Table
From: Multidisciplinary guidelines for the care of late preterm infants
HEALTHCARE TEAM | FAMILY EDUCATION* | |
|---|---|---|
STABILITY | ||
Respiratory Distress References: 87 | • Assess infant for current signs of respiratory distress. • Ask parents if infant has had any history of apnea, cyanosis, or respiratory distress. | • Reinforce LPI’s increased risk for apnea and respiratory instability, especially when in car seat and upright devices. |
Sepsis References: 88 | • Assess infant for current signs of sepsis. • Ask parents about any recent symptoms of sepsis. • Ask parents if the infant’s care givers or any of the care givers’ family members have signs of illness. | • Reinforce LPI’s increased risk for sepsis and re-hospitalization. • Review ways to reduce illness: » Wash hands, limit visitors, avoid crowds, protect against contact with sick people. » Breastfeed for as long as possible during the first year after birth or longer. • Review signs and symptoms of sepsis: » Difficulty in breathing or feeding, increased or decreased temperature, decreased energy level. • Review how to take infant’s temperature. • If temperature >100.4°F (38°C), take infant to primary care provider. |
• Assess weight 1–2 days after hospital transition/discharge using appropriate preterm growth curves and compare with infant’s transition/discharge weight. In addition to weight loss, take into account the number of wet diapers and stools when evaluating adequacy of intake (3 voids and 3 stools by day 3, 4 voids and 4 stools by day 4, 6 voids and 4 stools by day 6 and thereafter). • Evaluate feeding practices if weight loss greater than appropriate for age. » Ask mother about any pain with breastfeeding. » Do oral exam and check for abnormalities, such as ankyloglossia, cleft palate, or thrush. » Observe infant feeding (breast or bottle). » Modify feeding and supplementation appropriately. » If unable to observe infant feeding, immediately refer mother to lactation consultant or feeding specialist. » Make appointment for repeat infant weight check. | • Reinforce LPI’s increased risk for excessive weight loss. • Review normal weight-loss parameters: » No more than 3% per day or total of 10% loss. » Regained by 14 days after birth. • Review and validate understanding of feeding plan. » Explain need for supplementation of breastmilk if infant has excessive weight loss. » Explain need to prevent infant dehydration by ensuring infant has adequate fluid intake. • Stress importance of follow-up for weight check: » Date, time, and location of follow-up appointment | |
Feeding References: 23 | • Determine family understanding of post-discharge feeding plan and assess adherence to plan (including iron and Vitamin D supplementation). • Assess current feeding practices, including type of milk, length of time feeding, amount taken (if formula fed). • Assess urine output, stool color, and frequency and symptoms of gastroesophageal reflux disease (GERD), colic, or oral aversion. • Modify feeding and supplementation plan if indicated. » Encourage pumping and supplementing with expressed breastmilk if supplementation is needed for breastfed infants. » Provide prescription for breast pump, if indicated. » Supplement with formula only as last resort. • Encourage and support breastfeeding. » Congratulate mother about choosing to breastfeed. » Ask about pain with breastfeeding or any other concerns. » Observe breastfeeding if concerns or pain are described by mother (evaluate for ankyloglossia). » Make immediate referral to lactation consultant if needed. | • Reinforce LPI’s increased risk for failure to thrive and re-hospitalization: » Immature feeding skills. » Ineffective sucking/swallowing. » Uncoordinated suck/swallow/breathe; may not be noticed until after increase in breastmilk supply. » Longer sleep cycles, may need to wake for feedings. • Review normal feeding frequencies: » 10–12 times/day for breastfeeding infants. » 8–10 times/day for formula-fed infants. • Review normal urine output and stool frequency and color as indicators of adequate feeding intake (and lack of normal urine/stool as signs of dehydration): » At least 6 wet diapers/24 h by day 5 after birth. » At least 1 yellow seedy stool daily by day 4 after birth. • Review benefits of breastfeeding/breastmilk for all infants and their mothers. • Provide contact information for lactation specialist and community breastfeeding support. |
• Assess infant for jaundice 1–2 days after transition/discharge. • Assess for any feeding difficulties or dehydration, especially if infant is breastfeeding exclusively. • Follow-up maternal and infant blood type and Direct Coombs tests if available. • Review 24-h bilirubin level and repeated evaluation done prior to transition/discharge. • If concerned about elevated bilirubin, obtain Total Serum Bilirubin (TSB) or Transcutaneous Bilirubin (TcB) level (visual assessment is not reliable). • Arrange for repeat bilirubin check, home phototherapy with follow-up, or hospital admission, as indicated. | • Reinforce LPI’s increased risk for jaundice requiring hospitalization and/or phototherapy. » Stress increased risk for kernicterus • Review delayed peak in bilirubin levels for LPIs (at days 5–7 after birth) and possible need for additional testing to coincide with this peak. • Review signs and symptoms of worsening hyperbilirubinemia: » Deepening yellow skin and eye color (visual assessment alone is not reliable). » Sleepiness and lethargy. » Decreased feeding. » Increased irritability with high-pitched cry. • Stress critical importance of follow-up with primary care provider if infant has signs or symptoms of worsening jaundice. • Explain that breastfed infants are at higher risk for jaundice and need close monitoring of feedings to reduce risk of hyperbilirubinemia. » Infant may need supplementation. » Expressed breastmilk is ideal first choice. » If mother’s own milk or donor human milk is not available, cow’s-milk-based formula may be used for supplementation. | |
