The late preterm infant - care and management

The late preterm infant is at increased risk of the following:

1. Hypoglycaemia:
   • higher metabolic rate
   • limited brown fat stores
   • low glycogen stores
   • temperature instability
   • ineffective feeding due to weak suck and/or fatigue
2. Hypothermia:
   • decreased brown fat for thermogenesis and white fat for insulation
   • increased heat loss due to higher surface-area-to-mass-ratio
3. Respiratory distress and/or apnoea:
   • immature lung development
   • decreased surfactant
   • immature breathing control
   • reduced clearance of lung fluid
   • decreased airway muscle tone
4. Sepsis:
   • immaturity of the immune system
   • precipitating factors of preterm birth - eg: chorioamnionitis, pre-labour rupture of membranes
   • GBS positive
   • exposure to nosocomial pathogens
   • invasive procedures
   • potential delay in initiation and establishment of breastfeeding
5. Hyperbilirubinemia:
   • slower passage of meconium
   • decreased bilirubin-conjugating glucuronyl transferase
   • poor arousal and immature suck reflex leading to ineffective feeding and increased risk of dehydration and jaundice
   • peak serum bilirubin at 5-7 days rather than 2-3 days
   • higher incidence of kernicterus up to 10-fold increase in risk for re-hospitalisation for phototherapy
6. Feeding difficulties:
   • immature suck/swallow/breathing co-ordination
   • low oromotor tone, central nervous system (CNS) immaturity, limited brown fat stores, poor regulation of state behaviour and excessive sleepiness contribute to feeding issues
   • separation from mother affecting milk supply and establishment of breastfeeding
7. Poor weight gain:
   • Poor suck feeding
   • use of supplementation (formula, fortification, vitamins) may be medically indicated
8. Psychosocial issues:
   • higher incidence of breast feeding problems in mothers of late preterm infants due to separation and associated maternal morbidity (eg diabetes, pre-eclampsia)
   • maternal anxiety and fatigue
   • medicalised and stressful environment of the neonatal unit

• A Paediatrician / Registrar or Clinician with experience in neonatal resuscitation should be in attendance if the gestation is 34.0 - 36.6 weeks or the baby is expected to have a birth weight < 2.5 kg.
• Provide immediate skin-to-skin contact with mother, dry infant on mother's chest, remove wet wrap, cover infant with dry warm wraps and cover head with a woollen hat.
• If no respiratory distress, attempt feeding within the first hour of life, and subsequently feed 3 hourly. The baby should be transferred to the SCN for closer observation if there are signs of respiratory distress, concerns regarding temperature control, vital signs, colour or tone.
• Perform weight and blood glucose level (BGL) prior to leaving birthing suite (within 2-4 hours of birth) or BGL earlier if clinical signs of hypoglycaemia.
• Determine if small for gestational age, appropriate for gestational age, or large for gestational age.
• Hourly axillary temperatures and vital signs should be performed for 4 hours from birth.
• Identify maternal or fetal risk factors that may impact on the infant's ability to transition to extrauterine life, and /or impact on the ability for these babies to be managed on the post-natal ward

Vital signs

• The baby should have temperature, heart rate and respiratory rate /effort performed following admission to the ward and then prior to feeds for at least 24 hours
• Assessment of level of activity and colour should be documented with vital signs.

Normal vital sign parameters will be within the white zone on the ViCTOR Newborn charts.

• Any abnormal vital signs should be reported to the Paediatric team for medical review.
• Temperature checks should continue before each feed.
• If the baby is nursed on a warming mattress (eg KanMed or CosyTherm) to maintain normal body temperature, then temperature checks need to continue for the duration of its use and throughout the weaning process.

Blood glucose levels

• Manage BGL monitoring according to postnatal-ward-management-of-infants-at-risk-of-hypoglycaemia (PNW).
• Blood glucose should be performed at 2 hours of age (or earlier if clinical signs of hypoglycaemia) and before each feed until three consecutive measurements are >/= 2.6 mmol/.

If at any time the BGL is < 2.6 mmol/L the baby requires a medical review.

