Evidence-based Care Managment of the Late Preterm Infant

Authors and Disclosures

Ana Souto, MS, PNP, Miriam Pudel, MS, PNP, & Donna Hallas, PhD, PNP-BC, CPNP

Ana Souto, Student, Master Student Independent Study Project, New York University College of Nursing, New York, NY.
Miriam Pudel, Student, Master Student Independent Study Project, New York University College of Nursing, New York, NY.
Donna Hallas, Clinical Associate Professor and Coordinator, Pediatric Nurse Practitioner Program, New York University College of Nursing, New York, NY.

Correspondence
Donna Hallas, PhD, PNP-BC, CPNP, 10th Floor, 726 Broadway, New York, NY 10003

From Journal of Pediatric Health Care

Evidence-based Care Management of the Late Preterm Infant

Ana Souto, MS, PNP; Miriam Pudel, MS, PNP; Donna Hallas, PhD, PNP-BC, CPNP

Posted: 12/21/2010; J Pediatr Health Care. 2011;25(11):44-49. © 2011 Mosby, Inc.

A 2-week-old male infant born at 35 weeks’ gestational age (GA) to a 36-year-old multi-gravida woman presents to the pediatric office for the first primary care office visit after discharge from the hospital. The GA of 35 weeks was confirmed by the Dubowitz assessment performed 4 hours after birth. A review of the hospital discharge record revealed a positive maternal history for hepatitis B antigen (HBsAg+); non-reactive rapid plasma reagin; and an emergency Caesarean section after 6 hours of labor because of fetal heart rate decelerations. Apgar scores were 7 and 8 at 1 and 5 minutes, respectively. The infant measurements at birth were as follows: weight, 1.814 kg (4 lb, 8 oz); length, 45.72 cm (18 in); and head circumference, 31 cm. After an initial assessment in the newborn nursery, the infant was transferred to the Neonatal Intensive Care Unit (NICU) for transient tachypnea. The mother began breastfeeding on the second postpartum day and continued breastfeeding every 3 hours during the infant’s hospital stay. The record also revealed that the infant’s bilirubin level was 14.8 mg/dL during the first week of life. The infant was discharged home at 4 days of age with instructions to continue breastfeeding every 3 hours, and a pediatric office appointment was scheduled.

Since discharge from the hospital, the mother breastfed the infant every 2 to 3 hours. The infant’s suck had improved since he was discharged. The infant has stools two to three times daily and has several wet diapers each day. He is alert and active for a few hours in the daytime and eats and sleeps the remainder of the day and night. The mother expressed concern about the amount of breast milk she was producing.

The infant received hepatitis B vaccine and hepatitis B immune globulin (HBIG) within 12 hours of birth. The transient tachypnea resolved spontaneously, and after day 4 of life, the infant was discharged from the newborn nursery with a bilirubin level of 12 mg/dL. The newborn screening report was received in the pediatric office, and results were negative.

The mother denied a history of drug or alcohol abuse. Prenatal care began during the first trimester, and no complications occurred. There was a maternal and family history of asthma. The remainder of the maternal and family history was noncontributory.

During periods when he is awake, the infant lifts his chin for a few seconds when lying on his tummy and firmly grasps small objects placed in his hand. He explores his surroundings with his eyes, turns in the direction of some sounds, and cries when left alone but responds positively when held and comforted. The infant moves all his extremities well.

A review of systems is non-contributory except for feeding concerns as documented in the History of Present Illness. The infant is not taking any medications.

At the initial examination the infant weighed 2.3 kg (5 lb), with a height of 48 cm (18.9 in) and a head circumference of 32 cm. The infant is alert, active, and in no acute distress. A complete physical examination revealed a healthy late preterm infant.

1. Is the late preterm infant, that is, a newborn born between 34 weeks 0 days and 36 weeks 6 days GA, at a greater risk of complications during the newborn period than a full-term infant? [PICO prognosis question; seeTablefor PICO acronym]
2. In the late preterm infant, what is the effect of breastfeeding on overall growth compared with formula feeding? [PICO prognosis question]
3. For late preterm infants and all infants born to HBsAg+ mothers, what are current evidence-based practice guidelines? [PICO therapy question]
4. Should the late preterm infant receive respiratory syncytial virus prophylaxis as part of routine care to prevent respiratory syncytial virus infection? [PICO therapy question]

1. Is the late preterm infant, that is, a newborn born between 34 weeks 0 days and 36 weeks 6 days GA, at a greater risk of complications during the newborn period than a full-term infant?

