacement

  29. RDS: Parent Education • Signs of re-occurring respiratory distress • When to notify pediatrician • Late preterm infants are at increased risk for infection – good infection control hygiene measures • All infants should be placed on their backs to sleep

  30. Thermoregulation • Controlled by the hypothalamus • Cold stress • Heat stress

  31. Non-Shivering Thermogenesis • Cold stress stimulates the hypothalamus to release epinephrine at the site of brown fat • Major function: heat production • Axilla, nape of neck, between scapulas • Stores continue to increase 3-5 weeks postnatal life – most laid down after 35 wks • Free fatty acids + thermogenin = heat • Requires oxygen and glucose

  32. Heat Transfer Mechanisms:Conduction • Heat transfer by direct contact • Varies with exposed surface area • Late preterm infant may not be able to change position • Decreased subcutaneous fat for insulation • Superficial blood vessels constrict • Measures to minimize heat loss

  33. Heat Transfer Mechanisms: Convection • Air currents remove the baby’s boundary layer of warm air, moving heat away from the body • Ambient temperature, air flow velocity, relative humidity, cool oxygen during resuscitation • Measures to minimize heat loss

  34. Heat Transfer Mechanisms:Evaporation • Liquid is converted into a vapor • Water losses through skin and respiratory system • Major source of heat loss at delivery/bathing • Dependent upon air speed and relative humidity • Measures to minimize heat loss

  35. Heat Transfer Mechanisms:Radiation • Transfer of radiant energy from the body to objects without direct contact • Radiant warmer • “Greenhouse effect”- overheating • Measures to minimize heat loss

  36. Transition to Extrauterine LifeThermal Stability • At birth: wet baby placed in cold/dry environment. Rapidly cooling occurs by convection and evaporation • Increased activity, vasoconstriction, non-shivering thermogenesis – increased energy use • Increased metabolic rate • Possible difficulty in maintaining temp

  37. Monitoring Body Temp • Axillary temp every 1-4 hours • Term: 97.9-99.5 F (36.5 – 37.5 C) • Preterm: 97.5-98.5 F (36.3-36.9 C) • Skin Temp • Term: 96.8-97.7 F (36-36.5 C) • Preterm: 97.2-99 F (36.2-37.2 C) • Rectal and tympanic temperatures not recommended

  38. Warmer Overview Radiant Warmers: • Skin servo-controlled • Quickly and safely re-warms infant • Allows direct patient access • Does not insulate baby from noise, light and other noxious stimuli Incubators • Skin or air servo-controlled • Advantage in weaning to crib • Temperature fluctuations with portholes • Limited access to patient

  39. Skin-to-Skin Care • Placed against parent’s skin clothed with diaper and covering blanket • Can be close to breast for feeding • Vital signs and oxygenation more stable • Improved sleeping patterns and direct social eye contact

  40. Hypothermia: Clinical Presentation • Pale, cool to touch • Acrocyanosis • Respiratory distress • Apnea, bradycardia, central cyanosis • Irritability progressing to lethargy • Progressive or chronic cold stress

  41. Temperature Instability:Lab Data • Arterial blood gas • CBC with diff • Blood glucose • Electrolytes • BUN • Serum and urine osmo

  42. Hypothermia: Treatment • Re-warm carefully by providing external heat • Prevent further heat loss • Frequent evaluation of temp • Potential complications- metabolic acidosis, respiratory distress, hypoglycemia, hyperbilirubinemia

  43. Hyperthermia: Clinical Presentation • Warm to touch; appears very pink or red • Sweating not present until 36 weeks • Tachypnea and apnea • Tachycardia, weak cry, hypotonic, irritable/lethargic, poor feeding

  44. Hyperthermia: Treatment • Remove external heat source • Check for iatrogenic cause: • Servo probe off; excessive bundling • Direct sunlight, heater, phototherapy units Non-enviornmental causes – dehydration, CNS abnormalities, sepsis Complications: increased insensible water loss, dehydration, hypotension, apnea

  45. Thermoregulation: Parent Education • Explain normal range of temperatures • Show/tell how to obtain axillary temp • Describe home environment and clothing suitable for baby • Provide written instructions for when to call physicians

  46. Hyperbilirubinemia and the Late Preterm Infant • More at risk for significant hyperbili • 25% need phototherapy • Immature liver • Higher bilirubin levels and later peaks • Less vigorous feeding leads to decreased oral intake

  47. Hyperbilirubinemia:Overproduction and Decreased Excretion • Prematurity • Bacterial sepsis • Urinary tract infection • Intrauterine viral infections • Hypopituitarism • Hypothyroidism

  48. Breastfeeding and Jaundice • Rates of breastfeeding increased from 33% in 70’s to ~50-60% today • Length of routine hospital stay is 48 hours • Inadequate lactation associated with increased bilirubin levels • Late preterm infant at risk for feeding problems • Lactation support valuable

  49. Hyperbilirubinemia: Parent Education • Give information on causes and treatment • Stress importance of adequate and frequent feeds • Signs and symptoms of hyperbili • When to call Pediatrician

  50. Feeding Issues • Risk of inadequate intake • Hypoglycemia • Increased incidence of hyperbili • Increased weight loss in first days/weeks of life • Readmission to hospital

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