Near Term Infants

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Near Term Infants

• Susan M. Ludington, CNM, Ph.D., FAAN
• Walters Professor of Pediatric Nursing
• Case Western Reserve University
• Susan.ludington_at_case.edu

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Near Term/Late Term

• Infants born at 34, 35, 36 and 37 weeks
  gestational age are called NEAR TERM (AKA Late
  Preterm) Infants -4-5 weeks before due date
• Near terms have a higher rate of post-discharge
  rehospitalization and illness than fullterm
  infants (Raju et al., 2006 Wang et al., 2004)

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Prevalence of Near Term Births

• Near terms comprise the largest and a growing
  proportion of preterm (lt37 wks GA) births
  (Mathews MacDorman, 2007).
• Represent approximately 7 of births
• in US near terms are 6.4-8.5 of all births
• in Canada 7.7 of infants are born lt37 weeks and
  5.6 of all infants are 34-36 weeks GA
  (Santo-Donato, 2006).

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Near term characteristics

• AGA
• Normal APGARS
• Usually go home with MOM in 2-3 days
• Considered to be healthy, like full term infant,
  BUT

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They are more like preterm infants than fullterm
infants

• though often treated like full term newborns,
  near-term newborns are at risk for same problems
  that prematures experience respiratory
  distress, hyperbilirubinemia, feeding problems,
  and neurodevelopmental delays (AWHONN).

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• 1. Increased Mortality
• 2. Increased Morbidity
• 3. Respiratory Instability apnea
• 4. Cardiovascular instability
• 5. Thermoregulation
• 6. Hypoglycemia
• 7. Sepsis
• 8. Hyperbilirubinemia
• 9. Feeding Problems
• 10. Neurodevelopmental delay

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For all these problems, theres KC
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Increased Mortality

• 2001 mortality rate for 32-36 GA8.9/1000
• 2002 mortality rate 9.2/1000 (MacDorman et al.,
  2005) with similar results in 2004 (Mathews
  MacDorman, 2007)
• Kangaroo Care decreases mortality
• (Kambarami, Chided Pereira, 2003 Worku
  Kassie, 2005)

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Increased Morbidity

• Wang et al., 2004 90 near term vs 95 FT
• Near terms had more evaluations for sepsis,
  hypoglycemia, breathing probs, jaundice, and 27
  needed IV fluids (only 5 FT needed IV fluids).
• LOS was longer and costs for near terms were
  2630 more than FT
• Kangaroo Care reduces LOS (27.2 days vs 34.6)
  (Ramanathan et al., 2001)

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Respiratory Instability

• Due to ? diffusion capability lungs
  underdeveloped, few gas exchange sites at 29-35
  wks, surface area in alveoli ? at 36 wks
• Due to ? fluid clearance ability esp C/S
• Due to ? surfactant ?? elasticity of alveolae

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Respiratory Assessment

• Check for Apnea of Prematurity Periodic
  Breathing Biggest use of home monitor
• lt 20 secs with spontaneous recovery
• lt 20 secs with HR? /or cyanosis, stimulate
  meds
• gt 20 secs stimulate meds

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Apnea Treatment

• 3 types of Apnea
• 1. Central (controlled by brain, airflow goes in
  and out of lungs without respiratory effort)
• 2. Obstructive (due to airway obstruction like
  flexed neck, airflow goes in but does not go down
  into lungs but respiratory effort continues
• 3. Mixed (combination of central obstructive)

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Nasal Thermistor for Apnea Study
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Apnea reduction by 75 during KMC
Ludington-Hoe et al Neonatal Network 1994
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(No Transcript)
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Peaceful slumber 1 hour after birth
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KC for apnea

• Apnea rarely occurs during KC (Chen et al., 2000
  Clifford Barnsteiner, 2001 Ludington-Hoe et
  al., 2004 Tornhage et al., 1999)
• Apnea does not increase during KC (Bohnhorst et
  al., 2001, 2004 Kadam et al., 2005)
• Apnea may decrease during KC (Ludington-Hoe et
  al., 1994 Hadeed et al., 1995 Meier, 2003)
• Because apnea mostly occurs during active sleep
  and arousals and these are minimized during
  Kangaroo Care (Ludington-Hoe et al. 2006
  Lehtonen Martin, 2004)

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• Quiet sleep in Kangaroo Care

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Cardiovascular Instability

• When changing position, being manipulated,
  feeding, or having apnea, HR ? ? BP vacillates
• Full term BP 50-85 mmHg
• Near term BP 25-50 mmHg

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Cardiovascular Instability TX