Weighing of baby

• The baby should be weighed as soon as practical after birth.
• The baby should be weighed regularly according to local policy, at least second daily.
• A weight loss of greater than 10% requires a medical review and feeding plan instigated.
• After day 3 it expected that the baby will gain at least 10g/kg/day.
• Babies of 34 - 35.6 week's gestation at birth should not be discharged until they have regained their birth weight.
• Babies 36 - 36.6 week's gestation at birth should not be discharged unless they are gaining weight and heading back towards their birth weight.
• More mature babies (weighing < 2.5 kg) should not be discharged until they are approaching birth weight.
• Consider the need for fortification or supplementation of breast milk or formula if infant is not meeting targeted weight gains.
• Involve a multi-disciplinary team of lactation consultants, dietician or speech pathologist as necessary.

• The newborn baby may require an extra blanket or cardigan to stay warm (on top of a singlet, nappy, jump suit, blanket).
• Avoid positioning cot near draughts or windows.
• The baby should only have their first bath once their observations and blood glucose levels are normal.
• If the baby's temperature remains </= 36.0o Celsius despite warming the baby (eg radiant heater), they should have a medical review and be admitted to SCN.
• Staff need to be aware that temperature instability may be a sign of sepsis and should be reported to the medical team for further investigation.

• Breastfeeding is recommended and should be supported and encouraged.
• Breastfed babies should not be offered complementary feeds unless frequent (at least 3 hourly) breastfeeding is associated with:
  • a BGL < 2.6 mmol/L or
  • there is significant weight loss (>10% birth weight) or
  • poor weight gain despite frequent breastfeeding.
• The baby should be fed as soon as stable within the first hour after birth and 3 hourly until they have regained their birth weight.
• Babies who are feeding poorly, not interested or not attaching/sucking well should remain in the SCN as gavage (oral or nasogastric) feeds may be required. The mother should be assisted and encouraged to express breastmilk frequently to aid lactation.
• If mother is choosing to formula feed baby, then refer to Formula feeding guideline for volume and frequency of feeds.

Provide ongoing support and education for parents on the following:

• maintaining normal temperature
• breast feeding or bottle feeding, including a written feeding plan
• wet/dirty nappies
• bathing
• weight gain
• SUDI and safe sleeping recommendations.

Upon discharge, the mother will be required to have had education on:

• assessing infant's general health and condition (including taking the infant's temperature)
• identifying signs of common health problems and strategies to manage these
• recognising when to contact health care professionals or emergency services.

The baby may be discharged home when the following criteria are met:

• baby is medically stable, assessed by Paediatrician
• most often ≥ 36 weeks corrected age
• has had adequate weight gains and approaching birthweight
• feeding well at the breast and / or bottle or cup
• sucking all feeds for 48 hours
• temperature maintained for 48 hours
• age appropriate urine and stool output
• parent(s) are agreeable to taking the baby home and able to manage daily care
• domiciliary visiting available by experienced midwives; Maternal Child Health Service referral attended (consider need for Enhanced home visiting or Post-Acute Care referral)
• parents are supported and encouraged to contact the hospital if they have any concerns following discharge
• arrangements are made for Paediatric follow up.

Management of the Well Near Term &/or 2.0-2.5 kg Infant (Southern Health) 2010.

Darcy AE. Complications of the Late Preterm Infant. J Perinat Neonat Nurs 2009;23:78-86.

Wight NE. Breastfeeding the borderline (near term) preterm infant. Pediatr Ann 2003;329-36.

Care of the well late preterm and/or 2.0 - 2.5kg baby on the postnatal ward (Monash Health) 2014.

Multidisciplinary Guidelines for the Care of Late Preterm Infants (National Perinatal Association) 2012.

Barfield, W.D., Lee, K.G. (2016) Late Preterm Infants.

WHO: Born Too Soon: The Global Action Report on Preterm Birth.

Escobar, G.J.., Clark, R.H., Greene, J.D. (2006) Short-term outcomes of infants born at 35 and 36 weeks gestation: we need to ask more questions. Elsevier Seminars In Perinatology.

Lipsey, T.L., Ouzounian, J.G., Barton, L., Ingles, S., Mullin, P.M., Lee, R.H (2015) The prevalence of neonatal morbidities associated with late-preterm birth. Journal of Neonatal Nursing 22, 16-20.

ABM Clinical Protocol #10: Breastfeeding the late preterm infant (34.0 to 36.6 weeks gestation) 2011.