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Guideline Summary
Guideline Title
Assessment and care of the late preterm infant. Evidence-based clinical practice guideline.
Bibliographic Source(s)
Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). Assessment and care of the late preterm infant. Evidence-based clinical practice guideline. Washington (DC): Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN); 2010. 57 p. [109 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Neonatal complications associated with late preterm births (LPIs) including:

  • Respiratory distress
  • Temperature instability
  • Hypoglycemia
  • Jaundice and hyperbilirubinemia
  • Inadequate feeding
  • Infection
  • Neurodevelopmental delay
Guideline Category
Counseling
Diagnosis
Evaluation
Management
Prevention
Risk Assessment
Treatment
Clinical Specialty
Family Practice
Nursing
Obstetrics and Gynecology
Pediatrics
Intended Users
Advanced Practice Nurses
Nurses
Patients
Physician Assistants
Physicians
Public Health Departments
Social Workers
Guideline Objective(s)
  • To provide perinatal and neonatal registered nurses and advanced practice registered nurses and other healthcare providers with clinical practice recommendations for care of the late preterm infant (LPI) based on the best available evidence
  • To enhance nurses' and other healthcare providers' knowledge of the risks of late preterm birth and the unique needs of the late preterm neonate to facilitate timely assessment and intervention that is derived from scientific evidence
  • To address a broad range of risks associated with late preterm birth. Some are parameters that present significant but perhaps preventable risk, and others may be categorized as unavoidable risks related to factors such as gender or birth.
Target Population

Late preterm neonate who is born at 34 0/7 to 36 6/7 weeks of gestation, their mothers, and their mothers' primary support person(s). The Guideline is primarily applicable to hospitalized late preterm infants (LPIs).

Note: For the purposes of this guideline, "LPI" is the term used consistently to refer to this population of neonates.

Interventions and Practices Considered
  1. Assess gestational age of neonate
  2. Assess and monitor respiratory status
  3. Appropriate respiratory interventions
  4. Assess for risk factors and symptoms of heat loss and/or cold stress
  5. Interventions to maintain a neutral thermal environment
  6. Interventions and assessment of hypoglycemia including transfer to higher acuity unit or facility if indicated
  7. Assess for maternal and neonatal risk factors for sepsis
  8. Antibiotic therapy and diagnostic evaluation if sepsis is suspected
  9. Assess for presence of jaundice and hyperbilirubinemia
  10. Phototherapy as indicated
  11. Parent education regarding signs and symptoms of jaundice and hyperbilirubinemia
  12. Breastfeeding, and support for breastfeeding mothers including observation, education and validation
  13. Discharge planning including parent education, counseling, and validation of knowledge about recognizing and acting on risk factors
Major Outcomes Considered

Rates of complications in the late preterm infant

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Several topic-specific electronic database searches and manual searches were conducted to identify relevant literature. Specifically, MEDLINE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, and the Cochrane Library were searched for journal articles written in English and published between 1990 and April 2010. The primary search terms included near term and late preterm infant cross-referenced with the following topics: gestational age assessment, thermoregulation, parenting and premature newborn, risk factors, risk assessment, care of, kangaroo care (KC), and neurodevelopmental issues. Relevant American Academy of Pediatrics (AAP) and Canadian Paediatric Society (CPS) guidelines were also searched for information on management of hypoglycemia, hyperbilirubinemia, sepsis, and respiratory distress.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Quality of Evidence

I: Evidence obtained from at least one properly designed randomized, controlled trial or meta-analysis of randomized controlled trials.

II-1: Evidence obtained from well-designed controlled trials without randomization.

II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.

II-3: Evidence from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence.

III: Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees.

Methods Used to Analyze the Evidence
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Evaluation and Scoring

A system and tool for scoring the quantitative literature was developed based on the method for literature analysis presented in the American Nurses Association (ANA) Manual to Develop Guidelines*. Using this framework, each study reviewed by the Guideline team was evaluated according to the following eight criteria:

  • Problem or question studied: Clearly stated, significant, and relevant
  • Sampling: Representative sampling, less than 20% dropout rate, and random selection process
  • Measurement: Tools/methods appropriate, reliable, and valid
  • Internal validity: Accurate conclusions about covariation
  • External validity: Valid conclusions about generalizability
  • Construct validity: Appropriate independent and dependent variables identified
  • Statistical conclusion validity: Statistical significance supported by data (p ≤0.05)
  • Justification for conclusions: Causal conclusions justified

A description of the above criteria and a sample scoring tool can be found in the ANA Manual*.

