Transition of the Premature Infant from Hospital to Home Ma. Teresa C. Ambat, MD Neonatology-TTUHSC 10/7/2008

Introduction PCPs are taking care of a growing population of former premature infants PCPs should understand the special difficulties facing these infants and their families PCPs should understand how to follow problems identified in the NICU and be attentive to new issues that may develop

Terms Commonly Used to Describe Premature Infants Late preterm Low birth weight (LBW) Very low birth weight (VLBW) Extremely low birth weight (ELBW) Born < 37 weeks’ estimated GA Previously referred to as “near term”. Born between 34 -36 6/7 wks BW <2500g (5 lbs 8oz) BW <1500g (3lb 5oz) BW <100g (2lb 3oz)

Terms Commonly Used to Describe Premature Infants Gestational age Chronological age Postmenstrual age Corrected age Age based on time elapsed between the 1st day of LMP and the day of delivery Age based on time elapsed after birth = postnatal age Age based on time elapsed bet the 1st day of LMP and birth + chronological age Ex. 26 wk GA who is 10 wks chronological age would have postmenstrual age of Age of the infant based on expected delivery date (Chronological age - number of weeks born before 40 wks) Ex. 12 month old former 28 wks has corrected age of 36wks 9 months

Late Preterm Potential short term morbidities: respiratory distress, jaundice, feeding difficulties, hypoglycemia, temperature instability and sepsis Higher rate of rehospitalization within the first 2 weeks after discharge

Guidelines for PCP Caring for Late Preterm Infant Newborn nursery care Monitor for feeding difficulties, respiratory distress, jaundice, temperature instability, hypoglycemia and sepsis Lower threshold for supplementing breastfeeding and obtaining lactation consultant who can continue to advise the mother after discharge Car seat safety screening Determine need for RSV prophylaxis Educate family about differences between late preterm and full term

Guidelines for PCP Caring for Late Preterm Infant Family education Feeding Usually eat less and may need to be fed more often Difficulty coordinating sucking, swallowing, and breathing during the feeding needs to be observed closely while eating May feed well initially at the hospital  become tired and feed poorly contact PCP if the infant has decreased oral intake 5-6 wet diapers in every 24 hour period

Guidelines for PCP Caring for Late Preterm Infant Family education Sleeping Sleepier than full term and sleep through feedings  should awaken the infant to feed Should sleep on their backs Thermoregulation Difficulty regulating body temperature (decreased subq fat) Should wear hats to decrease heat loss, if environmental temperature is cool Jaundice Greater risk for jaundice. Families should be taught how to look for jaundice and need for close-ffup

Guidelines for PCP Caring for Late Preterm Infant Family education Infection Greater risk for infections  watch for signs of infection (fever, difficulty breathing, lethargy) Minimize exposure to crowded places Practice good handwashing Car safety seat Minimize time in car seats until good head control is achieved

Guidelines for PCP Caring for Late Preterm Infant Follow up Schedule appointments in 1-2 days after discharge At first visit, PCP should: Assess dehydration with weight check and P.E. Evaluate for jaundice Arrange for continued ff-up Reemphasize educational points Record results of the newborn screening

Guidelines for PCP Caring for Premature Infant Manage complications of prematurity Monitor for potential new problems Support the family Coordinate various medical and social services needed Determine whether an Infant follow up program is needed Refer infant to an early intervention program as needed (in most states NICU graduates are eligible for this program) Educate the family by providing anticipatory guidance and a list of resources

Discharge Criteria Thermoregulation Ability to maintain a normal body temperature when clothed in an open crib No apnea or bradycardia for a defined period Observational days that are spell free varies by unit Exclusively taking oral feedings with adequate weight gain Should demonstrate a sustained pattern of weight gain

Discharge Teaching Teach good handwashing and minimize exposure to crowded places Antibacterial solution in case soap and water are not easily accessible Infant must sleep on their backs AAP recommends that infants sleep on their backs to decrease SIDS When to call PCP Instruct parents to contact PCP if with any abdominal issues, breathing problems, feeding intolerance, fever, decreased activity that could represent illness. Medication administration Fill prescriptions before discharge. Teach family how to administer medications. Caloric supplementation Written instructions for formula/milk preparation.

Discharge Checklist Car seat safety screen Assessed in all infants <37 wks Phone contact with PCP Phone contact Written summary of medical course for PCP Newborn hearing screen Perform prior to discharge and if needed arrange for out-patient follow-up Newborn state screening PT often have initial NBS results that are “out of range” requiring ff-up Immunizations Routine immunizations Assess need for RSV prophylaxis CPR Ideally, all care providers should learn CPR

Discharge Planning Follow-up appointments/referrals Arrange discharge appointments at times that would decrease exposure to children with infections PCP Early childhood intervention (ECI) Visiting nurse Ophthalmologist High-risk clinic Other consultants

Discharge Planning Discharge paper works to families Supply the family with a copy of infants’ discharge summary Discharge summary (recent weight, length, HC) Immunization record Growth curve List of medications and doses Appointments and contact numbers of consultants, including lactation consultant

Potential Medical Problems for Premature Infants Respiratory BPD, ventilator dependent with need for tracheostomy tube, apnea of prematurity Growth and Nutrition Inadequate nutrition and growth, difficulty with breastfeeding, nutritional deficiencies, complications of IUGR GI GER, colic, oral aversion, constipation, need for enteral tubes, NEC, SBS, direct hyperbilirubinemia

Potential Medical Problems for Premature Infants Neurologic IVH, post hemorrhagic HCP, white matter injury, CP, delayed neurodevelopment Hematologic Anemia of prematurity, indirect hyperbilirubinemia Endocrine Hypothyroidism, osteopenia Neurosensory ROP, other ophthalmologic issues, hearing loss Surgical Cryptorchidism, inguinal or umbilical hernia