deb fraser, mn, rnc-nic - - capwhn · deb fraser, mn, rnc-nic identify the etiology of late preterm...
Post on 21-Jun-2018
212 Views
Preview:
TRANSCRIPT
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
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
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
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.
127(3):575-9.
Darcy AE (2009). Complications of the late preterm infant. J
Perinat Neonatal Nurs.23(1):78-86.
Mally PV, Bailey S, Hendricks-Muñoz KD (2010). Clinical issues in
the management oflate preterm infants. Curr Probl Pediatr
Adolesc Health Care.40(9):218-33.
Radtke JV (2011). The paradox of breastfeeding-associated
morbidity among latepreterm infants. J Obstet Gynecol Neonatal
Nurs. 40(1):9-24.
.
Ramachandrappa A, Jain L (2009). Health issues of the late
preterm infant. PediatrClin North Am.56(3):565-77,
Reddy UM, Ko CW, Raju TN, Willinger M.2009. Delivery
indications at late-preterm gestations and infant mortality rates
in the United States. Pediatrics. 124(1):234-40
Verklan MT (2009). So, he's a little premature...what's the big
deal? Crit Care Nurs Clin North Am. 21(2):149-61.
Walker M (2008). Breastfeeding the late preterm infant. J Obstet
Gynecol NeonatalNurs. 37(6):692-701
top related