Deb Fraser, MN, RNC-NIC

Identify the etiology of late preterm birth

(LPTI)

Discuss the complications of late preterm

birth

Outline a plan for clinical management of

the LPTI

Describe system issues that impact the care

of late preterm infants

refers to infants born between 34 and 366/7

weeks gestation (LNMP)

Some authors use 35-36 6/7

Formerly known as near-term infants, the

term was changed to LPTI to more accurately

ascribe risk to this vulnerable population

We are now talking about early term infants-

those infants 37 to 38 6/7 who also have

increased morbidity

Incidences range widely in the literature depending on the denominator 6.4-6.6% of well-infant births (Bhutani 2004) 8.5% of all U.S births in 2002 (NICHD, 2005) 70% of all preterm births

Good news- a slight decline in the last two years after a number of years of steady incrase

US, 1998-2008

Late preterm is between 34 and 36 weeks gestation.

Source: National Center for Health Statistics, final natality data. Retrieved August 11, 2011, from

www.marchofdimes.com/peristats.

US, 2008

Multiple deliveries include twin, triplet and higher order deliveries. Late preterm is between 34 and 36 weeks gestation.

Source: National Center for Health Statistics, final natality data. Retrieved August 11, 2011, from www.marchofdimes.com/peristats.

US, 2006-2008 Average

Late preterm is between 34 and 36 weeks gestation.

Source: National Center for Health Statistics, final natality data. Retrieved August 11, 2011, from

www.marchofdimes.com/peristats.

They appear big

(positively pudgy

sometimes)

They appear well

developed compared to

their more premature

cousins

But how do they do?

Mortality for moderately premature infants (32-36 weeks) 2002: 9.2/100,0002 Compared to Term infants: 2.5 per 100,0002

2MacDorman, Martin, Matthews, Hoyert, & Ventura, 2005

Stillbirth and infant mortality rates in comparison

with late preterm births, 1990–2005

Mohan & Jain 2011.

Clin Perinatol

Wang et al. (2004) compared 120 infants 35-36 6/7 to 125

full term infants and found the following:

Temp instability:

10% of LPTIs

Hypoglycemia was 3x more common in LPIs

Evaluation for sepsis:

36.7% vs 12.6%

IV infusions:

26% vs 5.3%

Resp distress:

28.9% vs 4.2%

Jaundice: 54.4% vs 37.9%

Required repeated assistance to achieve consistent

feeding

10% of LPTIs with respiratory distress were tx with

antibiotics for 7 days

57 LPTIs had delayed discharge home vs 7 term

infants, ¼ for poor feeding

Mean cost difference per LPTI was $2630

Study of 2,478 LPTI- no multips, no

PPROM, no C/S, no fetal or mat.

Complications

RDS 4.2% (0.1%)

Sepsis 0.4% (0.04%)

IVH 0.2% (0.02%)

Hypoglycemia 6.8% (0.4%)

Jaundice 18% (2.5%)

Reached term rates by 39 2 weeks Melamed et al 2009. Obstet Gynecol

.

Death and/or severe neurologic

disorder

Engle, 2011. Clin Perinatol

Study of 235 LP infants (34-366)

40% stayed in the hospital longer than their

mothers

25% of 36 weekers

50% of 35 weekers

75% of 34 weekers

Pulvers et al 2010 Clin Pediatrics

A 2003 California study estimated that

preventing late preterm birth could save

$49.9 million dollars!

