Premature Baby Assessment

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PREMATURE BABY ASSESSMENT

Prematurity is defined by the gestational age at which infants are born. Previously, any
infant weighing < 2.5 kg was termed premature. Although premature infants tend to be
small, this weight-based definition is incorrect because many infants weighing  < 2.5 kg are
mature or postterm and postmature and small for gestational age; they have a different
appearance and different problems.
In 2015, 9.63% of births in the US were premature (decreased from 10.44% in 2007). Of
these, 71% were late preterm and 29% (2.76% of births) occurred at < 34 weeks .
Premature infants, even late preterm infants who are the size of some full-term infants, have
increased morbidity and mortality compared to full-term infants due to their prematurity.
Gestational age

Gestational age is loosely defined as the number of weeks between the first day of the
mother's last normal menstrual period and the day of delivery. More accurately, the
gestational age is the difference between 14 days before the date of conception and the date
of delivery. Gestational age is not the actual embryologic age of the fetus, but it is the
universal standard among obstetricians and neonatologists for discussing fetal maturation.
Birth prior to 37 weeks gestation is considered premature. Premature infants are further
categorized as

 Extremely preterm: < 28 weeks


 Very preterm: 28 to 31 6/7 weeks
 Moderately preterm: 32 to 33 6/7 weeks
 Late preterm: 34 to < 36 6/7 weeks
Birthweight

Premature infants tend to be smaller than term infants. The Fenton growth charts provide a
more precise assessment of growth vs gestational age (see Figure: Fenton growth chart for
preterm boys and see Figure: Fenton growth chart for preterm girls).
Premature infants are categorized by birthweight:

 < 1000 g: Extremely low birthweight (ELBW)

 1000 to 1499 g: Very low birthweight (VLBW)


 1500 to 2500 g: Low birthweight (LBW)

Etiology

Preterm delivery may be

 Elective

 Spontaneous

Elective preterm delivery


The American College of Obstetricians and Gynecologists (ACOG) recommends late
preterm delivery in conditions such as multiple gestation with
complications, preeclampsia, placenta previa/placenta accreta, and premature rupture of
membranes.
ACOG recommends delivery as early as 32 weeks in selected cases involving multiple
gestation with complications. Quasi-elective delivery earlier than 32 weeks is done on a
case-by-case basis to manage severe maternal and/or fetal complications.

Spontaneous preterm delivery


In a given patient, spontaneous preterm delivery may or may not have an obvious
immediate trigger (eg, infection [see Intra–Amniotic Infection and Infectious Disease in
Pregnancy], placental abruption). There are many risk factors:
Past obstetric history
 Prior premature births (biggest risk factor)
 Prior multiple pregnancies
 Prior multiple therapeutic abortions and/or spontaneous miscarriages
Current pregnancy-related factors
 Pregnancy achieved by in vitro fertilization
 Little or no prenatal care

 Poor nutrition during gestation (and perhaps before)

 Cigarette smoking
 Younger or older maternal age (eg, < 16 years, > 35 years)
 Untreated infections (eg, bacterial vaginosis, intra-amniotic infection [formerly
chorioamnionitis])
 Multiple gestation (eg, twins, triplets)
 Cervical insufficiency (formerly cervical incompetence)
 Preeclampsia
 Placental abruption
 Certain congenital defects (fetuses with structural congenital heart defects are nearly
twice as likely to be delivered prematurely as fetuses without congenital heart
defects)
Multiple gestation is an important risk factor; 59% of twins and > 98% of higher-order
multiples are delivered prematurely. Many of these infants are very premature; 10.7% of
twins, 37% of triplets, and > 80% of higher-order multiples are delivered at < 32 weeks ( 1).
Socioeconomic factors
 Low socioeconomic status

 Mothers with less formal education

It is unclear how much risk these socioeconomic factors contribute independent of their
effect on other risk factors (eg, nutrition, access to medical care).

