1 / 59

Optimizing Health for the Late Preterm Infant

Optimizing Health for the Late Preterm Infant. The AWHONN Initiative Presented by: Bette T. Johnson, CRNP St. Charles Medical Center Bend, OR. Objectives. Discuss the definition, incidence and contributing factors of late preterm birth

nardo
Télécharger la présentation

Optimizing Health for the Late Preterm Infant

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Optimizing Health for the Late Preterm Infant The AWHONN Initiative Presented by: Bette T. Johnson, CRNP St. Charles Medical Center Bend, OR

  2. Objectives • Discuss the definition, incidence and contributing factors of late preterm birth • Identify the mortality and morbidity issues associated with late preterm birth • Describe AWHONN’s Late Preterm Infant Inititatives • Discuss risks for and etiology of respiratory distress in the late preterm newborn • Describe the clinical presentation, diagnostic evaluation and management of transient tachypnea versus respiratory distress

  3. Objectives • Indentify methods of heat loss and gain • Recognize symptoms of hypo/hyperthermia • Describe the increased risk for, evaluation and management of hyperbilirubinemia • Understand how immaturity increases the risk of hypoglycemia and feeding difficulties • Articulate and nursing care plan for parent education

  4. Definition of the Late Preterm Infant • Infants born between 34 and 36 completed weeks of gestation • Terminology changed in literature 2006 • Late preterm is synonymous with near-term

  5. Scope and Significance of Late Preterm Issues • Incidence Increasing incidence of late preterm births Late preterm infants makeup > 70% of all births • Morbidity: full risk not clear • Mortality: some explained by medical reasons for early delivery

  6. Importance of the Third Trimester • Vital period of maturation Lung development Brain maturation Liver maturation • Vital period of growth Body mass increases Fat stores increase

  7. Late Preterm Complications • Respiratory Distress • Temperature instability • Hyperbilirubinemia • Feeding challenges

  8. AWHONN’s Late Preterm Infant Initiative • Raise awareness of unique needs of late preterm infants • Emphasize need for research • Encourage development and adoption of evidence-based guidelines for late preterm care • Provide resources for systematic clinical assessment and parent education • Foster collaboration among other health care providers

  9. Physiological Functional Status The late preterm infant’s physiologic and functional well-being is influenced by many factors: • Postmenstrual age • Maternal and fetal health and history • Timing and method of birth • Transition to extrauterine life • Location and quality of care provided

  10. Contributing Factors • Advanced Maternal Age • Birth rate for women >35 has been rising while rates for women between 20-24 have declined • Increased incidence of pregnancy induced hypertension and subsequent IUGR • AMA associated with chromosomal abnormalities, gestational disorders, chronic health disorders, the use of assisted reproductive technologies (ART), multiple births and c-sections

  11. Contributing Factors Assisted Reproductive Techniques (ART) • Associated with delayed childbearing and AMA and increased numbers of multiple births • 2004 CDC reported 128,000 ART procedures resulting in 50,000 infants – 50% were multiples. Increasing risk of preterm deliveries

  12. Contributing Factors Multiple births • 2003- 67% increase in twins and 500% in triplets and other higher-order multiples since 1980. • Average age of twins is 35.3 weeks, triplets 32.2 weeks. • Complications that may cause late preterm birth- gestational diabetes, preeclampsia, abruptio placenta, maternal hemorrhage

  13. Contributing Factors C-Section • 2004 US Vital Statistics showed that c-section rates rose to 29 % Preterm Premature Rupture of Membranes • PPROM is responsible for 1/3 of all preterm deliveries. High association with intrauterine infections. Other known causes- smoking, STD’s, prior cervical surgery, abnormal placentas

  14. Contributing Factors Human Papillomavirus (HPV) • Most common STD in US • Associated with high incidence of cervical cancer • Surgical treatment is cone biopsy which removes portion of cervix • Cryosurgery and LEEP (loop electrosurgical excision procedure • Treatments may increase risk of preterm deliveries

  15. Contributing Factors Stillbirth Prevention and Medical Legal Concerns • Stillbirth rate has dropped from 14% in 1970 to 6.7/1,000 births in 1998. • Advances in OB care and fetal monitoring detect problems early and allows for early delivery when indicated

