the late preterm infant (lpt) wahib mena, m.d. glenda dickerson, ms, rn, ibclc brookwood women’s...

THE LATE PRETERM THE LATE PRETERM INFANT (LPT)INFANT (LPT)

WAHIB MENA, M.D.WAHIB MENA, M.D.

Glenda Dickerson, MS, RN, IBCLCGlenda Dickerson, MS, RN, IBCLCBROOKWOOD WOMEN’S MEDICAL CENTERBROOKWOOD WOMEN’S MEDICAL CENTER

HOMEWOOD, ALHOMEWOOD, AL

DEFINITIONDEFINITION

INFANTS BORN 34 0/7-36 6/7 WKSINFANTS BORN 34 0/7-36 6/7 WKS

EPIDEMIOLOGYEPIDEMIOLOGY

2003: 12.3% OF BIRTHS < 37 WKS2003: 12.3% OF BIRTHS < 37 WKS 31% INCREASE SINCE 198131% INCREASE SINCE 1981 34-36.6 WKS (75%)34-36.6 WKS (75%) 2002: 342,234 vs. 394,9962002: 342,234 vs. 394,996

CLINICAL ISSUESCLINICAL ISSUES

TEMP INSTABILITYTEMP INSTABILITY HYPOGLYCEMIAHYPOGLYCEMIA TTNTTN RDSRDS APNEAAPNEA SIDSSIDS NEUROLOGIC ISSUESNEUROLOGIC ISSUES HYPERBILIRUBINEMIA AND KERNICTERUSHYPERBILIRUBINEMIA AND KERNICTERUS

TEMPERATURETEMPERATURE

HYPOTHERMIA HYPOTHERMIA HYPERTHERMIAHYPERTHERMIA

? SEPSIS? SEPSIS LONGER HOSPITAL STAYLONGER HOSPITAL STAY RARE MORBIDITY AND MORTALITY(NEC)RARE MORBIDITY AND MORTALITY(NEC)

HYPOGLYCEMIAHYPOGLYCEMIA

LOW SUPPLYLOW SUPPLY INSULIN GLUCAGON BALANCEINSULIN GLUCAGON BALANCE BRAIN FUELBRAIN FUEL

What About What We Can’t See?What About What We Can’t See?

HumanHuman

BrainBrain

DevelopmentDevelopment

TTN/RDS/APNEATTN/RDS/APNEA

CLEARLY INCREASED TTN AND RDSCLEARLY INCREASED TTN AND RDS APNEA APNEA USUALLY NO LONGTERM ISSUESUSUALLY NO LONGTERM ISSUES

SIDSSIDS

RISK OF SIDS DOUBLESRISK OF SIDS DOUBLES 1.4 vs. 0.7/10001.4 vs. 0.7/1000

NEUROLOGICNEUROLOGIC

INCREASED BEHAVIORAL DISORDERSINCREASED BEHAVIORAL DISORDERS NO GOOD STUDIES NO GOOD STUDIES DECREASED PERFORMANCE IN MATH DECREASED PERFORMANCE IN MATH

AND ENGLISH AND ENGLISH

What About What We Can’t See?What About What We Can’t See?

HumanHuman

BrainBrain

DevelopmentDevelopment

JAUNDICEJAUNDICE

INCREASED BILI PRODUCTIONINCREASED BILI PRODUCTION DECREASED CLEARINGDECREASED CLEARING IMMATURE BLOOD BRAIN BARRIERIMMATURE BLOOD BRAIN BARRIER INCREASED RISK FOR KERNICTERUSINCREASED RISK FOR KERNICTERUS

WHAT TO DOWHAT TO DO

BE AWARE OF ORGAN IMMATURITYBE AWARE OF ORGAN IMMATURITY BRAINBRAIN LUNGLUNG HORMONAL AXISHORMONAL AXIS DIVING REFLEXDIVING REFLEX

I AM PREMATUREI AM PREMATURE

DO NOT DELAY TREATMENTDO NOT DELAY TREATMENT AGGRESSIVE APPROACHAGGRESSIVE APPROACH EDUCATE PARENTSEDUCATE PARENTS EDUCATE HEALTHCARE WORKERSEDUCATE HEALTHCARE WORKERS HOME ENVIRONMENTHOME ENVIRONMENT

