near-term infants, the term was changed to lpti to more ... national... · awhonn guidelines for...

The Great Pretenders: Late Preterm Infant Deb Fraser, MN, RNC-NIC

Canadian Association of Neonatal Nurses – ONE Day of Education

Monday, April 13, 2015

8:15 a.m. – 9:15 a.m. 1

Deb Fraser, MN, RNC-NIC

� refers to infants born between 34 and 366/7

weeks gestation (LNMP)

Formerly known as near-term infants, the term was changed to LPTI to more accurately ascribe risk to this vulnerable population

We now know that early term infants- those infants 37 to 38 6/7 also have increased morbidity

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8:15 a.m. – 9:15 a.m. 2

�LPI� 7.5-8% of all births (Ananth et al, Engle 2011)

� ~351,000 LPI births in the US in 2008� Good news- a 3% decline in the few years after a number of years of steady increase

�Early Term- 23-29% of all US births� After ACOG statement discouraging elective births before 39 weeks the incidence of those births decreased from 28% of ET births to 3%

�The majority of LPT and ET births are spontaneous

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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.

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8:15 a.m. – 9:15 a.m. 3

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.

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�They appear big (positively pudgy sometimes)

�They appear well developed compared to their more premature cousins

�But how do they do?

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8:15 a.m. – 9:15 a.m. 4

�34-36 weeks: 7.1 deaths/1,000 live births

�37-38 weeks: 4.8 deaths/1,000 live births

�39 weeks: 2.8 deaths/1,000 live births



�>42 weeks: 2.69 deaths/1,000 live births

� Infant mortality rates are deaths under age 1 year

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Clark et al 2009 Am J Obstet Gyncecol 200:156

�Elective delivery at 37 weeks, 38 weeks and later= NICU admission rates of 17.8%, 8% and 4.6% respectively

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8:15 a.m. – 9:15 a.m. 5

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2011 study of 152 late preterm/early term infants (Kamanth et al Am J Obs Gynec)

outcome Late preterm

Early term Term P value

Adverse outcome 21% 13% 4.2% <0.01

hypoglycemia 23.7% 17.1% 5.7% <0.01

Sepsis evaluation 17.1% 5.3% 3.1% <0.01

NICU admission 18.4% 5.3 3.1% <0.01

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8:15 a.m. – 9:15 a.m. 6

Laughon et al 2010 Obstet Gynec 116:1047

�34 weeks: 10-14 days

�35 weeks 7-8 days


�37 weeks 5 days


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� 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%

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8:15 a.m. – 9:15 a.m. 7

�Hyperbilirubinemia (54% vs 37%)

� 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

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� Consortium on Safe Labor (2010 JAMA 304:419)

�Birth at 37 weeks vs 39 weeks� 3.1 x increase in RDS

� 2.5 x increase in TTN

� 1.7 fold increase in pneumonia

� 4.8 fold increase in surfactant use

� 2.8 fold increase in ventilator use

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8:15 a.m. – 9:15 a.m. 8

Risk of Death and/or severe neurologic disorder

Engle, 2011. Clin Perinatol15

�Mortality

�Increased health care utilization

�Poor growth

�Learning disabilities

�Cerebral Palsy

�Adverse neurodevelopmental outcome

�Diabetes16




8:15 a.m. – 9:15 a.m. 9

�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

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� 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

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8:15 a.m. – 9:15 a.m. 10

� Increased risk of:

� Psychomotor delay (OR 1.59) (Woyather et al Ped 2011 127:e622)

�Cerebral Palsy (RR 3.1) (Teune et al 2011 Am J Obs Gyne 205:374)

�Diabetes as a young adult (Crump et al 2011 Diabetes Care 34:1109)

�ADHD (RR 1.7) Linnet et al 2008 Arch Dis Child 91:655)

�Decreased chance of finishing college or university (OR 0.87) (Teune et al 2011 Am J Obs Gyne 205:374)

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Developmental delay/cognitive dysfunction, cerebral palsy

