Pediatric Primary Care Case Studies (131 page)

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Chapter 33

The Late-Preterm Baby Beginning Well-Child Care

Lori J. Silao

Late-preterm infants present a unique situation for the healthcare provider because these infants have higher morbidity and mortality rates than term infants. Thus, they need additional surveillance during their early health supervision visits. The healthcare provider needs to focus on both the infant’s gestational age and potential associated problems when examining such patients. In addition, the family must be educated about the need to watch for worrisome signs and symptoms of illness or failure to thrive. Potential problems must first be addressed with parents when their baby is discharged home from the hospital and then continue to be addressed at subsequent health supervision visits.

Educational Objectives

1.   Identify potential risk factors and apply management guidelines for the late-preterm infant.

2.   Consider the age of the infant’s primary caregivers and the impact of their maturity on the management plan developed.

3.   Address cultural and socioeconomic factors that may affect the management plan and adherence with the identified plan of care.

4.   Identify any infant health problems that may require further evaluation, and make appropriate referrals.

   Case Presentation and Discussion

Sandra Jones is a 17-year-old white female who presents to your clinic with her newborn infant boy, Bobby, born at 35 and 4/7 weeks gestation. Sandra and her infant are accompanied by the baby’s father who is also 17 years old and in his senior year of high school. They are here for the baby’s first visit since being discharged from the hospital 2 days ago. Sandra is concerned that her son does not seem to be eating well and sleeps all the time. Initially, you need to attend to the facts that this is a late preterm infant being cared for by teen parents.

The Late-Preterm Infant

A late-preterm infant is defined as a baby born between 34 and 36 and 6/7 weeks gestation (Engle, Tomashek, & Wallman, 2007). It is known that infants generally gain approximately ½ pound per week during the last 6 weeks of gestation, so an infant born even slightly premature may be at risk for a lower birth weight. Although some late-preterm infants may weigh as much as a term infant, the late-preterm infant is still premature and arrives with his or her own set of potential health risks. Traditionally there have been few studies in this population (Engle et al., 2007). However, because of the increased number of late-preterm births in recent years and the associated problems these infants experience due to their immature physiologic and metabolic systems, there has been a recent increase in the number of research studies focusing on this cohort of infants. Noteworthy, some interesting early data are beginning to surface regarding in-utero development and postnatal adaptation in this population (Wang, Dorer, Fleming, & Catlin, 2004). Most of the research data point to certain disease processes that seem to be prevalent or place such infants at increased risk for potentially life-threatening situations. Thus, the late-preterm infant must be closely monitored with careful follow-up by the healthcare provider. The most common problems facing this group of infants are discussed in this case study.

Lung Function

Because of the potential for immature pulmonary functioning, the lack of fully mature alveoli units, possible surfactant insufficiency, and delayed intrapul-monary fluid absorption, the late-preterm infant may need oxygen, positive pressure ventilation, and possibly surfactant therapy. Keep in mind that even if a late-preterm infant does not require pulmonary assistance after birth, he or she is still at risk for problems such as apnea that are associated with a potentially immature neurologic system. There are very few studies about apnea in this population, but one of the classic studies in this age population suggests that the incidence of apnea in a late-preterm infant is small, reported at 4–7%, compared to 1–2% for a term infant (Ramanathan et al., 2001). Nevertheless, this can be a life-threatening occurrence.

Sepsis

All infants are at risk for sepsis; however, the more preterm the infant is, the higher the risk factor due to the greater immaturity of their immune system. The late preterm infant is most at risk for group B streptococcal (GBS) sepsis; current American Academy of Pediatrics (AAP) recommendations include screening for GBS and sepsis, as well as monitoring the infant in the hospital for 48 hours after birth (AAP, 2004b; Engle et al., 2007).

Hyperbilirubinemia

Jaundice and hyperbilirubinemia occur more commonly in late-preterm infants than in term infants. This is due to a number of factors including the immaturity
of the liver in which there are lower levels of the necessary enzymes to synthesize bilirubin, immature gastrointestinal function, and potential feeding difficulties that predispose infants to dehydration, decreased stooling, and subsequent hyperbilirubinemia. The two basic mechanisms that lead to unconjugated hyperbilirubinemia are increased bilirubin production and decreased bilirubin clearance (such as decreased hepatic clearance or increased enterohepatic circulation; Moerschel, Cianciaruso, & Tracy, 2008). Studies investigating the rates of and reasons for readmission to hospitals for the late-preterm infant note that the most common cause of readmissions in this population was hyperbilirubinemia (Engle et al., 2007).

