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

2. 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

3. 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 /7 wks
BW <2500g (5 lbs 8oz)
BW <1500g (3lb 5oz)
BW <100g (2lb 3oz)

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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.

14. 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

15. 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

16. 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

17. 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

18. 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