Care of the Late Preterm Infant
Patricia A. Scott, MSN, APN, NNP-BC, C-NPT
Vanderbilt University School of Nursing, Neonatal Nurse
Practitioner Faculty
Pediatrix Medical Group of Tennessee at Centennial Medical
Center – The Women’s Hospital
University of Tennessee Health Science Center DNP Student
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Presentation Objectives
• Discuss the definition and incidence of late preterm birth.
• Discuss the incidence, risks for, and etiology of
respiratory distress in the late preterm infant.
• Identify signs of hypo/hyperthermia.
• Describe the physiology, assessment, and management
of hyperbilirubinemia and why the late preterm infant is
at increased risk.
• Discuss why this population is at increased risk for
hypoglycemia and feeding difficulties.
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Definition of the Late Preterm Infant
Infants born between
34 and 36 completed
weeks of gestation

“Near term” thought
to imply that these
babies are “near
enough” term to be
physiologically the
same (Engle, 2009)
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Distribution of Preterm Births (CDC)
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Morbidity and Mortality
•Morbidity: not fully known
•Mortality: 3 X higher than the term infant
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What does the Late Preterm Infant Miss?
•Vital period of maturation
 Lung development
 Brain maturation
 Liver maturation
•Vital period of growth
 Body mass increases
 Fat stores increase
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Complications
(Adamkin, 2009)
Complication
Late Preterm Infant
Term Infant
Feeding
32%
7%
Hypoglycemia
16%
5%
Jaundice
54%
38%
Temperature Instability
10%
0
Apnea
6%
< 0.1%
Required IV Fluids
27%
5%
Septic Evaluation
37%
13%
Mechanical Ventilation
3.4%
0.9%
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Late Preterm Care Delivery Issues
•Longer hospital stays
•Higher rate of readmission
•Increased nursing care
•Location of care varies
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Most Common Complications
•Respiratory distress
•Temperature instability
•Hyperbilirubinemia
•Feeding challenges
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Respiratory Distress
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Respiratory Distress: Incidence
•35 to 36 week infants: 28.9% respiratory
distress at birth compared to 4.2% of term
infants
•35 to 36 week ventilated infants: RDS in 62%
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Respiratory Distress
•Delayed transition or respiratory distress?
•Differential diagnosis includes:
 TTN
 RDS
 Sepsis
 PPHN
 Congenital anomalies
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Risk Factors for Respiratory Distress
•Elective cesarean
birth without the
benefit of labor
•Maternal
complications
•Fetal factors
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Transient Tachypnea of the Newborn
•Delayed reabsorption of lung fluid
•Onset: 2 to 6 hours of life
•Risk factors for TTN
 Cesarean delivery
 Precipitous delivery
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Transient Tachypnea of the Newborn
• Clinical presentation
Tachypnea
 Grunting / flaring / retractions

• Diagnostic studies
Blood gases
 Chest x-ray
 Septic work-up

• Management / Outcome

Supportive care
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Chest X-Rays
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Respiratory Distress Syndrome
•Immature lungs and surfactant deficiency
•Onset: within minutes to hours of birth
•Risk Factors
 Prematurity
 Cesarean delivery
 Maternal diabetes
 Second born twin
 Perinatal
asphyxia
 Male gender
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RDS: Clinical Presentation
•Tachypnea
•Grunting
•Flaring
•Retractions
•Pallor or cyanosis
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•Decreased breath
sounds/fine rales
•Hypotension
•Decreased perfusion
•Tachycardia
• RDS: Diagnosis
•Arterial blood gases
 Hypoxemia
 Respiratory acidosis
•Chest x-ray
•Infection should be ruled out
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Chest X-Rays
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RDS: Management
•Provide a NTE
•Oxygen support, as needed
•Ventilatory support, as needed
•Surfactant replacement therapy
 As early as possible
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RDS: Management
•Fluid restriction
•Monitor serum electrolytes
•Minimal stimulation
•Blood pressure support
•Continued, comprehensive assessment
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RDS: Outcome
Directly related to birth weight and
gestational age
 Affected by prenatal glucocorticoid treatment and
surfactant replacement
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Thermoregulation
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Non-Shivering Thermogenesis
Cold stress →
hypothalamus →
epinephrine →brown
fat metabolism



Function: heat production
Location: axilla, nape of neck,
between scapulas, mediastinum,
around the kidneys
Stores increase until 3-5 weeks
postnatal life
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Heat Transfer Mechanisms
•Conduction
•Convection
•Evaporation
•Radiation
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Conduction
•Heat transfer by direct contact
•Varies with exposed surface area
 Decreased ability to flex extremities
 Decreased subcutaneous fat
 Limited ability to VC peripheral blood vessels
•Ways to minimize
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Convection
•Air currents move heat away from the body
•Affected by ambient temperature, air flow
velocity, and relative humidity
•Ways to minimize
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Evaporation
•Liquid is converted into a vapor


