Late Preterm Infant

The Late Preterm Infant (34 0/7 to 36 6/7 weeks) Physical Exam & Physiologic Challenges

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Why is this a problem? • The Late Preterm Infant (LPTI) population has increased by 30% since the 1980’s and accounts for as much as 75% of all preterm births in the US. • Possibly due to increasing maternal age, increased use of fertility treatments, multiple gestation, increasing obesity rates, maternal morbidity. • One study reports that a cost of $51,600 is associated with each late preterm birth.

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Physical Exam Findings • LPTI should essentially have a normal exam, but may have some of these variations: – Increased lanugo, increased vernix, thin appearing skin, more visible veins – Boys may have high rising testes and a smoother appearing scrotum – Girls may have more prominent labia minora

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Physical Exam Findings – – – –

Decreased creases on soles of feet Lack of fully developed cartilage in ear Decreased subcutaneous fat May have decreased tone, with resting tone not in flexed position

• Most of the differences between a full term and late preterm infant are things you can’t see during a routine physical exam!

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Risks to the Late Preterm Infant • Excessive sleepiness • Excessive weight loss • Feeding problems • Hyperbilirubinemia • Hypoglycemia • Respiratory distress • Sepsis

• Hypothermia and temp instability • ED visits and readmissions • Development delay • Increased medical costs

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Physiologic Challenges: Thermoregulation • Increased risk for COLD STRESS: – Less subQ fat to insulate and less brown fat/adipose tissue to generate heat – Immature skin does not function well as a barrier for evaporative heat loss – High surface area to body mass ratio – Higher metabolic rate and little reserve – Less muscle tone and activity

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Cold Stress • Can lead to metabolic acidosis, increased metabolic rate, pulmonary vasoconstriction • Signs and symptoms may include: apnea, bradycardia, lethargy, poor tone, mottled or pale skin. • May contribute to poor transitioning and lead to unnecessary sepsis work ups.

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Minimizing Cold Stress • Goal: neutral thermal environment in which infant maintains temp without increased O2 or glucose/energy demand. • Drying skin and hair with warm blankets after delivery and placing skin to skin • Swaddle in 2-3 blankets • Use of hats • Use radiant warmer as needed EB

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Thermoregulation: Clinical Pathway Interventions • Increased frequency of VS and temp checks • Ensure neutral thermal environment • Frequent skin to skin – If not skin to skin, keep infant dressed with hat on and wrapped in 1-2 blankets

• Continue delayed 1st bath • Hypothermia: slow rewarming with radiant warmer, check blood sugar. EB

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Physiologic Challenges: Breathing • Development of terminal air sacs in the lungs continues in utero during weeks 34-36 6/7. • Alveoli are maturing and becoming lined with Type 1 epithelial cells. These cells are closer in proximity to capillaries to help with gas exchange. • Type 2 cells develop during this time also to secrete surfactant. • Immaturity can lead to poor lung compliance and increased pulmonary resistance.

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Physiologic Challenges: Breathing • Less effective clearance of amniotic fluid • Difficult to maintain alveolar expansion • More likely to experience RDS, TTN, even respiratory failure. • Other risks include apnea, bradycardia, ALTE’s, SIDS

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Respiratory Distress • Usually manifests in first hours after birth with grunting, flaring, tachypnea, retractions. • Risk increases if c-section delivery with no labor. – During labor, catecholamines are released which help with absorption of lung fluid and surfactant release helping to improve lung compliance.

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Breathing: Clinical Pathway Interventions • More frequent VS and respiratory assessments • Pulse ox screenings with VS • Parent education regarding respiratory distress • If RR >60 breathes per minute, consider holding feeding temporarily

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Physiologic Challenges: Energy and Metabolism • Regulation of temperature helps minimize risk of hypoglycemia • All babies have physiologic nadir of blood sugar between 1-2 hours of life. This decrease in blood sugar is more pronounced in the late preterm than full term infant. • Should have blood sugars monitored and have first feeding within 1 hour of life (if stable) and no less than every 3 hours after EB

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Physiologic Challenges: Hypoglycemia • LPTI 3x more likely to suffer from hypoglycemia than term infants. • Decreased glycogen stores and adipose tissue • Immature liver enzymes less able to increase glucose production through gluconeogenesis • Immature pancreatic beta cells may secrete more insulin than necessary • Medical complications increasing demand. EB

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Hypoglycemia • Sources vary as to what is a ‘normal’ glucose in infants. Reported ranges: 40-45 to 55-70. • 80% of total glucose is consumed by the brain • LPTIs cannot effectively use other forms of fuel such as ketones, amino acids, and glycerol to raise blood sugar. • This, combined with immature protective systems in the brain, make the LPTI more at risk for adverse neurologic outcomes related to hypoglycemia. EB

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Energy and Metabolism: Clinical Pathway Interventions • Hypoglycemia protocol • Assess weight loss daily • Assess ability to eat safely: coordination of suck, swallow, breathe. • Early and effective feedings

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Physiologic Challenges: Feeding & Nutrition • Risk for poor feeding & inadequate caloric intake – Mom at risk for delayed/low milk production, weak suck, small mouth, high energy demand with low stores, sleepy, uncoordinated suck/swallow/breathe, lack of hunger cues, ineffective milk transfer.