Engle 2011 Clin Perinatol

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8:15 a.m. – 9:15 a.m. 11

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�Cost of an LPI infant over 10 years of life-$10,010

�$208.2 million total national cost per year� Johnson et al 2014, BMC Peds 14:93

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8:15 a.m. – 9:15 a.m. 12

� Revisit the use of tocolytics (Marchado et al 2014)

� Consider offering corticosteroids beyond 34 weeks-

� Decreased resp morbidity (Champion et al 2010 Arch Pediatr, Balci et al 2010 Obs Gynec Invest)

� Review pregnancy interruption policies

� PPROM- often induced if >34 weeks

� Cochrane review (Buchanan 2010) showed no difference btwn induction vs expectant management for either maternal or neonatal outcomes

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�Managing growth restriction and oligiohydramnios

� If fetal assessment reassuring, delay intervention until 37-38 weeks (Galen 2012. Semin Perinat 35)

�Diabetes- when to deliver controversial

� Pre-eclampsia- no clear recommendations as to when is best

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8:15 a.m. – 9:15 a.m. 13

� 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

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�ACOG 2008 statement on Late-preterm infants� No elective deliveries before 39 weeks

� Determination of fetal lung maturity before scheduled delivery at <39 weeks

�Do you do case reviews for all deliveries less than 39 weeks?

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8:15 a.m. – 9:15 a.m. 14

�Engle (2011)� 35 completed weeks, >1800 grams Mother baby unit or newborn nursery (SBGH >2kg)

� < 35 weeks, < 1800 grams- Special care

� If PPV in DR, observe at least 6 hours in special care

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� 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

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8:15 a.m. – 9:15 a.m. 15

� AWHONN Guidelines for Care of the Late Preterm Infant (more later) 2010

�National Perinatal Association

� Phillips et al 2013 J Perinatology 33:S5-S22

� Engle 2011 Clin Perinat 38:493

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� Starting an initiative to leave stable LPI infants with their mother for skin-to-skin during transition

� 1-2 hours, vital signs taken, can use oximeter if available

� Sugars done per protocol

�Delay routine interventions (Vit K, eye care)

� Initiate breastfeeding during the intial skin-to-skin period

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8:15 a.m. – 9:15 a.m. 16

�AWHONN and NPA recommendations� Review history to determine risk factors

� Plot wt, length and HC

� Determine if this infant is SGA, AGA or LGA

� Perform gestational age assessment by 12 hours of age

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How often should these babies be checked:

� Every 30 minutes until stable for 2 hours

� Every 4 hours during the first 24 hours

� After 24 hours, once every shift until discharge

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8:15 a.m. – 9:15 a.m. 17

� Signs of distress� Grunting

� Nasal flaring

� Retractions

� Tachypnea

� Cyanosis

� Maintain skin-to-skin to optimize

respiratory transition

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�History suggestive of infection or disease

�Worsening distress

�Accompanying central cyanosis or cardiac murmurs

�Apnea

�Hypoglycemia

�Symptoms of >2hr

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8:15 a.m. – 9:15 a.m. 18

� Symptoms of respiratory distress

�Other signs of infection

� Crowd-control measures

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� 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

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8:15 a.m. – 9:15 a.m. 19

� 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 (Engle hourly for 6 hours)

� Take measures to avoid heat loss

� Postpone bath for 2-12 hrs or until stable (NPA guidelines, 2013)

� If <36, swaddle and recheck in 30 mins, if still <36 radiant warmer. Two failures, transfer to Special Care (Engle 2011)

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� 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

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8:15 a.m. – 9:15 a.m. 20

� 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

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� Screen within 2 hrs of birth, 30 mins after a feed. If symptomatic screen immediately

� Provide early and frequent feedings

� BF q2-3h, formula q3-4h

�Monitor for signs of hypoglycemia and check blood sugar if signs present

� Follow hospital/regional algorithm for management of asymptomatic infants with hypoglycemia

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8:15 a.m. – 9:15 a.m. 21

�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

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� Identify risk factors

� Assess breastfeeding and provide ongoing assistance

�Monitor for signs of early jaundice (first 24 hrs) and, if present, send serum bili