The late preterm is a neonate who is born between 34 weeks 0 days and 36 weeks 6 days of gestation. Previously, infants born during this time frame were called “near term” or “slightly premature,” which was a misnomer because the infants have special care needs (Coffman, 2009). Late preterm infants are the fastest growing group of preterm infants and account for 75% of all preterm births (Verklan, 2009). Despite the increased weight and more mature appearance of late preterm infants, they are described as a vulnerable population who are at greater risk for complications when compared with full-term infants (Verklan, 2009). The mortality rate for late preterm infants is higher than that of full-term infants (Pulver, Guest-Warnick, Stoddard, Byington, & Young, 2009). Pulver et al. (2009) examined the linked birth and death certificates for all infants born in Utah between 1999 and 2005. These researchers found that small for gestational age late preterm infants were about 44 times more likely than appropriate for gestational age infants to die in the first month of life, and 22 times more likely to die in the first year of life. The authors stressed the significance of provider attention to weight in relation to GA, factors that should be included when formulating care management plans for the late preterm infants. Early recognition of health problems in these infants is critical if we are to reduce the high incidence of death in this population.

Some of the most common complications for late preterm infants are cold stress, respiratory distress, hypoglycemia, sepsis, cognitive delays, hyperbilirubinemia, and feeding difficulties.

Late preterm infants are more susceptible than full-term infants to cold stress because of underdeveloped glycogen stores, an immature epidermal barrier, a higher surface to body mass ratio, and decreased levels of subcutaneous and brown fat. They have a high metabolic rate but a decreased ability to generate heat (Hubbard, Stellwagen, & Wolf, 2007). Decreased muscle tone and activity increases the body surface area exposed to the environment (Verklan, 2009). The immature epidermal barrier results in an increased transepidermal water loss. The late preterm infant’s body temperature should be maintained between 36.5 °C to 37.5 °C (Darcy, 2009). In this case presentation, the late preterm infant was immediately placed in an infant warmer; his temperature gradually rose to 37 °C, and thus he did not experience cold stress.

The late preterm infant is at high risk for respiratory distress within the first few hours of birth. Many late preterm infants are delivered by Caesarean section, which increases the risk for transient tachypnea of the newborn, respiratory distress syndrome, pulmonary hypertension, and hypoxic respiratory failure (Verklan, 2009). In this case study, as anticipated, the late preterm infant experienced transient tachypnea and was transferred to the NICU. Spontaneous resolution of transient tachypnea occurred, and the NICU provided an environment in which the infant was closely monitored for other known respiratory complications.

The late preterm infant is at high risk for hypoglycemia because of decreased glycogen and fat stores, decreased ability to produce glucose, and immature glucose-regulated insulin secretion. Full-term infants have a higher metabolic rate than do late preterm infants. The lower metabolic rate of late preterm infants makes them more susceptible to hypoglycemia after birth (Verklan, 2009). Best practice guidelines recommend monitoring blood glucose levels in the late preterm infant each hour for the first 3 hours after birth, at which time the glucose level is expected to stabilize.

The late preterm infant is at greater risk for infection than the full-term newborn because maternal antibodies are not fully transferred prior to the 37th week of pregnancy (Verklan, 2009). Maternal infections commonly induce preterm labor and must be considered as a possible cause for the preterm labor. Additionally, a positive maternal group B streptococcal status places the infant at risk for neonatal sepsis (Hubbard et al., 2007). Additional information on sepsis in late preterm infants is provided at the following website: http://www.ncbi.nlm.nih.gov/pubmed/19953725?dopt=AbstractPlus.

Compared with full-term infants, late preterm infants are at increased risk for major neurodevelopmental complications such as severe intraventricular hemorrhage and periventricular leukomalacia. Much of the brain growth and development is accomplished during the last few weeks of intrauterine life. The 34-week-old late preterm infant’s cortical volume of the brain is 50% that of the full-term infant. Moreover, early research shows that late preterm infants have a higher incidence of diagnosis with developmental delay in the first 3 years of life compared with full-term infants (Verklan, 2009). These data support routine developmental assessments at each primary health care visit to monitor achievement of age-adjusted milestones. Screening tools such as the Denver Developmental Screening Tool II and referrals for an early intervention program are recommended. Researchers compared pre-kindergarten and kindergarten outcomes for healthy late preterm infants to healthy term infants and found that late preterm infants displayed a greater risk for developmental delays and school problems throughout the first 5 years of life (Morse, Zheng, Tang, & Roth, 2009).