*Marek, K. (1995). Manual to develop guidelines. ANA Committee on Nursing Practice Standards & Guidelines. Washington, DC: American Nurses Publishing, American Nurses Foundation/American Nurses Association.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

The Assessment and Care of the Late Preterm Infant Evidence-Based Clinical Practice Guideline was developed by the Late Preterm Infant Guideline Development Team. This group was a subcommittee of the Late Preterm Infant Science Team that convened in late 2007 to begin work on the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) Late Preterm Infant Research-Based Practice Project. The Guideline Development Team included AWHONN member experts who are nationally and internationally recognized for their significant contributions in neonatal nursing. The team members were selected for their expertise as scientists and clinicians dedicated to improving the health and well-being of women and newborns.

Team members participated throughout 2008 and early 2009 in teleconferences and extensive literature review, evaluation, and scoring. During regularly scheduled teleconferences, members reviewed and achieved consensus on each clinical practice recommendation, accompanying referenced rationale, and quality-of-evidence rating. In early 2010, the Guideline was updated to include selected recommendations provided by the Late Preterm Infant Research-Based Practice Project site coordinators and Science Team and to reflect current literature.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

Not stated

Recommendations

Major Recommendations

Note from the National Guideline Clearinghouse (NGC): Referenced rationale and quality of evidence ratings for each recommendation are provided in the original guideline document.

Gestational Age Assessment

Assessment

  1. Determine the neonate's gestational age:
    1. Review the prenatal record to determine whether ultrasonography was performed between 15 and 19 weeks of gestation.
    2. Perform postnatal gestational assessment within 12 hours of age using an appropriate scoring tool such as the New Ballard Score (NBS).
  1. Obtain the neonate's length, weight, and head circumference and plot the results, ideally on a validated growth curve.
  2. Classify the neonate as small for gestational age (SGA), appropriate for gestational age (AGA), or large for gestational age (LGA), ideally using a growth curve with appropriate norms (e.g., one that accommodates normal variations in altitude and ethnicity).

Respiratory Assessment

Immediate Assessment and Care (First 30 Minutes of Life)

  1. Assess respiratory status immediately after birth:
    1. Observe the neonate's physiologic functional status in an undisturbed state and environment whenever possible.
    2. Count the respiratory rate for one full minute. Respiratory rate for neonates should be between 30 and 60 breaths per minute.
      • Respirations may be irregular during the first 15 minutes of life, with respiratory rate reaching 60-80 breaths per minute, and may be up to 100 breaths per minute for a limited time.
    1. Note signs of increased work of breathing including chest retractions, grunting, nasal flaring, tachypnea, tachycardia, and asymmetrical chest movement.
  1. Identify events from the maternal obstetrical history and labor and delivery record — such as low gestational age, male gender, presence of maternal complications, Apgar score less than 7 at 5 minutes of age, cesarean birth, maternal fever, or infection — to evaluate the risk for the following:
    1. Apnea
    2. Transient tachypnea of the newborn (TTN)
    3. Respiratory distress syndrome (RDS)
    4. Hypoglycemia
    5. Hypothermia or cold stress
    6. Sepsis
    7. Anemia
  1. If respiratory distress symptoms such as tachypnea, retractions, nasal flaring, grunting, and cyanosis are present, implement appropriate interventions such as the following:
    1. Seek evaluation of the infant by the primary neonatal health care provider
    2. Administer supplemental oxygen until respiratory distress resolves. Monitored, heated, and humidified oxygen is recommended.
    3. Apply a pulse oximetry monitor (ranges should be between 85% and 95%).
    4. Provide a supplemental heat source, such as a radiant warmer, an incubator, or chemical thermal mattress.
    5. Check blood serum glucose levels.
  1. If the baby is stable, and the mother desires, implement kangaroo care (KC) (also known as skin-to-skin care). If KC is not feasible, provide an alternate heat source, such as a radiant warmer.

