THE LATE PRETERM INFANT

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THE LATE PRETERM
INFANT (LPT)
WAHIB MENA, M.D.
Glenda Dickerson, MS, RN, IBCLC
BROOKWOOD WOMEN’S MEDICAL CENTER
HOMEWOOD, AL
DEFINITION
INFANTS BORN 34 0/7-36 6/7 WKS
EPIDEMIOLOGY
 2003:
12.3% OF BIRTHS < 37 WKS
 31% INCREASE SINCE 1981
 34-36.6 WKS (75%)
 2002: 342,234 vs. 394,996
CLINICAL ISSUES








TEMP INSTABILITY
HYPOGLYCEMIA
TTN
RDS
APNEA
SIDS
NEUROLOGIC ISSUES
HYPERBILIRUBINEMIA AND KERNICTERUS
TEMPERATURE
 HYPOTHERMIA
 HYPERTHERMIA



? SEPSIS
LONGER HOSPITAL STAY
RARE MORBIDITY AND MORTALITY(NEC)
HYPOGLYCEMIA
 LOW
SUPPLY
 INSULIN GLUCAGON BALANCE
 BRAIN FUEL
What About What We Can’t See?
Human
Brain
Development
TTN/RDS/APNEA
 CLEARLY
INCREASED TTN AND RDS
 APNEA
 USUALLY
NO LONGTERM ISSUES
SIDS
 RISK

OF SIDS DOUBLES
1.4 vs. 0.7/1000
NEUROLOGIC
 INCREASED
BEHAVIORAL DISORDERS
 NO GOOD STUDIES
 DECREASED PERFORMANCE IN MATH
AND ENGLISH
What About What We Can’t See?
Human
Brain
Development
JAUNDICE
 INCREASED
BILI PRODUCTION
 DECREASED CLEARING
 IMMATURE BLOOD BRAIN BARRIER
 INCREASED RISK FOR KERNICTERUS
WHAT TO DO
 BE




AWARE OF ORGAN IMMATURITY
BRAIN
LUNG
HORMONAL AXIS
DIVING REFLEX
I AM PREMATURE
 DO
NOT DELAY TREATMENT
 AGGRESSIVE APPROACH
 EDUCATE PARENTS
 EDUCATE HEALTHCARE WORKERS
 HOME ENVIRONMENT
Breastfeeding Management
 Vulnerabilities
1.
2.
3.
4.
5.
6.
7.
Hypothermia
Hypoglycemia
Respiratory Instability
Immature state regulation
Hypotonia and Immature Feeding Skills
Insufficient milk (delayed lactogenesis)
Hyperbilirubinemia
1. Hypothermia and 2.Hypoglycemia
Skin-to-skin
care (STS)
Hypothermia and Hypoglycemia
 Skin-to-skin
 Newborn infant’s natural habitat/safe
environment
• Helps to stabilize temperature

Mothers thermo-regulate their infant’s temp
• Stabilizes blood glucose levels

Even when a feeding does not take place
• Stabilizes respiratory effort
• Colonize the infant’s skin

Helps protect against URI and Intestinal
infections
STS is Evidence Based Care
 Should
not be based on “I like” or “I
don’t like”
 Should not be based on “there is not
enough time”
Hypothermia and Hypoglycemia
 Immediate
STS (Mom and infant
stable)
Dried
 Covered with warm blankets
 Cap placed on head
 Initial assessment accomplished
 Postpone task till after first feeding is
accomplished

Extended STS Care
 Encourages
frequent feedings
3. Respiratory Instability
 LPT

is more prone to positional apnea
Careful feeding position
• Avoid cradle hold
• Clutch (football) or cross-cradle is preferred



Mom should be instructed not to flex head in these
positions
Breast should not rest on the infant’s chest
Avoid use of slings
• Wraps/KC garments may work well
Preferred: Clutch (Football)
Preferred: Cross-Cradle Hold
Avoid—Over-flexed Position
4. Immature State Regulation
 STS

care
Modulates the under-aroused, overaroused, and shut down infant
 Minimize
interruptions
 Parent education
Avoid excessive stroking, massaging,
rocking, talking, bright lights, loud noise,
and being handed of to multiple visitors
 Limit visitors

5. Hypotonia and Immature Feeding Skills
 Hypotonia
May result from maternal use of labor
medications
rd
 Fetal exposure to SSRI’s during 3
trimester
 Will contribute to ineffective feeding

Hypotonia and Immature Feeding Skills
 Wide
range of sucking patterns,
frequency, and intensity


May tire quickly and be unable to sustain
nutritive sucking
Electromyographic study of sucking patterns
• 15% to 60% of time spent sucking

May lack strength for appropriate sucking
pressure (60 mm Hg)
• Render unable to secure nipple in place between
sucking burst
Hypotonia and Immature Feeding Skills
Feed
the baby
Facilitate
Protect
direct breastfeeding
mother’s milk supply
Hypotonia and Immature Feeding Skills
 Feed

the Baby
Encourage initiation of breastfeeding
within one hour after birth
• Latch if possible

Cross-cradle/football

Use Dancer-Hand to stabilize jaw

May help to prevent clamping
• Consider use of nipple shield
Hypotonia and Immature Feeding Skills
Evaluate
need for supplement
Expressed colostrum/breastmilk
 Banked human milk
 Hydrolyzed formula

• Reduce the risk of sensitizing a
susceptible infant to allergies or
diabetes
• May help to lower bili levels
Hypotonia and Immature Feeding Skills
 Should


be breastfed or breastmilk fed
8 times in 24 hours
Awaken if baby does not indicate hunger
 Continue



use of nipple shield if needed
Difficult latch
Evidence of ineffective milk transfer
Follow-up with mother’s using shield after
discharge
• Infant may need to use until 40 weeks postconceptual age
Hypotonia and Immature Feeding Skills
 Supplementation

