NEAR TERM INFANT PROBLEMS and INNOVATIVE CARE



NEAR TERM INFANT PROBLEMS and INNOVATIVE CARE

Susan M. Ludington-Hoe, CNM, Ph.D., FAAN Bolton School of Nursing

Susan.ludington@case.edu, 216-368-5130.

Definition. New terms have emerged: NEAR TERM (Late Preterm) and MODERATELY PRETERM. Moderately preterm infants are those born at 32, 33, and 34 weeks. Near term are infants born at 34, 35, 36, and 37 weeks GA (AKA Late Preterm).

Prevalence.

Near terms are larges and still growing proportion of preterm infants.

Moderately preterm: Paradigm Health evaluated 453 NICUS in 24 states over 3.5 years (Jan. 2001-June 2004) where they have hospitals and found that 4932 moderately preterm 32-34 wk GA were born (out of 19,923 total preterms = 24.8% of preterm admissions)(Kirkby et al., 2007). Cohort had LOW MORTALITY (0.5%),

Average length of stay = 17.6 days

Average cost per infant = $31,000 (21.6% of total NICU costs)

Problems were : Respiratory compromise with ventilation, CPAP, or supplemental O2 = 54%; Intravenous nutrition needed by 56%; 19% discharged home with ongoing medical needs and use of medical equipment. THERE IS SIGNIFICANT BURDEN on Infant, family and health care team for 32-34 week GA infants.

Problems:

1. Respiratory

2. Thermoregulation

3. Hypoglycemia

4. Hyperbilirubinemia. Most occurs in first week of life, so the earlier the discharge, the more likely this will be a problem mandated readmission and the greater the likelihood of severe jaundice.

4a. Prevalence: Hyperbilirubinemia is common (Watchko, 2006), as is kernicterus (Bhutani & Johnson, 2006) and dehydration (Jones et al., 2003) in near term infants..

4b. Assessment. Do first assessment at 12 hours of life. Use icterometer (called the Ingram Icterometer from Cascade Health Care Products, Salem, Mass.) First, observe color of skin at tip of nose with sufficient pressure to make the skin bloodless. Take reading and record. Then take reading from frontal region (forehead) with same pressure. Take reading and record. Calculate the average of the two readings. An icterometer reading >2 during the first 24 hours of life =estimated mean bilirubinemia of 5.5-8.7 (+/-2 SD) (Facchini et al., 2007). An icterometer reading >3 after 24 hours of life =estimated 10.0-14,5 mg/dl). If > 3.00, then take total bilirubin value using bilirubinometer (Bilicheck or Unistat). If transcutaneous values come back > 11.0 mg/dl, confirm with serum bilirubin value (Johnson & Bhutani, 1998).

when greater than or more than 40th percentile on Bhutani’s nomogram. Can use icterometer, Bilicheck or Unistat bilirubinometer. Always assess bilirubin level before discharge because near term infants have high risk of kernicturus (Bhutani & Johnson, 2006).

4c. Treatment. Phototherapy lights. Discharge if bilirubinemia < 15 mg/dl (because not all infants will return to follow-up). Retake bilirubinemia value 24 hours after discontinuance of phototherapy, and if > 20 mg/dl restart phototherapy. Approximately 13.2% of all treated near term infants will have to be readmitted for further hyperbilirubinemia treatment (Facchini et al., 2007)

Remember that phototherapy has a negative impact on numerous parts of the oxidant/antioxidant defense system in infants, exposing them to potential oxidative stress and more infections (Aycicek & Erel, 2007).

Kangaroo Care can continue during phototherapy with use of a bili-blanket, and does not deter treatment in any way and there are fewer cases of bilirubinemia rebound with phototherapy during KC (Ludington-Hoe & Swinth,??? ).

As to infections, KC minimizes infections and improves immunity in preterm infants, as mother picks up antigens from infant, develops antibodies to them and passes the antibodies back to the infant (Schanler et al., ???). Also, Kangaroo Care

5. Feeding. They have many breastfeeding problems: decreased milk intake secondary to inefficient sucking, and consequent reduced maternal milk supply (Shapiro-Mendoza et a l., 2006)

Feeding Assessment

Feeding Treatment.

For Breastfeeding in general: Babies fed better when given KC simultaneous to breastfeeding. In Wheeler et al.’s study (1999), 41 near term infants (32-37 weeks with M=34.21 wks, MBW = 2225 g) were given KC for 21 days. On Day 1 of life, 22% got nude KC on breast while feeding, on Days 2-9, 8.7% got KC, on Days 10-14 0% got KC because infants were successful breastfeeders, but by Day 15, feeding problems and slower weight gain resulted and KC breastfeeding started up again such that on Day 15 18.2% got KC.

