During the past 15 years, late preterm births have increased by more than 15%. In fact, in 2005 LPI accounted for more than 70% of all the preterm births. Yet, often nurses don't really understand what this means for new parents from a teaching perspective. Often times, the LPI in our care may initially respond in ways that resemble the full term baby. Furthermore, often LPIs are the same weight and same size as full term babies. It is important to keep in mind that LPIs are indeed physiologically and metabolically immature. This immaturity places them at a higher risk for morbidity and mortality. Below are a few key facts that nurses need to remember when caring for this population:
• In 2002, the mortality rate for LPIs was 4.6% higher than term infants
• LPIs also have a higher rate or readmission during the neonatal period than do term infants for reasons such as jaundice, feeding difficulties, dehydration, and suspected sepsis.
• Both AWHONN and the AAP identify 7 areas of concern for the LPI during the birth hospitalization
How does the nurse in the level I newborn nursery screen and refine her postpartum teaching to deliver high impact messages to these parents? How can nursing education to these parents help to prevent readmissions? Although more research is needed to fill in our knowledge gap of this population, the AAP has identified LPI risk factors for readmission (listed in their 2007 policy statement; hyperlink here to policy). These risk readmission and morbidity factors are:
• Being the first baby in the family
• Breastfeeding at hospital discharge
• Having a mom who had complications during labor and delivery
• Being a recipient of public insurance at delivery
• Asian/Pacific Island Descent
Maternity educators/caregivers have a key opportunity to lower the morbidity and readmission rate for LPIs by refining their education in these 7 key areas. Maternity staff can teach new parents how to prevent or mitigate possible complications, as well as how to assess and act quickly on possible concerns. Below are education and clinical suggestions from the AAP and AWHONN, as related to these 7 key areas:
• Demonstration of 24 hours of successful feeding, along with the ability to coordinate sucking, swallowing, and breathing
• More than a 7% loss in birth weight, or 2-3% of birth weight per day, should be assessed further for possible dehydration prior to discharge
• A “formal” evaluation (not patient report) of breastfeeding is documented by caregivers at least 2 times a day after birth. (this evaluation includes position, latch, and milk transfer)
• A feeding plan is to be developed and shared with the family
• The breast fed baby should be awakened for feeds in the hospital every 3-4 hours if necessary
• The breastfed baby may need to feed more often than the full term breastfed baby, as there is less gastric reserve.
• Regardless of feeding method, a follow-up visit is scheduled with the physician for 24-48 hrs after discharge
• LPIs have insufficient metabolic responses, glycogenolysis, and gastric reserve which places them at an increased risk for hypoglycemia for 12-24 hours after birth. For this first 24 hours of life, blood sugars may need to be assessed more frequently than just before feeds at every 3 hours. Checking blood sugars and encouraging feeding every 2 or 2 ½ hours may be a good strategy if hypoglycemia becomes an issue.
3. Sleep and breathing-
• LPI infants may be sleepier and slower to wake up than term infants. They should be awakened to breastfeed at least every 3-4 hours, or more often as clinically appropriate, to maintain adequate glucose levels, hydration, and calorie intake. LPI infants are also at a higher risk for SIDS and respiratory insults due to positioning. Parents need to be educated in providing a safe sleeping environment, as well as avoiding the over-use of baby-gear items that place baby in the semi-upright or “C” position. This includes swings, bouncy seats, baby slings, and car seat carriers. A position tolerance test within the baby’s car seat is recommended to observe for apnea, bradycardia, or oxygen desaturation prior to discharge. LPI should only sleep in their crib – where they can be positioned on their back in correct body alignment to facilitate respiratory function.
4. Temperature instability and Infection:
• Temperature should be assessed in an open crib with appropriate clothing. Vital signs should be documented as being within stable range for at least 12 hours preceeding discharge. This includes a respiratory rate of 40 - 60, heart rate 100 – 160, and axillary temp of 97.7 – 99.3. Parents need additional education or demonstrated competency in the skill of temperature taking using both the axillary and rectal technique. Parents should be cautioned against less accurate measures of temperature taking, such as using the ear thermometers. Education should also be provided regarding the possible sign of hypothermia as an early indicator of infection. Practices that decrease the risk of infection need to be stressed with parents - Good hand hygiene, sterilization of feeding/sucking equipment, immunizations, breastfeeding, and avoidance of crowds/sick people.
• LPIs are 2X more likely to have increased bilirubin levels, especially at 5 – 7 days of birth. A risk assessment for the development of severe hyperbilirubinemia needs to be performed and appropriate follow-up arranged. Parents should be made aware of any risk issues and provided with a demonstration of how to blanch the skin to assess for worsening jaundice.
AWHONN, through its Late Preterm Infant Initiative, has developed many educational resources for nurses who work with LPIs. The patient handout, “What Parents of Late Preterm (Near-Term) Infants Need to Know” is available free of charge from their site. This is a great tool to provide to parents, as well as a ‘checklist’ for nurses to use when providing discharge information.
PEDIATRICS Vol. 120 No. 6 December 2007, pp. 1390-1401 (doi:10.1542/peds.2007-2952)
AWHONN, Late Preterm Infant Assessment Guide 2007
Anne Santa-Donato, RNC, MSN; Barbara Medoff-Cooper, Phd, FAAN; Susan Bakewell-Sachs, PhD, RN, APRN, BC; Debbie Frazer Askin, MN, RNC and Suzanne Rosenberg, MS, RN