Circumcision | • Assess circumcision site for healing. | • Review normal course of healing and care of circumcised penis. • Review care of intact penis if infant is not circumcised. |
• Evaluate appropriateness of infant’s clothing for warmth and general cleanliness. • Evaluate evidence for proper care of umbilicus and diaper area. • Assess parents’ knowledge and skill regarding routine newborn care. | • Review parents’ understanding of all routine newborn care procedures, e.g., taking temperatures, appropriate clothing, bathing, and diapering. | |
• Evaluate parents’ level of understanding about the special developmental care needs of the LPI. | • Explain the differences between corrected gestational age (GA) and chronological age. » Developmental milestone expectations are based on corrected GA rather than chronological age. • Stress importance of close monitoring of developmental milestones by primary care provider. • Provide written and verbal education about developmental care of preterms (including LPI): » Need for protection from overstimulation. » Need for positional support if low muscle tone. » Normal sleep/wake cycles and need for extra sleep • Teach signs (behavioral cues) of stress and overstimulation, including: » Limb extension, finger or toe splaying. » Twitches or startles. » Arching or limpness. » Facial grimace or scowl. » Abrupt color changes. » Irregular breathing. » Gaze aversion. » Crying. • Teach signs of relaxation and readiness for engagement, including: » Limb flexion, relaxed fingers and toes. » Smooth movements. » Rounded, flexed trunk and back. » Relaxed face and mouth. » Normal color. » Regular breathing. » Eyes open and engaged. » Quiet-alert state. • Stress the importance of skin-to-skin holding for optimal brain development. | |
SCREENING | ||
• Ensure familiarity with requirements of individual state’s newborn screening mandates. • Follow-up on state-specific newborn screening mandates as indicated. • Make referral or follow-up plan, if indicated. | • Respond to parents’ questions about newborn screening results. • Explain any abnormalities found during newborn screening results. • Stress importance of any follow-up that is indicated: » Date, time, location of follow-up appointment. | |
Hearing References: 92 | • Within the first 3 months after birth, order brainstem auditory evoked response (BAER) for any infant with Total Serum Bilirubin (TSB) ⩾20 mg/dL. | • Explain reason for BAER if ordered: » Vulnerability of hearing to high bilirubin levels. » Importance of normal hearing for speech development. • Stress importance of following-up on any hearing screening ordered: » Date, time, and location of follow-up appointment. |
Anomalies References: 93 | • Identify physical or internal anomalies requiring further assessment or follow-up care. • Assess parents’ understanding of anomalies if present. • Make follow-up plan for family. | • Respond to any questions about infant’s anomalies. • Stress importance of any follow-up that is indicated: » Date, time and location of follow-up appointment |
• Review maternal prenatal lab results and risk factors. • Review ingestion of illicit and prescription drugs or other substances during pregnancy and referrals to drug or alcohol rehabilitation program. • Review use of prescription or herbal medications or supplements of concern, if identified. • Review smoking history (present or past use). » Refer family members who smoke to smoking cessation program. » Encourage mothers who quit smoking during or just prior to pregnancy to avoid relapse (high risk during the postpartum period). • Screen for psychiatric illness or perinatal mood disorders (including postpartum depression and post-traumatic stress disorder). » Parents separated from the infant at birth (e.g., due to cesarean delivery or NICU admission) are at higher risk for perinatal mood disorders. » Mothers of infants born prematurely are at increased risk for mood disorders in the first 6 months postpartum (three times higher than mothers of term infants). » Make referrals for treatment if indicated. • Evaluate mother’s understanding of any referrals made. | • Provide referrals to smoking cessation, drug or alcohol treatment, psychiatric, or support services, if indicated. • Explain risks of secondhand smoke exposure. » Stress importance of providing a smoke-free environment for all infants and children, especially those born prematurely. » Secondhand smoke exposure is associated with apnea, Sudden Infant Death Syndrome (SIDS), behavior disorders, hyperactivity, oppositional defiant disorder, sleep abnormalities, upper respiratory infections. • Explain risks and benefits of prescription and herbal medications and supplements, if indicated. » Where medications are indicated, encourage use of medications compatible with breastfeeding, if possible. Reference LactMed at http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT. • Provide information about postpartum depression and post-traumatic stress disorder and encourage parents to seek help if needed. • Review increased risk for postpartum mood disorders in mothers of infants born prematurely: » Nearly three times higher risk during first 6 months postpartum. | |
