4 the late preterm infant j.gute 9.2019 rj edits...2019/09/04 · 9/24/2019 1 the late preterm...

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The Late Preterm Infant: Care at 36 weeks vs 38 weeks

Prematurity Summit – September 26, 2019

Learning Objectives

• Learners will self-report an increase in knowledge about the risks associated with

birth at 36 weeks versus 38 weeks gestation and recommendations for providing comprehensive care.

• Learners will describe how they will integrate

the utilization of evidence-based practice to improve their processes for 36 week infants.

© 2016 Nebraska Methodist Health System. All rights reserved.All content provided herein is for educational, informational and guidance purposes only and is not intended to serve as a substitute for individualized professional medical advice, diagnosis, or treatment. Nothing contained

herein establishes or shall be used to establish a standard of care.

Late Preterm InfantsOverview and Prevalence

Defined as birth between 34 0/7 weeks and 36 6/7 weeks of gestation.

• Mortality Rate 3 times higher than those for term infants (37 to 41 weeks of gestation)

• Comprise more than 70% of all preterm births in the United States.

• Associated with adverse short-term and long-term outcomes.

• Present a unique challenge for health care providers both in community hospitals and tertiary care settings.

• Late preterm infants are at greater risk than their full-term counterparts for neonatal complications including respiratory distress, temperature instability, hypoglycemia, jaundice and hyperbilirubinemia, inadequate feeding and infection.

Late Preterm InfantsRisk Factors / Complications

• Respiratory

• Thermoregulation / Temperature Instability

• Hypoglycemia

• Sepsis

• Jaundice and Hyperbilirubinemia

• Feeding Challenges

• Neurodevelopmental Issues

• Short-term and long-term cognitive, behavioral and development problems

RESPIRATORY

• Pulmonary Disorders more common in Late Preterm Infants than Term

• Respiratory Distress Syndrome (RDS)

• Transient Tachypnea of the Newborn (TTN)

• Pneumonia

• Apnea of Prematurity

RESPIRATORY

• RDS• Most common respiratory morbidity in Late Preterm Infants.

• Results from a deficiency of pulmonary surfactant.

• TTN

• Incidence is 4% in Late Preterm Infants

• 2nd most common respiratory morbidity

• Results from lack of timely clearance of pulmonary fluid from

alveolar spaces

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RESPIRATORY

• Pneumonia

• Fetal infections as an underlying cause for preterm delivery

places them at risk for pneumonia

• Mechanical ventilation can injure the immature lung

increasing the risk for pulmonary infections

• Apnea of Prematurity

• The control of breathing and maturation of brainstem regions

are less mature in late preterm infants

• More susceptible to bradycardia due to less mature

parasympathetic nervous system

THERMOREGULATION

• Late preterm infants at high risk for hypothermia and cold stress due to:

• Insufficient brown fat for non-shivering thermogenesis

• Thin skin

• Large surface area compared to body weight

• Deficient subcutaneous fat

• Less ability to maintain flexion

• Underdeveloped temperature sensors for regulation

• More frequent delivery room interventions

THERMOREGULATION

• Hypothermia puts infant at risk for hypoglycemia

• Hypothermia also linked to deteriorating respiratory distress/hypoxia

HYPOGLYCEMIA

• Incidence in late preterm infants is threefold greater than in the term neonate• Reduced glycogen and adipose stores

• Inadequate enteral intake

• Increased energy demands due to other etiologies

• Hypothermia

• Sepsis

• Respiratory Distress

SEPSIS

• Decreased maternal antibody transfer• Typically not complete until term gestation is reached

• Reduced vernix

• Skin is less acidic

• Immature immune system

• What further complicates this is that s/s of problems common to the late preterm infant population are often the same as those found among infants with sepis.• Hypothermia

• Respiratory Distress

• Feeding Intolerance

JAUNDICE

HYPERBILIRUBINEMIA

• Late Preterm Infants are 2x more likely than term infants to

• Develop hyperbilirubinemia

• Have high bilirubin concentrations at 5-7 days of life

• Approximately 1 in 4 Late Preterm Infants will

require phototherapy

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JAUNDICE

HYPERBILIRUBINEMIA

• Delayed physiologic maturation leads to deficiency in the enzyme needed to metabolize bilirubin

• Immaturity of the liver

• Decreased GI motility, immature function

• Poor feeding / feeding difficulties can lead to gastric reabsorption

• Narrow range of safety with regard to bilirubin toxicity

• Shown to develop at an earlier postnatal age

• Kernicterus can result from high concentrations of

unconjugated bilirubin

FEEDING CHALLENGES

• Safe and efficient feeding is based on oral-motor competence, neurobehavioral organization and gastrointestinal maturity• Uncoordinated Suck-Swallow-Breathe pattern

