THE LATE PRETERM INFANT (LPT) WAHIB MENA, M.D. Glenda Dickerson, MS, RN, IBCLC BROOKWOOD WOMEN’S...
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Transcript of THE LATE PRETERM INFANT (LPT) WAHIB MENA, M.D. Glenda Dickerson, MS, RN, IBCLC BROOKWOOD WOMEN’S...
THE LATE PRETERM THE LATE PRETERM INFANT (LPT)INFANT (LPT)
WAHIB MENA, M.D.WAHIB MENA, M.D.
Glenda Dickerson, MS, RN, IBCLCGlenda Dickerson, MS, RN, IBCLCBROOKWOOD WOMEN’S MEDICAL CENTERBROOKWOOD WOMEN’S MEDICAL CENTER
HOMEWOOD, ALHOMEWOOD, AL
DEFINITIONDEFINITION
INFANTS BORN 34 0/7-36 6/7 WKSINFANTS BORN 34 0/7-36 6/7 WKS
EPIDEMIOLOGYEPIDEMIOLOGY
2003: 12.3% OF BIRTHS < 37 WKS2003: 12.3% OF BIRTHS < 37 WKS 31% INCREASE SINCE 198131% INCREASE SINCE 1981 34-36.6 WKS (75%)34-36.6 WKS (75%) 2002: 342,234 vs. 394,9962002: 342,234 vs. 394,996
CLINICAL ISSUESCLINICAL ISSUES
TEMP INSTABILITYTEMP INSTABILITY HYPOGLYCEMIAHYPOGLYCEMIA TTNTTN RDSRDS APNEAAPNEA SIDSSIDS NEUROLOGIC ISSUESNEUROLOGIC ISSUES HYPERBILIRUBINEMIA AND KERNICTERUSHYPERBILIRUBINEMIA AND KERNICTERUS
TEMPERATURETEMPERATURE
HYPOTHERMIA HYPOTHERMIA HYPERTHERMIAHYPERTHERMIA
? SEPSIS? SEPSIS LONGER HOSPITAL STAYLONGER HOSPITAL STAY RARE MORBIDITY AND MORTALITY(NEC)RARE MORBIDITY AND MORTALITY(NEC)
HYPOGLYCEMIAHYPOGLYCEMIA
LOW SUPPLYLOW SUPPLY INSULIN GLUCAGON BALANCEINSULIN GLUCAGON BALANCE BRAIN FUELBRAIN FUEL
What About What We Can’t See?What About What We Can’t See?
HumanHuman
BrainBrain
DevelopmentDevelopment
TTN/RDS/APNEATTN/RDS/APNEA
CLEARLY INCREASED TTN AND RDSCLEARLY INCREASED TTN AND RDS APNEA APNEA USUALLY NO LONGTERM ISSUESUSUALLY NO LONGTERM ISSUES
SIDSSIDS
RISK OF SIDS DOUBLESRISK OF SIDS DOUBLES 1.4 vs. 0.7/10001.4 vs. 0.7/1000
NEUROLOGICNEUROLOGIC
INCREASED BEHAVIORAL DISORDERSINCREASED BEHAVIORAL DISORDERS NO GOOD STUDIES NO GOOD STUDIES DECREASED PERFORMANCE IN MATH DECREASED PERFORMANCE IN MATH
AND ENGLISH AND ENGLISH
What About What We Can’t See?What About What We Can’t See?