  16. Assessment of Risk Factors • Respiratory Distress • Temperature instability • Hyperbilirubinemia • Feeding issues

  17. Respiratory Distress Incidence: • 35-36 week infants: 28.9% respiratory distress at birth compared to 4.2% of term infants • 35-36 week ventilated infants: 62% with RDS

  18. Respiratory Distress in the Late Preterm Infant • Distinguish difficult transition to extra-uterine life from significant respiratory distress • Differential diagnosis TTN RDS Sepsis PPHN Congenital anomalies

  19. Transient Tachypnea of the Newborn • TTN occurs due to delayed re-absorption of lung fluid • Onset: 2-6 hours of life • Risk Factors – c/s without labor, precipitous delivery, polyhydramnios • Clinical presentation – tachypnea 80-120 bpm, grunting, flaring and retractions

  20. Transient Tachypnea • Diagnostic studies Blood gases- mild, mixed acidosis Chest xray – peri-hilar streaking, fluid, over-inflated CBC, blood culture – r/o sepsis screen • Management Supportive care- oxygen, NPO, IV’s, antibiotics • Outcome: usually self-limiting

  21. Respiratory Distress: Risk Factors • Elective C-section without labor • Maternal complications • Gestational diabetes, hypertension • Placental abnormalities • Premature rupture of membranes

  22. Respiratory Distress: Risk Factors • Fetal Factors • Male sex • Prematurity • Intrauterine growth retardation • Fetal distress

  23. Respiratory Distress Syndrome • RDS occurs due to a deficiency in amount of surfactant • Onset: within minutes to hours of birth • Risk Factors for RDS: late preterm birth, male, IDM, pre/natal or perinatal stress, traumatic delivery

  24. RDS: Clinical Presentation • Tachypnea up to 120 bpm • Grunting, flaring and retractions • Pallor or cyanosis with increasing hypoxemia • Decreased breath sounds/fine rales • Hypotension, decreased perfusion, tachycardia

  25. RDS Diagnosis • Arterial blood gases PaO2 < 50-60 mm Hg with FiO2 > 60% Severe Hypercapnia (PaCo2 > 55-65 mm Hg with pH < 7.20-7.25) • Chest xray: characteristic granular pattern with air bronchograms • Rule out sepsis

  26. RDS: Management • Lung expansion NCPAP, mechanical ventilation if needed • Neutral thermal environment • Oxygen • Surfactant replacement therapy • 100mg/kg in 2-4 aliquots per the ETT as early as possible q 6-12 hours for 2 – 3 doses

  27. RDS: Management • Fluid restriction – NPO • Monitor serum electrolytes • Minimal stimulation • Blood pressure support • Alkali therapy

  28. RDS: Outcome • Morbidity and mortality of RDS directly related to birth weight and gestational age • Affected by prenatal glucocorticoid treatment and surfactant replacement

  29. RDS: Parent Education • Signs of re-occurring respiratory distress • When to notify pediatrician • Late preterm infants are at increased risk for infection – good infection control hygiene measures • All infants should be placed on their backs to sleep

  30. Thermoregulation • Controlled by the hypothalamus • Cold stress • Heat stress

  31. Non-Shivering Thermogenesis • Cold stress stimulates the hypothalamus to release epinephrine at the site of brown fat • Major function: heat production • Axilla, nape of neck, between scapulas • Stores continue to increase 3-5 weeks postnatal life – most laid down after 35 wks • Free fatty acids + thermogenin = heat • Requires oxygen and glucose

  32. Heat Transfer Mechanisms:Conduction • Heat transfer by direct contact • Varies with exposed surface area • Late preterm infant may not be able to change position • Decreased subcutaneous fat for insulation • Superficial blood vessels constrict • Measures to minimize heat loss

  33. Heat Transfer Mechanisms: Convection • Air currents remove the baby’s boundary layer of warm air, moving heat away from the body • Ambient temperature, air flow velocity, relative humidity, cool oxygen during resuscitation • Measures to minimize heat loss

