Transition of the Premature Infant Transition of the Premature Infant from Hospital to Homefrom Hospital to Home

Ma. Teresa C. Ambat, MDMa. Teresa C. Ambat, MDNeonatology-TTUHSCNeonatology-TTUHSC

10/7/200810/7/2008

IntroductionIntroduction PCPs are taking care of a growing population of former PCPs are taking care of a growing population of former

premature infantspremature infants

PCPs should understand the special difficulties facing PCPs should understand the special difficulties facing these infants and their familiesthese infants and their families

PCPs should understand how to follow problems PCPs should understand how to follow problems identified in the NICU and be attentive to new issues that identified in the NICU and be attentive to new issues that may developmay develop

Terms Commonly Used to Describe Terms Commonly Used to Describe Premature InfantsPremature Infants

PrematurePremature

Late pretermLate preterm

Low birth weight (LBW)Low birth weight (LBW)

Very low birth weight (VLBW)Very low birth weight (VLBW)

Extremely low birth weight Extremely low birth weight (ELBW)(ELBW)

Born < 37 weeks’ estimated GABorn < 37 weeks’ estimated GA

Previously referred to as “near Previously referred to as “near term”. Born between 34 -36 6/7 term”. Born between 34 -36 6/7 wkswks

BW <2500g (5 lbs 8oz)BW <2500g (5 lbs 8oz)

BW <1500g (3lb 5oz)BW <1500g (3lb 5oz)

BW <100g (2lb 3oz)BW <100g (2lb 3oz)

Terms Commonly Used to Describe Terms Commonly Used to Describe Premature InfantsPremature Infants

Gestational ageGestational age

Chronological ageChronological age

Postmenstrual agePostmenstrual age

Corrected ageCorrected age

Age based on time elapsed between the 1Age based on time elapsed between the 1stst day day of LMP and the day of deliveryof LMP and the day of delivery

Age based on time elapsed after birth = Age based on time elapsed after birth = postnatal agepostnatal age

Age based on time elapsed bet the 1Age based on time elapsed bet the 1stst day of day of LMP and birth + chronological ageLMP and birth + chronological age

Ex. 26 wk GA who is 10 wks chronological age Ex. 26 wk GA who is 10 wks chronological age would have postmenstrual age of would have postmenstrual age of

Age of the infant based on expected delivery Age of the infant based on expected delivery date (Chronological age - number of weeks date (Chronological age - number of weeks born before 40 wks)born before 40 wks)

Ex. 12 month old former 28 wks has corrected Ex. 12 month old former 28 wks has corrected age of age of

36wks

9 months

Late PretermLate Preterm

Potential short term morbidities: respiratory distress, Potential short term morbidities: respiratory distress, jaundice, feeding difficulties, hypoglycemia, temperature jaundice, feeding difficulties, hypoglycemia, temperature instability and sepsisinstability and sepsis

Higher rate of rehospitalization within the first 2 weeks Higher rate of rehospitalization within the first 2 weeks after dischargeafter discharge

Guidelines for PCP Caring for Guidelines for PCP Caring for Late Preterm InfantLate Preterm Infant

Newborn nursery careNewborn nursery care– Monitor for feeding difficulties, respiratory distress, jaundice, Monitor for feeding difficulties, respiratory distress, jaundice,

temperature instability, hypoglycemia and sepsistemperature instability, hypoglycemia and sepsis– Lower threshold for supplementing breastfeeding and obtaining Lower threshold for supplementing breastfeeding and obtaining

lactation consultant who can continue to advise the mother after lactation consultant who can continue to advise the mother after dischargedischarge

– Car seat safety screeningCar seat safety screening– Determine need for RSV prophylaxisDetermine need for RSV prophylaxis– Educate family about differences between late preterm and full Educate family about differences between late preterm and full

termterm

Guidelines for PCP Caring for Guidelines for PCP Caring for Late Preterm InfantLate Preterm Infant

Family educationFamily education FeedingFeeding

– Usually eat less and may need to be fed more oftenUsually eat less and may need to be fed more often