Complications

The incidence and severity of complications of prematurity increase with decreasing


gestational age and birthweight. Some complications (eg, necrotizing enterocolitis,
retinopathy of prematurity, bronchopulmonary dysplasia, intraventricular hemorrhage) are
uncommon in late preterm infants.

Most complications relate to dysfunction of immature organ systems. In some cases,


complications resolve completely; in others, there is residual organ dysfunction.

Cardiac
The overall incidence of structural congenital heart defects among premature infants is low.
The most common cardiac complication is

 Patent ductus arteriosus (PDA)


The ductus arteriosus is more likely to fail to close after birth in premature infants. The
incidence of PDA increases with increasing prematurity; PDA occurs in almost half of
infants whose birthweight is < 1750 g and in about 80% of those < 1000 g. About one third
to one half of infants with PDA have some degree of heart failure. Premature infants  ≤ 29
weeks gestation at birth who have respiratory distress syndrome have a 65 to 88% risk of a
symptomatic PDA. If infants are ≥ 30 weeks gestation at birth, the ductus closes
spontaneously in 98% by the time of hospital discharge.
Central nervous system (CNS)
CNS complications include

 Poor sucking and swallowing reflexes

 Apneic episodes
 Intraventricular hemorrhage
 Developmental and/or cognitive delays
Infants born before 34 weeks gestation have inadequate coordination of sucking and
swallowing reflexes and need to be fed intravenously or by gavage.

Immaturity of the respiratory center in the brain stem results in apneic spells (central
apnea). Apnea may also result from hypopharyngeal obstruction alone (obstructive apnea).
Both may be present (mixed apnea).
The periventricular germinal matrix (a highly cellular mass of embryonic cells that lies over
the caudate nucleus on the lateral wall of the lateral ventricles of a fetus) is prone to
hemorrhage, which may extend into the cerebral ventricles (intraventricular hemorrhage).
Infarction of the periventricular white matter (periventricular leukomalacia) may also occur
for reasons that are incompletely understood. Hypotension, inadequate or unstable brain
perfusion, and blood pressure peaks (as when fluid or colloid is given rapidly IV) may
contribute to cerebral infarction or hemorrhage. Periventricular white matter injury is a
major risk factor for cerebral palsy and neurodevelopmental delays.
Premature infants, particularly those with a history of sepsis, necrotizing enterocolitis,
hypoxia, and intraventricular and/or periventricular hemorrhages, are at risk of
developmental and cognitive delays (see also Childhood Development). These infants
require careful follow-up during the first year of life to identify auditory, visual, and
neurodevelopmental delays. Careful attention must be paid to developmental milestones,
muscle tone, language skills, and growth (weight, length, and head circumference). Infants
with identified delays in visual skills should be referred to a pediatric ophthalmologist.
Infants with auditory and neurodevelopmental delays (including increased muscle tone and
abnormal protective reflexes) should be referred to early intervention programs that provide
physical, occupational, and speech therapy. Infants with severe neurodevelopmental
problems may need to be referred to a pediatric neurologist.
Eyes
Ocular complications include

 Retinopathy of prematurity (ROP)
 Myopia and/or strabismus
Retinal vascularization is not complete until near term. Preterm delivery may interfere with
the normal vascularization process, resulting in abnormal vessel development and
sometimes defects in vision including blindness (ROP). Incidence of ROP is inversely
proportional to gestational age. Disease usually manifests between 32 weeks and 34 weeks
gestational age.

Incidence of myopia and strabismus increases independently of ROP.

Gastrointestinal tract
Gastrointestinal complications include

 Feeding intolerance, with increased risk of aspiration

 Necrotizing enterocolitis
Feeding intolerance is extremely common because premature infants have a small stomach,
immature sucking and swallowing reflexes, and inadequate gastric and intestinal motility.
These factors hinder the ability to tolerate both oral and nasogastric feedings and create a
risk of aspiration. Feeding tolerance increases over time, particularly when infants are able
to be given some enteral feedings.