Feeding difficulties and hyperbilirubinemia are probably the most common problems for late preterm infants and are discussed later in this article.

2. In the late preterm infant, what is the effect of breastfeeding on overall growth compared with formula feeding?

Late preterm infants have a weak suck that may diminish breast milk volume per suck (Walker, 2008). Thus, the mother of a late preterm infant requires special attention during the immediate postnatal period and at each pediatric well-child visit to successfully breastfeed her infant. Members of the Academy of Breastfeeding Protocol Committee (Boies, Chantry, Howard, & Vaucher, 2004) developed a guideline for breastfeeding the near-term (late preterm) infant, whom they defined as infants born between 35 to 37 weeks’ gestation. This guideline was intended for implementation on postpartum units by nursery nurses and by pediatric nurses, pediatric nurse practitioners (PNPs), and pediatricians in outpatient settings. The guideline offers strategies to anticipate, identify, and manage frequently experienced breastfeeding problems in inpatient settings and at home.

During the initial office visit, the health care provider must conduct a thorough review of the inpatient maternal and infant records (Boies et al., 2004). The PNP should question the mother about the infant’s stool and urine output, color of stools, and the infant’s awake and sleep cycle and make appropriate recommendations. Physical examination must include accurate assessments of weight without clothing and calculation of change in weight from birth and discharge from the hospital to assess for hydration and effectiveness of breastfeeding. The infant should make consistent gains along the growth curve. The guideline recommends that the first office visit be scheduled 2 to 3 days after hospital discharge.

PNPs should be skilled in assessing the breastfeeding abilities of breastfeeding mothers of late preterm infants and in performing breast assessments during the visit. It is important for the PNP to observe the baby breastfeeding in the office to assess the latch, suck, and swallowing abilities of the infant. If the infant has poor weight gain, the PNP should assess whether the problem is insufficient breast milk production, inability of the infant to obtain enough milk, or a combination of these problems. The infant who is getting enough breast milk should (a) have six to eight voids each day and at least one yellow seedy stool daily by day 4, (b) have lost no more than 8% of birth weight, and (c) be satisfied after 20 to 30 minutes of nursing. For the late preterm infant in this case study who breastfed for longer than this recommended time frame, we recommended placing him at the breast for 30 minutes, keeping him awake by stroking his feet, and supplementing between feedings (preferably with expressed breast milk); these suggestions were consistent with recommendations in this guideline. The mother was referred to a lactation specialist for additional support.

For late preterm infants with latch difficulties, the PNP should assess the infant’s mouth for anatomic abnormalities and perform a digital suck examination. If the infant has ankyloglossia, a referral to a pediatric dentist or an ear, nose, and throat specialist is recommended for evaluation and a possible frenotomy, which can be performed in the office (Hallas, Fernandez, Lim, & Carobene, 2010). The infant in this case study had a normal oral examination and was able to latch onto the nipple without difficulty. The infant sucked adequately, and the mother was given further instruction on feeding positions.

During the initial office visit, assessment for jaundice is essential. Cutaneous bilirubin screening and/or a serum bilirubin determination may be indicated based on clinical findings. Research on the ability of nurses who care for newborns to determine the infants’ progression to jaundice through a cephalocaudal assessment compared with laboratory evaluation revealed that the nursing assessment strategy often failed to identify jaundiced infants; this finding was especially true for late preterm infants (Keren, Tremont, Luan, & Cnaan, 2009). The jaundiced late preterm infant requires special consideration for the management of hyperbilirubinemia. The differential diagnosis of hyperbilirubinemia should be considered. If the outcome of the differential diagnosis is lack of milk, then primary treatment of hyperbilirubinemia is to increase the amount of milk fed to the infant, ideally through improved breastfeeding techniques or via expressed breast milk. Institution of phototherapy for breastfeeding jaundice, either in the home or in the hospital, may actually interfere with the primary treatment of getting increased quantities of milk to the baby (Meier, Furman, & Degenhardt, 2007). Evidence-based care management for the late preterm infant includes weekly weight checks until 40 weeks after conceptual age or until it is demonstrated that the infant is thriving with no supplements (Walker, 2008). This infant’s clinical presentation did not warrant any additional bilirubin testing. The infant was scheduled to return to the office 3 days after discharge for a weight check, consistent with the evidence-based guideline.

