Transcript THE “NEAR TERM” NEWBORN: Not Ready for “Term Time”

THE “LATE PRETERM”
Newborn
Not Ready for “Term Time”
Mary Johnson RNC/MSN
Gwinnett Medical Center
Objectives
• Describe the variations seen in
the birth weight and gestational
age of the late preterm infant
• Identify two health problems for
which the late preterm infant
has an increased risk
• List two discharge needs of the
late preterm infant
Definitions
• Term: 37 weeks and 0 days
through 42 complete weeks of
gestation
• “Late Preterm”: 34 to 36.6
weeks gestation
• Preterm: Has become a
gestational age of under 34
weeks
Incidence
• 6.4 to 8.5 % of all births are
born between 34 and 36.6
weeks gestation
• Incidence of prematurity has
risen from 7.9% to 11.9%
• African American
rate:7.6%;Caucasian 15.6%
Fact or Fiction
• The prematurity rate has
remained stable for the past 20
years
• Because of the successes of
NICUs, energy toward
prematurity prevention can be
decreased
Fact or fiction
• The reasons for premature labor
are well understood
• Risk factors predict the majority
of preterm births
• Media and public service ads
have had a large impact on
public awareness and
knowledge of prematurity
Why the Current
Interest
• Previous focus on normal
newborn and extremely low
birth weight infants
• Prevalence rate (6.4 to 8.5 %)
• Increased hospital readmissions
• Previously absorbed into the
regular population in NICU or
intermediate nurseries
Current Interest
• Now absorbed into the “well”
baby nursery
• Cost restraints regarding unit
placement and nurse staffing
ratios
Current Interest
• Pediatrics study: 90 late preterm and
95 full term babies
• Late preterm babies had
significantly more
• Medical Problems:
• 27 % of Late Preterms had IVF’s vs 5% of
Term babies
• More like to be evaluated for infection,
hypoglycemia breathing problems and
jaundice
Current Interest
• Medical Costs:
• Mean difference of $2630 between
Late Preterm and Term
• Lengths of stay:
• 50 of the late preterm babies did not
go home with their mothers versus 8
of the full term babies.
− Wang, et al (2004). Pediatrics: 114:2
NOT READY !!
• Why the increase in late
preterm births?
• C/S on Demand
• US single birth distribution of
gestational age has shifted
towards earlier gestation
• 39 weeks is now the most common
length of gestation (not 40)
Not Ready
• The 34 to 36 week gestational
age infant is the fastest growing
segment of single preterm
births
C/S on Demand
• C/S initially an emergency procedure
• Now advocated as a routine
technique
• Women as Health Care Consumers:
avoid stretch marks; fit into family
schedule;
• Better bladder control in the future;
mostly in multips
C/S on Demand
• Labor and SVD no longer
“desired” outcome
• “Informed” consent for SVD
• Maternal “risks” of SVD
• Neonatal risks of C/S
• Respiratory issues; difficult
transition; etc.
LABOR IS GOOD!
Increase of catecholamines
which increases neonatal
cardiac output and
contractility
Enhances surfactant release
Inhibits fetal lung fluid
secretion
Increases glycogenolysis
Characteristics
• 34 to 37weeks: weights
• 34: 1500 grams to 2800 grams
(3lbs 5oz to 6 lbs 3 oz)
• 35: 1700 grams to 3 kgs
(3lbs 12oz to 6lbs 10oz)
• 36: 1900 grams to 3200 grams
(4 lbs 3 to 7 lbs 1 oz)
• 37: 2100 grams to 3400 grams
( 4 lbs 10 oz to 7 lbs 8 oz)
Not Ready
• DANGER!! DANGER!! AT RISK!!
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Respiratory instability
Hypoglycemia
Sepsis
Hypothermia
Feeding Issues
Hyperbilirubinemia
Respiratory Instability
• RDS
• TTN
• Apnea
Respiratory Distress
Syndrome
• Etiology: Lack of surfactant
• Surfactant produced in last
stages of pregnancy
• Begins at about 32-33 weeks
and increases slowly to
maximum levels at 38 to 40
weeks
RDS Symptoms
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Grunting
Flaring
Retractions
Cyanosis
RDS TREATMENT
• Oxygenation
• Ventilation
• Surfactant replacement
Transient Tachypnea
“TTN”
• Risk factors
• Asphyxia: Term babies better
equipped to deal with low ph’s and
po2 than late preterm babies
because of decreased glucose
metabolism and decreased
oxygenation capacity
• C/S: no vag squeeze;
catecholamine release decreased
TTN
• Self limiting condition
• Symptoms include: tachypnea;
retractions; grunting
• Symptoms mild and resolve over
hours to days
• Require O2 and supportive
therapy
TTN Etiology
• Retained fetal lung fluid
• Why increased in the late preterm
population?