Necrotizing enterocolitis usually manifests with bloody stool, feeding intolerance, and a
distended, tender abdomen. Necrotizing enterocolitis is the most common surgical
emergency in the premature infant. Complications of neonatal necrotizing enterocolitis
include bowel perforation with pneumoperitoneum, intra-abdominal abscess formation,
stricture formation, short bowel syndrome, septicemia, and death.
Infection
Infectious complications include

 Sepsis
 Meningitis
Sepsis or meningitis is about 4 times more likely in the premature infant, occurring in
almost 25% of very low-birthweight infants. The increased likelihood results from
indwelling intravascular catheters and endotracheal tubes, areas of skin breakdown, and
markedly reduced serum immunoglobulin levels (see Perinatal Physiology : Neonatal
immunologic function).
Kidneys
Renal complications include

 Metabolic acidosis
 Growth failure

Renal function is limited, so the concentrating and diluting limits of urine are decreased.
Late metabolic acidosis and growth failure may result from the immature kidneys’ inability
to excrete fixed acids, which accumulate with high-protein formula feedings and as a result
of bone growth. Sodium and bicarbonate are lost in the urine.

Lungs
Pulmonary complications include

 Respiratory distress syndrome


 Respiratory insufficiency of prematurity

 Chronic lung disease (bronchopulmonary dysplasia)


Surfactant production is often inadequate to prevent alveolar collapse and atelectasis, which
result in respiratory distress syndrome (hyaline membrane disease). Many other factors can
contribute to respiratory distress in the first week of life. Regardless of the cause, many
extremely premature and very premature infants have persistent respiratory distress and an
ongoing need for respiratory support (termed Wilson-Mikity disease, chronic pulmonary
insufficiency of prematurity, or respiratory insufficiency of prematurity). Some infants are
successfully weaned off support over a few weeks; others develop chronic lung disease
(bronchopulmonary dysplasia) with need for prolonged respiratory support using a high-
flow nasal cannula, continuous positive airway pressure (CPAP) or other noninvasive
ventilatory assistance, or mechanical ventilation. Respiratory support may be given with
room air or with supplemental oxygen. If supplemental oxygen is required, the lowest
oxygen concentration that can maintain target oxygen saturation levels of 90 to 95% should
be used (see Table: Neonatal Oxygen Saturation Targets).
Palivizumab prophylaxis for respiratory syncytial virus is important for infants with chronic
lung disease.
Metabolic problems
Metabolic complications include

 Hypoglycemia
 Hyperbilirubinemia
 Metabolic bone disease (osteopenia of prematurity)

Neonatal hypoglycemia and neonatal hyperglycemia are discussed elsewhere.


Hyperbilirubinemia occurs more commonly in the premature as compared to the term
infant, and kernicterus (brain damage caused by hyperbilirubinemia) may occur at serum
bilirubin levels as low as 10 mg/dL (170 micromol/L) in small, sick, premature infants. The
higher bilirubin levels may be partially due to inadequately developed hepatic excretion
mechanisms, including deficiencies in the uptake of bilirubin from the serum, its hepatic
conjugation to bilirubin diglucuronide, and its excretion into the biliary tree. Decreased
intestinal motility enables more bilirubin diglucuronide to be deconjugated within the
intestinal lumen by the luminal enzyme beta-glucuronidase, thus permitting increased
reabsorption of unconjugated bilirubin (enterohepatic circulation of bilirubin). Conversely,
early feedings increase intestinal motility and reduce bilirubin reabsorption and can thereby
significantly decrease the incidence and severity of physiologic jaundice. Uncommonly,
delayed clamping of the umbilical cord (which has several benefits and is generally
recommended) may increase the risk of hyperbilirubinemia by allowing the transfusion of
RBCs thus increasing RBC breakdown and bilirubin production.
Metabolic bone disease with osteopenia is common, particularly in extremely premature
infants. It is caused by inadequate intake of calcium, phosphorus, and vitamin D and is
exacerbated by administration of diuretics and corticosteroids. Breast milk also has
insufficient calcium and phosphorus and must be fortified. Supplemental vitamin D is
necessary to optimize intestinal absorption of calcium and control urinary excretion.
Congenital hypothyroidism, characterized by low thyroxine (T4) and elevated thyroid-
stimulating hormone (TSH) levels, is much more common among premature infants than
full-term infants. In infants with a birthweight of < 1500 g, the rise in TSH may be delayed
for several weeks, necessitating repeated screening for detection. Transient
hypothyroxinemia, characterized by low T4 and normal TSH levels, is very common
among extremely premature infants; treatment with L-thyroxine is not beneficial

