Do Not Ignore the Risks for Late-Preterm Newborns

Late-preterm infants are at risk for a host of problems and are often discharged from the hospital too soon, said Barbara Medoff-Cooper, PhD, CRNP, FAAN, RN, the Ruth M. Colket Professor in Pediatric Nursing and Director, Center for Biobehavioral Research, University of Pennsylvania School of Nursing, Philadelphia.

The key concerns are thermoregulation, respiratory distress, jaundice/hyperbilirubinemia, and feeding issues.

“We should keep these infants longer. As a nurse practitioner, this was one of my battles with neonatologists and insurance companies, but I wound up losing the battle, because there were no policies in place to support me,” Dr Medoff-Cooper told nurses at the Association of Women’s Health, Obstet - ric and Neonatal Nurses (AWHONN) 2010 meeting.

AWHONN was the first organization to initiate a conversation about this issue to improve the quality of care for these infants. In 2005, AWHONN launched a multiyear initiative to raise awareness of these risks and develop evidence-based guidelines.

Increased Morbidity and Mortality Rates
More than 9% of all births in the United States, or 377,000 infants, are born between 34 and 36 weeks, the late-preterm period. The mortality rate at this period is tripled—to 9.3 deaths per 100,000 births—compared with 2.5 deaths per 100,000 births for full-term infants. Neonatal respiratory morbidity is 4.4 times greater, neonatal infections are 5.2 times greater, and mean hospital stay is 142 hours longer for late-preterm infants than for term infants, she said.

“The problem is that size, appearance, and initial stability at delivery often result in normal newborn care,” Dr Medoff-Cooper said. “They often look like healthy full-term kids, and this fools you.”

These newborns may be physiologically immature in terms of control of lung volume, laryngeal reflexes, upper airway, and coordination of suckswallow- breathe functions. Their clinical risks are primarily related to organ immaturity and include cardiopulmonary problems, such as respiratory distress syndrome; gastrointestinal problems and feeding issues; inadequate brain development; and jaundice and hyperbilirubinemia.

In addition, late-preterm infants are at increased risk for hypoglycemia, temperature instability, signs resulting in a sepsis workup, conditions requiring intravenous lines, and apnea and bradycardia. They are likely to require intensive care, especially those born at 35 weeks (54%) and 34 weeks (88%).

Proper Clinical Assessment Is Critical
Clinical assessment is critical to identifying these infants and preventing problems. The first step is to do an accurate gestational age assessment using standardized tools, because “these babies may be more immature than they appear,” Dr Medoff-Cooper emphasized. This provides more accurate data for the newborn risk assessment.

The younger the gestational age, the higher the risk for respiratory distress. In evaluating for respiratory distress syndrome, nurses should consider the perinatal history and risk factors, type of delivery, and factors related to the immediate transition to extrauterine life (ie, Apgar score, need for oxygen or resuscitation). Nurses should try to minimize cold stress, which increases oxygen consumption. The risk for abnormal thermoregulation is greatest during the first few hours of birth because of heat loss. Nurses should closely monitor body temperature and watch for hypothermia and hypoglycemia. Supplemental heat sources are often necessary to minimize heat loss and properly insulate these infants, she said.

“Throughout the hospital stay, you should monitor the newborn’s ability to maintain body temperature in the open crib,” she said. Thermoregulation should be normal before hospital discharge.

Jaundice and hyperbilirubinemia are concerns, because of the risk for brain injury. Risk factors include gestational age <36 weeks, asphyxia, acidosis, sepsis, poor feeding, hemolytic disease, lethargy, and temperature instability. Breastfeeding infants are particularly at risk, and hyperbilirubinemia in these infants can be prolonged.

“Do a feeding assessment and measure bilirubin levels in any infant with jaundice,” Dr Medoff-Cooper advised, adding that a nomogram of hour-specific serum total bilirubin concentration is helpful. “Do not rely on visual assessment and interpret all bilirubin levels in terms of infant’s age in hours. A bilirubin over 18 mg/dL should require a rapid response.”

Feeding Issues
Common breastfeeding problems are magnified in late-preterm infants, including decreased ability to latch on, difficulty in getting to an alert state, increased risk of hyperbilirubinemia, increased weight loss in the first days/weeks after birth, and maternal difficulty in establishing a milk supply.

“Late-preterm infants should not be expected to feed like a full-term infant on the first days of life,” she said. “They have decreased stamina, which results in less effective suckling and breast stimulation, and their suckswallow- breathe cycle may not be fully developed. Delay discharge if feeding is suboptimal.”

Dr Medoff-Cooper recommended getting the baby to the breast within the first hour of birth if possible, and maintaining continuous skin-to-skin contact (avoiding separation from the mother). Nurses should evaluate the infant’s ability to breastfeed on demand, monitor the quality of the feedings, and assess for weight loss and dehydration.

“Also, it’s important to educate the mother about behavioral state and early feeding cues,” she said