  34. Heat Transfer Mechanisms:Evaporation • Liquid is converted into a vapor • Water losses through skin and respiratory system • Major source of heat loss at delivery/bathing • Dependent upon air speed and relative humidity • Measures to minimize heat loss

  35. Heat Transfer Mechanisms:Radiation • Transfer of radiant energy from the body to objects without direct contact • Radiant warmer • “Greenhouse effect”- overheating • Measures to minimize heat loss

  36. Transition to Extrauterine LifeThermal Stability • At birth: wet baby placed in cold/dry environment. Rapidly cooling occurs by convection and evaporation • Increased activity, vasoconstriction, non-shivering thermogenesis – increased energy use • Increased metabolic rate • Possible difficulty in maintaining temp

  37. Monitoring Body Temp • Axillary temp every 1-4 hours • Term: 97.9-99.5 F (36.5 – 37.5 C) • Preterm: 97.5-98.5 F (36.3-36.9 C) • Skin Temp • Term: 96.8-97.7 F (36-36.5 C) • Preterm: 97.2-99 F (36.2-37.2 C) • Rectal and tympanic temperatures not recommended

  38. Warmer Overview Radiant Warmers: • Skin servo-controlled • Quickly and safely re-warms infant • Allows direct patient access • Does not insulate baby from noise, light and other noxious stimuli Incubators • Skin or air servo-controlled • Advantage in weaning to crib • Temperature fluctuations with portholes • Limited access to patient

  39. Skin-to-Skin Care • Placed against parent’s skin clothed with diaper and covering blanket • Can be close to breast for feeding • Vital signs and oxygenation more stable • Improved sleeping patterns and direct social eye contact

  40. Hypothermia: Clinical Presentation • Pale, cool to touch • Acrocyanosis • Respiratory distress • Apnea, bradycardia, central cyanosis • Irritability progressing to lethargy • Progressive or chronic cold stress

  41. Temperature Instability:Lab Data • Arterial blood gas • CBC with diff • Blood glucose • Electrolytes • BUN • Serum and urine osmo

  42. Hypothermia: Treatment • Re-warm carefully by providing external heat • Prevent further heat loss • Frequent evaluation of temp • Potential complications- metabolic acidosis, respiratory distress, hypoglycemia, hyperbilirubinemia

  43. Hyperthermia: Clinical Presentation • Warm to touch; appears very pink or red • Sweating not present until 36 weeks • Tachypnea and apnea • Tachycardia, weak cry, hypotonic, irritable/lethargic, poor feeding

  44. Hyperthermia: Treatment • Remove external heat source • Check for iatrogenic cause: • Servo probe off; excessive bundling • Direct sunlight, heater, phototherapy units Non-enviornmental causes – dehydration, CNS abnormalities, sepsis Complications: increased insensible water loss, dehydration, hypotension, apnea

  45. Thermoregulation: Parent Education • Explain normal range of temperatures • Show/tell how to obtain axillary temp • Describe home environment and clothing suitable for baby • Provide written instructions for when to call physicians

  46. Hyperbilirubinemia and the Late Preterm Infant • More at risk for significant hyperbili • 25% need phototherapy • Immature liver • Higher bilirubin levels and later peaks • Less vigorous feeding leads to decreased oral intake

  47. Hyperbilirubinemia:Overproduction and Decreased Excretion • Prematurity • Bacterial sepsis • Urinary tract infection • Intrauterine viral infections • Hypopituitarism • Hypothyroidism

  48. Breastfeeding and Jaundice • Rates of breastfeeding increased from 33% in 70’s to ~50-60% today • Length of routine hospital stay is 48 hours • Inadequate lactation associated with increased bilirubin levels • Late preterm infant at risk for feeding problems • Lactation support valuable

  49. Hyperbilirubinemia: Parent Education • Give information on causes and treatment • Stress importance of adequate and frequent feeds • Signs and symptoms of hyperbili • When to call Pediatrician

  50. Feeding Issues • Risk of inadequate intake • Hypoglycemia • Increased incidence of hyperbili • Increased weight loss in first days/weeks of life • Readmission to hospital

More Related