Breastfeeding ManagementBreastfeeding Management

VulnerabilitiesVulnerabilities1.1. HypothermiaHypothermia

2.2. HypoglycemiaHypoglycemia

3.3. Respiratory InstabilityRespiratory Instability

4.4. Immature state regulationImmature state regulation

5.5. Hypotonia and Immature Feeding SkillsHypotonia and Immature Feeding Skills

6.6. Insufficient milk (delayed lactogenesis)Insufficient milk (delayed lactogenesis)

7.7. HyperbilirubinemiaHyperbilirubinemia

1. Hypothermia and 2.Hypoglycemia1. Hypothermia and 2.Hypoglycemia

Skin-to-skin care (STS)Skin-to-skin care (STS)

Hypothermia and HypoglycemiaHypothermia and Hypoglycemia

Skin-to-skinSkin-to-skin Newborn infant’s natural habitat/safe environmentNewborn infant’s natural habitat/safe environment

• Helps to stabilize temperatureHelps to stabilize temperature Mothers thermo-regulate their infant’s tempMothers thermo-regulate their infant’s temp

• Stabilizes blood glucose levelsStabilizes blood glucose levels Even when a feeding does not take placeEven when a feeding does not take place

• Stabilizes respiratory effortStabilizes respiratory effort• Colonize the infant’s skinColonize the infant’s skin

Helps protect against URI and Intestinal Helps protect against URI and Intestinal infectionsinfections

STS is Evidence Based CareSTS is Evidence Based Care

Should not be based on “I like” or “I Should not be based on “I like” or “I don’t like” don’t like”

Should not be based on “there is not Should not be based on “there is not enough time”enough time”

Hypothermia and HypoglycemiaHypothermia and Hypoglycemia

Immediate STS (Mom and infant Immediate STS (Mom and infant stable)stable) Dried Dried Covered with warm blanketsCovered with warm blankets Cap placed on headCap placed on head Initial assessment accomplishedInitial assessment accomplished Postpone task till after first feeding is Postpone task till after first feeding is

accomplishedaccomplished

Extended STS CareExtended STS Care

Encourages frequent feedingsEncourages frequent feedings

3. Respiratory Instability3. Respiratory Instability

LPT is more prone to positional apneaLPT is more prone to positional apnea Careful feeding positionCareful feeding position

• Avoid cradle holdAvoid cradle hold

• Clutch (football) or cross-cradle is preferredClutch (football) or cross-cradle is preferred Mom should be instructed not to flex head in these Mom should be instructed not to flex head in these

positionspositions Breast should not rest on the infant’s chestBreast should not rest on the infant’s chest

Avoid use of slingsAvoid use of slings• Wraps/KC garments may work wellWraps/KC garments may work well

Preferred: Clutch (Football)Preferred: Clutch (Football)

Preferred: Cross-Cradle HoldPreferred: Cross-Cradle Hold

Avoid—Over-flexed PositionAvoid—Over-flexed Position

4. Immature State Regulation4. Immature State Regulation

STS careSTS care Modulates the under-aroused, over-aroused, Modulates the under-aroused, over-aroused,

and shut down infantand shut down infant Minimize interruptionsMinimize interruptions Parent educationParent education

Avoid excessive stroking, massaging, Avoid excessive stroking, massaging, rocking, talking, bright lights, loud noise, and rocking, talking, bright lights, loud noise, and being handed of to multiple visitors being handed of to multiple visitors

Limit visitorsLimit visitors

5. Hypotonia and Immature Feeding Skills5. Hypotonia and Immature Feeding Skills

HypotoniaHypotonia May result from maternal use of labor May result from maternal use of labor

medicationsmedications Fetal exposure to SSRI’s during 3Fetal exposure to SSRI’s during 3rdrd

trimestertrimester Will contribute to ineffective feedingWill contribute to ineffective feeding

Hypotonia and Immature Feeding SkillsHypotonia and Immature Feeding Skills

Wide range of sucking patterns, Wide range of sucking patterns, frequency, and intensityfrequency, and intensity May tire quickly and be unable to sustain May tire quickly and be unable to sustain

nutritive suckingnutritive sucking Electromyographic study of sucking patternsElectromyographic study of sucking patterns