• Sleepier and less stamina than full-term infants

• Breastfeeding

• Difficulty latching on to the mother’s breast

• Weak suction pressures with breastfeeding (unable to empty breast)

FEEDING CHALLENGES

• Consequences of inadequate intake:

• Hyperbilirubinemia

• Decreased weight gain

• Hypoglycemia

• Dehydration

• Hospital readmissions

• Potential to interfere with establishment of successful lactation

• Inadequate milk supply

• Most Late Preterm Infants unable to exclusively

breastfeed until term

NEURODEVELOPMENTAL

ISSUES

• Brain at 35 weeks gestation weighs only 2/3 of what it will weigh at 39 to 40 weeks gestation

• Potential for short-term and long-term cognitive, behavioral and development problems

• Behaviors for Late Preterm Infants are less clearly understood than those of full-term infants

• Infant may show unique behavioral cues

36 Week Work Group

• Project was started in the Fall of 2016

• At MWH, we have a process to review any Code Pink and newborn unplanned transfer to NICU cases. During one of these meetings, questions were asked about the current practice we had in place for our 36 week infants.

• At MWH all infants that are < 35 weeks gestation

automatically go to the NICU

• Around the same time, each service line within our health system was asked to work on an evidence-based practice project.

• The Iowa Model is the tool we utilize for implementation of

evidence – based practice.

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36 Week Work Group

• Focus: utilization of evidence-based practice to improve our process with 36 week (36.0 to 36.6)

infants to provide optimal care and potentially prevent some from being admitted to the NICU.

• Question – Do specific nursing care measures for inpatient 36 week gestation babies compared to current care measures impact patient outcomes?

36 Week Work Group

• The group is made up of the following individuals:

• Neonatolgist, NNP’s, NICU CNS, NICU SDN, OB CNS,SDN for L&D and OB/GYN, Staff RN’s from L&D, M/B and Gyn, Lactation Consultants, Service Leaders and Team Leaders for L&D/HROB, Postpartum/Newborn and Birthing Center

• Included staff members from MWH and MJE

36 Week Work Group

• First meeting was in September, 2016

• Monthly meetings

• Initial discussion was to review our data for the 36

week infant population:

• Data for 36 week infants who are transferred to NICU –trending with such things as temperature instability, feeding, respiratory status

• Data does not support having all of these babies automatically

go to the NICU even though they do have risk factors that need to be addressed

• See next 2 slides for 2015 & 2016 data comparison

36 Week Work Group

• Data for infants 36.0 to 36.5 weeks

• 2015

• 237 total unplanned transfer (36.0 weeks and above)

• 87/237 were 36.0 to 36.6 weeks (37%)• L&D – 34

• NBN – 53

• Tops Reasons for Transfer to NICU: Respiratory Distress, Hypoglycemia, Hypothermia,

Failed Car Seat Studies

• 2016

• 223 total unplanned transfer (36.0 weeks and above)

• 51/223 were 36.0 to 36.6 weeks (23%)• L&D – 107

• NBN – 116

• Top Reasons for Transfer to NICU: Respiratory Distress, Hypoglycemia, Failed Car Seat Studies

36 Week Work Group

• Further Discussion points with initial meetings included:

• Current workflow and practice with 36 week infants

• Areas of concern or where practice changes could potentially be made.

36 Week Work Group

• Input from Multidisciplinary Team Members• L&D RN’s

• Comfort level of staff with assessments regarding transition time period.

• Mother/Baby-GYN RN’s

• Acuity level – more time needed for assessments and cares

• Lactation Consultants

• Feedings – observe all of feeding or partial

• Supplementation and pumping

• Lactation Consultants seeing all of these patients – timing is key

• Providers

• Feeding Plans – inconsistency with providers

• Thermoregulation - Temperature stability, Skin to skin

• All Professions

• Education for parents – consistent teaching from staff, compliance

from parents/family, understanding of physiology as these babies look fine on the outside

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36 Week Work Group

Outside

• These infants appear to be “normal” on the outside

Inside• These infants are very

different on the inside

36 Week Work Group

• Current Protocols

• Numerous protocols in place to assess risk with infants and provide interventions as needed

Newborn Glucose Management

Newborn Bilirubin Management

36 Week Work Group

• Current Protocols• Numerous protocols in place to assess risk with

infants and provide interventions as needed

• Newborn Congenital Heart Disease Screening

• Car Safety Seat Study

© 2016 Nebraska Methodist Health System. All rights reserved.All content provided herein is for educational, informational and guidance purposes only and is not intended to

serve as a substitute for individualized professional medical advice, diagnosis, or treatment. Nothing contained


36 Week Work Group

• Even though we have decreased the number of 36 week infants born, decreased the

number of 36 week infants transferred to the NICU and have numerous protocols and practices in place to care for these infants…

What can we do better for this population of

infants?

