Care of the Late Preterm Infant
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Where Tradition Meets Innovation
Care of the Late Preterm Infant
Patricia A. Scott, MSN, APN, NNP-BC, C-NPTVanderbilt University School of Nursing, Neonatal Nurse
Practitioner FacultyPediatrix Medical Group of Tennessee at Centennial Medical
Center – The Women’s HospitalUniversity of Tennessee Health Science Center DNP Student
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Where Tradition Meets Innovation
•Discuss the definition and incidence of late preterm birth.
•Discuss the incidence, risks for, and etiology ofrespiratory distress in the late preterm infant.
•Identify signs of hypo/hyperthermia.
•Describe the physiology, assessment, and managementof hyperbilirubinemia and why the late preterm infant isat increased risk.
•Discuss why this population is at increased risk forhypoglycemia and feeding difficulties.
Presentation Objectives
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Where Tradition Meets Innovation
Definition of the Late Preterm Infant
Infants born between 34 and 36 completed weeks of gestation
“Near term” thought to imply that these babies are “near enough” term to be physiologically the same (Engle, 2009)
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Where Tradition Meets Innovation
Distribution of Preterm Births (CDC)
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Where Tradition Meets Innovation
•Morbidity: not fully known•Mortality: 3 X higher than the term infant
Morbidity and Mortality
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Where Tradition Meets Innovation
•Vital period of maturationLung developmentBrain maturationLiver maturation
•Vital period of growthBody mass increasesFat stores increase
What does the Late Preterm Infant Miss?
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Where Tradition Meets Innovation
Complications (Adamkin, 2009)
Complication Late Preterm Infant Term Infant
Feeding 32% 7%
Hypoglycemia 16% 5%
Jaundice 54% 38%
Temperature Instability 10% 0
Apnea 6% < 0.1%
Required IV Fluids 27% 5%
Septic Evaluation 37% 13%
Mechanical Ventilation 3.4% 0.9%
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Where Tradition Meets Innovation
•Longer hospital stays•Higher rate of readmission •Increased nursing care•Location of care varies
Late Preterm Care Delivery Issues
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Where Tradition Meets Innovation
•Respiratory distress•Temperature instability•Hyperbilirubinemia•Feeding challenges
Most Common Complications
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Where Tradition Meets Innovation
Respiratory Distress
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Where Tradition Meets Innovation
•35 to 36 week infants: 28.9% respiratory distress at birth compared to 4.2% of term infants
•35 to 36 week ventilated infants: RDS in 62%
Respiratory Distress: Incidence
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Where Tradition Meets Innovation
•Delayed transition or respiratory distress?•Differential diagnosis includes:
TTN RDS Sepsis PPHN Congenital anomalies
Respiratory Distress
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Where Tradition Meets Innovation
Risk Factors for Respiratory Distress
•Elective cesarean birth without the benefit of labor
•Maternal complications
•Fetal factors
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Where Tradition Meets Innovation
•Delayed reabsorption of lung fluid•Onset: 2 to 6 hours of life•Risk factors for TTN
Cesarean delivery Precipitous delivery
Transient Tachypnea of the Newborn
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Where Tradition Meets Innovation
• Clinical presentation Tachypnea Grunting / flaring / retractions
• Diagnostic studies Blood gases Chest x-ray Septic work-up
• Management / Outcome Supportive care
Transient Tachypnea of the Newborn
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Where Tradition Meets Innovation
Chest X-Rays
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Where Tradition Meets Innovation
•Immature lungs and surfactant deficiency •Onset: within minutes to hours of birth•Risk Factors PrematurityCesarean deliveryMaternal diabetesSecond born twinPerinatal asphyxiaMale gender
Respiratory Distress Syndrome
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Where Tradition Meets Innovation
RDS: Clinical Presentation