Transitional (First 6–12 Hours After Birth) and Ongoing Assessment and Care

  1. Assess gestational age and determine whether the infant is small for gestational age, appropriate for gestational age, or large for gestational age.
  2. Monitor respiratory rate, type of respiration, tone, and activity at least every 30 minutes until the newborn's condition has remained stable for 2 hours. Continue respiratory status assessment at least every 4 hours for the first 24 hours and then once per shift with routine assessments.
  3. Monitor heart rate, perfusion, and muscle tone at least every 4 hours for the first 24 hours of life and then once per shift with routine assessments.
  4. Encourage rooming in and KC whenever possible.
  5. Maintain a neutral thermal environment (NTE).

Discharge Planning

  1. Discharge should not be considered before 48 hours of age for the late preterm infant (LPI).
    1. Confirm that respiratory rate is stable and less than 60 breaths per minute.
    2. Teach mothers how to assess respiratory rate and observe for signs of respiratory distress (e.g., change in color, tachypnea, grunting, retracting, nasal flaring).
    3. Provide education and counseling regarding avoidance of exposure to secondhand smoke.
    4. Teach supine positioning for sleep (lying wholly on back) and avoid placing soft blankets, pillows, and toys in crib.
  1. Assess the infant for risk factors for respiratory syncytial virus (RSV) including the following:
    1. Less than 35 weeks of gestation
    2. Child care attendance
    3. Presence of preschool-aged siblings
    4. Exposure to environmental pollutants, including tobacco smoke
    5. Male gender
    6. Living in household with more than five persons
    7. Small for gestational age
  1. Ideally, the first respiratory syncytial virus prophylaxis dose should be administered 48–72 hours before discharge and according to facility protocol.
  2. Confirm that follow-up visit with a pediatric care provider is planned for 24-48 hours of hospital discharge. Note that risk factors for rehospitalization include:
    1. Firstborn child
    2. Breastfeeding
    3. Labor and delivery complications
    4. Receipt of public assistance
    5. Asian/Pacific Island descent
    6. Male gender
    7. Use of assisted ventilation
  1. Complete or ensure that a car seat safety test is performed before discharge:
    1. Ideally, the car seat test should take place in the infant's own car seat.
    2. Monitor heart rate, respiratory rate, and oxygen saturation for 90 minutes or for the time it takes to travel home, whichever is longer.
    3. Refer to community car seat safety professionals.

Thermoregulation Issues

Immediate Assessment and Care (First 30 Minutes of Life)

  1. Review perinatal and intrapartum history for factors that could increase risk for heat loss and cold stress, such as lower Apgar scores, gestational age, and need for resuscitation.
  2. Immediately after birth, initiate actions to maintain and promote an NTE, such as the following:
    1. Thoroughly dry the neonate and place a prewarmed blanket over the neonate's back and a dry cap on the head.
    2. Provide immediate and sustained skin-to-skin contact, or KC, between mother and infant whenever possible.
    3. The premature infant who requires assistance with transition should be dried completely with prewarmed towels and placed on a preheated radiant warmer bed with temperature controls in place.
  1. Assess axillary temperature within 30 minutes of life. In preterm infants, axillary temperature should be 97.7°–99.3° F (36.5°–37.4° C).