HumanHuman
BrainBrain
DevelopmentDevelopment
JAUNDICEJAUNDICE
INCREASED BILI PRODUCTIONINCREASED BILI PRODUCTION DECREASED CLEARINGDECREASED CLEARING IMMATURE BLOOD BRAIN BARRIERIMMATURE BLOOD BRAIN BARRIER INCREASED RISK FOR KERNICTERUSINCREASED RISK FOR KERNICTERUS
WHAT TO DOWHAT TO DO
BE AWARE OF ORGAN IMMATURITYBE AWARE OF ORGAN IMMATURITY BRAINBRAIN LUNGLUNG HORMONAL AXISHORMONAL AXIS DIVING REFLEXDIVING REFLEX
I AM PREMATUREI AM PREMATURE
DO NOT DELAY TREATMENTDO NOT DELAY TREATMENT AGGRESSIVE APPROACHAGGRESSIVE APPROACH EDUCATE PARENTSEDUCATE PARENTS EDUCATE HEALTHCARE WORKERSEDUCATE HEALTHCARE WORKERS HOME ENVIRONMENTHOME ENVIRONMENT
Breastfeeding ManagementBreastfeeding Management
VulnerabilitiesVulnerabilities1.1. HypothermiaHypothermia
2.2. HypoglycemiaHypoglycemia
3.3. Respiratory InstabilityRespiratory Instability
4.4. Immature state regulationImmature state regulation
5.5. Hypotonia and Immature Feeding SkillsHypotonia and Immature Feeding Skills
6.6. Insufficient milk (delayed lactogenesis)Insufficient milk (delayed lactogenesis)
7.7. HyperbilirubinemiaHyperbilirubinemia
1. Hypothermia and 2.Hypoglycemia1. Hypothermia and 2.Hypoglycemia
Skin-to-skin care (STS)Skin-to-skin care (STS)
Hypothermia and HypoglycemiaHypothermia and Hypoglycemia
Skin-to-skinSkin-to-skin Newborn infant’s natural habitat/safe environmentNewborn infant’s natural habitat/safe environment
• Helps to stabilize temperatureHelps to stabilize temperature Mothers thermo-regulate their infant’s tempMothers thermo-regulate their infant’s temp
• Stabilizes blood glucose levelsStabilizes blood glucose levels Even when a feeding does not take placeEven when a feeding does not take place
• Stabilizes respiratory effortStabilizes respiratory effort• Colonize the infant’s skinColonize the infant’s skin
Helps protect against URI and Intestinal Helps protect against URI and Intestinal infectionsinfections
STS is Evidence Based CareSTS is Evidence Based Care
Should not be based on “I like” or “I Should not be based on “I like” or “I don’t like” don’t like”
Should not be based on “there is not Should not be based on “there is not enough time”enough time”
Hypothermia and HypoglycemiaHypothermia and Hypoglycemia
Immediate STS (Mom and infant Immediate STS (Mom and infant stable)stable) Dried Dried Covered with warm blanketsCovered with warm blankets Cap placed on headCap placed on head Initial assessment accomplishedInitial assessment accomplished Postpone task till after first feeding is Postpone task till after first feeding is
accomplishedaccomplished
Extended STS CareExtended STS Care
Encourages frequent feedingsEncourages frequent feedings
3. Respiratory Instability3. Respiratory Instability
LPT is more prone to positional apneaLPT is more prone to positional apnea Careful feeding positionCareful feeding position
• Avoid cradle holdAvoid cradle hold
• Clutch (football) or cross-cradle is preferredClutch (football) or cross-cradle is preferred Mom should be instructed not to flex head in these Mom should be instructed not to flex head in these
positionspositions Breast should not rest on the infant’s chestBreast should not rest on the infant’s chest
Avoid use of slingsAvoid use of slings• Wraps/KC garments may work wellWraps/KC garments may work well
Preferred: Clutch (Football)Preferred: Clutch (Football)
Preferred: Cross-Cradle HoldPreferred: Cross-Cradle Hold
Avoid—Over-flexed PositionAvoid—Over-flexed Position
4. Immature State Regulation4. Immature State Regulation
STS careSTS care Modulates the under-aroused, over-aroused, Modulates the under-aroused, over-aroused,
and shut down infantand shut down infant Minimize interruptionsMinimize interruptions Parent educationParent education
Avoid excessive stroking, massaging, Avoid excessive stroking, massaging, rocking, talking, bright lights, loud noise, and rocking, talking, bright lights, loud noise, and being handed of to multiple visitors being handed of to multiple visitors
Limit visitorsLimit visitors
5. Hypotonia and Immature Feeding Skills5. Hypotonia and Immature Feeding Skills
HypotoniaHypotonia May result from maternal use of labor May result from maternal use of labor
medicationsmedications Fetal exposure to SSRI’s during 3Fetal exposure to SSRI’s during 3rdrd