Parent-Infant Bonding References: 77 | • Assess family, home, and social risk factors that may affect bonding. • Assess maternal health and parents’ ability to cope with challenges of newborn care and monitoring that can affect healthy bonding. • Assess signs of bonding and attachment: » Infant’s ability to demonstrate cues. » Parents’ ability to recognize and respond appropriately to infant’s cues. | • Review parents’ understanding of infant cues. • Encourage skin-to-skin contact of LPI with both parents. • Encourage parents to verbalize feelings about caring for their LPI and challenges they face that may affect healthy bonding and attachment. |
SAFETY | ||
• Assess and address family risk factors and make referrals if needed: » Drug or alcohol use in home. » Smokers in home. » Domestic violence. » Mental health issues. » Social services involvement. » Provide additional education as needed. • Evaluate parents’ understanding of any referrals made. | • Provide verbal and written information about where to get professional and community support. | |
Home Environment | • Assess and address parents’ knowledge of how to make the home environment safe for infants. » See Tips and Tools, Safety for Your Child (www.healthychildren.org/English/tips-tools/Pages/default.aspx). » Provide additional education as needed. • Document screening and referrals made for the following: » Adequate housing/shelter. » Utilities. » Phone. » Fire alarms. » Transportation. | • Teach ways to make the home environment safe for infants. • Stress importance of adequate shelter for infant. • Provide written and verbal information about available support services, if indicated. • Review family’s plan for communication with and transportation to primary care provider for infant follow-up visits. |
• Assess and address parents’ understanding of safe sleep practices. » Provide additional education as needed. | • Reinforce LPI’s increased risk for SIDS. • Provide written and verbal information about placing infant on his/her back to sleep and on tummy to play. • Explain unsafe sleeping practices. • Recommend use of pacifier after first month after birth. | |
• Assess and address parents’ views and understanding about importance of immunizations for infant and family members. » Provide additional education as needed. | • Reinforce importance of immunizations for infant: » Scheduled immunizations as recommended by American Academy of Pediatrics (AAP). » Flu shots during flu season. » Respiratory syncytial virus (RSV) prophylaxis as indicated. • Stress importance of flu shots and pertussis boosters for family and care providers. | |
Car Seat Safety References: 84 | • Determine whether parents have an appropriate car seat and refer for help as needed. » Refer for assistance in obtaining appropriate car seat as needed. • Assess and address parents’ understanding of proper use of car seats. » Provide additional education/training in proper car seat use as needed. | • Review proper use of car seats: » Correct way to secure car seat in car. » Correct way to secure infant in car seat » Age of transition to front-facing car seat. |
Shaken Baby Prevention Education References: 117 | • Assess and address parents’ understanding of risks of shaking baby. » Provide additional education as needed. • Assess and address parents’ knowledge of ways to calm infants and cope with infant crying. » Provide additional education as needed. • Assess and address parents’ coping and stress levels as risks for shaken baby syndrome. » Provide additional education as needed. | • Review risks of shaking any baby. • Review ways to calm crying infants. • Review ways to cope with infant crying. • Provide information about community or professional resources as needed for support. |
When To Call 911 or Local Emergency Number | • Assess and address parents’ understanding of when to call 911. » Provide additional education as needed. | • Review how to recognize life-threatening events and when to call 911, including: » Apnea. » Choking. » Difficulty breathing. » Cyanosis. • Review CPR. |
When To Call Primary Care Provider | • Assess and address parents’ understanding of when to call a primary care provider for urgent evaluation of infant. » Provide additional education as needed. | • Teach how to recognize signs of illness and when to call primary care provider, including: » Lethargy. » Fever, hypothermia. » Poor skin color. » Decreased urine output. » Abdominal distension. » Vomiting. » Bloody stool. » Inconsolable infant. » Uncertainty about significance of infant’s symptoms. |
SUPPORT | ||
Family and Social Support | • Evaluate support needs and address barriers to care: » Family/Social support network. » Community-based services (e.g., WIC, lactation support, social services). » Home health care referral. » Ongoing infant care education • Ask parents if they have any questions or concerns that have not already been addressed. • Provide a call-back number for general questions that come up after when family is home. | • Provide verbal and written information about where to find support if needed. • Reinforce potential challenges of caring for LPI at home and encourage utilization of resources as needed. |