The most common temperature regulation complication is

 Hypothermia
Premature infants have an exceptionally large body surface area to volume ratio. Therefore,
when exposed to temperatures below the neutral thermal environment, they rapidly lose
heat and have difficulty maintaining body temperature. The neutral thermal environment is
the environmental temperature at which metabolic demands (and thus calorie expenditure)
to maintain normal body temperature (36.5 to 37.5° C rectal) are lowest.

Diagnosis

 Obstetric history and postnatal physical parameters

 Fetal ultrasonography

 Screening tests for complications

When periods are regular and recorded contemporaneously, the menstrual history is
relatively reliable for establishing gestational age. Ultrasonographic measurements of the
fetus in the 1st trimester give the most accurate estimate of gestational age.
Ultrasonographic estimates are less accurate later in pregnancy; 2nd and 3rd trimester
ultrasonographic results should rarely be used to revise those done during the 1st trimester.
After delivery, newborn physical examination findings also allow clinicians to estimate
gestational age, which can be confirmed by the new Ballard score.
Along with appropriate testing for any identified problems or disorders, routine evaluations
include pulse oximetry, complete blood count, electrolytes, bilirubin level, blood culture,
serum calcium, alkaline phosphatase, and phosphorus levels (to screen for osteopenia of
prematurity), hearing evaluation, cranial ultrasonography (to screen for intraventricular
hemorrhage and periventricular leukomalacia), and screening by an ophthalmologist for
retinopathy of prematurity. Weight, length, and head circumference should be plotted on an
appropriate growth chart at weekly intervals.

As with older neonates, routine newborn screening tests are done at 24 to 48 hours of age.


Unlike full-term infants, premature infants, especially extremely preterm infants, have a
high rate of false-positives (1). Mild elevations of several amino acids and abnormal
acylcarnitine profiles are common and slight elevations of 17-hydroxyprogesterone levels
and low thyroxine (T4) levels (typically with normal thyroid-stimulating hormone levels)
are often present. Extremely preterm infants and very preterm infants are at risk of a
delayed presentation of congenital hypothyroidism and should be periodically screened.
X-rays, often obtained for other reasons, may provide evidence of osteopenia and/or
unsuspected fractures. DXA scanning and quantitative ultrasonography scanning may
detect osteopenia but are not in widespread use.
Premature, Very Preterm, and Extremely Preterm Infants

Complications
The incidence and severity of complications of premature infants increase with decreasing
gestational age and birthweight. Some complications (eg, necrotizing
enterocolitis, retinopathy of prematurity, bronchopulmonary dysplasia, intraventricular
hemorrhage) occur primarily in infants delivered at < 34 weeks.
Symptoms and Signs
The premature infant is small, usually weighing < 2.5 kg, and tends to have thin, shiny,
pink skin through which the underlying veins are easily seen. Little subcutaneous fat, hair,
or external ear cartilage exists. Spontaneous activity and tone are reduced, and extremities
are not held in the flexed position typical of term infants.
In males, the scrotum may have few rugae, and the testes may be undescended. In females,
the labia majora do not yet cover the labia minora.

