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THE LATE PRETERM INFANT (PowerPoint)

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					THE LATE PRETERM
   INFANT (LPT)
      WAHIB MENA, M.D.
Glenda Dickerson, MS, RN, IBCLC
 BROOKWOOD WOMEN’S MEDICAL CENTER
          HOMEWOOD, AL
         DEFINITION


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


 2003: 12.3% OF BIRTHS < 37 WKS
 31% INCREASE SINCE 1981
 34-36.6 WKS (75%)
 2002: 342,234 vs. 394,996
         CLINICAL ISSUES
   TEMP INSTABILITY
   HYPOGLYCEMIA
   TTN
   RDS
   APNEA
   SIDS
   NEUROLOGIC ISSUES
   HYPERBILIRUBINEMIA AND KERNICTERUS
          TEMPERATURE

 HYPOTHERMIA
 HYPERTHERMIA
    ? SEPSIS
    LONGER HOSPITAL STAY
    RARE MORBIDITY AND MORTALITY(NEC)
        HYPOGLYCEMIA


 LOW SUPPLY
 INSULIN GLUCAGON BALANCE
 BRAIN FUEL
  What About What We Can’t See?

Human
Brain
Development
      TTN/RDS/APNEA


 CLEARLY   INCREASED TTN AND RDS
 APNEA
 USUALLY   NO LONGTERM ISSUES
                         SIDS


 RISK    OF SIDS DOUBLES
     1.4 vs. 0.7/1000
        NEUROLOGIC


 INCREASED BEHAVIORAL DISORDERS
 NO GOOD STUDIES
 DECREASED PERFORMANCE IN MATH
  AND ENGLISH
  What About What We Can’t See?

Human
Brain
Development
         JAUNDICE


 INCREASED BILI PRODUCTION
 DECREASED CLEARING
 IMMATURE BLOOD BRAIN BARRIER
 INCREASED RISK FOR KERNICTERUS
            WHAT TO DO

 BE   AWARE OF ORGAN IMMATURITY
     BRAIN
     LUNG
     HORMONAL AXIS
     DIVING REFLEX
       I AM PREMATURE

 DO NOT DELAY TREATMENT
 AGGRESSIVE APPROACH
 EDUCATE PARENTS
 EDUCATE HEALTHCARE WORKERS
 HOME ENVIRONMENT
      Breastfeeding Management

 Vulnerabilities
 1.   Hypothermia
 2.   Hypoglycemia
 3.   Respiratory Instability
 4.   Immature state regulation
 5.   Hypotonia and Immature Feeding Skills
 6.   Insufficient milk (delayed lactogenesis)
 7.   Hyperbilirubinemia
 1. Hypothermia and 2.Hypoglycemia

Skin-to-skin   care (STS)
  Hypothermia and Hypoglycemia
 Skin-to-skin
   Newborn infant’s natural habitat/safe

    environment
     • Helps to stabilize temperature
            Mothers thermo-regulate their infant’s temp
      • Stabilizes blood glucose levels
            Even when a feeding does not take place
      • Stabilizes respiratory effort
      • Colonize the infant’s skin
            Helps protect against URI and Intestinal
             infections
  STS is Evidence Based Care
 Should   not be based on “I like” or “I
  don’t like”
 Should not be based on “there is not
  enough time”
Hypothermia and Hypoglycemia
 Immediate    STS (Mom and infant
 stable)
  Dried
  Covered with warm blankets

  Cap placed on head

  Initial assessment accomplished

  Postpone task till after first feeding is

   accomplished
      Extended STS Care
 Encourages   frequent feedings
       3. Respiratory Instability
 LPT   is more prone to positional apnea
    Careful feeding position
     • Avoid cradle hold
     • Clutch (football) or cross-cradle is preferred
           Mom should be instructed not to flex head in these
            positions
           Breast should not rest on the infant’s chest
    Avoid use of slings
     • Wraps/KC garments may work well
Preferred: Clutch (Football)
Preferred: Cross-Cradle Hold
Avoid—Over-flexed Position
  4. Immature State Regulation
 STS   care
    Modulates the under-aroused, over-
     aroused, and shut down infant
 Minimize interruptions
 Parent education
  Avoid excessive stroking, massaging,
   rocking, talking, bright lights, loud noise,
   and being handed of to multiple visitors
  Limit visitors
 5. Hypotonia and Immature Feeding Skills