• 15% to 60% of time spent sucking15% to 60% of time spent sucking May lack strength for appropriate sucking May lack strength for appropriate sucking

pressure (60 mm Hg)pressure (60 mm Hg)• Render unable to secure nipple in place between Render unable to secure nipple in place between

sucking burstsucking burst

Hypotonia and Immature Feeding SkillsHypotonia and Immature Feeding Skills

Feed the babyFeed the baby

Facilitate direct breastfeedingFacilitate direct breastfeeding

Protect mother’s milk supplyProtect mother’s milk supply

Hypotonia and Immature Feeding SkillsHypotonia and Immature Feeding Skills

Feed the BabyFeed the Baby Encourage initiation of breastfeeding Encourage initiation of breastfeeding

within one hour after birthwithin one hour after birth• Latch if possibleLatch if possible

Cross-cradle/footballCross-cradle/football Use Dancer-Hand to stabilize jawUse Dancer-Hand to stabilize jaw May help to prevent clampingMay help to prevent clamping

• Consider use of nipple shieldConsider use of nipple shield

Hypotonia and Immature Feeding SkillsHypotonia and Immature Feeding Skills

Evaluate need for supplementEvaluate need for supplement Expressed colostrum/breastmilkExpressed colostrum/breastmilk Banked human milkBanked human milk Hydrolyzed formulaHydrolyzed formula

• Reduce the risk of sensitizing a Reduce the risk of sensitizing a susceptible infant to allergies or diabetessusceptible infant to allergies or diabetes

• May help to lower bili levelsMay help to lower bili levels

Hypotonia and Immature Feeding SkillsHypotonia and Immature Feeding Skills

Should be breastfed or breastmilk fed Should be breastfed or breastmilk fed 8 times in 24 hours8 times in 24 hours Awaken if baby does not indicate hungerAwaken if baby does not indicate hunger

Continue use of nipple shield if neededContinue use of nipple shield if needed Difficult latchDifficult latch Evidence of ineffective milk transferEvidence of ineffective milk transfer Follow-up with mother’s using shield after Follow-up with mother’s using shield after

dischargedischarge• Infant may need to use until 40 weeks post-conceptual Infant may need to use until 40 weeks post-conceptual

ageage

Hypotonia and Immature Feeding SkillsHypotonia and Immature Feeding Skills

SupplementationSupplementation Best done at the breast if possibleBest done at the breast if possible

• 5 French feeding tube/10 ml syringe5 French feeding tube/10 ml syringe

• Commercial supplementer systemsCommercial supplementer systems Can be used in conjunction with a Can be used in conjunction with a

nipple shieldnipple shield

Hypotonia and Immature Feeding SkillsHypotonia and Immature Feeding Skills

If infant is not latching or able to If infant is not latching or able to supplement at breastsupplement at breast Feed expressed milk every 3 hoursFeed expressed milk every 3 hours

• 5-10 ml per feeding on day 15-10 ml per feeding on day 1 Spoon (small quantities)Spoon (small quantities)

• 10-20 ml per feeding on day 210-20 ml per feeding on day 2 Cup (as quantity increases)Cup (as quantity increases) Paced feedingPaced feeding

• 20-30 ml per feeding on day 320-30 ml per feeding on day 3

Hypotonia and Immature Feeding SkillsHypotonia and Immature Feeding Skills

If supplementing away from the breastIf supplementing away from the breast Facilitate direct breastfeeding Facilitate direct breastfeeding

• Use alternative methods as the mother desiresUse alternative methods as the mother desires Spoon feeding for small amountsSpoon feeding for small amounts Cup feeding for larger amountsCup feeding for larger amounts

• Paced feedingPaced feeding

• Encourage mother to continue efforts at the Encourage mother to continue efforts at the breast as she is comfortablebreast as she is comfortable

Spoon FeedingSpoon Feeding

Hypotonia and Immature Feeding SkillsHypotonia and Immature Feeding Skills

Protect mother’s milk supplyProtect mother’s milk supply Assist the mother to begin pumpingAssist the mother to begin pumping

