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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 • Hyperbilirubinemi

a• 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

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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.

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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

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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.

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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.

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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.

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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

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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

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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.

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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

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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.

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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

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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.

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References• 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• 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.