36 Week Work Group

• Monthly meetings in 2017 focused on reviewing evidence-based literature to see if we can modify our process to better meet the needs of these infants

and decrease NICU admissions

• AWHONN developed an updated

evidence-based guidelines regarding this

patient population. • Assessment and Care of the Late Preterm Infant

• National Perinatal Association

• Multidisciplinary Guidelines for the Care of Late

Preterm Infants

36 Week Work Group

• 2018

• Monthly meetings continued as we worked on practice changes we wanted to

implement• Disposable Thermometers – Trial

• Glucose Gel – approved on formulary

• Use of the POC Glucose value for treatment and

follow-up instead of serum glucose

• Updates to provider orders, care plan and documentation

• Go Live: June 26, 2018

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36 Week Work Group

• Educational Plan for Staff

• Initial education to staff was in June, 2018

• Reviewed practice changes for 36 week infants

• Implementation of Glucose Gel

• Review of data we would monitor

• Additional education throughout the Fall of 2018 for glucose management changes

• Ongoing education

• Staffing

• Careful consideration of staffing ratios with Late Preterm Infants

Evidence-Based Practice (EBP) Approach to Management of 36 Week Population

• Respiratory

• Vital Signs every 3 hours

• Respiratory Assessment every 3 hours

• Work of breathing (retractions, nasal flaring, grunting and cyanosis)

• Respiratory Rate


• Thermal / Temperature Instability• Maintain room temperature at 72 degrees*

• At delivery and throughout duration of stay• Prior to vaginal delivery, room temperature is increased to 72

degrees

• Adjust room temperature in the postpartum room to 72 degrees

• Pre-warmed blanket and hat after delivery• Skin to skin as much as possible• Warm blanket on scale for weights *• Dress in t-shirt after weight and measurements *

• First bath at 12 hours and when stable*• Use of disposable thermometers*

Newborn Thermoregulation

Algorithm

EMR Changes EMR Changes

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• Glucose Management / Hypoglycemia

• AC POC Glucose every 3 hours for the first 24 hours

• Observe for signs & symptoms of hypoglycemia

• Follow Hypoglycemia Algorithm*

Evidence-Based Practice (EBP)Approach to Management of 36 Week Population

• Glucose Management / Hypoglycemia• For any POC glucose < 40 mg/dL

• Glucose Gel * will be given per Hypoglycemia Algorithm

• Supplement immediately with a minimum of 15 mL’s via bottle/gavage

• If a newborn does not take all 15 mL’s via bottle, the remaining volume is to be given through gavage

• For the remainder of the hospitalization and until the first Pediatric appointment, supplementation MUST BE GIVEN with a bottle after EVERY feed after 10 minutes at breast

Hypoglycemia Algorithm Glucose Gel

• Implemented with our 36 week practice changes.• Weight-based dose of 40% dextrose gel

rubbed into the buccal mucosa of a hypoglycemic newborn

• Benefits• No known side effects

• Non-invasive• Cheap

• Easy to administer• Compatible with exclusive breastfeeding• May decrease costly NICU admissions

• Always followed with a feeding

• May give up to 2 doses

Key Practice Changes

• Supplementation Volume Change• Minimum 15 mL donor breast milk, maternal

breast milk or formula when indicated

• Change in time for follow-up POC • 40 minutes after START of feeding

• Use of POC glucose for treatment and follow-up• Removed practice of waiting for Serum glucose

confirmation before treating.

• If newborn s/s do not match POC glucose value – RN can order Serum Glucose

New Power PlanHypoglycemia Algorithm

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• Sepsis

• Identify Maternal Risk Factors

• Rupture of Membranes > 18 hours

• Maternal Fever > 100.4°F

• GBS Positive

• Identify Neonatal Risk Factors

• Low Birth Weight

• Resuscitation needed at delivery

• Difficult Birth

• Obtain Temperature every 3 hours

• Watch for s/s of infection

• Good handwashing


• Jaundice and Hyperbilirubinemia

• Follow existing Newborn Bilirubin Protocol

• May require outpatient monitoring


• Feeding Challenges

• Feed within one hour of age

• Feed at least every 3 hours

• Limit attempts to 10 minutes if newborn had a low blood

sugar and supplement as directed in orders.

