THE LATE PRETERM INFANT (LPT)

WAHIB MENA, M.D.

Glenda Dickerson, MS, RN, IBCLC

BROOKWOOD WOMEN’S MEDICAL CENTER HOMEWOOD, AL

DEFINITION

INFANTS BORN 34 0/7-36 6/7 WKS

EPIDEMIOLOGY

 2003: 12.3% OF BIRTHS < 37 WKS  31% INCREASE SINCE 1981  34-36.6 WKS (75%)  2002: 342,234 vs. 394,996

CLINICAL ISSUES

 TEMP INSTABILITY  HYPOGLYCEMIA  TTN  RDS  APNEA  SIDS  NEUROLOGIC ISSUES  HYPERBILIRUBINEMIA AND KERNICTERUS

TEMPERATURE

 HYPOTHERMIA  HYPERTHERMIA  ? SEPSIS  LONGER HOSPITAL STAY  RARE MORBIDITY AND MORTALITY(NEC)

HYPOGLYCEMIA

 LOW SUPPLY  INSULIN GLUCAGON BALANCE  BRAIN FUEL

What About What We Can’t See?

Human Brain Development

TTN/RDS/APNEA

 CLEARLY INCREASED TTN AND RDS  APNEA  USUALLY NO LONGTERM ISSUES

SIDS

 RISK OF SIDS DOUBLES  1.4 vs. 0.7/1000

NEUROLOGIC

 INCREASED BEHAVIORAL DISORDERS  NO GOOD STUDIES  DECREASED PERFORMANCE IN MATH AND ENGLISH

What About What We Can’t See?

Human Brain Development

JAUNDICE

 INCREASED BILI PRODUCTION  DECREASED CLEARING  IMMATURE BLOOD BRAIN BARRIER  INCREASED RISK FOR KERNICTERUS

WHAT TO DO

 BE AWARE OF ORGAN IMMATURITY  BRAIN  LUNG  HORMONAL AXIS  DIVING REFLEX

I AM PREMATURE

 DO NOT DELAY TREATMENT  AGGRESSIVE APPROACH  EDUCATE PARENTS  EDUCATE HEALTHCARE WORKERS  HOME ENVIRONMENT

Breastfeeding Management  Vulnerabilities 1.

2.

3.

4.

5.

6.

7.

Hypothermia Hypoglycemia Respiratory Instability Immature state regulation Hypotonia and Immature Feeding Skills Insufficient milk (delayed lactogenesis) Hyperbilirubinemia

1. Hypothermia and 2.Hypoglycemia



Skin-to-skin care (STS)

Hypothermia and Hypoglycemia  Skin-to-skin  Newborn infant’s natural habitat/safe environment • Helps to stabilize temperature  Mothers thermo regulate their infant’s temp • Stabilizes blood glucose levels  Even when a feeding does not take place • • Stabilizes respiratory effort Colonize the infant’s skin  Helps protect against URI and Intestinal infections

STS is Evidence Based Care

 Should not be based on “I like” or “I don’t like”  Should not be based on “there is not enough time”

Hypothermia and Hypoglycemia

 Immediate STS (Mom and infant stable)  Dried  Covered with warm blankets  Cap placed on head  Initial assessment accomplished  Postpone task till after first feeding is accomplished

Extended STS Care

 Encourages frequent feedings

3. Respiratory Instability

 LPT is more prone to positional apnea  Careful feeding position • • Avoid cradle hold Clutch (football) or cross-cradle is preferred   Mom should be instructed not to flex head in these positions Breast should not rest on the infant’s chest  Avoid use of slings • Wraps/KC garments may work well

Preferred: Clutch (Football)

Preferred: Cross-Cradle Hold

Avoid —Over-flexed Position

4. Immature State Regulation

 STS care  Modulates the under-aroused, over aroused, and shut down infant  Minimize interruptions  Parent education  Avoid excessive stroking, massaging, rocking, talking, bright lights, loud noise, and being handed of to multiple visitors  Limit visitors

5. Hypotonia and Immature Feeding Skills  Hypotonia  May result from maternal use of labor medications  Fetal exposure to SSRI’s during 3 rd trimester  Will contribute to ineffective feeding

Hypotonia and Immature Feeding Skills  Wide range of sucking patterns, frequency, and intensity  May tire quickly and be unable to sustain nutritive sucking  Electromyographic study of sucking patterns • 15% to 60% of time spent sucking  May lack strength for appropriate sucking pressure (60 mm Hg) • Render unable to secure nipple in place between sucking burst

Hypotonia and Immature Feeding Skills 

Feed the baby



Facilitate direct breastfeeding



Protect mother’s milk supply

Hypotonia and Immature Feeding Skills  Feed the Baby  Encourage initiation of breastfeeding within one hour after birth • Latch if possible  Cross-cradle/football  Use Dancer-Hand to stabilize jaw  May help to prevent clamping • Consider use of nipple shield

Hypotonia and Immature Feeding Skills 

Evaluate need for supplement

 Expressed colostrum/breastmilk  Banked human milk  Hydrolyzed formula • Reduce the risk of sensitizing a susceptible infant to allergies or diabetes • May help to lower bili levels

Hypotonia and Immature Feeding Skills  Should be breastfed or breastmilk fed  8 times in 24 hours  Awaken if baby does not indicate hunger  Continue use of nipple shield if needed  Difficult latch   Evidence of ineffective milk transfer Follow up with mother’s using shield after discharge • Infant may need to use until 40 weeks post conceptual age