trimestertrimester Will contribute to ineffective feedingWill contribute to ineffective feeding
Hypotonia and Immature Feeding SkillsHypotonia and Immature Feeding Skills
Wide range of sucking patterns, Wide range of sucking patterns, frequency, and intensityfrequency, and intensity May tire quickly and be unable to sustain May tire quickly and be unable to sustain
nutritive suckingnutritive sucking Electromyographic study of sucking patternsElectromyographic study of sucking patterns
• 15% to 60% of time spent sucking15% to 60% of time spent sucking May lack strength for appropriate sucking May lack strength for appropriate sucking
pressure (60 mm Hg)pressure (60 mm Hg)• Render unable to secure nipple in place between Render unable to secure nipple in place between
sucking burstsucking burst
Hypotonia and Immature Feeding SkillsHypotonia and Immature Feeding Skills
Feed the babyFeed the baby
Facilitate direct breastfeedingFacilitate direct breastfeeding
Protect mother’s milk supplyProtect mother’s milk supply
Hypotonia and Immature Feeding SkillsHypotonia and Immature Feeding Skills
Feed the BabyFeed the Baby Encourage initiation of breastfeeding Encourage initiation of breastfeeding
within one hour after birthwithin one hour after birth• Latch if possibleLatch if possible
Cross-cradle/footballCross-cradle/football Use Dancer-Hand to stabilize jawUse Dancer-Hand to stabilize jaw May help to prevent clampingMay help to prevent clamping
• Consider use of nipple shieldConsider use of nipple shield
Hypotonia and Immature Feeding SkillsHypotonia and Immature Feeding Skills
Evaluate need for supplementEvaluate need for supplement Expressed colostrum/breastmilkExpressed colostrum/breastmilk Banked human milkBanked human milk Hydrolyzed formulaHydrolyzed formula
• Reduce the risk of sensitizing a Reduce the risk of sensitizing a susceptible infant to allergies or diabetessusceptible infant to allergies or diabetes
• May help to lower bili levelsMay help to lower bili levels
Hypotonia and Immature Feeding SkillsHypotonia and Immature Feeding Skills
Should be breastfed or breastmilk fed Should be breastfed or breastmilk fed 8 times in 24 hours8 times in 24 hours Awaken if baby does not indicate hungerAwaken if baby does not indicate hunger
Continue use of nipple shield if neededContinue use of nipple shield if needed Difficult latchDifficult latch Evidence of ineffective milk transferEvidence of ineffective milk transfer Follow-up with mother’s using shield after Follow-up with mother’s using shield after
dischargedischarge• Infant may need to use until 40 weeks post-conceptual Infant may need to use until 40 weeks post-conceptual
ageage
Hypotonia and Immature Feeding SkillsHypotonia and Immature Feeding Skills
SupplementationSupplementation Best done at the breast if possibleBest done at the breast if possible
• 5 French feeding tube/10 ml syringe5 French feeding tube/10 ml syringe
• Commercial supplementer systemsCommercial supplementer systems Can be used in conjunction with a Can be used in conjunction with a
nipple shieldnipple shield
Hypotonia and Immature Feeding SkillsHypotonia and Immature Feeding Skills
If infant is not latching or able to If infant is not latching or able to supplement at breastsupplement at breast Feed expressed milk every 3 hoursFeed expressed milk every 3 hours
• 5-10 ml per feeding on day 15-10 ml per feeding on day 1 Spoon (small quantities)Spoon (small quantities)
• 10-20 ml per feeding on day 210-20 ml per feeding on day 2 Cup (as quantity increases)Cup (as quantity increases) Paced feedingPaced feeding
• 20-30 ml per feeding on day 320-30 ml per feeding on day 3
Hypotonia and Immature Feeding SkillsHypotonia and Immature Feeding Skills
If supplementing away from the breastIf supplementing away from the breast Facilitate direct breastfeeding Facilitate direct breastfeeding
• Use alternative methods as the mother desiresUse alternative methods as the mother desires Spoon feeding for small amountsSpoon feeding for small amounts Cup feeding for larger amountsCup feeding for larger amounts
• Paced feedingPaced feeding
• Encourage mother to continue efforts at the Encourage mother to continue efforts at the breast as she is comfortablebreast as she is comfortable
Spoon FeedingSpoon Feeding
Hypotonia and Immature Feeding SkillsHypotonia and Immature Feeding Skills
