THE “LATE PRETERM” Newborn Not Ready for “Term Time”

1. THE “LATE PRETERM” Newborn Not Ready for “Term Time” Mary Johnson RNC/MSN Gwinnett Medical Center

2. Objectives • Describe the variations seen in the birth weight and gestational age of the late preterm infant • Identify two health problems for which the late preterm infant has an increased risk • List two discharge needs of the late preterm infant

3. Definitions • Term: 37 weeks and 0 days through 42 complete weeks of gestation • “Late Preterm”: 34 to 36.6 weeks gestation • Preterm: Has become a gestational age of under 34 weeks

4. Incidence • 6.4 to 8.5 % of all births are born between 34 and 36.6 weeks gestation • Incidence of prematurity has risen from 7.9% to 11.9% • African American rate:7.6%;Caucasian 15.6%

5. Fact or Fiction • The prematurity rate has remained stable for the past 20 years • Because of the successes of NICUs, energy toward prematurity prevention can be decreased

6. Fact or fiction • The reasons for premature labor are well understood • Risk factors predict the majority of preterm births • Media and public service ads have had a large impact on public awareness and knowledge of prematurity

7. Why the Current Interest • Previous focus on normal newborn and extremely low birth weight infants • Prevalence rate (6.4 to 8.5 %) • Increased hospital readmissions • Previously absorbed into the regular population in NICU or intermediate nurseries

8. Current Interest • Now absorbed into the “well” baby nursery • Cost restraints regarding unit placement and nurse staffing ratios

9. Current Interest • Pediatrics study: 90 late preterm and 95 full term babies • Late preterm babies had significantly more • Medical Problems: • 27 % of Late Preterms had IVF’s vs 5% of Term babies • More like to be evaluated for infection, hypoglycemia breathing problems and jaundice

10. Current Interest • Medical Costs: • Mean difference of $2630 between Late Preterm and Term • Lengths of stay: • 50 of the late preterm babies did not go home with their mothers versus 8 of the full term babies. • Wang, et al (2004). Pediatrics: 114:2

11. NOT READY !! • Why the increase in late preterm births? • C/S on Demand • US single birth distribution of gestational age has shifted towards earlier gestation • 39 weeks is now the most common length of gestation (not 40)

12. Not Ready • The 34 to 36 week gestational age infant is the fastest growing segment of single preterm births

13. C/S on Demand • C/S initially an emergency procedure • Now advocated as a routine technique • Women as Health Care Consumers: avoid stretch marks; fit into family schedule; • Better bladder control in the future; mostly in multips

14. C/S on Demand • Labor and SVD no longer “desired” outcome • “Informed” consent for SVD • Maternal “risks” of SVD • Neonatal risks of C/S • Respiratory issues; difficult transition; etc.

15. LABOR IS GOOD! Increase of catecholamines which increases neonatal cardiac output and contractility Enhances surfactant release Inhibits fetal lung fluid secretion Increases glycogenolysis

16. Characteristics • 34 to 37weeks: weights • 34: 1500 grams to 2800 grams (3lbs 5oz to 6 lbs 3 oz) • 35: 1700 grams to 3 kgs (3lbs 12oz to 6lbs 10oz) • 36: 1900 grams to 3200 grams (4 lbs 3 to 7 lbs 1 oz) • 37: 2100 grams to 3400 grams ( 4 lbs 10 oz to 7 lbs 8 oz)

17. Not Ready • DANGER!! DANGER!! AT RISK!! • Respiratory instability • Hypoglycemia • Sepsis • Hypothermia • Feeding Issues • Hyperbilirubinemia

18. Respiratory Instability • RDS • TTN • Apnea

19. Respiratory Distress Syndrome • Etiology: Lack of surfactant • Surfactant produced in last stages of pregnancy • Begins at about 32-33 weeks and increases slowly to maximum levels at 38 to 40 weeks

20. RDS Symptoms • Grunting • Flaring • Retractions • Cyanosis

21. RDS TREATMENT • Oxygenation • Ventilation • Surfactant replacement

22. Transient Tachypnea “TTN” • Risk factors • Asphyxia: Term babies better equipped to deal with low ph’s and po2 than late preterm babies because of decreased glucose metabolism and decreased oxygenation capacity • C/S: no vag squeeze; catecholamine release decreased