 Hypotonia
  May result from maternal use of labor
   medications
  Fetal exposure to SSRI’s during 3
                                        rd

   trimester
  Will contribute to ineffective feeding
 Hypotonia and Immature Feeding Skills

 Wide range of sucking patterns,
 frequency, and intensity
    May tire quickly and be unable to sustain
     nutritive sucking
    Electromyographic study of sucking patterns
     • 15% to 60% of time spent sucking
    May lack strength for appropriate sucking
     pressure (60 mm Hg)
     • Render unable to secure nipple in place between
       sucking burst
Hypotonia and Immature Feeding Skills

Feed   the baby

Facilitate   direct breastfeeding

Protect   mother’s milk supply
Hypotonia and Immature Feeding Skills

 Feed       the Baby
    Encourage initiation of breastfeeding
     within one hour after birth
     • Latch if possible
           Cross-cradle/football
           Use Dancer-Hand to stabilize jaw
           May help to prevent clamping
     • Consider use of nipple shield
Hypotonia and Immature Feeding Skills

Evaluate       need for supplement
  Expressed colostrum/breastmilk
  Banked human milk

  Hydrolyzed formula

     • Reduce the risk of sensitizing a
       susceptible infant to allergies or
       diabetes
     • May help to lower bili levels
 Hypotonia and Immature Feeding Skills

 Should     be breastfed or breastmilk fed
    8 times in 24 hours
    Awaken if baby does not indicate hunger
 Continue     use of nipple shield if needed
    Difficult latch
    Evidence of ineffective milk transfer
    Follow-up with mother’s using shield after
     discharge
     • Infant may need to use until 40 weeks post-
       conceptual age
Hypotonia and Immature Feeding Skills

 Supplementation
    Best done at the breast if possible
     • 5 French feeding tube/10 ml syringe
     • Commercial supplementer systems
          Can be used in conjunction with a
           nipple shield
 Hypotonia and Immature Feeding Skills

 Ifinfant is not latching or able to
  supplement at breast
      Feed expressed milk every 3 hours
       • 5-10 ml per feeding on day 1
           Spoon (small quantities)

       • 10-20 ml per feeding on day 2
            Cup (as quantity increases)
            Paced feeding
       • 20-30 ml per feeding on day 3
 Hypotonia and Immature Feeding Skills

 Ifsupplementing away from the
  breast
      Facilitate direct breastfeeding
       • Use alternative methods as the mother
         desires
            Spoon feeding for small amounts
            Cup feeding for larger amounts
       • Paced feeding
       • Encourage mother to continue efforts at the
         breast as she is comfortable
Spoon Feeding
Hypotonia and Immature Feeding Skills

 Protect      mother’s milk supply
    Assist the mother to begin pumping
     • Feeding ineffectively
            Pump every 3 hours during the day and at
             least once per night
     • Feeding effectively
            Pump about 4 times a day to provide
             additional stimulation to bring in a good
             milk supply
       6. Insufficient Milk Supply
 Initiate   and maintain supply
     Begin pumping within 6 hours of
      delivery
      • Colostrum bolus may be present
   Pump after each feeding (8-10 times
    per 24 hours) for first 2 weeks
   Use appropriate size

    breast shield for pumping
        Insufficient Milk Supply
 Protect Milk Supply
   Establishing milk supply