•Tachypnea•Grunting•Flaring •Retractions•Pallor or cyanosis
•Decreased breathsounds/fine rales•Hypotension•Decreased perfusion•Tachycardia
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Where Tradition Meets Innovation
•Arterial blood gasesHypoxemiaRespiratory acidosis
•Chest x-ray •Infection should be ruled out
• RDS: Diagnosis
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Where Tradition Meets Innovation
Chest X-Rays
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Where Tradition Meets Innovation
•Provide a NTE•Oxygen support, as needed•Ventilatory support, as needed•Surfactant replacement therapy
As early as possible
RDS: Management
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Where Tradition Meets Innovation
•Fluid restriction•Monitor serum electrolytes•Minimal stimulation•Blood pressure support•Continued, comprehensive assessment
RDS: Management
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Where Tradition Meets Innovation
Directly related to birth weight andgestational age Affected by prenatal glucocorticoid treatment and
surfactant replacement
RDS: Outcome
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Where Tradition Meets Innovation
Thermoregulation
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Where Tradition Meets Innovation
Non-Shivering Thermogenesis
Cold stress → hypothalamus → epinephrine →brown fat metabolism Function: heat production Location: axilla, nape of neck,
between scapulas, mediastinum, around the kidneys
Stores increase until 3-5 weeks postnatal life
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Where Tradition Meets Innovation
•Conduction•Convection•Evaporation•Radiation
Heat Transfer Mechanisms
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Where Tradition Meets Innovation
•Heat transfer by direct contact•Varies with exposed surface area
Decreased ability to flex extremitiesDecreased subcutaneous fat Limited ability to VC peripheral blood vessels
•Ways to minimize
Conduction
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Where Tradition Meets Innovation
•Air currents move heat away from the body•Affected by ambient temperature, air flow
velocity, and relative humidity•Ways to minimize
Convection
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Where Tradition Meets Innovation
•Liquid is converted into a vaporMajor source of heat loss at delivery/bathingLosses through skin and respiratory system
•Dependent upon air speed and relative humidity•Ways to minimize
Evaporation
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Where Tradition Meets Innovation
•Transfer of radiant energy from the bodyto objects without direct contact
Radiant warmer – heat gain“Greenhouse effect”
•Ways to minimize
Radiation
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Where Tradition Meets Innovation
•Axillary temperature Term: 97.9 – 99.5 F (36.5 – 37.5 C) ' 'Preterm: 97.5 – 98.5 F (36.3 – 36.9 C) ' '
•Skin temperatureTerm: 96.8 – 97.7 F (36 – 36.5 C) ' 'Preterm: 97.2 – 99 F (36.2 – 37.2 C) ' '
•Rectal/tympanic not recommended
Normal Temperature Ranges
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Where Tradition Meets Innovation
Radiant Warmers versus Isolettes
•Advantages•Disadvantages•Wean to crib
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Where Tradition Meets Innovation
Skin-To-Skin Care
•Can be close to thebreast for feeding
•Stable vital signs and oxygenation
•Improved sleepingpatterns and directsocial eye contact
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Where Tradition Meets Innovation
•Pale, cool to touch•Acrocyanosis•Respiratory distress•Apnea, bradycardia, central cyanosis•Irritability → lethargy•Progressive or chronic cold stress
Hypothermia: Clinical Presentation
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Where Tradition Meets Innovation
Free FattyFree FattyAcid ReleaseAcid Release
Brown Fat Brown Fat UtilizationUtilization
COOLINGCOOLING
Pulmonary VCPulmonary VC Peripheral VCPeripheral VC
Norepinephrine Norepinephrine ReleaseRelease
Metabolic Metabolic RateRate
OO22 ConsumptionConsumption
R to L ShuntingR to L Shunting
Dependence on Dependence on Anaerobic MetabolismAnaerobic Metabolism
Lactic Lactic AcidosisAcidosis
? DEATH? DEATH
HypoxemiaHypoxemiaHypoxiaHypoxia
OO22 Delivery to Tissues Delivery to Tissues
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Where Tradition Meets Innovation
•Arterial blood gas•Septic workup•Blood glucose•Electrolytes