Reflexes develop at different times during gestation. The Moro reflex begins by 28 to 32
weeks gestation and is well established by 37 weeks. The palmar reflex starts at 28 weeks
and is well established by 32 weeks. The tonic neck reflex starts at 35 weeks and is most
prominent at 1 month postterm.
Evaluation
 Monitoring in a neonatal intensive care unit (NICU)

 Screening for complications

NICU monitoring and screening


Serial physical examinations are important in monitoring infants' progress and detecting
new problems (eg, respiratory problems, jaundice). Frequent weight assessments are
necessary to optimize weight-based drug dosage and feeding.

 Growth and nutrition: Weight should be monitored closely, particularly in the first
days of life when there is a contraction of the extracellular volume; dehydration with
severe hypernatremia may develop. Weight, length, and head circumference should
be assessed weekly and plotted on an appropriate growth chart.
 Electrolyte balance: Serum electrolytes, glucose, calcium, and phosphate levels need
to be periodically measured, particularly in infants receiving parenteral fluids and/or
nutrition (eg, very premature and extremely premature infants).

 Respiratory status: Pulse oximetry and sometimes transcutaneous or end-tidal PCO2


are monitored continually; arterial or capillary blood gas tests are done as needed.

 Apnea and bradycardia: External cardiorespiratory monitoring is usually continued


until discharge.

 Hematologic abnormalities: Complete blood count (CBC), reticulocyte count, and


differential count are done initially and at intervals to detect common abnormalities.

 Hyperbilirubinemia: Transcutaneous and/or serum bilirubin levels are measured to


detect and monitor this disorder.

 Systemic infection: CBC, C-reactive protein, blood culture, and sometimes


procalcitonin levels are often done to facilitate early detection of neonatal sepsis.

 Central nervous system infection: Lumbar puncture is typically reserved for infants
with clear signs of infection and/or seizures, a positive blood culture, or an infection
that is not responding to antibiotics.
 Intraventricular hemorrhage: Screening cranial ultrasonography is indicated at 7 to
10 days in premature infants < 32 weeks and in older premature infants with complex
courses (eg, cardiorespiratory and/or metabolic instability).

Intraventricular hemorrhage (IVH) in extremely preterm infants is usually clinically silent,


and a routine cranial ultrasound is recommended for these infants. The incidence of IVH
decreases with increasing gestational age, so routine screening of premature infants > 32
weeks is not considered useful unless they had significant complications. Most IVHs occur
in the first week of life and, unless there are clinical indications of hemorrhage, the highest
yield is obtained by scanning at 7 to 10 days of age. Extremely preterm infants are at risk of
periventricular leukomalacia which may develop later in the course (with or without
hemorrhage), so they should have cranial ultrasonography at 6 weeks of age. Infants with
moderate or severe hemorrhages should be followed using head circumference
measurements and periodic cranial ultrasonography to detect and monitor hydrocephalus;
there is no benefit in repeat scanning of infants with minor hemorrhage.
Later screening
Screening for retinopathy of prematurity is recommended for infants born ≤ 1500 g or ≤ 30
weeks gestational age and for larger and more mature infants who have had an unstable
clinical course. The first examination is done according to a schedule based on the infant's
gestational age (see table Screening for Retinopathy of Prematurity). Examinations are
usually repeated at 1- to 3-week intervals depending on the initial findings and are
continued until the retina is mature. Some of these follow-up examinations are done after
the infant is discharged. The use of digital photographic retinal images is an alternate
method of examination and follow-up in areas where a skilled examiner is not routinely
available.

