Head off complications in late preterm infants

Reprinted with permission from: American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. 2004;114:297-316. Copyright © 2004 by the American Academy of Pediatrics.

Feeding difficulties
The advantages of breast milk feeding for these babies are great. Unfortunately, it is breastfed infants who are more likely to have feeding difficulties and are at higher risk for readmission.¹⁷ Early feeding skills are complex and challenging. Because of their immaturity, late preterm infants have less effective suck and swallow coordination. They can be sleepier and have less stamina.¹⁰ Infants require coordinated oral motor movements, breathing, and swallowing to avoid desaturation and aspiration.²⁰ It is also important to note that almost every reported case of kernicterus in the past 20 years has been in breastfed infants whose feeding was not well established.¹³ First-born infants are especially at risk, as it takes longer to establish an adequate supply of milk.

For late preterm infants, it is imperative to establish successful breastfeeding to avoid dehydration and jaundice. Lactation consultation, education, and close follow-up are essential to successful breastfeeding in this group.¹⁸ The AAP Committee on Fetus and Newborn recommends a formal breastfeeding evaluation by trained caregivers at least twice daily prior to discharge.²

Brain injury
Late gestation is a critical period of brain growth. The 34-week-old brain weighs 65% of the term brain and increases linearly with each week. Fifty percent of the increase in cortical volume happens after 34 weeks.²¹ The risk of intraventricular hemorrhage and periventricular leukomalacia, while common in earlier preemies, is rare in infants born after 34 weeks. However, there is evidence to suggest other complications. Late preterm infants are more likely to be diagnosed with developmental delay and require special resources in preschool and less likely to be ready for school.²²

Sepsis
While late preterm neonates do have a small but significant increase in culture-proven sepsis and pneumonia compared with term babies,⁶ the work-up for possible sepsis is 3 times more likely. When these infants have poor feeding, mild respiratory distress, or TTN, physicians become concerned about sepsis and initiate a work-up.⁵ Currently there are no management guidelines for sepsis evaluation in this subset of preterm infants.²³

Readmission is a distinct possibility

One study of healthy late preterm infants showed a readmission rate of 4.8%. The most common reasons for readmission were jaundice and infection.¹⁷ Risk factors for readmission were breastfeeding, primiparity, labor and delivery complications, public payer source at delivery, and a mother of Asian/Pacific Islander ethnicity.¹⁷ Another study showed that discharge at less than 48 hours significantly increased the likelihood of readmission, even more so if the infant was breastfeeding.¹⁵

Several recent studies have highlighted a relationship between decreasing gestational age and a wide range of long-term adverse outcomes. In the early years of childhood, there is an increased risk for developmental delay and decreased kindergarten readiness.²² There is also a significant risk for disability, including cerebral palsy, mental retardation, and behavioral disorders.

Late preterm infants are at greater risk for several complications and the mortality rate is high in this group, when compared with term infants. By initial appearance and even weight, they rival their term counterparts. However, while they may look much like term babies and not weigh much less, they need more intense monitoring and should meet stringent discharge criteria (TABLE 2²).

TABLE 2
Minimum discharge criteria for late preterm infants²
All criteria should be met prior to discharge.