3. For late preterm infants and all infants born to HBsAg+ mothers, what are current evidence-based practice guidelines?

The guideline of the Centers for Disease Control and Prevention (CDC) for the prevention of prenatal transmission of Hepatitis B, “Prenatal Care Provider Policies and Procedures to Prevent Perinatal Hepatitis B Virus Transmission,” directs hospitals to implement policies and procedures to ensure identification and initiation of postexposure immunization of all infants born to HBsAg+ mothers. The date and time of birth as well as the date and time of administration of the hepatitis B vaccine and of the HBIG for all infants born to HBsAg+ mothers must be documented. The hepatitis B vaccine and HBIG must be administered in separate syringes at separate sites within the first 12 hours of life. If the same extremity must be used, then the injections are administered at least 1 inch apart. The vaccine information sheets and an immunization record must be provided to the mother at discharge (www.cdc.gov/immunization). In states with immunization registries, the administration of the hepatitis B vaccine and HBIG must be reported to the registry. In the pediatric office setting, nurses, PNPs, and pediatricians should provide educational materials to the mother about hepatitis B and review previous explanations on transmission, medical evaluation, and care of the infant, including the necessary administration of the hepatitis B vaccine in the first 6 months of life per the CDC schedule (www.cdc.gov/immunization; American Academy of Pediatrics [AAP], 2010). In addition, the potential risk of chronic hepatitis B developing in the infant should be discussed with the parents. The infant should receive the second dose of the monovalent hepatitis B vaccine at 1 month of age and the third dose at 6 months of age (no earlier than 24 weeks of age) (CDC, n.d.). If the second dose is not administered at the 1-month- old visit, then the second dose must be administered at the 2-month-old visit. For infants born to mothers who are HBsAg+, the management plan for the infant includes testing for HBsAg and antibody (HBsAB) 1 to 2 months after completion of the third dose of hepatitis B. If the result of the follow-up testing is negative for the antibody, then a fourth dose of hepatitis B vaccine must be administered. Infants who remain HBsAg+ should be referred to a pediatric gastroenterologist because the infant is at high risk for the development of chronic hepatitis B and liver cancer later in life. HBsAg+ test results in infants should be reported to the department of health and to the CDC via the National Notifiable Diseases Surveillance System.

4. Should the late preterm infant receive respiratory syncytial viral prophylaxis as part of routine care to prevent RSV infection?

All late preterm infants are considered to be at risk for respiratory syncytial virus (RSV) infections (Coffman, 2009). In 2009, the recommendations from the AAP Infectious Disease Committee (AAP, 2009) revised indications for the use of palivizumab (Synagis) for the prevention of RSV infections in preterm and late preterm infants. These revisions were controversial because many pediatric experts and organizations (i.e., the AAP) argued that the recommendations were not based on the best available evidence (level I evidence, i.e., systematic reviews or randomized controlled trials) but instead were based on expert opinion. Thus there was strong opposition to change from the previously published recommendations for RSV prophylaxis (AAP, 2006). However, the late preterm infant presented in this case study was 35 weeks by gestational age and did not meet the criteria for RSV prophylaxis in either the 2006 or the 2009 guidelines (American Academy of Pediatrics, 2006, American Academy of Pediatrics, 2009).

Anticipatory guidance for parents of late preterm infants should include recommending an infant cardiopulmonary resuscitation course, educating about sudden infant death syndrome prevention protocol (Back to Sleep), and advising the parents to avoid public places and limit visitors for the first few weeks after being discharged from the hospital. Consistent follow-up medical care, weekly weight checks, and up-to-date immunizations can help late preterm infants avoid complications.

[ CLOSE WINDOW ]

References

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Conflicts of interest
None to report.

J Pediatr Health Care. 2011;25(11):44-49. © 2011 Mosby, Inc.

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