• Feeding ineffectivelyFeeding ineffectively Pump every 3 hours during the day and at Pump every 3 hours during the day and at

least once per nightleast once per night

• Feeding effectivelyFeeding effectively Pump about 4 times a day to provide Pump about 4 times a day to provide

additional stimulation to bring in a good milk additional stimulation to bring in a good milk supplysupply

6. Insufficient Milk Supply6. Insufficient Milk Supply

Initiate and maintain supplyInitiate and maintain supply Begin pumping within 6 hours of Begin pumping within 6 hours of

deliverydelivery• Colostrum bolus may be presentColostrum bolus may be present

Pump after each feeding (8-10 times Pump after each feeding (8-10 times per 24 hours) for first 2 weeksper 24 hours) for first 2 weeks

Use appropriate size Use appropriate size

breast shield for pumpingbreast shield for pumping

Insufficient Milk SupplyInsufficient Milk Supply

Protect Milk SupplyProtect Milk Supply Establishing milk supplyEstablishing milk supply

• Lactogenesis II occurs on average 60 hours following Lactogenesis II occurs on average 60 hours following deliverydelivery

Expected volumes (approximation) per 24 hrsExpected volumes (approximation) per 24 hrs

• Day oneDay one less than 100 mlless than 100 ml• Day twoDay two 200 ml 200 ml • Day threeDay three 350 ml (borderline)350 ml (borderline)• Day fourDay four 600 ml (adequate)600 ml (adequate)• Day 14Day 14 750 ml (ideal)750 ml (ideal)

Insufficient Milk SupplyInsufficient Milk Supply

Protect mother’s milk supplyProtect mother’s milk supply The amount of stimulation on day 2 is The amount of stimulation on day 2 is

positively correlated with adequate milk positively correlated with adequate milk volume on day fivevolume on day five

Milk supply at day 6 is indicative of Milk supply at day 6 is indicative of supply at 6 weekssupply at 6 weeks• Window of opportunity for establishing milk Window of opportunity for establishing milk

supplysupply

7. Hyperbilirubinemia7. HyperbilirubinemiaReadmission due to jaundiceReadmission due to jaundice

7 to 13 fold increased risk7 to 13 fold increased risk• Slower meconium passageSlower meconium passage• Low milk intakeLow milk intake• Decreased activity of bili-conjugating enzymeDecreased activity of bili-conjugating enzyme

Bilirubin peak levels typically occur around Bilirubin peak levels typically occur around 5 to 7 days of life5 to 7 days of life

Kernicterus is seen more frequently in LPTKernicterus is seen more frequently in LPT

HyberbilirubinemiaHyberbilirubinemia

Preventative goalsPreventative goals Optimize milk intakeOptimize milk intake Promote rapid meconium Promote rapid meconium

clearance and increase stool clearance and increase stool volumevolume

Prevent excessive weight lossPrevent excessive weight loss

HyperbilirubinemiaHyperbilirubinemia

Optimize Milk IntakeOptimize Milk Intake Frequent feedingsFrequent feedings

• 8-10 times in 24 hours8-10 times in 24 hours Evaluate for deep latchEvaluate for deep latch Use breast compression or massageUse breast compression or massage Use a nipple shield if neededUse a nipple shield if needed

HyperbilirubinemiaHyperbilirubinemia

Promote Rapid Meconium Promote Rapid Meconium ClearanceClearance Frequent colostrum feedsFrequent colostrum feeds

• At breastAt breast• Hand expressedHand expressed

5-10 ml every 2-3 hours on day one5-10 ml every 2-3 hours on day one 10-20 ml every 2-3 hours on day two10-20 ml every 2-3 hours on day two 20-30 ml every 2-3 hours on day three20-30 ml every 2-3 hours on day three

HyperbilirubinemiaHyperbilirubinemia

Prevent Excessive Weight LossPrevent Excessive Weight Loss Discourage missed feedingsDiscourage missed feedings

• VisitorsVisitors• Excessive interruptionsExcessive interruptions

Evaluation of feeding once per shiftEvaluation of feeding once per shift• Qualified professionalQualified professional• DocumentDocument