Hypotonia and Immature Feeding Skills  Supplementation  Best done at the breast if possible • 5 French feeding tube/10 ml syringe • Commercial supplementer systems  Can be used in conjunction with a nipple shield

Hypotonia and Immature Feeding Skills  If infant is not latching or able to supplement at breast  Feed expressed milk every 3 hours • 5-10 ml per feeding on day 1  Spoon (small quantities) • 10-20 ml per feeding on day 2  Cup (as quantity increases)  Paced feeding • 20-30 ml per feeding on day 3

Hypotonia and Immature Feeding Skills  If supplementing away from the breast  Facilitate direct breastfeeding • Use alternative methods as the mother desires  Spoon feeding for small amounts  Cup feeding for larger amounts • Paced feeding • Encourage mother to continue efforts at the breast as she is comfortable

Spoon Feeding

Hypotonia and Immature Feeding Skills  Protect mother’s milk supply  Assist the mother to begin pumping • Feeding ineffectively  Pump every 3 hours during the day and at least once per night • Feeding effectively  Pump about 4 times a day to provide additional stimulation to bring in a good milk supply

6. Insufficient Milk Supply

 Initiate and maintain supply  Begin pumping within 6 hours of delivery • Colostrum bolus may be present  Pump after each feeding (8-10 times per 24 hours) for first 2 weeks  Use appropriate size breast shield for pumping

Insufficient Milk Supply

 Protect Milk Supply  Establishing milk supply • Lactogenesis II occurs on average 60 hours following delivery  Expected volumes (approximation) per 24 hrs • • Day one Day two less than 100 ml 200 ml • • • Day three Day four Day 14 350 ml (borderline) 600 ml (adequate) 750 ml (ideal)

Insufficient Milk Supply

 Protect mother’s milk supply  The amount of stimulation on day 2 is positively correlated with adequate milk volume on day five  Milk supply at day 6 is indicative of supply at 6 weeks • Window of opportunity for establishing milk supply

7. Hyperbilirubinemia

 Readmission due to jaundice  7 to 13 fold increased risk • Slower meconium passage • Low milk intake • Decreased activity of bili-conjugating enzyme  Bilirubin peak levels typically occur around 5 to 7 days of life  Kernicterus is seen more frequently in LPT

Hyberbilirubinemia



Preventative goals

 Optimize milk intake  Promote rapid meconium clearance and increase stool volume  Prevent excessive weight loss

Hyperbilirubinemia

 Optimize Milk Intake  Frequent feedings • 8-10 times in 24 hours  Evaluate for deep latch  Use breast compression or massage  Use a nipple shield if needed

Hyperbilirubinemia  Promote Rapid Meconium Clearance  Frequent colostrum feeds • At breast • Hand expressed  5-10 ml every 2-3 hours on day one  10-20 ml every 2-3 hours on day two  20-30 ml every 2-3 hours on day three

Hyperbilirubinemia

 Prevent Excessive Weight Loss  Discourage missed feedings • Visitors • Excessive interruptions  Evaluation of feeding once per shift • Qualified professional • Document  Pre and post feed weights if needed

Hyperbilirubinemia

 Data from the Pilot Kernicterus Registry (1992 2003)   The greatest risk for kernicterus • The exclusively breastfed “large” LPT infant Hospital admission within 7 days post birth   Present with severe jaundice and inadequate intake Most parents had contacted their primary care providers with concerns about jaundice, poor feeding, and excessive sleepiness and had been told these were normal behaviors

Discharge Feeding Plan  Team effort that includes the mother  STS Care   Feed the Baby/Determine the method Protect Mother’s Milk Supply  Early and Appropriate Follow-up  Communicate this plan with outpatient care provider  Continue evaluation

Initial Outpatient Follow-up  Should be 3-5 days of life, or one or two days after discharge  Weight check  Assessment for jaundice  Review of written feeding record • Parameters of adequate intake  Assessment of breastfeeding effectiveness

Poor Weight Gain



Less than 20 grams/day

 Ineffective feeding • Refer to a lactation specialist

Follow-up



How are mom and baby coping?

 Modify plan to something that is more manageable  Work with her to find help  Don’t assume you know  Ask!

Extended Follow-up

 Weekly follow-up until 40 weeks post conceptual age or until it is demonstrated that he/she is thriving with no supplements  With each adjustment that is made a visit/weight check in 2-4 days should be done

Continued Monitoring



Adequate growth

 Weight gain should average >20 g/day  Length and head circumference should each increase by an average of .0.5 cm/week

Our Findings



Recollected data to see if we had improved readmission rates

 Decreased by 50% in the first year  Goal is to decrease to same rate as term infant

Interventions Reviewed

 L Lots of STS  P Position Appropriately  I Initiate Stimulation Controls  C Calories Count  A Adequate Milk Supply  R Reinforce awareness of bili  E Educate for discharge!

Objectives

 Define the sub-classification of late preterm infant.

 Discuss the physical characteristics and vulnerabilities of the late preterm infant.

 List strategies to address the identified vulnerabilities of the late preterm infant as they relate to breastfeeding management.

 State the essential elements of discharge planning for the breastfeeding late preterm infant.

Late Preterm Babies Were Born to Breastfeed