Because premature infants are at risk of apnea, oxygen desaturation, and bradycardia while
in a car seat, the American Academy of Pediatrics currently recommends that before
discharge all premature infants have their oxygen saturation monitored for 90 to 120
minutes while seated in the car seat that they will use after discharge. However, there are no
agreed-upon criteria for passing or failing the test, and a recent report from the Canadian
Paediatric Society (CPS) found that the car seat test had poor reproducibility and did not
predict risk of mortality or neurodevelopmental delay. Thus, the CPS does not recommend
routine testing before discharge (1). Given the concerns about the car seat test, a common-
sense approach to car travel is for a newly discharged premature infant to be observed by a
non-driving adult during all car seat travel until the infant has reached the due date  and has
remained consistently able to tolerate being in the car seat. Because the infant's color needs
to be observed, travel should be limited to daylight hours. Long trips should be broken up
into 45- to 60-minute segments so that the infant can be taken out of the car seat and
repositioned.
After discharge, extremely preterm and very preterm infants should receive careful
neurodevelopmental follow-up and appropriate early referral to intervention programs as
needed for physical, occupational, and language therapy.

Prognosis
Prognosis varies with presence and severity of complications, but usually mortality and
likelihood of complications decrease greatly with increasing gestational age and
birthweight (see Figure: Survival and survival without severe impairment in extremely low-
birthweight infants).
Observed and maximal potential rates of survival (top) and survival without severe
impairment (bottom) in extremely low-birthweight infants. (Adapted from Tyson JE, Parikh
NA, Langer J, et al: Intensive care for extreme prematurity—moving beyond gestational
age. The New England Journal of Medicine 358:1672–81, 2008.)
Treatment
 Supportive care

Specific disorders are treated as discussed elsewhere in THE MANUAL. General


supportive care of the premature infant is best provided in a NICU or special care nursery
and involves careful attention to the thermal environment, using servo-controlled
incubators. Scrupulous adherence is paid to handwashing before and after all patient
contact. Infants are continually monitored for apnea, bradycardia, and hypoxemia until 34.5
or 35 weeks gestation.

Parents should be encouraged to visit and interact with the infant as much as possible
within the constraints of the infant’s medical condition. Skin-to-skin contact between the
infant and mother (kangaroo care) is beneficial for infant health and facilitates maternal
bonding. It is feasible and safe even when infants are supported by ventilators and
infusions.

Feeding
Feeding should be by nasogastric tube until coordination of sucking, swallowing, and
breathing is established at about 34 weeks gestation, at which time  breastfeeding is strongly
encouraged. Most premature infants tolerate breast milk, which provides immunologic and
nutritional factors that are absent in cow’s milk formulas. However, breast milk does not
provide sufficient calcium, phosphorus, and protein for very low-birthweight infants
(ie, < 1500 g), for whom it should be mixed with a breast milk fortifier. Alternatively,
specific premature infant formulas that contain 20 to 24 kcal/oz (2.8 to 3.3 joules/mL) can
be used.
In the initial 1 or 2 days, if adequate fluids and calories cannot be given by mouth or
nasogastric tube because of the infant’s condition, IV parenteral nutrition with protein,
glucose, and fats is given to prevent dehydration and undernutrition. Breast milk or preterm
formula feeding via nasogastric tube can satisfactorily maintain caloric intake in small,
sick, premature infants, especially those with respiratory distress or recurrent apneic spells.
Feedings are begun with small amounts (eg, 1 to 2 mL every 3 to 6 hours) to stimulate the
gastrointestinal tract. When tolerated, the volume and concentration of feedings are slowly
increased over 7 to 10 days. In very small or critically sick infants, total parenteral
hyperalimentation via a peripheral IV or a percutaneously or surgically placed central
catheter may be required for a prolonged period of time until full enteral feedings can be
tolerated.

Hospital discharge
Premature infants typically remain hospitalized until their medical problems are under
satisfactory control and they are

 Taking an adequate amount of milk without special assistance

 Gaining weight steadily

 Able to maintain a normal body temperature in a crib

Most premature infants are ready to go home when they are at 35 to 37 weeks gestational
age and weigh 2 to 2.5 kg. However, there is wide variation. Some infants are ready for
discharge earlier and some require longer stays in the hospital. The length of time the infant
stays in the hospital does not affect the long-term prognosis.