• C/S
• Fetal lung fluid production decreases
during late pregnancy and absorption
is increased with catecholamine
surge during labor
Apnea
• Immature respiratory centers in
the CNS
• Upper airway flaccidity
Hypoglycemia
• Infants at greatest risk:
• BW < 2500grams; <37 weeks
• IDM’s
• SGA or LGA
Hypoglycemia
• Why increased incidence in late
preterm babies?
• Poor mechanisms to regulate
glycogenolysis and gluconeogenesis as
both processes require glucose and
oxygen
• Preterm babies have lack of reserves of
glucose and methods of manufacturing
glucose
• More likely to have oxygenation
problems
Sepsis
• Respiratory Distress
• Decreased
perfusion/hypotension
• Poor Feeding
• Temperature Instability
• “Something is just not right”
Sepsis
• Why are Late Preterm babies
more likely to develop sepsis?
• Antibodies (IGA, IGM) are not at
adequate levels for protection until
3 to 6 months of age.
• Antibodies start to form at 20
weeks gestation and increase in
production beginning around 38
weeks
Sepsis
• Be cautious: don’t dismiss
subtle signs
• Antibiotics are a priority
Hypothermia
• Why are Late Preterm Babies at
risk for Hypothermia?
• Immature CNS for temp regulation
• Lack of brown fat
• Immature Hormone systems
decrease release of
norepinephrine (mediates
metabolism of brown fat)
Hypothermia
• This brown fat /norepinephrine
process relies heavily on
oxygen and glucose utilization
which is compromised in the
late preterm infant
Hypothermia
• What does hypothermia cause?
• Increased metabolic rate which
decreases an already limited
supply of glucose for energy.
• Increased oxygen consumption
which causes pulmonary vaso
constriction and hypoxemia which
also leads to worsening
respiratory distress.
Feeding Issues
• 10% of Late Preterm infants are
readmitted for “failure to thrive”
or “poor feedings”. Why do
these babies not fed well…
Feeding Issues
• Less stamina; less coordinated
S/S/B; Less effective suck; Less
awake alert periods. This
causes insufficient breast
stimulation and incomplete
breast emptying leading to
inadequate milk supply and
transfer and feeding volume
Feeding Issues
• This contributes to
hypoglycemia, jaundice,
dehydration and poor weight
gain which leads to:
• Delayed discharge, readmission,
supplementation and maternal
separation
Jaundice
• Why are Late Preterm babies
more at risk for jaundice?
• Increased production and
decreased elimination of bilirubin
• Hepatic immaturity results in
altered hepatic uptake and
conjugation of bilirubin
• Breastfeeding practices
Kernicterus
• When bilirubin at high enough
levels crosses the blood/brain
barrier leading to
developmental delays, CP like
symptoms.
Discharge and Follow up
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Stable temperature
Effective feeding performance
Effective milk production
Stable weight status
Bilirubin assessment and
treatment
• CAR SEAT TEST
Discharge
• Establish follow up care
• 24 to 48 hours after discharge!!
Maternal Perceptions
• These babies are fine; not
considered premature.
• All babies are sleepy and all
babies get jaundiced
• All babies have trouble
breastfeeding….
• I HAVE TO GO BACK TO THE
HOSPITAL?!?!?!?!
Late Preterm Initiative
• “Late preterm babies have unique
needs. This population, though often
treated like full term newborns, are
at the risk for the same problems
that premature newborns
experience, including jaundice, RDS,
feeding problems and potential
developmental delays.” AWHONN
Late Preterm Initiative
• Multi year national nurses initiative
to improve care and outcomes of
these infants
• National Advisory Panel
• Focus
• Neonatal physiological status
• Nursing Care Practices
• Care environment …NICU vs “Term
Nursery”
AWHONN’S goals
• Raise awareness of infants and
parents needs
• Encourage research
• Develop and adopt evidence based
guidelines for near term infants
• Health care team will be on the same
page
• Consistent parent education about care
of their late preterm baby
Four areas of focus
• Physiologic functional status
• Care environment at both
hospital and at home
• Family
• Nursing practice
Emphasis
• ESSENTIAL role of the family
• Arrangement of follow up care
practices
• Education of nurses AND
physicians
AWHONN
• “The best predictor of the
needs of the late preterm infant
is a skilled, experienced nurse
with a high index of
suspicion…”
THE END