• Monitor HR and skin color
• Mimimize agitation, avoid crying stress changes
  heart rate
• KC produces calm (Morelius et al., 2005 Moore
  et al., 2007)
• Prevent crying or answer quickly to prevent
  foramen ovale shunting (Ludington-Hoe, Cong
  Hashemi, 2002).
• Crying is rare in KC (Ludington, 1990 Anderson
  et al. 2003) and KC ?crying (Chwo et al., 2002
  Erlandsson et al., 2007 Lai et al., 2005, Moore
  et al., 2007)

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Note the infants smile in PKC
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Thermoregulation
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Hypothermia is big concern

• Lose body heat due to large surface area (lose
  40 through head alone), no shivering
  thermogenesis ability, limited brown fat supplies
  (only 207 of total weight at birth in near
  terms), limited glucose and oxygen reserves for
  thermogenesis, and spend most of reserves on
  maintaining temperature (near term spends twice
  the O2 consumption to stay warm than a fullterm
  infant does).

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Hypothermia Treatment

• Maintain warm environmental temp becuz a drop of
  2 doubles O2 consumption rate and ? anaerobic
  metabolism
• Do not wean from incubator until at least 1500
  grams
• KC infants are warmer in KC than in any
  incubator or radiant warmer (Ludington-Hoe et
  al., 2000)
• Best temp for near term is 36.8C (36.5-37.4)

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Advantages of Kangaroo Care to Thermal Regulation

• Mother conducts heat to infant (Bergstrom et al.,
  2007 Ludington-Hoe et al., 2000, 2004, 2005)
• KC warms entire body, not just trunk (Christidis
  et al., 2003)
• KC warms and keeps warm without causing change in
  O2 consumption nor metabolic rate (Karlsson,
  1996)
• KC maintains temp in neutral thermal zone (Jonas
  et al., 2007 Ludington-Hoe et al., 2004 Moore
  et al., 2007 Ndiaye et al., 2006)
• KC is more efficient for rewarming than any
  device (Galligan, 2006)
• AAP recommends KC for thermoregulation (AAP, 2005)

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Sepsis 4 times more common in near term than in
term infants

• Acquire infections in utero, during delivery, and
  during postpartum
• Early sign is ? apnea, poor feeding, and acting
  just not right
• TX work up, close monitoring, antibiotics and
  active KANGAROO CARE (ideally with Mothers own
  milk for enteromammary and enterodermal pathways
  (Schanler, 2001 Schanler et al., 2005). KC
  reduces infection (Conde-Agudelo et al., 2003
  Charpak et al., 2001, Kambarami et al., 1998)

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Hypoglycemia causes seizures

• Five times more often in near term than full term
  infants.
• Due to delivery (no more coming from mother and
  when it was, infants level was only 60 that of
  mothers), slow start up in first 2-4 hours of
  infants own gluconeongenesis and glycogenolysis,
  so
• All newborns will have drop unless you prevent it
  with treatment

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Hypoglycemia Treatment -1

• Monitoring glucose level lt40-45mg/dl
• New 2007 guidelines say do it at 12, 24, 48 and
  pre-discharge use nomogramfor near term infants
  (Bhutani Johnson, 2006 Beachy, 2007)
• Watch for apnea, lethargy, jittery behavior,
  tachypnea, hypothermia
• Common treatment is early feeds and IV glulcose
  with bolus of 2-4 ml/kg D10W then continuous
  infusion based on 4-8 mg/kg/minute

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Hypoglycemia Treatment -2

• Keep infant in Kangaroo Care. Over first 90
  minutes of life, even without feeding, blood
  glucose will stay closer to normal (Anderson et
  al., 2003 Christensson et al., 1996 Mazurek et
  al., 1999) because staying warm promotes
  euglycemia (Chantry, 2005)
• Feed infant breastmilk while in KC because this
  reduces hypoglycemia (American Academy of BF Med)

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Feeding Problems gut mature at 34 weeks but
still growing and building integrity of sphincters

• Though Breast Milk is best, many BF problems
• 1, decreased milk intake 2 inefficient
  (immature) sucking inadequate feeding volume,
  
• 2. consequent reduced maternal milk supply
  (Shapiro-Mendoza et al., 2006 Tomashek et al.,
  2006 Jain Cheng, 2006 Hall et al., 2000)