Preterm infants should be transitioned to the supine sleeping position before hospital
discharge. Parents should be instructed to keep cribs free of fluffy materials including
blankets, quilts, pillows, and stuffed toys, which have been associated with an increased
risk of sudden infant death syndrome (SIDS).
Surveys show that most car seats are not installed optimally, so a check of the car seat by a
certified car seat inspector is recommended. Inspection sites can be found here. Some
hospitals offer an inspection service, but casual advice provided by an uncertified hospital
staff member should not be considered equivalent to inspection by a certified car seat
expert.
The American Academy of Pediatrics recommends that car seats be used only for vehicular
transportation and not as an infant seat or bed at home.

Prevention
Although early and appropriate prenatal care is important overall, there is no good evidence
that such care or any other interventions decrease the incidence of premature birth.

The use of tocolytics to arrest premature labor and provide time for prenatal administration
of corticosteroids to hasten lung maturation is discussed elsewhere (see Preterm Labor :
Treatment).
Key Points
 There are many risk factors for premature birth but they are not present in most
cases.

 Complications include hypothermia, hypoglycemia, respiratory distress syndrome,


apneic episodes, intraventricular hemorrhage, developmental delay, sepsis,
retinopathy of prematurity, hyperbilirubinemia, necrotizing enterocolitis, and poor
feeding.

 Mortality and likelihood of complications decrease greatly with increasing


gestational age and birthweight.

 Treat disorders and support body temperature and feeding.

 Although women who have consistent prenatal care have a lower incidence of
preterm birth, there is no evidence that improved prenatal care or other interventions
decrease the incidence of premature birth.

More Information
 Child car seat inspection station locator
Late Preterm Infants

An infant born between 34 and 36 6/7 weeks gestation is considered late preterm.

Complications
Although clinicians tend to focus on the more dramatic and obvious manifestations of
problems of infants born < 34 weeks gestation, late preterm infants are at risk of many of
the same disorders (see complications of premature infants). Compared to term infants, they
have longer hospital stays and higher incidence of readmission and diagnosed medical
disorders. Most complications relate to dysfunction of immature organ systems and are
similar to, but typically less severe than, those of infants born more prematurely. However,
some complications of prematurity (eg, necrotizing enterocolitis, retinopathy of
prematurity, bronchopulmonary dysplasia, intraventricular hemorrhage) are uncommon in
late preterm infants. In most cases, complications resolve completely.
Complications more common among preterm infants include the following:
 Central nervous system: Apneic episodes (see Apnea of Prematurity)
 Gastrointestinal tract: Poor feeding due to delayed maturation of the suck and
swallow mechanism (primary reason for prolonged hospital stay and/or readmission)

 Hyperbilirubinemia: Caused by immature mechanisms for hepatic bilirubin


metabolism and/or increased intestinal reabsorption of bilirubin (eg, if feeding
difficulties cause decreased intestinal motility)
 Hypoglycemia: Caused by low glycogen stores
 Temperature instability: Some degree of neonatal hypothermia in half of infants
(caused by increased surface area to volume ratio, decreased adipose tissue, and
ineffective thermogenesis from brown fat)
Evaluation
 Routine screening for complications

There are variations in practice in the care of late preterm infants, particularly with respect
to the gestational age and/or birthweight at which infants are routinely admitted to a NICU.
Some hospitals routinely admit infants < 35 weeks gestation to the NICU, whereas others
may have a cutoff of < 34 weeks. Still other hospitals have a discretionary approach.
Regardless of the location of the infant, all late preterm infants need close monitoring of the
following:

 Temperature: There is a high risk of hypothermia, and some late preterm infants
may need to be in an incubator. The infant's temperature should be routinely
assessed. For infants who are in the mother's hospital room, the temperature of the
room should be maintained at 22 to 25° C (72 to 77° F) similar to that recommended
for newborn care areas.

 Weight: Depending on the infant's intake, there may be excessive weight loss,
dehydration, and hypernatremia. The infant should be weighed daily and the percent
weight loss should be calculated and tracked. Electrolytes should be checked if the
weight loss exceeds 10%.

