Care of the Late-Preterm Infant Constance Hymas CDR, NC, USN RNC-NIC, MN, MSHS, NNP-BC.
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Transcript of Care of the Late-Preterm Infant Constance Hymas CDR, NC, USN RNC-NIC, MN, MSHS, NNP-BC.
Care of the Late-Preterm Infant
Constance HymasCDR, 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 kgGiven 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 distressIncreased respiratory rate increases evaporative heat lossHeat 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
1. How often should I bring my baby in for examinations?
2. What is the minimum number of times I should feed him or her each day?
3. What is the longest period of time I should let him or her go without eating?
4. What sorts of things should I be watching out for in terms of behavior or appearance?
5. How will I know if I should call you and how do I reach you?
6. 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