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• Kangaroo Care CLEARLY promotes better
  breastfeeding, even in infants as low as 23 weeks
  GA (Moore Anderson, 2007 Moore, Anderson
  Bergman, 2007 Carfoot et al., 2005) and
  increases milk production (CDC, 2005 Hurst et
  al., 1997)
• Mothers Milk Club in Chicago (Meier, 2003)
• Uninterrupted KC, daily KC, pumping near baby, KC
  before anticipated feeding time, dont let sleep
  beyond 4 hours
• feed 8-12 times/day
• (includes night) and
• mothers need support
• EARLY PUMPING
• Aim for 15-20 gm/kg/day gain

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Hyperbilirubinemia is common

• ?bilirubin usually occurs in 1st week, so the
  earlier the discharge the more likely readmission
  (Watchko, 2006)
• 80 of preterms develop Hyperbili (Sola, 2007)
• Kernicterus in common (Bhutani Johnson, 2006)
  and
• Dehydration is common (Jones et al., 2003)
• Due to immaturity of liver and intestine, ?
  production, ?elimination, and more common in
  Breastfed infants

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Assessment of Bilirubinemia

• Expect hyperbilirubinemia in near terms
  (80-Sola, 2007)
• Do first assessment at 12 hours of life
  transdermal (icterometer) from forehead and nose
  tip. If gt2 in 1st 24 hrs, estimated mean
  bili5.5-8.7 mg/dl (Facchini et al., 2007). If gt3
  after 24 hours of life, then take total bili
  transcutaneously and if gt 11 mg/dl, take serum
  value and compare to critical chart (Bhutani
  Johnson, 2007)
• Initiate phototherapy when critical values are at
  or near 40th Percentile on NOMOGRAM for near
  terms (Bhutani, Johnson, Sivieri, 1999)
• Assess bili level 24 hours after discontinuing
  treatment and ALWAYS BEFORE DISCHARGE. Only
  discharge if bilirubinemia lt 15 mg/dl.
• If bilirubinemi or gt 20mg/dl, restart
  phototherapy.
• REMEMBER that 48Hours of Phototherapy leads to
  oxidative stress and metabolic derangements in
  near term infants (Sola, 2007).

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What to Tell Parents

• Infant has special, preemie-like needs
• Infant needs special monitoring
• Give them AWHONN near term booklet Optimizing
  Health of Near Term Infants. Available from
  www.awhonn.org/store, phone [phone] (US) or
  800-245-0231(Canada), fax [phone], mail
  AWHONN, Dept. 4015, Washington, DC 20042-4015.
• AND DO AS MUCH KC AS POSSIBLE (AAP, 2005 CDC,
  2005 WHO 2004)

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Going out with DaddyKC is infants right,
parents delight
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References

• Beachy JM. 2007. Investigating jaundice in the
  newborn. Neonatal Network 26(5), 327-333.
• Bhutani VK Johnson L. 2006. Kernicterus in
  late preterm infants cared for as term healthy
  infants. Semin Perinatology 30, 89-97.
• Hall RT, Simon S,Smith MT. 2000. Readmission of
  breastfed infants in the first 2 weeks of life.
  J. Perinatol 20, 432-437.
• Jain S Cheng J. 2006. Emergency department
  visits and rehospitalizations in late preterm
  infants. Clin Perinatol 33, 935-945.
• Jones G, Stekete RW, Black RE, Chutta ZA, Morris
  SS, Bellagio Child Survival Study Group. 2003.
  How many child deaths can we prevent this year?
  Lancet 362, 839-852.

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Bibliography Cont.

• Raju TNK, Higgins RD, Stark AR, Leveno K. 2006.
  Optimizing care and outcome for late preterm
  (near-term) infants a summary of the workshop
  sponsored by the National Institute of Child
  Health and Human Development. Pediatr 118,
  1207-1214.
• Shapiro-Mendoza C, Tomashek KM, Kotelchuck M. et
  al., 2006. Risk factors for neonatal morbidity
  and mortality among healthy later preterm
  newborns. Semin Perinatol, 30, 54-60.
• Tomashek KM, Shapiro-Mendoza CK, Weiss J et al.
  2006. Early discharge among later preterm and
  term newborns and risk of neonatal morbidity.
  Semin Perinatol 30, 61-68.

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Bibliography continued

• Wang ML, Dorer DJ, Fleming MP Catlin EA. 2004.
  Clinical outcomes of near term infants. Pediatr
  114, 372-376.
• Watchko JF. 2006. Hyperbilirubinemia and
  bilirubin toxicity in the late preterm infant.
  Clin Perinatol 33, 839-852.
• Kangaroo Care references are available on the
  annotated bibliography that is free and can be
  sent by email to you by asking for it from
  Susan.ludington_at_case.edu