– Difficulty coordinating sucking, swallowing, and breathing Difficulty coordinating sucking, swallowing, and breathing during the feeding during the feeding needs to be observed closely while needs to be observed closely while eatingeating

– May feed well initially at the hospital May feed well initially at the hospital become tired and become tired and feed poorlyfeed poorly contact PCP if the infant has decreased oral contact PCP if the infant has decreased oral intakeintake

– 5-6 wet diapers in every 24 hour period5-6 wet diapers in every 24 hour period

Guidelines for PCP Caring for Guidelines for PCP Caring for Late Preterm InfantLate Preterm Infant

Family educationFamily education SleepingSleeping

– Sleepier than full term and sleep through feedings Sleepier than full term and sleep through feedings should should awaken the infant to feedawaken the infant to feed

– Should sleep on their backsShould sleep on their backs

ThermoregulationThermoregulation– Difficulty regulating body temperature (decreased subq fat)Difficulty regulating body temperature (decreased subq fat)– Should wear hats to decrease heat loss, if environmental Should wear hats to decrease heat loss, if environmental

temperature is cooltemperature is cool

JaundiceJaundice– Greater risk for jaundice. Families should be taught how to look Greater risk for jaundice. Families should be taught how to look

for jaundice and need for close-ffupfor jaundice and need for close-ffup

Guidelines for PCP Caring for Guidelines for PCP Caring for Late Preterm InfantLate Preterm Infant

Family educationFamily education InfectionInfection

– Greater risk for infections Greater risk for infections watch for signs of watch for signs of infection (fever, difficulty breathing, lethargy)infection (fever, difficulty breathing, lethargy)

– Minimize exposure to crowded placesMinimize exposure to crowded places– Practice good handwashingPractice good handwashing

Car safety seat Car safety seat – Minimize time in car seats until good head control is Minimize time in car seats until good head control is

achievedachieved

Guidelines for PCP Caring for Guidelines for PCP Caring for Late Preterm InfantLate Preterm Infant

Follow upFollow up Schedule appointments in 1-2 days after dischargeSchedule appointments in 1-2 days after discharge At first visit, PCP should:At first visit, PCP should:

– Assess dehydration with weight check and P.E.Assess dehydration with weight check and P.E.– Evaluate for jaundiceEvaluate for jaundice– Arrange for continued ff-upArrange for continued ff-up– Reemphasize educational pointsReemphasize educational points– Record results of the newborn screeningRecord results of the newborn screening

Guidelines for PCP Caring for Guidelines for PCP Caring for Premature InfantPremature Infant

Manage complications of prematurityManage complications of prematurity Monitor for potential new problems Monitor for potential new problems Support the familySupport the family

Coordinate various medical and social services neededCoordinate various medical and social services needed– Determine whether an Infant follow up program is needed Determine whether an Infant follow up program is needed – Refer infant to an early intervention program as needed (in most Refer infant to an early intervention program as needed (in most

states NICU graduates are eligible for this program)states NICU graduates are eligible for this program)

Educate the family by providing anticipatory guidance Educate the family by providing anticipatory guidance and a list of resourcesand a list of resources

Discharge CriteriaDischarge Criteria

ThermoregulationThermoregulation Ability to maintain a normal body Ability to maintain a normal body temperature when clothed in an temperature when clothed in an open cribopen crib

No apnea or bradycardia for a No apnea or bradycardia for a defined perioddefined period

Observational days that are spell Observational days that are spell free varies by unitfree varies by unit

Exclusively taking oral feedings Exclusively taking oral feedings with adequate weight gainwith adequate weight gain

Should demonstrate a sustained Should demonstrate a sustained pattern of weight gainpattern of weight gain

Discharge TeachingDischarge Teaching

Teach good handwashing and Teach good handwashing and minimize exposure to crowded minimize exposure to crowded placesplaces

Antibacterial solution in case soap and Antibacterial solution in case soap and water are not easily accessiblewater are not easily accessible

Infant must sleep on their backsInfant must sleep on their backs AAP recommends that infants sleep on AAP recommends that infants sleep on their backs to decrease SIDStheir backs to decrease SIDS

When to call PCPWhen to call PCP Instruct parents to contact PCP if with any Instruct parents to contact PCP if with any abdominal issues, breathing problems, abdominal issues, breathing problems, feeding intolerance, fever, decreased feeding intolerance, fever, decreased activity that could represent illness.activity that could represent illness.

