Discharge of late preterm infant

Question 1

What is the definition of late preterm infant?

Answer 1

34 35 36 WK GA

Question 2

What percentage of births are late preterm?

What is the trend over time?

Answer 2

5.9%

Increasing - maybe secondary to increase in multiple pregnancies, obstetric interventions and improved accuracy of GA measurements

Question 3

Why are these babies born early?

Answer 3

Preterm labour (80%) 
Obstetrical intervention (20%)

Question 4

Why do we consider late preterm babies uniquely?

Answer 4

Because there is an increased risk of death (4.5 x higher than a term infant) and higher rates of CP (3x) and developmental delay (1.25 x).

WHY death: asphyxia (3.3x), infection (5x), SIDS (1.9x)

Question 5

What are the physiological differences in late preterm infants?

Answer 5

Impaired thermoregulation
Immature and weak suck and swallow
Incomplete adaptation of certain enzyme systems
Poor immunological and respiratory defence system

Question 6

What might late preterm infants struggle with at birth?

Answer 6

Poort thermal, metabolic and cardiovascular adaptation. May struggle with feeding.

May need to be observed in NICU with special attention to thermal environment and special help with lactation.

Question 7

If the baby is doing great but mom is recovering from a CS, can we discharge the baby?

Answer 7

No, we need to observe establishment of good feeding. This is especially important for moms who had interventions such as CS

Question 8

Who is more likely to be readmitted: 34, 35 or 36 wks GA?

Answer 8

Overall late pretermers are more likely to require readmission.
36 weeker > 34, 35.
WHY: ? maybe secondary to being discharged too early.

Question 9

What are the recommendations at birth for kids who are potentially late preterm?

Answer 9

Document GA
Evaluate for succesful adaptation - T, vitals and BG at 2 hours of life.
Monitor for CVS stability and feeding - this can be done with mom.
Wrap infants and measure core temperature. Do not bathe until they can regulate.
Early feeding

Question 10

What are the common reasons late pretermers are readmitted?

Answer 10

Hyperbili 
Feeding
Apnea
ALTE
Sepsis
Res problems
Hypothermia

Question 11

What is unique about their bill problems?

Answer 11

The bill levels peak later - at 7 days instead of 5
The bili stays elevated longer
The bili is higher (often by 4.5 days it reaches a significant peak)
Higher risk of kernicterus - the risk of extreme hyperbili doubles for every week of GA shorter than 40. This is especially true if breast fed (6x)

SO: late preterm infants who score in or above low-intermediate zone must be re-evaluated at 24-48 hours. If high risk, they must be observed throughout the first week of life.

Question 12

IF the baby is doing great but mom is recovering from a CS, can we discharge the baby?

Answer 12

No, we need to observe establishment of good feeding. This is especially important for moms who had interventions such as CS

Question 13

Who is more likely to be readmitted: 34, 35 or 36 wks GA?

Answer 13

Overall late pretermers are more likely to require readmission.
36 seekers > 34, 35.
WHY: ? maybe secondary to being discharged too early.

Question 14

So what do we do about Bili in late pretermers?

Answer 14

Assess within 48 hours
Late preterm infants who score in or above low-intermediate zone must be re-evaluated at 24-48 hours.
If high risk, they must be observed throughout the first week of life.
Monitor weight/feeding within first 10 days of life.

Question 15

What are the recommendations around feeding?

Answer 15

• need 24 hours of good feeding before DC

- Feeding

Question 16

Is apnea of prematurity a common cause of SIDS for late pretermers?

Answer 16

Apnea is more common in late preterm, as is SIDS. BUT SIDS is not a prolongation of apnea of prematurity and typically occurs

Question 17

What are the CPS recommendations around apnea of prematurity in this population?

Answer 17

34 wakers may be observed for a period of CVS monitoring
If an infant has apnea, they should be evaluated for a cause. If there is no cause, they should be monitored until they are 8 days apnea free.

Question 18

If a late pretermer is born, looks good, but GBS status unknown and no IPA, what do you do?
Why?

Answer 18

observe x 24 hours
CBC

Why: they are at increased risk of GBS sepsis, both early and late

Question 19

When these kids are home, what advise can you give parents regarding avoiding infection and why?

Answer 19

Wash hands.
Avoid ppl with URTI

WHY: high risk for sepsis and this extends beyond discharge.

Question 20

Why is thermoregulation more of an issue for these kids?

Answer 20

Large surface area to weight

Impaired ability to shiver

Question 21

What are the CPS recommendations re sugar and temperature?

Answer 21

Routine blood sugar monitoring

Keep home warm (18C) and do not use excessive clothing or bedding.

Question 22

What follow up should a late pretermer have?

Answer 22

Within 48 hours as a minimum