Temperature Regulation and Metabolic Function

Late-preterm infants, like all premature infants, have less body fat present to maintain thermoregulation. Brown-fat accumulation is crucial in the last trimester of pregnancy, and peaks at term. Therefore, the preterm infant does not have this protective insulation and loses heat more rapidly than a term infant does. Cold stress may also lead to hypoglycemia. When combined with the fact that all infants have insufficient metabolic response time when the maternal glucose supply is abruptly cut off, hypoglycemia may be a more persistent problem in the late-preterm infant as opposed to the term infant, who quickly develops the necessary enzymes to combat hypoglycemia.

Immature Gastrointestinal Function and Feeding Problems

As stated previously, the late-preterm infant is at greater risk for gastrointestinal problems than the term infant due to the greater immaturity of his or her gastrointestinal system and slow production of certain enzymes necessary for digestion. In addition, these infants tend to have longer sleep cycles than term infants and must be awakened frequently to eat. They also may not be able to consume the same volume as a term infant, so smaller more frequent feedings become necessary to maintain weight gain and growth and minimize hyperbilirubinemia. These infants may also have issues in coordinating sucking and swallowing that can lead to a delay in successful breastfeeding (Raju, Higgins, Stark, & Leveno, 2006).

Epidemiology

Approximately 13% of all births in the United States result in preterm (less than 37 weeks gestation) deliveries (Davidoff et al., 2006). Interestingly, studies have shown that almost two thirds of all preterm births from the years 1992–2002 were judged to be late-preterm births (Davidoff et al.). Research studies demonstrate that the rise in late-preterm births correlates with the rise in births to women over age 30, the rise in induction rates, multiple births, and the rise in primary and repeat cesarean deliveries (Raju et al., 2006; Trofatter, 2006). Furthermore, various ethnic and sociodemographic subgroups in the United States differ in their rates of premature birth, a factor that is currently
being investigated to examine the underlying variables. Factors such as low socioeconomic status, maternal age less than 18 years or advanced maternal age, lack of access to health care, and poor nutritional status all increase the risk of preterm delivery (Polin & Spitzer, 2001).

As reported by Chen and colleagues (2007) in the
International Journal of Epidemiology
, the number of teenage pregnancies in the United States had decreased over 10 years. However, this decline was short lived, with the birth rate for teenagers 15 to 19 rising from 40.5 to 41.9, and then to 42.5 births per 1,000 based on data collected in 2005, 2006, and 2007 respectively (Hamilton, Martin, & Ventura, 2009). Teenage pregnancy continues to be a major social, economical, and healthcare concern in the United States (Chen et al., 2007). Chen and colleagues reviewed multiple studies on teenage pregnancy, and one of the consistently identified adverse outcomes of teenage pregnancy was the increased risk for preterm birth.

In summary, the most common neonatal issues that arise include hyper-bilirubinemia, feeding issues, temperature instability, thermoregulation, potential breathing problems, and neonatal sepsis. Thus, prior to the infant’s discharge from the hospital, the healthcare provider must be assured that each of these areas of risk is no longer a threat to the infant and that the infant is stable enough to be discharged home. Furthermore, prior to the infant’s discharge home, the infant’s mother needs careful instructions about feeding and sleep issues, knowledge of signs and symptoms of illness indicating a need to immediately seek care, as well as the date of the first health supervision visit. Close follow-up during the subsequent weeks and the next few months is often necessary so the infant can be carefully evaluated for appropriate growth and development and a healthy progression from the newborn stage to that of the young infant. In addition, if the mother is a teen, her developmental level also needs to be factored into the care plan.

How will you begin your data collection with the information you have just learned?

You introduce yourself to Sandra and José, the dad, and ask them how they would like to be addressed (e.g., Sandra and José). You begin by responding that you realize that the first few days and weeks home with a preterm infant are a challenging time for parents and go over the goals for today’s visits. You explain that the information you are collecting will provide you with an overview of how things progressed from pregnancy to today’s visit. You start by asking Sandra to tell you about how she, the baby, and dad are doing.

Sandra looks tired and says that having the baby early was very scary for her, and motherhood is much more challenging than she thought it would be. She starts to cry and says she is concerned that her son does not seem to be eating as well as he did in the hospital and that he sleeps all the time. You acknowledge her feelings and notice that the father has put his arm around her shoulders as she hugs the baby. Sandra quickly replies, “I’m OK now, I was just upset because I had trouble filling out these forms. We
need you to help me and José do them right.” She hands you the pregnancy, labor and birth history, and family medical history forms that she completed while waiting to be seen. You decide to go over the forms first to give you some time to dialogue with Sandra and José and to relieve her stress about completing the forms correctly. You will address her obvious stress and emotional needs later during the visit.

What questions will you ask Sandra regarding the pregnancy, labor and delivery, and birth history?