Protect mother’s milk supplyProtect mother’s milk supply Assist the mother to begin pumpingAssist the mother to begin pumping
• Feeding ineffectivelyFeeding ineffectively Pump every 3 hours during the day and at Pump every 3 hours during the day and at
least once per nightleast once per night
• Feeding effectivelyFeeding effectively Pump about 4 times a day to provide Pump about 4 times a day to provide
additional stimulation to bring in a good milk additional stimulation to bring in a good milk supplysupply
6. Insufficient Milk Supply6. Insufficient Milk Supply
Initiate and maintain supplyInitiate and maintain supply Begin pumping within 6 hours of Begin pumping within 6 hours of
deliverydelivery• Colostrum bolus may be presentColostrum bolus may be present
Pump after each feeding (8-10 times Pump after each feeding (8-10 times per 24 hours) for first 2 weeksper 24 hours) for first 2 weeks
Use appropriate size Use appropriate size
breast shield for pumpingbreast shield for pumping
Insufficient Milk SupplyInsufficient Milk Supply
Protect Milk SupplyProtect Milk Supply Establishing milk supplyEstablishing milk supply
• Lactogenesis II occurs on average 60 hours following Lactogenesis II occurs on average 60 hours following deliverydelivery
Expected volumes (approximation) per 24 hrsExpected volumes (approximation) per 24 hrs
• Day oneDay one less than 100 mlless than 100 ml• Day twoDay two 200 ml 200 ml • Day threeDay three 350 ml (borderline)350 ml (borderline)• Day fourDay four 600 ml (adequate)600 ml (adequate)• Day 14Day 14 750 ml (ideal)750 ml (ideal)
Insufficient Milk SupplyInsufficient Milk Supply
Protect mother’s milk supplyProtect mother’s milk supply The amount of stimulation on day 2 is The amount of stimulation on day 2 is
positively correlated with adequate milk positively correlated with adequate milk volume on day fivevolume on day five
Milk supply at day 6 is indicative of Milk supply at day 6 is indicative of supply at 6 weekssupply at 6 weeks• Window of opportunity for establishing milk Window of opportunity for establishing milk
supplysupply
7. Hyperbilirubinemia7. HyperbilirubinemiaReadmission due to jaundiceReadmission due to jaundice
7 to 13 fold increased risk7 to 13 fold increased risk• Slower meconium passageSlower meconium passage• Low milk intakeLow milk intake• Decreased activity of bili-conjugating enzymeDecreased activity of bili-conjugating enzyme
Bilirubin peak levels typically occur around Bilirubin peak levels typically occur around 5 to 7 days of life5 to 7 days of life
Kernicterus is seen more frequently in LPTKernicterus is seen more frequently in LPT
HyberbilirubinemiaHyberbilirubinemia
Preventative goalsPreventative goals Optimize milk intakeOptimize milk intake Promote rapid meconium Promote rapid meconium
clearance and increase stool clearance and increase stool volumevolume
Prevent excessive weight lossPrevent excessive weight loss
HyperbilirubinemiaHyperbilirubinemia
Optimize Milk IntakeOptimize Milk Intake Frequent feedingsFrequent feedings
• 8-10 times in 24 hours8-10 times in 24 hours Evaluate for deep latchEvaluate for deep latch Use breast compression or massageUse breast compression or massage Use a nipple shield if neededUse a nipple shield if needed
HyperbilirubinemiaHyperbilirubinemia
Promote Rapid Meconium Promote Rapid Meconium ClearanceClearance Frequent colostrum feedsFrequent colostrum feeds
• At breastAt breast• Hand expressedHand expressed
5-10 ml every 2-3 hours on day one5-10 ml every 2-3 hours on day one 10-20 ml every 2-3 hours on day two10-20 ml every 2-3 hours on day two 20-30 ml every 2-3 hours on day three20-30 ml every 2-3 hours on day three
HyperbilirubinemiaHyperbilirubinemia
Prevent Excessive Weight LossPrevent Excessive Weight Loss Discourage missed feedingsDiscourage missed feedings
• VisitorsVisitors• Excessive interruptionsExcessive interruptions
Evaluation of feeding once per shiftEvaluation of feeding once per shift• Qualified professionalQualified professional• DocumentDocument
Pre and post feed weights if neededPre and post feed weights if needed
HyperbilirubinemiaHyperbilirubinemia
Data from the Pilot Kernicterus Registry (1992-Data from the Pilot Kernicterus Registry (1992-2003)2003) The greatest risk for kernicterusThe greatest risk for kernicterus