Pre and post feed weights if neededPre and post feed weights if needed

HyperbilirubinemiaHyperbilirubinemia

Data from the Pilot Kernicterus Registry (1992-Data from the Pilot Kernicterus Registry (1992-2003)2003) The greatest risk for kernicterusThe greatest risk for kernicterus

• The exclusively breastfed “large” LPT infantThe exclusively breastfed “large” LPT infant Hospital admission within 7 days post birthHospital admission within 7 days post birth Present with severe jaundice and inadequate intakePresent with severe jaundice and inadequate intake Most parents had contacted their primary care Most parents had contacted their primary care

providers with concerns about jaundice, poor feeding, providers with concerns about jaundice, poor feeding, and excessive sleepiness and had been told these and excessive sleepiness and had been told these were normal behaviorswere normal behaviors

Discharge Feeding PlanDischarge Feeding Plan

Team effort that includes the motherTeam effort that includes the mother STS CareSTS Care Feed the Baby/Determine the methodFeed the Baby/Determine the method Protect Mother’s Milk SupplyProtect Mother’s Milk Supply Early and Appropriate Follow-upEarly and Appropriate Follow-up

Communicate this plan with outpatient Communicate this plan with outpatient care providercare provider Continue evaluationContinue evaluation

Initial Outpatient Follow-upInitial Outpatient Follow-up

Should be 3-5 days of life, or one or Should be 3-5 days of life, or one or two days after dischargetwo days after discharge Weight checkWeight check Assessment for jaundiceAssessment for jaundice Review of written feeding recordReview of written feeding record

• Parameters of adequate intakeParameters of adequate intake Assessment of breastfeeding Assessment of breastfeeding

effectivenesseffectiveness

Poor Weight GainPoor Weight Gain

Less than 20 grams/dayLess than 20 grams/day Ineffective feedingIneffective feeding

• Refer to a lactation specialist Refer to a lactation specialist

Follow-upFollow-up

How are mom and baby coping?How are mom and baby coping? Modify plan to something that is Modify plan to something that is

more manageablemore manageable Work with her to find helpWork with her to find help

Don’t assume you knowDon’t assume you know Ask!Ask!

Extended Follow-upExtended Follow-up

Weekly follow-up until 40 weeks Weekly follow-up until 40 weeks post conceptual age or until it is post conceptual age or until it is demonstrated that he/she is demonstrated that he/she is thriving with no supplementsthriving with no supplements With each adjustment that is made With each adjustment that is made

a visit/weight check in 2-4 days a visit/weight check in 2-4 days should be doneshould be done

Continued MonitoringContinued Monitoring

Adequate growthAdequate growth Weight gain should average >20 Weight gain should average >20

g/dayg/day Length and head circumference Length and head circumference

should each increase by an average should each increase by an average of .0.5 cm/weekof .0.5 cm/week

Our FindingsOur Findings

Recollected data to see if we Recollected data to see if we had improved readmission rateshad improved readmission rates Decreased by 50% in the first yearDecreased by 50% in the first year Goal is to decrease to same rate Goal is to decrease to same rate

as term infantas term infant

Interventions ReviewedInterventions Reviewed

LL Lots of STS Lots of STS PP Position AppropriatelyPosition Appropriately II Initiate Stimulation ControlsInitiate Stimulation Controls C C Calories CountCalories Count AA Adequate Milk SupplyAdequate Milk Supply RR Reinforce awareness of biliReinforce awareness of bili EE Educate for discharge!Educate for discharge!

ObjectivesObjectives

Define the sub-classification of late preterm infant.Define the sub-classification of late preterm infant. Discuss the physical characteristics and Discuss the physical characteristics and

vulnerabilities of the late preterm infant.vulnerabilities of the late preterm infant. List strategies to address the identified List strategies to address the identified

vulnerabilities of the late preterm infant as they vulnerabilities of the late preterm infant as they relate to breastfeeding management.relate to breastfeeding management.

State the essential elements of discharge State the essential elements of discharge planning for the breastfeeding late preterm infant.planning for the breastfeeding late preterm infant.

Late Preterm Babies Were Born to BreastfeedLate Preterm Babies Were Born to Breastfeed