Few studies have specifically examined this

preterm subgroup

One study of LBW infants found that nearly 19%

to 20% of the cohort 34-37 weeks had clinically

significant behavior problems through age 8 years

Morse et al found that LPTIs were

more likely to have a diagnosis of

developmental delay within the first

3 years of life

More likely to require special needs

preschool resources

More likely to have problems with

school readiness

Morse et al. 2006. Pediatr Res Supp

Study of infants 32-36 weeks gestation

Below average reading and maths skills through

5th Grade

More use of educational resources

More likely to have educational assistants

Lower teacher evaluations of ability

Chyi L et al J Peds 2008 25-31

Developmental delay/cognitive

dysfunction, cerebral palsy

Engle 2011 Clin Perinatol

A signif portion of

brain growth

occurs in last 6

weeks-esp gray

matter, white

matter and

cerebellum

@34 week-brain

wt is 65% of term

wt

ACOG 2008 statement on Late-preterm

infants

It is important to limit late preterm births to

those with a clear maternal or fetal indication

for delivery

Examples include- a maternal condition that is likely

to improve with delivery

Non-reassuring fetal status

Avoid elective inductions and

cesarean sections before 39 weeks

gestation!

Some even suggest induction of

labor before elective C/S to

stimulate the catecholamine surge

that is thought to dry up fetal lung

fluid

Too often the LPTI infant is put on the

‘normal term infant’ care map, expected to

feed like a term infant

Discharged home on a term infant schedule

AWHONN Late Preterm Evidence Based

Practice Guideline

4 year project

Science team examined all literature related to

LPT infants

Developed and tested a guideline for

management of this population including

teaching points for parents

Available from www.awhonn.org

**AWHONN

recommendation

Perform gestational

age assessment by

12 hours of age

Determine if this

infant is SGA, AGA

or LGA

Multicenter study of 19,334 LPTI 7% are admitted to the NICU

15% of those have respiratory symptoms 10.5% have RDS

6.4% have TTN

1.5% pneumonia

1.6% respiratory failure

Respiratory risk did not approach that of term infants until 38 weeks

Consortium on safe labor et al 2010 JAMA

AWHONN recommendations

Assess for signs of respiratory distress in first 30

mins of life and q30 mins until condition is stable

for 2 hrs then q4h x 24 hrs

Signs of distress

Grunting

Nasal flaring

Retractions

Tachypnea

Cyanosis

History suggestive of infection or disease

Worsening distress

Accompanying central cyanosis or cardiac murmurs

Apnea

Hypoglycemia

Symptoms of >2hr

Symptoms of respiratory distress

Other signs of infection

Crowd-control measures

Predisposed to heat loss

Large surface area, decreased tone, no shivering,

limited subq fat

Late preterm infants have not finished laying down the

layer of fat that protects against heat loss. They also

lack glycogen stores and brown fat

In Wang’s study 10% of LPTI had temperature

instability

Instability most common in transition

Can continue to be an issue for up to 48 hrs

Risk factors Reduced white and

brown fat

Decreased tone

Illness

Skin-to-skin after birth if stable

Thoroughly dry and place cap on head

Assess temp within 30 mins of birth, q30 mins

until stable for 2 hrs

Take measures to avoid heat loss

Postpone bath for 2-4 hrs or until stable

Assess blood glucose levels

*AWHONN LPTI Clinical Practice Guideline 2010

An infant who is

sleepy and feeding

poorly may be a

baby that is energy

depleted because

of cold stress.

The temperature

may be ‘normal’

bc of

compensation

Appropriate dress

How to take a temperature

Range of normal temperature and signs of

instability

Techniques to preserve thermal stability with

bathing

When to call their care-provider

Temp >38.6 or < 36.1

Signs of dehydration or thermal

instability

Incidence of hypoglycemia is thought to be

10-15% in LPTI infants

Contributing factors

Decreased glycogen stores

Increased incidence of hyperinsulinism

Thermal instability

Delayed/poor feeding

Delay in hepatic G6-phosphate metabolism (Hume &

Burchell 1993)

Screen within 2 hrs of birth

Provide early and frequent feedings

BF q2-3h, formula q3-4h

Monitor for signs of hypoglycemia and check

blood sugar if signs present

If blood glucose >2.2-2.6 continue freq feeds

If true blood glucose < 2.2, feed and rpt within

30 mins

If symptomatic, or not able to feed, D10W IV

*AWHONN LPTI Clinical Practice Guideline 2010

LPTIs 2.4 x more likely to

develop significant

hyperbilirubinemia

Have significantly higher

peak bilis

The peak is later (day 5-7)

in these babies

Late preterm

infants

disproportionately

represented in the

US Kernicterus

registry

FROM:

Clinical report from the pilot USA

Kernicterus Registry (1992 to 2004)

L Johnson, V K Bhutani, K Karp, E

M Sivieri and S M Shapiro

Greatest risk is in

large LPTI infant

(often IDMs) who

are exclusively

breastfed

Peak readmission

time: 4.1-5 days Data from Kernicterus

Registry 1992-2003

Assess breastfeeding and provide ongoing

assistance

Monitor for signs of early jaundice (first 24

hrs) and, if present send serum bili

Do TcBili or serum bili prior to discharge and

check results with hour-specific nomogram

*AWHONN LPTI Clinical Practice Guideline 2010

Provide written and verbal explanation of

signs of jaundice

How to assess adequacy of feeding and

hydration

Ensure follow-up with

care-provider within 72 hrs of

discharge

LPTI infants are more likely to come in pairs (or more) or to be delivered to mums with medical conditions (diabetes, PIH, chorioamnionitis, prolonged bed rest, excessive blood loss)

or by C/S

All of these factors (and the drugs used in tx) may impact feeding

Infants with a PMA of

35-36 weeks

produced fewer sucks,

fewer sucks per burst, and

lower mean maximum

pressure during a 5-minute

sucking assessment on

second day of life

(Medoff-Cooper, 1991,

2001)

Immature feeding cues

Not waking to feed

Falling asleep early

Slipping off the breast

Appearing full after minimal intake

Baby to breast within first hour if possible.

Continuous skin-to-skin contact, avoid separation from mother.

Evaluate infant’s ability to breast or bottle feed on demand.

Monitor quality of feedings using objective tool (LATCH or other). However these tools do not measure actual milk transfer-only latch therefore need caution!

Meier et al 2007

Nearly all LPT mums

will need to use a

breast pump and

lactation aids (nipple

shields, scale etc) and

give extra milk to

their infant until ~

term gest age

If the infant does not sustain at least 15

minutes of effective sucking 8-10 times per

24 hours, mother should use a hospital-grade

breast pump to stimulate milk production

Mums should anticipate several weeks of

pumping

Pump should be

hospital-grade

electric till milk

well-established

Can switch to a

personal model once

the baby becomes a

more effective

feeder

Paula Meier and colleagues recommend ultra-

thin silicone breast shields as an aid for

infants who have trouble sustaining an

effective latch

Temporary until infant suction strength

improves (till term)

Size important to ensure

success

Can be combined with

milk delivery device if

delayed lactogenesis

also a problem

Readiness for exclusive

non-assisted

breastfeeding may

correspond with infant

reaching term gestation

Positions providing head support will help the

LPTI feed more effectively

Weaker neck musculature vs heavy head

Football or cross-cradle especially helpful

Maintain straight

-line alignment

Normal feeding patterns, feeding cues

Need for frequent feeds

For Breastfeeding mums- strategies to

facilitate milk transfer, effective suck

Positioning, breast shields, breast pump

How and when to contact lactation support

and primary care provider

Not before 48 hours

Normal vitals for preceding 12 hours

Adequate urine output

24 hours of successful feeding

Wt loss less than 7% in 48 hours

Risk assessment for jaundice

Family, environment and social risk

factors assessed

Ramachandrappa & Jain 2009. Ped Clin N Am

AWHONN.2010. Assessment and Care of the Late Preterm Infant.

Evidence Based Clinical Practice Guideline. Washington DC author

Adamkin DH (2009). Late preterm infants: severe

hyperbilirubinemia and postnatal glucose homeostasis. J

Perinatol. 29 Suppl 2:S12-7

Committee on Fetus and Newborn, Adamkin DH (2011). Postnatal

glucose homeostasis inlate-preterm and term infants. Pediatrics.

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Radtke JV (2011). The paradox of breastfeeding-associated

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