1. Care of the Late-Preterm Infant
Constance Hymas
CDR, NC, USN
RNC-NIC, MN, MSHS, NNP-BC

2. The AWHONN Initiative
June 2005, AWHONN launched the Late Preterm Infant (formerly “Near-Term” Infant) initiative .
The population is defined as those born between 34 and 37 weeks gestation

3. The AWHONN Initiative The initiative is designed to
Raise awareness of the unique needs of the LPI
Emphasizes the need for research
Encourages development of evidence based-guidelines in caring for this population
Provide clinical resources for care and parent education
Foster collaboration with other health care stakeholders to enhance awareness of impact on the health care system and families

4. The Late Preterm Infant
8.9% of all births in the U.S.
71% of all preterm births
Greatest proportional increase in the last decade
Increase accounts for almost all of the 30% increase in preterm births in the last 10 years
Birthweight generally between kg
Given their size, initial stability and relatively mature physical appearance
often cared for in the well newborn nursery

5. The Late Preterm Infant
Mortality rate for infants weeks rose from per 100,000 live births (2002)
Mortality rate for term infants remained stable at 2.5 / 100,000 live births ( 2002)
These infants can be 3-8 weeks less mature than full term infants

6. The Late Preterm Infant
Retrospective chart review study of 90 full term and 95 Late-Preterm Infants
No significant difference in Apgar scores
Temp instability ( 10% vs. 0%)
Hypoglycemia (15.6% vs. 5.3 %)
Need for IV infusions ( 26.7% vs. 5%)
Respiratory distress ( 28.9 % vs. 4.2 %)
Apnea and bradycardia (4.4 % vs. 0 %)
Sepsis evaluation (36.7% vs. 12.6%)
Clinical jaundice ( 54.4% vs. 37.9%)
Wang, et. Al., 2004

7. Physiology of Fetal Development
Third Trimester Fetal Development
Surfactant production
Neurological maturity
Maturation of the regulation of breathing
Coordination of sucking/swallowing/breathing
Increased glycogen stores
Increased brown fat stores

8. Clinical Risks Associated with the Late Preterm Infant
The risks should not be underestimated
Clinical protocols, policies and procedures for full term infants may not be appropriate
Even “well” Late Preterm Infants with a normal hospital course are at increased risk for hospital re-admittance

9. Care of the Late Preterm Infant
Thermoregulation
Minimize heat loss
Supply heat as needed, promote skins to skin contact
Assess alertness, muscle tone, and activity
If irritable, infant may be attempting to increase muscle activity to generate heat
Tachypnea and respiratory distress
Increased respiratory rate increases evaporative heat loss
Heat and humidify oxygen asap
Ensure thermal stability prior to discharge

10. Care of the Late Preterm Infant
Hypoglycemia
10-15% in LPI
Glucose needed for cerebral outcome, linked to neurodevelopmental outcome (it’s all about the brain cells)
Frequent monitoring and assessment
Early, frequent feeding, especially in the first 24 hours

11. Care of the Late Preterm Infant
Jaundice
2.4x more likely to develop significant hyperbilirubinemia; 25% require photo tx
Peak is at 5-7 days
Immature liver function, infective albumin binding decreases conjugation of bilirubin
Frequent feeding and assessment critical
bilitool.org

12. Care of the Late Preterm Infant
Feeding
Suck/ swallow coordination develops at weeks gestation
Fewer sucks, lower pressure
Little empirical data on feeding protocols for the Late Preterm Infant
an excellent research opportunity for you future grad students

13. Care of the Late Preterm Infant
Feeding protocol
Feed within first hour, skin to skin contact
Provide lactation support
Provide test weights
Skin to skin contact 30 minutes per day increases milk volume
Frequent feedings
State assessment- teach parents

14. The Environment: The AWHONN Initiative
Matching the needs of the Late Preterm Infant with appropriate care environment
NICU and well-baby nurseries often fail to meet the needs of this population
Need to develop practice guidelines and a standard of care for the environment
Lack of widespread recognition threatens delivery of optimal care

15. Family Role: The AWHONN Initiative
The Late Preterm Infant may not be mature enough to provide adequate cues to assist the family in meeting care needs
The expectation to perform like their full term counterpart can lead to parental frustration and sense of inadequacy
Lack of evidence-based information

16. Parent-Education for Late Preterm Infants
Feeding
Feed slower and need to be fed more often
Less volume
Feed often to prevent jaundice
If baby refusing feedings, contact provider
May have problems initiating or maintaining breastfeeding

17. Parent-Education for Late-Preterm Infants
Sleeping
May be sleepier than term infants and may sleep through feedings
Need to awakened for feeds every 3 or 4 hours
All infants, including LPI’s, should be placed on their backs to sleep

18. Parent-Education for Late-Preterm Infants
Breathing
Greater risk for respiratory distress
Any symptoms or trouble, call their provider
Remind parents to look at their lips and mucus membranes for color changes

19. Parent-Education for Late-Preterm Infants
Temperature
Have less body fat
May be less able to regulate their own body temperature
Should be kept away from drafts
Do not need to be overdressed

20. Parent-Education for Late-Preterm Infants
Jaundice
These infants are more likely to develop jaundice that can lead to severe neurological damage if not identified and treated
Should be screened for jaundice prior to discharge
Should see provider within hours of discharge, and any time skin appears yellow or infant not feeding well

21. Parent-Education for Late-Preterm Infants
Infections
May have immature immune system
Watch for signs for illness or infection such as:
temp instability
difficulty breathing

22. Questions Parents of Late Preterm Infant’s Should Ask Their Provider
How often should I bring my baby in for examinations?
What is the minimum number of times I should feed him or her each day?
What is the longest period of time I should let him or her go without eating?
What sorts of things should I be watching out for in terms of behavior or appearance?
How will I know if I should call you and how do I reach you?
When should my baby have a test for jaundice?
(This list is available for print/ download at awhonn.org)

23. Bibliography
American Academy of Pediatrics (2004) Clinical Practice Guideline “Management of Hyperbilirubinemia in the newborn 35 or more weeks gestation”, aap.org.
Cockley, C. (2005) focus on the Near-tem infant) , AWHONN Lifelines, 9, (4).
“Emerging Issues in Late Preterm ( near-term) Infant Care” AWHONN Lifelines, 9, (10)
Medoff-Cooper, et.al. “The AWHONN Near-Term Initiative”, JOGGN, 34,
Near-Term Initiative:
‘Near-term’ unease grows:
Wang, M.L., Dorer, D.J., et al (2004) Clinical Outcomes of Near-Term Infants. Pediatrics 114:
Wright, Gretchen (2005) “What the Parents of Near-Term Infants Need to Know”. AWHONN.Org