      • Lactogenesis II occurs on average 60 hours
        following delivery
            Expected volumes (approximation) per 24 hrs
              • Day one             less than 100 ml
              • Day two             200 ml
              • Day three           350 ml (borderline)
              • Day four            600 ml (adequate)
              • Day 14              750 ml (ideal)
        Insufficient Milk Supply
 Protect    mother’s milk supply
  The amount of stimulation on day 2 is
   positively correlated with adequate milk
   volume on day five
  Milk supply at day 6 is indicative of

   supply at 6 weeks
     • Window of opportunity for establishing milk
       supply
         7. Hyperbilirubinemia
 Readmission        due to jaundice
     7 to 13 fold increased risk
      • Slower meconium passage
      • Low milk intake
      • Decreased activity of bili-conjugating enzyme
 Bilirubin
          peak levels typically occur
  around 5 to 7 days of life
 Kernicterus is seen more frequently in
  LPT
         Hyberbilirubinemia
Preventative goals
  Optimize milk intake

  Promote rapid meconium

   clearance and increase stool
   volume
  Prevent excessive weight loss
           Hyperbilirubinemia
 Optimize     Milk Intake
    Frequent feedings
     • 8-10 times in 24 hours
  Evaluate for deep latch
  Use breast compression or massage

  Use a nipple shield if needed
           Hyperbilirubinemia

Promote Rapid Meconium
 Clearance
    Frequent colostrum feeds
     • At breast
     • Hand expressed
        5-10 ml every 2-3 hours on day one
        10-20 ml every 2-3 hours on day two

        20-30 ml every 2-3 hours on day three
           Hyperbilirubinemia

 Prevent    Excessive Weight Loss
    Discourage missed feedings
     • Visitors
     • Excessive interruptions
    Evaluation of feeding once per shift
     • Qualified professional
     • Document
    Pre and post feed weights if needed
                Hyperbilirubinemia
   Data from the Pilot Kernicterus Registry (1992-
    2003)
       The greatest risk for kernicterus
         • The exclusively breastfed “large” LPT infant
       Hospital admission within 7 days post birth
       Present with severe jaundice and inadequate intake
       Most parents had contacted their primary care
        providers with concerns about jaundice, poor feeding,
        and excessive sleepiness and had been told these
        were normal behaviors
        Discharge Feeding Plan
 Teameffort that includes the
 mother
    STS Care
    Feed the Baby/Determine the method
    Protect Mother’s Milk Supply
    Early and Appropriate Follow-up
 Communicate      this plan with outpatient
 care provider
    Continue evaluation
       Initial Outpatient Follow-up

 Shouldbe 3-5 days of life, or one or
 two days after discharge
  Weight check
  Assessment for jaundice

  Review of written feeding record

     • Parameters of adequate intake
    Assessment of breastfeeding
     effectiveness
           Poor Weight Gain
Less     than 20 grams/day
    Ineffective feeding
     • Refer to a lactation specialist
                Follow-up
How        are mom and baby coping?
  Modify plan to something that is
   more manageable
  Work with her to find help

 Don’t   assume you know
    Ask!
         Extended Follow-up
 Weekly  follow-up until 40 weeks
 post conceptual age or until it is
 demonstrated that he/she is
 thriving with no supplements
    With each adjustment that is made
     a visit/weight check in 2-4 days
     should be done
        Continued Monitoring
Adequate     growth
    Weight gain should average >20
     g/day
    Length and head circumference
     should each increase by an average
     of .0.5 cm/week
          Our Findings
Recollecteddata to see if we
 had improved readmission rates
  Decreased by 50% in the first year
  Goal is to decrease to same rate

   as term infant
      Interventions Reviewed
L   Lots of STS
P   Position Appropriately
I   Initiate Stimulation Controls
C   Calories Count
A   Adequate Milk Supply
R   Reinforce awareness of bili
E   Educate for discharge!
                  Objectives
 Define the sub-classification of late preterm
  infant.
 Discuss the physical characteristics and
  vulnerabilities of the late preterm infant.
 List strategies to address the identified
  vulnerabilities of the late preterm infant as they
  relate to breastfeeding management.
 State the essential elements of discharge
  planning for the breastfeeding late preterm
  infant.
Late Preterm Babies Were Born to Breastfeed

				
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