Best done at the breast if possible
• 5 French feeding tube/10 ml syringe
• Commercial supplementer systems

Can be used in conjunction with a
nipple shield
Hypotonia and Immature Feeding Skills
 If
infant is not latching or able to
supplement at breast

Feed expressed milk every 3 hours
• 5-10 ml per feeding on day 1
 Spoon (small quantities)
• 10-20 ml per feeding on day 2


Cup (as quantity increases)
Paced feeding
• 20-30 ml per feeding on day 3
Hypotonia and Immature Feeding Skills
 If
supplementing away from the
breast

Facilitate direct breastfeeding
• Use alternative methods as the mother
desires


Spoon feeding for small amounts
Cup feeding for larger amounts
• Paced feeding
• Encourage mother to continue efforts at the
breast as she is comfortable
Spoon Feeding
Hypotonia and Immature Feeding Skills
 Protect

mother’s milk supply
Assist the mother to begin pumping
• Feeding ineffectively

Pump every 3 hours during the day and at
least once per night
• Feeding effectively

Pump about 4 times a day to provide
additional stimulation to bring in a good
milk supply
6. Insufficient Milk Supply
 Initiate

and maintain supply
Begin pumping within 6 hours of
delivery
• Colostrum bolus may be present
Pump after each feeding (8-10 times
per 24 hours) for first 2 weeks
 Use appropriate size
breast shield for pumping

Insufficient Milk Supply
 Protect Milk Supply
 Establishing milk supply
• Lactogenesis II occurs on average 60 hours
following delivery

Expected volumes (approximation) per 24 hrs
• Day one
• Day two
• Day three
• Day four
• Day 14
less than 100 ml
200 ml
350 ml (borderline)
600 ml (adequate)
750 ml (ideal)
Insufficient Milk Supply
 Protect
mother’s milk supply
The amount of stimulation on day 2 is
positively correlated with adequate milk
volume on day five
 Milk supply at day 6 is indicative of
supply at 6 weeks

• Window of opportunity for establishing milk
supply
7. Hyperbilirubinemia
 Readmission

due to jaundice
7 to 13 fold increased risk
• Slower meconium passage
• Low milk intake
• Decreased activity of bili-conjugating enzyme
 Bilirubin
peak levels typically occur
around 5 to 7 days of life
 Kernicterus is seen more frequently in
LPT
Hyberbilirubinemia
Preventative goals
 Optimize milk intake
 Promote rapid meconium
clearance and increase stool
volume
 Prevent excessive weight loss
Hyperbilirubinemia
 Optimize

Milk Intake
Frequent feedings
• 8-10 times in 24 hours
Evaluate for deep latch
 Use breast compression or massage
 Use a nipple shield if needed

Hyperbilirubinemia
Promote
Rapid Meconium
Clearance

Frequent colostrum feeds
• At breast
• Hand expressed
5-10 ml every 2-3 hours on day one
 10-20 ml every 2-3 hours on day two
 20-30 ml every 2-3 hours on day three

Hyperbilirubinemia
 Prevent

Excessive Weight Loss
Discourage missed feedings
• Visitors
• Excessive interruptions

Evaluation of feeding once per shift
• Qualified professional
• Document

Pre and post feed weights if needed
Hyperbilirubinemia

Data from the Pilot Kernicterus Registry (19922003)

The greatest risk for kernicterus
• The exclusively breastfed “large” LPT infant



Hospital admission within 7 days post birth
Present with severe jaundice and inadequate intake
Most parents had contacted their primary care
providers with concerns about jaundice, poor feeding,
and excessive sleepiness and had been told these
were normal behaviors
Discharge Feeding Plan
 Team
effort that includes the
mother




STS Care
Feed the Baby/Determine the method
Protect Mother’s Milk Supply
Early and Appropriate Follow-up
 Communicate
this plan with outpatient
care provider

Continue evaluation
Initial Outpatient Follow-up
 Should
be 3-5 days of life, or one or
two days after discharge
Weight check
 Assessment for jaundice
 Review of written feeding record

• Parameters of adequate intake

Assessment of breastfeeding
effectiveness
Poor Weight Gain
Less

than 20 grams/day
Ineffective feeding
• Refer to a lactation specialist
Follow-up
How
are mom and baby coping?
Modify plan to something that is
more manageable
 Work with her to find help

 Don’t

assume you know
Ask!
Extended Follow-up
 Weekly
follow-up until 40 weeks
post conceptual age or until it is
demonstrated that he/she is
thriving with no supplements

With each adjustment that is made
a visit/weight check in 2-4 days
should be done
Continued Monitoring
Adequate


growth
Weight gain should average >20
g/day
Length and head circumference
should each increase by an average
of .0.5 cm/week
Our Findings
Recollected
data to see if we
had improved readmission rates
Decreased by 50% in the first year
 Goal is to decrease to same rate
as term infant

Interventions Reviewed
L
P
I
C
A
R
E
Lots of STS
Position Appropriately
Initiate Stimulation Controls
Calories Count
Adequate Milk Supply
Reinforce awareness of bili
Educate for discharge!
Objectives

Define the sub-classification of late preterm
infant.
 Discuss the physical characteristics and
vulnerabilities of the late preterm infant.
 List strategies to address the identified
vulnerabilities of the late preterm infant as they
relate to breastfeeding management.
 State the essential elements of discharge
planning for the breastfeeding late preterm
infant.
Late Preterm Babies Were Born to Breastfeed
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