For Decreased Milk Intake, put them to breast each day and let them suckle with a drop of milk being there, because this builds up the efficient sucking mechanism (Meier, ???). Having baby in KC each day increases maternal milk production (Hurst, etc. ), and weight gain increases with KC being practiced (Moore, et al., 2007).

6. Rehospitalization. Near terms have a higher rate of post-discharge rehospitalization and illness than fullterm infants (Raju et al., 2006; Wang et al., 2004)

Recommendation: Quote from Nyqvist 2009 for KMC recomomendations with near term infants.

Resources

AWHONN. 2007. Optimizing health for the late preterm infant. This is a presentation package to build awareness of nurses about knowledge needed to plan and deliver care to late preterm infants to optimize their health outcomes. Package includes instructions for presentere, handouts for parents), references, program evaluation tool, and a selection of articles from JOGNN on the topic. Available from store, phone 800-354-2268 (US) or 800-245-0231(Canada), fax: 202-728-6726, mail: AWHONN, Dept. 4015, Washington, DC 20042-4015.

AWHONN, 2007. Late Preterm Infant Assessment Guide. This is a continuing education programl that provides latest evidence-based information about risks of late preterm infant, details on the special needs of late preterm infants and assessment with intervention strategies for each risk category. 2.1 contacthours, available from store, phone 800-354-2268 (US) or 800-245-0231(Canada), fax: 202-728-6726, mail: AWHONN, Dept. 4015, Washington, DC 20042-4015.

References

Aycicek A. & Erel O. 2007. Total oxidant/antioxidant status in jaundiced newborns before and after phototherapy. J Pediatrics (Rio Journal) 83(4), 319-322.

Bhutani, V.K., & Johnson, L. 2006. Kernicterus in late preterm infants cared for as term healthy infants. Seminars in Perinatology 30, 89-97.

Bhutani VK & Johnson L. 2007. Prevention of severe neonatal hyperbilirubinemia in healthy infants of 35 or more weeks of gestation: implementation of a systems-based approach. J Pediatrics (Rio J) 83, 289-293.

Facchini FP, Mezzacappa MA, Rosa IRM, Filho FM, Netto AA & Marba STM. 2007. Follow-up of neonatal jaundice in term and late premature newborns. J Pediatrics (Rio J), 83(4), 313-318.

Hall, R.T., Simon, S., & Smith, M.T. 2000. Readmission of breastfed infants in the first two weeks of life. J. Perinatology 20, 432-437.

Jain S & Cheng J. 2006. Emergency department visits and rehospitalizations in late preterm infants. Clinics in Perinatology 33, 935-945.

Johnson L, & Bhutani VK. 1998. Guidelines for management of the jaundiced term and near term infant. Clinics in Perinatology, 25, 555-574.

Jones G, Stekete RW, Black RE, Chutta ZA, Morris SS, & Bellagio Child Survival Study Group. 20003. How many child deaths can we prevent this year? Lancet 362, 839-852.

Kirkby, S., Greenspan, JS, Kornhauser, M., & Schneiderman R. 2007. Clinical outcomes and cost of the moderately preterm infant. Advances in Neonatal Care, 7(2), 80-87.

Moore, El, Anderson, GC, Bergman, N. 2007. A Cochrane review with some near term infants studied.

Raju TNK, Higgins RD, Stark AR, Leveno K. 2006. Optimizing care and outcome for late preterm (near term) infants: a summary of lthe workshop sponsored by the National Institute of Child Health and Human Development. Pediatrics 118, 1207-1214.

Shapiro-Mendoza C, Tomashek KM, Kotelchuck M et al., 2006. Risk factors for neonatal morbidity and mortality among “healthy” later preterm newborns. Seminars in Perinatology 30, 54-60.

Tomashek KM, Shapiro-Mendoza CK, Weiss J, et al., 2006. Early discharge among later preterm and term newborns and risk of neonatal morbidity. Seminars in Perinatology 30, 61-68.

Wawng ML, Dorer DJ, Fleming MP & Catlin EA. 2004. Clinical outcomes of near term infants. Pediatrics 114, 372-376.

Watchko JF. 2006. Hypoerbilirubinemia and bilirubin toxicity in the late preterm infant. Clinics in Perinatology 33, 839-852.

Wheeler JL, Johnson M, Collie L, Sutherland D, Chapman C. (1999). Promoting breastfeeding in the neonatal intensive care unit. Breastfeeding Review, 7(2): 15-18.

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