� Repeat bili prior to discharge and check results rate of rise

�Outpatient assessment may be needed if discharge occurs prior to peak (5-7 days)

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8:15 a.m. – 9:15 a.m. 22

� 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

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� 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

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8:15 a.m. – 9:15 a.m. 23

� 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)

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� Immature feeding cues

� Not waking to feed

� Falling asleep early

� Slipping off the breast

� Appearing full after minimal intake

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8:15 a.m. – 9:15 a.m. 24

�More likely to receive cow’s milk formula

� Less likely to breastfeed beyond 10 weeks

� Risk of requiring readmission due to

feeding issues – dehydration, weight loss –

and hyperbilirubinemia

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� 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!

� 10-12 BF daily or 8-10 formula feedings

� Document voiding and stooling patterns

� Meier et al 2007, Walker 2008, AWHONN LPI guide 2010

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8:15 a.m. – 9:15 a.m. 25

�Wake every 2-3 hours

� Avoid cold stress during feeds

� Limit feeding attempts to 30 minutes

�Have mom use breast compressions with every feed

� Carefully follow weight loss

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� Supplement only if medically indicated

�Do not provide volumes greater than needed

� First 24 hours: 2-10 ml/feed

� 24-48 hours: 5-15 ml/feed

� 48-72 hours: 15-30 ml/feed

� 72-96 hours: 30-60 ml/feed

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8:15 a.m. – 9:15 a.m. 26

�Nearly all LPI 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

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� 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

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8:15 a.m. – 9:15 a.m. 27

�Pump should be hospital-grade electric till milk well-established

�Can switch to a personal model once the baby becomes a more effective feeder

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� 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

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8:15 a.m. – 9:15 a.m. 28

�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

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� 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

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8:15 a.m. – 9:15 a.m. 29

�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

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�Not before 48 hours

�Normal vitals for preceding 24 hours

�Adequate urine output

�24 hours of successful feeding

� Assmt by LC or staff with BF expertise x 2

�Wt loss less than 7% of BW or less than 3% per day of age

�Risk assessment for jaundice, bilirubin measured

�Family, environment and social risk factors assessed. Follow-up in 24-48 hrs� Engle 2011 Clin Perinatol 58




8:15 a.m. – 9:15 a.m. 30

� AWHONN.2014. Assessment and Care of the Late Preterm Infant. Evidence Based Clinical Practice Guideline. Washington DC author

� Adamkin, D. H. & Committee on Fetus and Newborn. (2011). Postnatal glucose homeostatis in late-preterm and term infants. Pediatrics, 127(3), 575–579

� Darcy AE (2009). Complications of the late preterm infant. J Perinat Neonatal Nurs.23(1):78-86.

� Harris, D. L., Weston, P. J., & Harding, J. E. (2012). Incidence of neonatal hypoglycemia in babies identified as at risk. J Peds, 161 (5), 787–791.

� Mally PV, Bailey S, Hendricks-Muñoz KD (2010). Clinical issues in the management of late preterm infants. Curr Probl Pediatr Adolesc Health Care.40(9):218-33.

� Medoff Cooper, B., Holditch-Davis, D., Verklan, M. T., Fraser-Askin, D., Lamp, J., Santa-Donato, A., Onokpise, B., Soeken, K. L., & Bingham, D. (2012). Newborn clinical outcomes of the AWHONN late preterm infant research-based practice project. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 41(6), 774-785.

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� 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

� Stuckey-Schrock, K., & Schrock, S. D. (2013). Head off complications in late preterm infants. The Journal of Family Practice, 62(4), E3–8

� Verklan MT (2009). So, he's a little premature...what's the big deal? CritCare Nurs Clin North Am. 21(2):149-61.

� Walker M (2008). Breastfeeding the late preterm infant. J Obstet GynecolNeonatalNurs. 37(6):692-701

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near-term infants, the term was changed to lpti to more ... national... · awhonn guidelines for...

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