Major source of heat loss at delivery/bathing
Losses through skin and respiratory system
•Dependent upon air
speed and
relative humidity
•Ways to minimize
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Radiation
• Transfer of radiant energy from the body
to objects without direct contact

Radiant warmer – heat gain
 “Greenhouse effect”
• Ways to minimize
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Normal Temperature Ranges
• Axillary temperature
 Term:
97.9 – 99.5 ̊ F (36.5 – 37.5 ̊ C)
 Preterm: 97.5 – 98.5 ̊ F (36.3 – 36.9 ̊ C)
• Skin temperature
 Term:
96.8 – 97.7 ̊ F (36 – 36.5 ̊ C)
 Preterm: 97.2 – 99 ̊ F (36.2 – 37.2 ̊ C)
• Rectal/tympanic not recommended
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Radiant Warmers versus Isolettes
•Advantages
•Disadvantages
•Wean to crib
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Skin-To-Skin Care
•Can be close to the
breast for feeding
•Stable vital signs
and oxygenation
•Improved sleeping
patterns and direct
social eye contact
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Hypothermia: Clinical Presentation
•Pale, cool to touch
•Acrocyanosis
•Respiratory distress
•Apnea, bradycardia, central cyanosis
•Irritability → lethargy
•Progressive or chronic cold stress
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COOLING
Norepinephrine
Release
Brown Fat
Utilization
Pulmonary VC
 R to L Shunting
Peripheral VC
 O2 Delivery to Tissues
Hypoxia
Hypoxemia
Free Fatty
Acid Release
 Metabolic
Rate
Dependence on
Anaerobic Metabolism
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Lactic
Acidosis
 O2
Consumption
? DEATH
Temp Instability: Differential Diagnosis
•Arterial blood gas
•Septic workup
•Blood glucose
•Electrolytes
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Hypothermia: Treatment
•Gradual re-warming
•Prevent further heat loss
•Frequent evaluation of temperature
•Potential complications
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Hyperthermia
•Clinical presentation
•Etiology
•Treatment
•Complications
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Hyperbilirubinemia
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Hyperbilirubinemia in the Late Preterm
•↑risk of significant hyperbilirubinemia
 Immature liver
 Higher bilirubin levels
 Later bilirubin peak
 Less vigorous feeding
•25% require phototherapy
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Overview of Bilirubin Pathway
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Neonatal Jaundice
•Also called physiologic jaundice
•Contributing factors:
 Increased bilirubin load
 Decreased hepatic uptake of bilirubin from plasma
 Decreased bilirubin conjugation
 Defective bilirubin excretion
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Overproduction
•Hemolytic disease

ABO and/or Rh incompatibility
•RBC enzyme abnormalities


Glucose-6-phosphate dehydrogenase deficiency
Pyruvate Kinase Deficiency
•Polycythemia
•Extravascular blood
•↑ enterohepatic circulation
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↓ Excretion
•↓ hepatic uptake of bilirubin
•↓ bilirubin conjugation
•Inadequate transport out of hepatocyte
•Biliary obstruction
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Overproduction + ↓ Excretion
•Prematurity
•Bacterial sepsis
•Urinary tract infection
•Intrauterine viral infections
•Hypopituitarism
•Hypothyroidism
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Breastfeeding and Jaundice
•Many advantages
•Important to ensure good lactation support
Inadequate lactation associated with increased TSB level
 Late preterm infant at risk for feeding problems
 Less vigorous suck
 Less stamina with feedings
 Less coordination of suck and swallow
 Less alert-awake states

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Breastfeeding and Jaundice
•May be prevented/reduced with frequent
feedings in first days of life
•Late onset or prolonged hyperbilirubinemia
•Affects 10-30% in 2nd to 6th week of life
•Screen for risk factors to plan F/U
•Unconjugated bilirubin level > 12 mg/dl
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Hyperbilirubinemia: History
•Family
•Obstetric
•Neonatal





Decreasing gestational age
Apgar scores
LGA
Elevated PCV
Poor feeding
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Hyperbilirubinemia: Clinical Presentation
•Clinical presentation:

