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The Late Preterm Infant Family and Community Medicine Grand Rounds April 11, 2012 Nicole J. Urrea, M.D. Heather Pratt-Chavez, M.D.

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Presentation on theme: "The Late Preterm Infant Family and Community Medicine Grand Rounds April 11, 2012 Nicole J. Urrea, M.D. Heather Pratt-Chavez, M.D."— Presentation transcript:

1 The Late Preterm Infant Family and Community Medicine Grand Rounds April 11, 2012 Nicole J. Urrea, M.D. Heather Pratt-Chavez, M.D.

2 Objectives 1. Discuss recent trends in late preterm births 2. Explain the risk of infant morbidity in the late preterm infant and common complications in this population 3. Discuss the impact of late preterm birth on childhood outcomes

3 Late Preterm Infants Define late preterm infant (LPI) GA. Why do we need a special name for this group? Epidemiology Etiology

4 Late Preterm Infants Morbidity and mortality in NB period (first 2-4 weeks of life) Apnea Respiratory distress Poor feeding - dehydration Hyperbilirubinemia Hypoglycemia – hypothermia Sepsis - SBI

5 Case: Baby Hunter 27 y.o. G2P1 at 35 0/7 weeks gestation with severe pre- eclampsia - Will my baby be OK? When can I take him home? Why does he have to stay in the hospital?

6 Definition 34 0/7 to 36 6/7 weeks gestation 2005 workshop, Eunice Kennedy Shriver National Institute of Child Health and Human Development 2007 report by AAP Committee on Fetus and the Newborn What happened to draw this attention?

7 Definition Kominiarek M, Engle W. Clin Perinatol,2008

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11 Why the shift? Increased surveillance - improved ultrasound technology, (increased form 68.1%-85.4% ) Infertility treatments - increased multiple gestations (2.4% - 3.2%) Increased rates of PROM and preterm labor, PTL increased by 13.8%; PROM by 10.4% ( ) Dating problems - iatrogenic Davidoff MJ, 2006

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14 Births at University of Cincinnati

15 Ananth CV, Gyamfi C, Jain L. Am J Obstet Gynecol Oct;199(4):

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17 Epidemiology Where are we now? In US, total births in 2010 = 4,000,279 Late Preterm Births in 2010 = 339,625 (8.49%)

18 Hamilton BE, Martin JA, Ventura SJ. Births: Preliminary data for National vital statistics reports web release; vol 60 no 2. Hyattsville, MD: National Center for Health Statistics

19 Epidemiology In New Mexico total births in 2010 = 27,028 Late Preterm total = 2,352 (8.7% of total births)

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21 Timing of Indicated Late-Preterm and Early-Term Birth. Obstetrics & Gynecology. 118(2, Part 1): , August 2011.

22 © 2011 The American College of Obstetricians and Gynecologists. Published by The American College of Obstetricians and Gynecologists. 3 Table 1. Timing of Indicated Late-Preterm and Early-Term Birth. Spong, Catherine; Mercer, Brian; DAlton, Mary; Kilpatrick, Sarah; MD, PhD; Blackwell, Sean; Saade, George Obstetrics & Gynecology. 118(2, Part 1): , August DOI: /AOG.0b013e Table 1. Guidance Regarding Timing of Delivery When Conditions Complicate Pregnancy at or After 34 Weeks of Gestation

23 © 2011 The American College of Obstetricians and Gynecologists. Published by The American College of Obstetricians and Gynecologists. 4 Table 1. Timing of Indicated Late-Preterm and Early-Term Birth. Spong, Catherine; Mercer, Brian; DAlton, Mary; Kilpatrick, Sarah; MD, PhD; Blackwell, Sean; Saade, George Obstetrics & Gynecology. 118(2, Part 1): , August DOI: /AOG.0b013e Table 1. Guidance Regarding Timing of Delivery When Conditions Complicate Pregnancy at or After 34 Weeks of Gestation (continued)

24 Early Morbidity and Mortality What milestones are missed by infants born late preterm?

25 Neurologic Immaturity

26 Decreased awake state Low tone Poor coordination of suck/swallow/breathe Apnea (17.7 RR) SIDS (1.37 RR) Teune MJ, et al. Am J Obstet Gynecol Oct;205(4):374.e1-9 Hunt CE Semin Perinatol 2006

27 Lung Immaturity

28 Use of nasal oxygen - 6% of late preterms (24.4 RR) RDS - 5.3% (17.3 RR)

29 Gastro-Intestinal Immaturity Slowed transit Less UGT - bilirubin metabolism Increased enterohepatic circulation

30 Gastro-Intestinal Immaturity Feeding Difficulties - 34% of late preterm infants Hyperbilirubinemia % of late preterm infants Prolonged and delayed presentation

31 Metabolic Immaturity Small size SGA Less brown fat Less white adipose

32 Metabolic Immaturity Hypoglycemia - 7.1% of LPIs Hypothermia - 1.5% of LPIs

33 Immune System Immaturity Incomplete activity of both humoral and cellular immunity Low storage of neutrophils IgG increases with GA Mechanical barriers and mucosal surfaces decreased stratum corneum