Temp Instability: Differential Diagnosis
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Where Tradition Meets Innovation
•Gradual re-warming•Prevent further heat loss•Frequent evaluation of temperature•Potential complications
Hypothermia: Treatment
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Where Tradition Meets Innovation
•Clinical presentation•Etiology•Treatment•Complications
Hyperthermia
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Where Tradition Meets Innovation
Hyperbilirubinemia
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Where Tradition Meets Innovation
•↑risk of significant hyperbilirubinemiaImmature liverHigher bilirubin levelsLater bilirubin peakLess vigorous feeding
•25% require phototherapy
Hyperbilirubinemia in the Late Preterm
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Where Tradition Meets Innovation
Overview of Bilirubin Pathway
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Where Tradition Meets Innovation
•Also called physiologic jaundice•Contributing factors: Increased bilirubin load Decreased hepatic uptake of bilirubin from plasma Decreased bilirubin conjugation Defective bilirubin excretion
Neonatal Jaundice
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Where Tradition Meets Innovation
•Hemolytic disease ABO and/or Rh incompatibility
•RBC enzyme abnormalitiesGlucose-6-phosphate dehydrogenase deficiencyPyruvate Kinase Deficiency
•Polycythemia•Extravascular blood•↑ enterohepatic circulation
Overproduction
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Where Tradition Meets Innovation
•↓ hepatic uptake of bilirubin•↓ bilirubin conjugation•Inadequate transport out of hepatocyte•Biliary obstruction
↓ Excretion
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Where Tradition Meets Innovation
•Prematurity•Bacterial sepsis•Urinary tract infection•Intrauterine viral infections•Hypopituitarism•Hypothyroidism
Overproduction + ↓ Excretion
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Where Tradition Meets Innovation
•Many advantages •Important to ensure good lactation support Inadequate lactation associated with increased TSB level Late preterm infant at risk for feeding problems
Less vigorous suck Less stamina with feedings Less coordination of suck and swallow Less alert-awake states
Breastfeeding and Jaundice
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Where Tradition Meets Innovation
•May be prevented/reduced with frequent feedings in first days of life •Late onset or prolonged hyperbilirubinemia•Affects 10-30% in 2nd to 6th week of life•Screen for risk factors to plan F/U•Unconjugated bilirubin level > 12 mg/dl
Breastfeeding and Jaundice
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Where Tradition Meets Innovation
•Family•Obstetric•Neonatal Decreasing gestational age Apgar scores LGA Elevated PCV Poor feeding
Hyperbilirubinemia: History
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Where Tradition Meets Innovation
•Clinical presentation:Jaundice may be the only presentation
Hyperbilirubinemia: Clinical Presentation
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Where Tradition Meets Innovation
•Maternal and infant blood types, Rh, and Coomb’s test•CBC/differential•Bilirubin levels
Hyperbilirubinemia: Laboratory Data
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Where Tradition Meets Innovation
Hour-Specific Total Serum Bilirubin
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Where Tradition Meets Innovation
•Develops subtly as the result of high bilirubinlevels causing neurological damage This damage may or may not be reversible with treatment. Prompt, aggressive treatment is more likely to reverse and
improve the outcome.
Acute Bilirubin Encephalopathy
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Where Tradition Meets Innovation
•Permanent brain damage resulting •Clinical picture: Spasticity Deafness / decreased hearing Setting sun sign Dental enamel dysplasia Intellectual capacity is normal, but may not be evident
Chronic Bilirubin Encephalopathy
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Where Tradition Meets Innovation
Feeding Difficulties
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Where Tradition Meets Innovation
•Hypoglycemia•Hyperbilirubinemia•↑Increased weight loss initially•Slower return to birthweight•Readmission to the hospital
Why is adequate intake important?