Jaundice may be the only presentation
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Hyperbilirubinemia: Laboratory Data
•Maternal and infant blood types, Rh,
and Coomb’s test
•CBC/differential
•Bilirubin levels
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Hour-Specific Total Serum Bilirubin
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Acute Bilirubin Encephalopathy
•Develops subtly as the result of high bilirubin
levels causing neurological damage
 This damage may or may not be reversible with treatment.
 Prompt, aggressive treatment is more likely to reverse and
improve the outcome.
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Chronic Bilirubin Encephalopathy
•Permanent brain damage resulting
•Clinical picture:
 Spasticity
 Deafness / decreased hearing
 Setting sun sign
 Dental enamel dysplasia
 Intellectual capacity is normal, but may not be evident
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Feeding Difficulties
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Why is adequate intake important?
•Hypoglycemia
•Hyperbilirubinemia
•↑Increased weight loss initially
•Slower return to birthweight
•Readmission to the hospital
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Feeding Concerns
•Decreased stamina
 Less effective suckling
 Decreased transfer of milk
 Sub-optimal breast stimulation
•Ability to suck-swallow-breathe
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Feeding Concerns
•Poor muscle tone
 Leading to fatigue, latch difficulty, and suboptimal feeding
•Fewer alert-awake periods
 Not as likely to initiate feeds and may end them prematurely
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Nursing Care
•Ensure adequate nutrition
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Hypoglycemia
•How often does this happen in late preterm
infant?
 10-15% incidence
 2/3 of late preterm infants will require intravenous
dextrose for a blood glucose level < 40 mg/dl
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Hypoglycemia: Etiologies
•Inadequate substrate
•Abnormal endocrine function
•Increased glucose utilization
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Hypoglycemia: Risk Factors
•Maternal




Glucose infusion in labor
Maternal diabetes
Maternal hypertension
Tocolytic treatment
•Fetal/Neonatal





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IUGR
Perinatal asphyxia
Sepsis
Temperature stability
Respiratory distress
Hypoglycemia: Clinical Presentation
•Irritability, lethargy
•Cyanosis, apnea
•Poor feeding
•Tachycardia
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•Respiratory distress
•Hypotonia
•Tremors, jitters,
seizures
•Hypothermia
Hypoglycemia: Treatment
•Assessment



Lowest glucose level is 30 to 90 minutes after birth
Frequent assessments are needed in this population
Glucose levels associated with neurological injury not well-established
•Treatment




Treat underlying problem
Early feeding
Glucose infusion as needed
Other medications
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In Summary
•Knowledge of needs specific to this population

Significance and scope of the problem
•Care practices specific to this population



Assessment
Appropriate time for discharge
Risk for complications and readmission
•Continued research on best- and evidencebased practices in late preterm infant care
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References
• Adamkin, D.H. (2009). Late preterm infants: severe hyperbilirubinemia
and postnatal glucose homeostasis. Journal of Perinatology, 29, S12-S17.
• American Academy of Pediatrics Subcommittee on Hyperbilirubinemia
(2004). Management of hyperbilirubinemia in the newborn infant 35 or
more weeks of gestation. Pediatrics, 114, 297-316.
• Askin, D.F. (2002). Complications in the transition from fetal to neonatal
life. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 31, 318-327.
• Bhutani, V.K., & Johnson, L.H. (2001). Jaundice technologies: Prediction of
hyperbilirubinemia in term and near-term newborns. Journal of
Perinatology, 21, S72-82.
• Bhutani, V.K., & Johnson, L.H. (2006). Kernicterus in late preterm infants
cared for as term healthy infants. Seminars in Perinatology, 30, 89-97.
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References
• Blackburn, S.T. (2003). Thermoregulation. In S.T. Blackburn (Ed.),
Maternal, fetal, & neonatal physiology: A clinical perspective (2nd ed.,
pp. 77-730). St. Louis: Elsevier Saunders.
• Blackburn, S.T. (2003). Bilirubin metabolism. In S.T. Blackburn (Ed.),
Maternal, fetal, & neonatal physiology (2nd ed., pp. 656-676). Philadelphia:
Elsevier Saunders.
• Center for Disease Control and Prevention, National Center for Health
Statistics Final Natality Data, 2005.
• Clark, R. (2005). The epidemiology of respiratory failure in neonates born
at an estimated gestational age of 34 weeks or more. Journal of
Perinatology, 25, 251-257.
• Engle, W.A. (2009). Infants born late preterm: Definition, physiologic
and metabolic immaturity, and outcomes. NeoReviews, 10, e280-286.
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References
• Escobar, G.J., Clark, R.H., & Green, J.D. (2006). Short-term outcomes of
infants born at 35 and 36 weeks gestation: We need to ask more
questions. Seminars in Perinatology, 30, 28-33.
• Maisels, M.J. (2005). Jaundice. In M.G. MacDonald, M.D. Mullett, &
M.M.K. Seshia (Eds.), Avery’s neonatology: Pathophysiology &
management of the newborn (6th ed., pp. 768-846). Philadelphia:
Lippincott Williams & Wilkins.
• Shapiro-Mendoza, C.K. (2009). Infants born late preterm: Epidemiology,
trends, and morbidity risk. NeoReviews, 10, e287-294.
• Wang, M.L., Dorer, D.J., Fleming, M.P., & Caitlin, E.A. (2004). Clinical
outcomes of near-term infants. Pediatrics, 114, 372-376.
• Wight, N. (2003). Breastfeeding the borderline (near-term) preterm infant.
Pediatric Annals, 32(5), 329-336.
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