Transitional (First 6–12 Hours After Birth) and Ongoing Assessment and Care

  1. Assess temperature every 30 minutes until the newborn's condition has remained stable for 2 hours. Continue temperature status assessment every 4 hours for the first 24 hours, then once per shift until discharge. Normal axillary temperature range is 97.7°–99.3° F (36.5°–37.4° C).
  2. Assess for cold stress symptoms, such as the following:
    1. Tachypnea
    2. Poor color: cyanosis or pallor
    3. Mottling
    4. Altered pulmonary vasomotor tone
    5. Metabolic acidosis
    6. Lethargy
  1. Take measures to ensure an NTE by avoiding heat loss that can occur through the mechanisms of:
    1. Conduction
    2. Convection
    3. Evaporation
    4. Radiation
  1. Initiate additional measures to maintain an NTE:
    1. Maintaining maternal–newborn contact.
    2. Encourage rooming in, breastfeeding and KC or swaddling.
    3. Twins may be placed simultaneously in KC.
    4. Keep a dry cap on the neonate's head as needed.
    5. Keep the neonate warm during weighing by using one or more of the following measures:
      • Place a warm blanket on the scale.
      • Stay away from air vents and drafts.
      • Ensure that the neonate's body surface and hair stay dry.
    1. Postpone the bath until thermal and cardiorespiratory stability are ensured, typically 2–4 hours after birth, then bathe the infant, incorporating the following environmental controls:
      • Keep the bath duration as short as possible.
      • Use a sponge bath or swaddled bath.
      • Ensure that the bath water temperature is 100° to <104° F (38° to <40° C). (Consider using a thermometer to test water temperature before bathing).
      • Minimize or avoid drafts in the room.
      • Ensure that the room temperature is between 79° and 81° F (26° and 27° C).
      • Use prewarmed towels for drying.
      • Dry the newborn immediately after bathing, place a diaper and dry cap on the baby, and wrap her in warm blankets.
    1. Minimize interruptions of KC or swaddled holding by considering the following measures:
      • Delaying temperature taking until after a KC or swaddling session is complete.
      • Being flexible about feeding schedules to permit KC before or during feedings.
  1. Monitor for signs of hypoglycemia that may be indicative of hypothermia following the bath, such as irritability, lethargy, jitteriness, apnea, tachypnea, pallor, and cyanosis (see also the section Hypoglycemia, below).
  2. If the neonate becomes hypothermic:
    1. Place in KC in an incubator or under a radiant warmer
    2. Monitor temperature every 30 minutes until it is within normal limits, and
    3. Review risk factors and potential signs of illness.

Discharge Planning

Discharge should not be considered before 48 hours of age for LPIs.

  1. Confirm that the infant's temperature is 97.7°–99.3° F (36.5°– 37.4°C) while in an open crib and with appropriate clothing (or while in KC) for 12 hours preceding discharge.
  2. Teach the parents and assess learning about signs and symptoms of thermal instability, such as:
    1. Low or high temperature
    2. Baby looks "just not well"
    3. Breathing difficulties
    4. Pale, cool skin
    5. Poor feeding
    6. Flushed appearance
  1. Complete parent teaching and assess learning about:
    1. The procedure for taking an axillary temperature
    2. The range of normal temperature and signs of instability
    3. The procedure for bathing and bath water temperatures based on the parameters presented above
    4. Normal home environment temperature and dressing the infant in layers appropriately to maintain normal body temperature but not to overheat
    5. When to call the primary pediatric care provider:
      • Temperature above 100.4° F (38.6° C) or below 97° F (36.1° C).
      • Signs of thermal instability
      • Signs of dehydration, such as:
        • Low urine output
        • Poor skin turgor
        • Dry skin and mucous membranes
        • Pale, cool skin with prolonged capillary refill
        • Lethargy or increased irritability

Hypoglycemia

Assessment

  1. Review the antepartum/intrapartum history for conditions that increase the risk of hypoglycemia:
    1. Maternal conditions:
      • Gestational or diabetes mellitus
      • Pregnancy-induced hypertension
      • Maternal obesity
      • Tocolytic use for preterm labor
      • Late antepartum/intrapartum administration of intravenous glucose
      • Difficult/prolonged delivery
      • Nonreassuring fetal heart rate pattern
    1. Neonatal conditions:
      • Prematurity
      • Intrauterine growth restriction
      • Twin gestation
      • 5-minute Apgar score <7
      • Hypothermia/temperature instability
      • Sepsis
      • Respiratory distress
      • Polycythemia-hyperviscosity
  1. Use information determined from the gestational age assessment (New Ballard Score), growth assessment, and physical examination to evaluate risks for hypoglycemia.