23. TTN • Self limiting condition • Symptoms include: tachypnea; retractions; grunting • Symptoms mild and resolve over hours to days • Require O2 and supportive therapy

24. TTN Etiology • Retained fetal lung fluid • Why increased in the late preterm population? • C/S • Fetal lung fluid production decreases during late pregnancy and absorption is increased with catecholamine surge during labor

25. Apnea • Immature respiratory centers in the CNS • Upper airway flaccidity

26. Hypoglycemia • Infants at greatest risk: • BW < 2500grams; <37 weeks • IDM’s • SGA or LGA

27. Hypoglycemia • Why increased incidence in late preterm babies? • Poor mechanisms to regulate glycogenolysis and gluconeogenesis as both processes require glucose and oxygen • Preterm babies have lack of reserves of glucose and methods of manufacturing glucose • More likely to have oxygenation problems

28. Sepsis • Respiratory Distress • Decreased perfusion/hypotension • Poor Feeding • Temperature Instability • “Something is just not right”

29. Sepsis • Why are Late Preterm babies more likely to develop sepsis? • Antibodies (IGA, IGM) are not at adequate levels for protection until 3 to 6 months of age. • Antibodies start to form at 20 weeks gestation and increase in production beginning around 38 weeks

30. Sepsis • Be cautious: don’t dismiss subtle signs • Antibiotics are a priority

31. Hypothermia • Why are Late Preterm Babies at risk for Hypothermia? • Immature CNS for temp regulation • Lack of brown fat • Immature Hormone systems decrease release of norepinephrine (mediates metabolism of brown fat)

32. Hypothermia • This brown fat /norepinephrine process relies heavily on oxygen and glucose utilization which is compromised in the late preterm infant

33. Hypothermia • What does hypothermia cause? • Increased metabolic rate which decreases an already limited supply of glucose for energy. • Increased oxygen consumption which causes pulmonary vaso constriction and hypoxemia which also leads to worsening respiratory distress.

34. Feeding Issues • 10% of Late Preterm infants are readmitted for “failure to thrive” or “poor feedings”. Why do these babies not fed well…

35. Feeding Issues • Less stamina; less coordinated S/S/B; Less effective suck; Less awake alert periods. This causes insufficient breast stimulation and incomplete breast emptying leading to inadequate milk supply and transfer and feeding volume

36. Feeding Issues • This contributes to hypoglycemia, jaundice, dehydration and poor weight gain which leads to: • Delayed discharge, readmission, supplementation and maternal separation

37. Jaundice • Why are Late Preterm babies more at risk for jaundice? • Increased production and decreased elimination of bilirubin • Hepatic immaturity results in altered hepatic uptake and conjugation of bilirubin • Breastfeeding practices

38. Kernicterus • When bilirubin at high enough levels crosses the blood/brain barrier leading to developmental delays, CP like symptoms.

39. Discharge and Follow up • Stable temperature • Effective feeding performance • Effective milk production • Stable weight status • Bilirubin assessment and treatment • CAR SEAT TEST

40. Discharge • Establish follow up care • 24 to 48 hours after discharge!!

41. Maternal Perceptions • These babies are fine; not considered premature. • All babies are sleepy and all babies get jaundiced • All babies have trouble breastfeeding…. • I HAVE TO GO BACK TO THE HOSPITAL?!?!?!?!

42. Late Preterm Initiative • “Late preterm babies have unique needs. This population, though often treated like full term newborns, are at the risk for the same problems that premature newborns experience, including jaundice, RDS, feeding problems and potential developmental delays.” AWHONN

43. Late Preterm Initiative • Multi year national nurses initiative to improve care and outcomes of these infants • National Advisory Panel • Focus • Neonatal physiological status • Nursing Care Practices • Care environment …NICU vs “Term Nursery”

44. AWHONN’S goals • Raise awareness of infants and parents needs • Encourage research • Develop and adopt evidence based guidelines for near term infants • Health care team will be on the same page • Consistent parent education about care of their late preterm baby

45. Four areas of focus • Physiologic functional status • Care environment at both hospital and at home • Family • Nursing practice

46. Emphasis • ESSENTIAL role of the family • Arrangement of follow up care practices • Education of nurses AND physicians

47. AWHONN • “The best predictor of the needs of the late preterm infant is a skilled, experienced nurse with a high index of suspicion…”

48. THE END