• These mother baby dyads need extra help: – Assistance with latch, education on frequency of feeding and hunger cues, use of nipple shield, pumping, supplementing. EB

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Feeding and Nutrition: Clinical Pathway Interventions • Early and effective feedings with assessment of milk transfer • Initiate feeding plan based on infants method of feeding. Feeding plan for discharge. • Assist mother with learning to pump. • Early supplementation or increased caloric formula for excessive weight loss as indicated in feeding plan EB

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Physiologic Challenges: Hyperbilirubinemia • LPTIs have a later peak (day 5-7) and prolonged phase of elevated bilirubin. – Low milk intake and transient slower intestinal motility leads to slowing passage of meconium – This increases enterohepatic circulation and reuptake of bilirubin – Bilirubin conjugating enzyme activity is lower

• Increased risk of readmission for jaundice. • Risk of kernicterus is higher EB

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Minimizing Hyperbilirubinemia • Optimize feeding with increased milk intake – Consider early supplementation – Assist with meconium clearance – Prevent excessive weight loss

• Keep moms and babies together and maximize stay in hospital • Monitor with TC or serum bilirubin checks • Start phototherapy at a lower threshhold. EB

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Hyperbilirubinemia: Clinical Pathway Interventions • Serum bilirubin at 24 hours of life (obtain with newborn screen). • Early and effective feedings • Daily assessment of jaundice with clinical assessment and TC/serum checks • Maximize length of hospital stay

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Physiologic Challenges: Immature Nervous System • Significant brain growth and maturation occurs in last 6-8 weeks of pregnancy – 34 weeker has 50% less brain volume than term infant

• LPTI less able to control state regulation and regulate internal processes. – Decreased tone, positional apnea, disorganized suck/swallow/breathe, frequent startling, more spitting up, unpredictable response to stimuli (even when attempting to soothe) – Minimizing or clustering stimulation is helpful EB

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Physiologic Challenges: Immature Nervous System • Because of the significant amount of brain growth, neuronal connections to be made, and overall nervous system development that still is occuring, the LTPI is at a higher risk for long term neurodevelopmental delays. • In severe cases, IVH and PVL, although this is not common

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Immature Nervous System: Clinical Pathway Interventions • • • •

Encourage skin to skin Minimize unnecessary stimulation Allow uninterrupted periods of rest Parent education of behavioral states, infant soothing techniques, developmental milestones, etc.

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Physiologic Challenges: Immature Immune System • Less maternal antibody transfer across placenta as compared to full term infant. • Other risk factors are common to all infants, although preterm infants more susceptible. – Chorioamnionitis, ROM >18h, maternal fever.

• Signs and symptoms can be vague. – Temp instability, respiratory distress, hypoglycemia, lethargy, jaundice, irritability, feeding difficulties. EB

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Immature Immune System: Clinical Pathway Interventions • Handwashing! • GBS protocol • Evaluate maternal and infant risk factors that may predispose infant to infection • No sick contacts

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LPTI Discharge Considerations: Suggestions from the AAP • Demonstrate weight gain • Competent feeding by parents preferred method • Able to maintain body temperature while dressed in open crib with normal room temp • Stable cardiorespiratory function • Parents educated on special needs of LPTI and competent in all care • PCP identified and close follow up arranged EB

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Additional UNC LPTI Discharge Considerations • Discourage any discharge prior to 48 hours of age. • Feeding plan in place prior to going home • Late preterm specific parent education • PCP follow up within 24 (or 48) hours of discharge required. • Consider outpatient follow up with LC 24-48 hours after discharge. EB

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References • • •

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Darcy, A. (2009). Complications of the Late Preterm Infant. Journal of Perinatal Neonatal Nursing , 23 (1), 78-86. Hubbard, E., Stellwagen, L., & Wolf, A. (2007). The Late Preterm Infant: A Little Baby with Big Needs. Contemporary Pediatrics . Mally, P., Bailey, S., & Hendricks-Munoz, K. (2010). Clinical Issues in the Management of Late Preterm Infants. Current Problems in Pediatric and Adolescent Healthcare , 40 (21), 218-233. National Guideline Clearinghouse. (2010). Assessment and Care of the

Late Preterm Infant. Evidence-based clinical practice guideline.

Oklahoma Infant Alliance. (2010, September). Caring for the Late Preterm Infant. A Clinical Practice Guideline.

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References • •

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University of California, San Diego Medical Center. (2006, October). Late Preterm Infant Policy Statement. Raju, T., Higgins, R., Stark, A., & Leveno, K. (2006). Optimizing Care and Outcome for Late-Preterm (Near Term) Infants: A Summary of the Workshop Sponsored by the National Institute of Child Health and Human Development. Pediatrics (118), 1207-1214. Ramachandrappa, A., & Jain, L. (2009). Health Issues of the Late Preterm Infant. Pediatric Clinics of North America (56), 565-577. Verklan, M. T. (2009). So, He's a Little Premature...What's the Big Deal? Critical Care Nursing Clinics of North America , 21, 149-161.

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