• The exclusively breastfed “large” LPT infantThe exclusively breastfed “large” LPT infant Hospital admission within 7 days post birthHospital admission within 7 days post birth Present with severe jaundice and inadequate intakePresent with severe jaundice and inadequate intake Most parents had contacted their primary care Most parents had contacted their primary care
providers with concerns about jaundice, poor feeding, providers with concerns about jaundice, poor feeding, and excessive sleepiness and had been told these and excessive sleepiness and had been told these were normal behaviorswere normal behaviors
Discharge Feeding PlanDischarge Feeding Plan
Team effort that includes the motherTeam effort that includes the mother STS CareSTS Care Feed the Baby/Determine the methodFeed the Baby/Determine the method Protect Mother’s Milk SupplyProtect Mother’s Milk Supply Early and Appropriate Follow-upEarly and Appropriate Follow-up
Communicate this plan with outpatient Communicate this plan with outpatient care providercare provider Continue evaluationContinue evaluation
Initial Outpatient Follow-upInitial Outpatient Follow-up
Should be 3-5 days of life, or one or Should be 3-5 days of life, or one or two days after dischargetwo days after discharge Weight checkWeight check Assessment for jaundiceAssessment for jaundice Review of written feeding recordReview of written feeding record
• Parameters of adequate intakeParameters of adequate intake Assessment of breastfeeding Assessment of breastfeeding
effectivenesseffectiveness
Poor Weight GainPoor Weight Gain
Less than 20 grams/dayLess than 20 grams/day Ineffective feedingIneffective feeding
• Refer to a lactation specialist Refer to a lactation specialist
Follow-upFollow-up
How are mom and baby coping?How are mom and baby coping? Modify plan to something that is Modify plan to something that is
more manageablemore manageable Work with her to find helpWork with her to find help
Don’t assume you knowDon’t assume you know Ask!Ask!
Extended Follow-upExtended Follow-up
Weekly follow-up until 40 weeks Weekly follow-up until 40 weeks post conceptual age or until it is post conceptual age or until it is demonstrated that he/she is demonstrated that he/she is thriving with no supplementsthriving with no supplements With each adjustment that is made With each adjustment that is made
a visit/weight check in 2-4 days a visit/weight check in 2-4 days should be doneshould be done
Continued MonitoringContinued Monitoring
Adequate growthAdequate growth Weight gain should average >20 Weight gain should average >20
g/dayg/day Length and head circumference Length and head circumference
should each increase by an average should each increase by an average of .0.5 cm/weekof .0.5 cm/week
Our FindingsOur Findings
Recollected data to see if we Recollected data to see if we had improved readmission rateshad improved readmission rates Decreased by 50% in the first yearDecreased by 50% in the first year Goal is to decrease to same rate Goal is to decrease to same rate
as term infantas term infant
Interventions ReviewedInterventions Reviewed
LL Lots of STS Lots of STS PP Position AppropriatelyPosition Appropriately II Initiate Stimulation ControlsInitiate Stimulation Controls C C Calories CountCalories Count AA Adequate Milk SupplyAdequate Milk Supply RR Reinforce awareness of biliReinforce awareness of bili EE Educate for discharge!Educate for discharge!
ObjectivesObjectives
Define the sub-classification of late preterm infant.Define the sub-classification of late preterm infant. Discuss the physical characteristics and Discuss the physical characteristics and
vulnerabilities of the late preterm infant.vulnerabilities of the late preterm infant. List strategies to address the identified List strategies to address the identified
vulnerabilities of the late preterm infant as they vulnerabilities of the late preterm infant as they relate to breastfeeding management.relate to breastfeeding management.
State the essential elements of discharge State the essential elements of discharge planning for the breastfeeding late preterm infant.planning for the breastfeeding late preterm infant.
Late Preterm Babies Were Born to BreastfeedLate Preterm Babies Were Born to Breastfeed