• Mom to pump after each breastfeed using hospital grade electric pump

• Pumping to be initiated within 2 hours after Vaginal

delivery and 4 hours after Cesarean delivery

• Daily weights with warm blanket on the scale

• Lactation Consultants to see within 24 hours of age


• Nurse to assess and document feeding cues every 3 hours

• Nurse to observe EVERY feeding EVERY 3 hours

• Supplementation

• Late Preterm Infants should not be fed by cup, finger or syringe as they need to prove they can take adequate volumes from breast or bottle/nipple prior to discharge

EMR Changes Evidence-Based Practice (EBP)Approach to

Management of 36 Week Population

• Neurodevelopmental Issues

• Provide uninterrupted periods of sleep

• Cluster the every 3 hour feedings and

cares as much as possible

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At Delivery…

• Along with the interventions just discussed, staff initiate the Late Preterm Infant Discharge

Sheet

• Education and communication tool to be used throughout hospital stay

• New Crib Card for 36 week infants

• Side with name and delivery information faces out

• Side with care reminders faces infant

Discharge Teaching Sheet

36 Week Crib Card Education for Parents

• Maintain appropriate environmental temperature

• Dress infant appropriately

• Use of thermometer

• Many late preterm infants will not exclusively breastfeed until 40-44 weeks corrected gestational age• Continue pumping after breastfeeding until infant is mature

enough to take all feedings from the breast

• Supine positioning

• Good handwashing

• Limit visitors

• Avoid crowds

Education for Parents

• Encourage no discharge prior to 48 hours

• Follow-up with newborn provider within 48 hours of discharge.

• Encourage this appointment to be made prior to discharge and include with discharge instructions.

• “Late Preterm (Near Term Baby) – What

Parents Need to Know” teaching sheet given to parents

Late Preterm Teaching Sheet

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EMR Changes New Power PlanNewborn Admission 36 to 36.6 Weeks Gestation

36 Week Nursing Care Plan

36 Week Nursing Care Plan 36 Week Discharge Checklist

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Data

• Data for Outcome Measurements• NNP’s monitor data on admissions to NICU

• Admission Diagnosis

• Clinical Data

• Temperature, Blood Sugar Value, Feeding

• Length of Stay

• Readmission Data – only to MWH NICU

• “Modifiable” Risk Factors were added to our data as a way to focus on those areas nursing could possibly impact with the interventions we put in place

• Hypoglycemia, Hypothermia, Poor PO Feeding, Temperature > 97.5 when admitted to NICU

Data

© 2016 Nebraska Methodist Health System. All rights reserved.All content provided herein is for educational, informational and guidance purposes only and is not intended to serve as a substitute for individualized professional medical advice, diagnosis, or treatment. Nothing contained


Data Opportunities

• Outcome Data / Readmissions

• Very hard data to track but information that is ideal to see possible impact we have on this population

• We did a 3 month trial where our Lactation Consultants asked about readmission in their follow-up phone call

• Around 24 hours post-discharge so too soon

• New suggestion is to see if there is any way we can ask this information at the 6 week postpartum check

Opportunities

• Feeding Management

• Looking at our process of watching every feeding for duration of the feeding

• Trial period where LC’s monitor all feedings, gather information see if we can look at doing anything different

• Huddle after 24 hours

• Review plan of care, feedings, etc.

• Can we change anything?

References

• Assessment and Care of the Late Preterm Infant: Evidence-Based Clinical Practice Guideline, 1st edition updated. (2014). Washington D.C.: AWHONN

• Bennet, C., Fagan, E., Chaharbakhshi, E., Zamfirova, I. and Flicker, J. (2016). Implementing a Protocol: Using Glucose Gel to Treat Neonatal Hypoglycemia. Nursing for Women’s Health, Feb/Mar, p. 64-74

• Briere, C.E., Lucas, R., McGrath, J.M., Lussier, M., & Brownell, E. (2015). Establishing Breastfeeding with the Late Preterm Infant in the NICU. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 44(1), 102-111

• Harris, D.L., Weston, P.J., Signal, M., Chase, J.G. and Harding, J.E. (2013). Dextrose gel for neonatal hypoglycaemia (the Sugar Babies Study): A randomized, double-blind,

placebo-controlled trial. The Lancet, 382, p. 2077-2083

• Harris, D.L., et. al. (2016). Outcome at 2 Years after Dextrose Gel Treatment for Neonatal

Hypoglycemia: Follow-Up of a Randomized Trial. The Journal of Pediatrics, 170, p. 54-59

• Jain, L. & Tonse, R. (2013). Moderate Preterm, Late Preterm and Early Term Births. Clinics in Perinatology 40(4). Philadelphia, Pennsylvania: Elsevier

• Multidisciplinary Guidelines for the Care of Late Preterm Infants. (2013). National Perinatal Association

• Phillips, R.M., Goldstein, M., Hougland, K., Nandyal, R., Pizzica, A., Santa-Donato, A., etal. (2013). Practice Guidelines: Multidisciplinary guidelines for the care of late preterm infants.

Journal of Perinatology, 33, S5-S22

© 2016 Nebraska Methodist Health System. All rights reserved.All content provided herein is for educational, informational and guidance purposes only and is not intended to

serve as a substitute for individualized professional medical advice, diagnosis, or treatment. Nothing contained


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