34 Immune System Immaturity More sepsis work-ups % of late preterms Sepsis (RR 5.6) Meningitis (RR 21) PNA (RR 3.5) NEC (RR 7.5)

35 Mortality National Vital Statistics Reports, June 2011

36 Newborn Period Missed events of development in last 6 weeks of gestation = morbidity risks in newborn period

37 Newborn period Tell families their baby will stay until close to their due date Every baby is different Some presentation is delayed, need to follow closely

38 Case: Baby Hunter Delivered by cesarian section, 2300 grams No respiratory distress, vitals stable, glucose 75, admitted to ICN3, nippled well on day 1 and 2 with advancing feeding volumes, working on breast-feeding

39 Case Day 3 and 4, Hunter is more easily fatigued with nippling, some lower temps recorded, naso-gastric tube placed, nippling now once per shift, mom expressing breast milk

40 Case Day 5, Hunter’s needs phototherapy for increasing bilirubin, still working on feeds, poor weight gain Day 6-8, Hunter’s mom has to return to Gallup to care for 2 y.o. at home, still trying to express and store breast milk

41 Case Day 12, taking full feeds, waking every 2-3 hours to feed, gaining weight, passed car seat trial, ready for discharge

42 Nutrition Breastmilk Human-milk fortifier? Formula? Many challenges in the breastfeeding late preterm infant

43 Breastfeeding Cascade Less stamina Less coordinated S/S/B Less effective suckling Less alert, awake periods Insufficient breast stimulation Incomplete emptying Insufficient milk transfer Insufficient milk supply Hypoglycemia Jaundice Poor weight gain Readmission Supplementation Separation from mother Wight, Pediatric Annals 2003; 32:5

44 Breastfeeding Management Strategies Kangeroo skin-to-skin contact Strong evidence of increased breastfeeding at 1 month after discharge (RR 4.76, 95% CI 1.19 to 19.1) and for more than 6 wks (RR 1.95, 95% CI 1.03 to 3.7) Minimize pain during painful procedures Peer support Simultaneous pumping Multidisciplinary staff training Baby Friendly accreditation Renfrew et al., Health Technol Assess, 2009

45 Growth Catch up growth Abnormal growth patterns may be associated with adult morbidity Limited investigations on the growth development of LPIs Santos et al. BMC Pediatrics, 2009 Risk of being underweight was at least two folds higher for LPIs

46 Readmission LPIs are readmitted 2 to 3 times more often than term infants Common reasons: Jaundice, infection, feeding issues, failure to thrive Risk factors: Primigravida mother, breastfeeding, maternal complications, public insurance and Asian/Pacific Island heritage

47 Readmission after NICU Discharge Group (LOS)n Percentage Rehospitalized Diagnoses ≥ 37 wk (< 96 h) Jaundice (46%) r/o sepsis (20%) Feeding diff (13%) ≥37 wk (≥ 96 h) Jaundice (25%) Feeding diff (16%) CHD (9%) wk (< 96 h) Jaundice (71%) Feeding diff (16%) r/o sepsis (6%) wk (≥ 96 h) Dehydration (28%) Jaundice (20%) r/o sepsis (20%) < 32 wk (all LOS) Bronchiolitis (21%) GER (16%) Hernia repair (10%) Escobar et al., Pediatrics 1999

48 Neurodevelopmental Outcomes

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51 Few studies Neurologic abnormalities, learning difficulties, poor scholastic achievement, and behavioral problems have been reported CP is three times more likely DD and MR have been found to be times more likely No evidence of increased risk of autism has been reported Arpino et al, Childs Nerv Syst, 2010

52 Engle, Clin Perinatol, 2011 Data from Moster et al., N Engl J Med, 2008

53 Learning Disability Compared to full term: LPIs have 24% increased odds for reading scores below average in the first grade of education risk for special education Arpino et al, Childs Nerv Syst, 2010

54 Morse et al., Pediatrics, 2009

55 Early School and Developmental Outcomes 61 healthy infants born between weeks gestation At 12 and 18 months corrected GA, LPI showed a mean developmental index similar to term infants Romeo et al., Euro Ped Neur Soc, 2010

56 Case: Baby Hunter Hunter is seen by his pediatrician for his 9 month well child check He continues to breastfeed and mom has introduced solids without difficulty He babbles, says “mama”, and likes to play “peek-a-boo” On exam his physician notes that he is unable to sit without support He is referred to Early Intervention

57 Linnet KM et al., Arch Dis Child 2006 Engle

58 Cost Birth HospitalizationRehospitalization Total first year costs (after birth hospitalization) Length of Stay Cost Term2.2 days$2,0617.9%$4,069 Late preterm 8.8 days$26, %$12,247 McLaurin et al, Pediatrics, 2009

59 Future Research National Institute of Child Health and Human Development: Optimizing Care and Outcome for Late-Preterm Infants Education Epidemiology and Etiology Gestational-age-specific morbidities and mortalities Evidence-based intervention guidelines Assessing the total cost of LPI birth Outcomes of LPIs and relationship to indication for delivery

60 Conclusions Although the risk of poor outcome is less than that of an early preterm infant, LPIs are a vulnerable population. Early discharge should not occur in these infants and diligent follow up is important, both in the post neonatal period and for continued long-term care. More research is needed

61 Questions?


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