Late Preterm InfantsConsiderations for Nursing Care

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Extent of the Problem

About 1 in 8 babies is preterm, less than 37 weeks

Late preterm infants (LPI), 34-37 weeks and moderately preterm, 32-33 weeks = 84% of all preterm births, and 14% of infant deaths.

Late preterm infants experience morbidities 7 times more frequently than term infants (22% versus 3%).

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Major Morbidities in Late Preterm Infants (LPI)Include:

• Temperature instability

• Respiratory distress

• Apnea

• Sepsis

• Hypoglycemia

• Feeding difficulties

• Hyperbilirubinemia

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Physiological Underpinnings for Clinical Problems1. Thermoregulation

2. Respiratory morbidities

• Respiratory distress syndrome

• Transient tachypnea of the newborn

• Hypoxic respiratory failure

• Pneumonia

• Autonomic regulation, control of breathing, apnea of prematurity

3. Immunologic immaturity and infections

4. Glucose Homeostasis

5. Gastrointestinal immaturity and feeding

6. Hepatic immaturity and hyperbilirubinemia

7. Brain dysmaturity and risk for periventicular leukomalacia

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Transition

• LPI may experience delayed or inadequate transition to extra-uterine life (1-12 hours).

• Follow NRP guidelines and infant keep warm and dry.

• Place infant skin-to-skin as soon as possible after birth.

• Do Apgar scores while infant is skin-to-skin.

• Requires close monitoring during the first 24 hours.

• Stays with mother.

• Frequent, prolonged skin-to-skin contact to promote physiological stability.

• Delay eye prophylaxis, Vitamin K, and weight until after first breastfeeding.

• After initial, assess infant every 30 minutes until stable for two hours.

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Initial Assessment

• Respiratory system: respiratory rate, type of respirations, and work of breathing.

• Cardiac system: heart rate, rhythm, presence of murmur, distal pulses, and perfusion.

• Axillary temperature.

• Tone and activity.

• Cord stump.

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Reduce Risk of Respiratory Distress• Monitor respiratory rate and work of breathing closely by

visual inspection during the first hour of life.

• Maintain skin-to-skin contact to decrease infant stress and protect from hypothermia-induced apnea.

• If signs of respiratory distress – notify MD and may need to transfer infant to NICU.

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Reduce risks of sepsis

Identify risk factors, e.g.,

• maternal Group B strep positive or unknown status with inadequate antenatal antibiotic prophylaxis

• Chorioamnionitis or maternal fever

• Maternal cold or flu-like symptoms

• Membranes ruptured longer than 18 hours

• Fetal instability during labour.

Assess and monitor for signs of infection, e.g.,

• Respiratory distress, apnea

• Temperature instability

• Glucose instability, jitteriness

• Pale, mottles, or cyanotic colour

• Lethargy, feeding problems, abdominal distension, vomiting.

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If Signs of Sepsis Occur

• Stabilize infant, likely in NICU

• Initiate septic workup

• Start intravenous antibiotics

Parent education• Explain that LPI is at increased risk for sepsis: immature immune

system.

• Wash hands, limit visitors, avoid crowds, protect against contact with sick people.

• Breastfeed as long as possible during the first year and longer.

• Teach how to recognize signs of infection.

• Teach when to notify healthcare provider for immediate evaluation of the infant.

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Reduce Risks of Hypoglycemia

Review maternal history for conditions that increase the risk of hypoglycemia, e.g.

• Gestational or pre-existing diabetes mellitus

• Hypertensive disorders in pregnancy

• Maternal obesity

• Difficult or prolonged labour

• Atypical or abnormal fetal heart rate pattern

Neonatal conditions:

• LPI always;

• IUGR; Apgar score at 5 minutes less than 7; hypothermia or temperature instability; sepsis; respiratory distress, polycythemia-hyperviscosity

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Reduce Hypoglycemia

• Monitor LPI for signs of hypoglycemia

• Facilitate breastfeeding within an hour of birth if possible

• At least 10-12 breast feedings or 8-10 formula feedings per day.

• Follow the posted guidelines for glucose monitoring

• Recheck glucose one hour after feeding

Parent education• Explain that LPI is at increased risk for hypoglycemia: immature

metabolic pathways to make glucose; low glycogen stores.

• Stress importance of feeding the baby at 10-12 times a day if breast fed and 8-10 times a day is formula fed.

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Reduce the Risks of Feeding DifficultiesIdentify maternal risk factors that may affect successful breastfeeding, e.g.,

• Multiple gestation

• Diabetes

• Hypertensive disorders of pregnancy, e.g., gestational hypertension

• Chorioamnionitis

• Caesarean section

Nursing Care:

• Assist with breastfeeding 10-12 times a day

• Refer to lactation consultant

• May require referral to speech/language pathologist for assessment of feeding

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Feeding Difficulties

Parent Education:

Explain that LPI is at increased risk for inadequate feeding:

• immature suck/swallow/breathe coordination;

• inadequate breast milk transfer because of low muscle tone, ineffective latch, and decreased stamina;

• low milk supply due to inadequate breast emptying.

Explain the value of colostrum in providing immune protection and nutrition.

Teach how to recognise early feeding cues.

Explain the probable need to awaken infant for feeds due to LPIs immature brain and sleepiness. Infant will transition to full cue-based feeds when closer to term.

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References

• Association of Women’s Health, Obstetric and Neonatal Nurses. (2014). AWHONN Assessment and Care of the Late Preterm Infant Evidence-Based Clinical Practice Guideline.

• Canadian Paediatric Society (2015). Position Statement: Safe discharge of the late preterm infant. Posted: Feb 1, 2011. Reaffirmed: Jan 30, 2015. http://www.cps.ca/documents/position/safe-discharge-late-preterm-infant

• Cooper, B., Holditch-Davis, D., Verklan, M.T., Fraser-Askin, D., Lamp, J., Santa-Donato, A., Onokpise, B., Soeken, K., & Bingham, D. (Nov/Dec,2012). Newborn Clinical Outcomes of the AWHONN Late Preterm Infant Research-Based Practice Project. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 41 (6), 774–785. DOI: 10.1111/j.1552-6909.2012.01401.x

• McIntire, D., & Leveno, K. (January, 2008). Neonatal Mortality and Morbidity Rates in Late Preterm Births Compared With Births at Term. Obstetrics & Gynecology, 111 (1), 35-41. DOI: 10.1097/01.AOG.0000297311.33046.73

• The National Perinatal Association. (2015). Multidisciplinary guidelines for the care of late preterm infants. Journal of Perinatology, 33(Suppl 2): S5–S22. DOI: 10.1038/jp.2013.53

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