Medication administrationMedication administration Fill prescriptions before discharge. Teach Fill prescriptions before discharge. Teach family how to administer medications.family how to administer medications.

Caloric supplementationCaloric supplementation Written instructions for formula/milk Written instructions for formula/milk preparation.preparation.

Discharge ChecklistDischarge Checklist

Car seat safety screenCar seat safety screen Assessed in all infants <37 wksAssessed in all infants <37 wks

Phone contact with PCPPhone contact with PCP Phone contactPhone contact

Written summary of medical course for Written summary of medical course for PCPPCP

Newborn hearing screenNewborn hearing screen Perform prior to discharge and if needed Perform prior to discharge and if needed arrange for out-patient follow-uparrange for out-patient follow-up

Newborn state screeningNewborn state screening PT often have initial NBS results that are PT often have initial NBS results that are “out of range” requiring ff-up“out of range” requiring ff-up

ImmunizationsImmunizations Routine immunizationsRoutine immunizations

Assess need for RSV prophylaxisAssess need for RSV prophylaxis

CPRCPR Ideally, all care providers should learn CPRIdeally, all care providers should learn CPR

Discharge PlanningDischarge Planning

Follow-up appointments/referralsFollow-up appointments/referrals Arrange discharge appointments at times that would decrease Arrange discharge appointments at times that would decrease

exposure to children with infectionsexposure to children with infections– PCPPCP– Early childhood intervention (ECI)Early childhood intervention (ECI)– Visiting nurseVisiting nurse– OphthalmologistOphthalmologist– High-risk clinicHigh-risk clinic– Other consultantsOther consultants

Discharge PlanningDischarge Planning

Discharge paper works to familiesDischarge paper works to families Supply the family with a copy of infants’ discharge summarySupply the family with a copy of infants’ discharge summary

– Discharge summary (recent weight, length, HC)Discharge summary (recent weight, length, HC)– Immunization recordImmunization record– Growth curveGrowth curve– List of medications and dosesList of medications and doses– Appointments and contact numbers of consultants, including Appointments and contact numbers of consultants, including

lactation consultantlactation consultant

Potential Medical Problems for Potential Medical Problems for Premature InfantsPremature Infants

RespiratoryRespiratory– BPD, ventilator dependent with need for tracheostomy BPD, ventilator dependent with need for tracheostomy

tube, apnea of prematuritytube, apnea of prematurity

Growth and NutritionGrowth and Nutrition– Inadequate nutrition and growth, difficulty with Inadequate nutrition and growth, difficulty with

breastfeeding, nutritional deficiencies, complications of breastfeeding, nutritional deficiencies, complications of IUGRIUGR

GIGI– GER, colic, oral aversion, constipation, need for enteral GER, colic, oral aversion, constipation, need for enteral

tubes, NEC, SBS, direct hyperbilirubinemiatubes, NEC, SBS, direct hyperbilirubinemia

Potential Medical Problems for Potential Medical Problems for Premature InfantsPremature Infants

NeurologicNeurologic– IVH, post hemorrhagic HCP, white matter injury, CP, delayed IVH, post hemorrhagic HCP, white matter injury, CP, delayed

neurodevelopmentneurodevelopment

HematologicHematologic– Anemia of prematurity, indirect hyperbilirubinemiaAnemia of prematurity, indirect hyperbilirubinemia

EndocrineEndocrine– Hypothyroidism, osteopeniaHypothyroidism, osteopenia

NeurosensoryNeurosensory– ROP, other ophthalmologic issues, hearing lossROP, other ophthalmologic issues, hearing loss

SurgicalSurgical– Cryptorchidism, inguinal or umbilical herniaCryptorchidism, inguinal or umbilical hernia