 Feedings and intake: Late preterm infants may breastfeed or bottle feed poorly and
take insufficient amounts of milk. Nasogastric feeding assistance is commonly
needed, particularly in infants who are 34 weeks gestation. Because the mother's milk
may take 1 to 4 days to come in, supplementation with donor milk or formula may be
necessary. The amount of milk that the infant receives as well as either the number of
wet diapers or the urine output (calculated as mL/kg/hour) should be tracked.

 Glucose: Early hypoglycemia (within the first 12 hours of life) is common, so


screening as is recommended by the American Academy of Pediatrics ( 1) for the first
24 hours of life should be done. In addition, some experts recommend continued
screening every 12 hours until discharge to detect infants with hypoglycemia due to
insufficient milk intake.
Evaluation reference
 1. Committee on Fetus and Newborn, Adamkin DH: Postnatal glucose homeostasis
in late-preterm and term infants. Pediatrics 127(3):575–579, 2011. doi: 10.1542/peds.2010-
3851.
Prognosis
Prognosis varies with presence and severity of complications. In general, mortality and the
likelihood of complications decrease greatly with increasing gestational age and
birthweight.

Respiratory issues typically resolve without long-term sequelae. Apneic episodes typically
resolve by 37 to 38 weeks gestation and almost always by 43 weeks.

Neurodevelopmental disorders (see Childhood Development) are more common among late


preterm infants (compared to full-term infants) assessed at 2 years of age and at
kindergarten age (1). Early identification by monitoring developmental milestones and
referring an intervention program for infants showing delays can be helpful.
Prognosis reference
 1. McGowan JE, Alderdice FA, Holmes VA, Johnston L: Early childhood
development of late-preterm infants: A systematic review. Pediatrics 127:1111–1124,
2011. doi: 10.1542/peds.2010-2257.
Treatment
 Supportive care

 Specific treatment for complications


Identified disorders are treated. For infants without specific conditions, support is focused
on body temperature and feeding.

Late preterm infants can be stressed by the metabolic demands of maintaining a normal
core temperature of 36.5 to 37.5° C (97.7 to 99.5° F), which roughly corresponds to an
axillary temperature of 36.5 to 37.3° C (97.7 to 99.1° F). The environmental temperature at
which metabolic demands (and thus calorie expenditure) to maintain body temperature in
the normal range are lowest is the thermoneutral temperature. A normal core temperature
can be maintained at lower environmental temperatures at the cost of increased metabolic
activity, so a normal core temperature is no assurance that the environmental temperature is
adequate. Once the core temperature falls below normal, the environmental temperature is
below what is called the thermoregulatory range and therefore far below the thermoneutral
range. In clinical practice, a room with a temperature of 22.2 to 25.6° C (72 to 78° F)
combined with skin-to-skin contact under blankets, swaddling with multiple blankets, and
wearing a hat may provide a thermoneutral environment for a large and somewhat more
mature late preterm infant. Smaller and less mature late preterm infants usually require an
incubator for a period of time to provide a thermoneutral environment.

Breastfeeding is strongly encouraged. Breast milk, which provides immunologic and


nutritional factors that are absent in cow’s milk formulas, is well tolerated by premature
infants. If infants do not suck and/or swallow adequately, feedings should be given by
nasogastric gavage beginning with small amounts and gradually increasing over time.
Key Points
 Although late preterm infants (born between ≥ 34 weeks and < 36 6/7 weeks
gestation) may appear to be similar in size and appearance to term infants, they are at
increased risk of complications.

 Complications include hypothermia, hypoglycemia, poor feeding, excessive weight


loss, respiratory distress, hyperbilirubinemia, and an increased likelihood of
readmission after discharge.

 Treat disorders and support body temperature and feeding.

 Monitor neurodevelopmental status and provide appropriate referral to address any


disabilities.

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