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Where Tradition Meets Innovation
•Decreased staminaLess effective sucklingDecreased transfer of milkSub-optimal breast stimulation
•Ability to suck-swallow-breathe
Feeding Concerns
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Where Tradition Meets Innovation
•Poor muscle tone Leading to fatigue, latch difficulty, and suboptimal feeding
•Fewer alert-awake periods Not as likely to initiate feeds and may end them prematurely
Feeding Concerns
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Where Tradition Meets Innovation
•Ensure adequate nutrition
Nursing Care
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Where Tradition Meets Innovation
•How often does this happen in late preterm infant? 10-15% incidence 2/3 of late preterm infants will require intravenous
dextrose for a blood glucose level < 40 mg/dl
Hypoglycemia
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Where Tradition Meets Innovation
•Inadequate substrate•Abnormal endocrine function•Increased glucose utilization
Hypoglycemia: Etiologies
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Where Tradition Meets Innovation
Hypoglycemia: Risk Factors
•MaternalGlucose infusion in laborMaternal diabetesMaternal hypertensionTocolytic treatment
•Fetal/NeonatalIUGRPerinatal asphyxiaSepsisTemperature stabilityRespiratory distress
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Where Tradition Meets Innovation
Hypoglycemia: Clinical Presentation
•Irritability, lethargy•Cyanosis, apnea•Poor feeding•Tachycardia
•Respiratory distress•Hypotonia•Tremors, jitters,
seizures•Hypothermia
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Where Tradition Meets Innovation
•Assessment Lowest glucose level is 30 to 90 minutes after birth Frequent assessments are needed in this population Glucose levels associated with neurological injury not well-established
•Treatment Treat underlying problem Early feeding Glucose infusion as needed Other medications
Hypoglycemia: Treatment
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Where Tradition Meets Innovation
•Knowledge of needs specific to this population
Significance and scope of the problem
•Care practices specific to this populationAssessmentAppropriate time for dischargeRisk for complications and readmission
•Continued research on best- and evidence-based practices in late preterm infant care
In Summary
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Where Tradition Meets Innovation
•Adamkin, D.H. (2009). Late preterm infants: severe hyperbilirubinemiaand postnatal glucose homeostasis. Journal of Perinatology, 29, S12-S17.
•American Academy of Pediatrics Subcommittee on Hyperbilirubinemia(2004). Management of hyperbilirubinemia in the newborn infant 35 ormore weeks of gestation. Pediatrics, 114, 297-316.
•Askin, D.F. (2002). Complications in the transition from fetal to neonatallife. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 31, 318-327.•Bhutani, V.K., & Johnson, L.H. (2001). Jaundice technologies: Prediction
ofhyperbilirubinemia in term and near-term newborns. Journal ofPerinatology, 21, S72-82.
•Bhutani, V.K., & Johnson, L.H. (2006). Kernicterus in late preterm infantscared for as term healthy infants. Seminars in Perinatology, 30, 89-97.
References
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Where Tradition Meets Innovation
•Blackburn, S.T. (2003). Thermoregulation. In S.T. Blackburn (Ed.),Maternal, fetal, & neonatal physiology: A clinical perspective (2nd ed., pp. 77-730). St. Louis: Elsevier Saunders.
•Blackburn, S.T. (2003). Bilirubin metabolism. In S.T. Blackburn (Ed.),Maternal, fetal, & neonatal physiology (2nd ed., pp. 656-676). Philadelphia:Elsevier Saunders.
•Center for Disease Control and Prevention, National Center for Health Statistics Final Natality Data, 2005.
•Clark, R. (2005). The epidemiology of respiratory failure in neonates bornat an estimated gestational age of 34 weeks or more. Journal ofPerinatology, 25, 251-257.
•Engle, W.A. (2009). Infants born late preterm: Definition, physiologic and metabolic immaturity, and outcomes. NeoReviews, 10, e280-286.
References
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Where Tradition Meets Innovation
•Escobar, G.J., Clark, R.H., & Green, J.D. (2006). Short-term outcomes ofinfants born at 35 and 36 weeks gestation: We need to ask morequestions. Seminars in Perinatology, 30, 28-33.•Maisels, M.J. (2005). Jaundice. In M.G. MacDonald, M.D. Mullett, &M.M.K. Seshia (Eds.), Avery’s neonatology: Pathophysiology &management of the newborn (6th ed., pp. 768-846). Philadelphia: Lippincott Williams & Wilkins.
•Shapiro-Mendoza, C.K. (2009). Infants born late preterm: Epidemiology,trends, and morbidity risk. NeoReviews, 10, e287-294.
•Wang, M.L., Dorer, D.J., Fleming, M.P., & Caitlin, E.A. (2004). Clinicaloutcomes of near-term infants. Pediatrics, 114, 372-376.
•Wight, N. (2003). Breastfeeding the borderline (near-term) preterm infant.
Pediatric Annals, 32(5), 329-336.
References