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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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)

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