Intervention

  1. Immediately after birth, quickly dry and assess the neonate, then place the stable neonate in KC with the mother until the first feeding is completed.
  2. Perform a screening plasma glucose test by heel or venous sampling within the first 2 hours of life if the baby is displaying symptoms of hypoglycemia.
  3. Assess the neonate frequently and at regular intervals for signs of hypoglycemia:
    1. Poor feeding
    2. Hypothermia
    3. Abnormal cry, irritability, lethargy
    4. Tremors, jitteriness, hypotonia, seizures
    5. Change in level of consciousness
    6. Apnea, tachypnea, pallor, cyanosis
    7. Periodic breathing
  1. Provide early, frequent feedings on demand, allowing no more than 2–3 hours between feedings if breastfeeding or 3–4 hours if formula-feeding.
  2. If hypoglycemia is suspected, immediately assess glucose levels, either from a heel stick or venous glucose concentration, preferably by glucometer, and report and record the results.
  3. Threshold glucose ranges for diagnosis and intervention vary according to facility protocol. However, in general, if the glucose value is less than 40–45 mg/dL (2.2–2.6 mmol/L), immediately send a blood specimen to the laboratory for confirmation.
  4. Institute treatment without delay as indicated based on the plasma glucose value obtained by point-of-care (bedside) testing.
  5. If the neonate has a plasma glucose value of 40–45 mg/dL (2.2–2.6 mmol/L) or more, frequent feedings should be established and the neonate followed clinically as warranted.
  6. If the neonate has a plasma glucose value below 40–45 mg/dL (2.2–2.6 mmol/L), the baby should immediately be put to the breast or formula-fed, by mouth or gavage as appropriate. If the breastfed newborn requires supplementation, breast milk should be provided whenever possible. A repeat plasma glucose level should be obtained within 30 minutes after the completion of the feeding.
  7. If the neonate exhibits clinical signs, has a plasma glucose value below 40–45 mg/dL (2.2–2.6 mmol/L), and refuses or does not tolerate feedings, the nurse should request orders for the following interventions:
    1. An intravenous bolus of 2 mL/kg of dextrose 10% in water (D10W) should be given immediately, and an intravenous D10W infusion initiated at a rate of 4–6 mg/kg/minute (80 mL/kg/day).
    2. A repeat plasma glucose level should be obtained within 30 minutes of completion of the D10W bolus.
    3. A recheck of the plasma glucose value every 1–2 hours until a safe, steady-state glucose concentration has been achieved.
  1. For persistent hypoglycemia, consider transferring the infant to a higher acuity unit or a high-risk facility.

Discharge Planning

  1. Teach parents and assess learning about signs of hypoglycemia including but not limited to:
    1. Poor feeding
    2. Hypothermia
    3. Abnormal cry, irritability, lethargy
    4. Tremors, jitteriness, hypotonia, seizures
    5. Change in level of consciousness
    6. Apnea, tachypnea, pallor, cyanosis, periodic breathing
  1. Reinforce the importance of frequent feedings to maintain hydration, euglycemia, and successful establishment of feeding regimens.

Sepsis

Assessment

  1. Recognize that the LPI is at increased risk for sepsis.
  2. Identify maternal risk factors that may predispose to early-onset sepsis:
    1. Prolonged rupture of membranes (>18 hours)
    2. Less than 37 completed weeks of gestation
    3. Evidence of intra-amniotic infection
    4. Intrapartum fever (temperature >100.4º F [38º C])
    5. Young maternal age
    6. Black race
    7. Hispanic ethnicity
    8. Low maternal levels of anticapsular antibody
    9. Previous delivery of an infant with invasive group B beta hemolytic streptococcus (GBS) disease
  1. Identify neonatal risk factors that may predispose to early-onset sepsis:
    1. Prematurity
    2. Male sex
    3. Multiple births
    4. Low birthweight (<2,500 grams)
    5. Congenital anomalies
    6. Difficulties during delivery, such as meconium staining, resuscitation, or birth asphyxia
    7. Black race
  1. Recognize the presenting signs of infection in the newborn, including the following:
    1. Temperature instability
    2. Lethargy
    3. Jitteriness
    4. Irritability
    5. Hypotonia
    6. Respiratory distress
    7. Hypotension
    8. Poor perfusion
    9. Poor feeding
    10. Gastric distension
    11. Vomiting or diarrhea
    12. Glucose instability
    13. Rashes, pustules, or petechiae
    14. Jaundice

Intervention

  1. Communicate assessment data to the primary care provider, anticipate the need for a sepsis workup, and initiate antibiotic therapy as ordered for infants who present with clinical signs consistent with infection.
  2. Anticipate that at least a limited diagnostic evaluation may be ordered in the asymptomatic LPI born to a mother whose group B beta hemolytic streptococcus status is unknown. This evaluation includes but may not be limited to obtaining a complete blood count analysis (CBC) and monitoring neonatal vital signs more frequently than every 4 hours for the first 24 hours as needed.
  3. Infants (term, late preterm, and preterm) with clinical signs of infection should have a full diagnostic evaluation, including complete blood count, blood culture, chest x-ray, and lumbar puncture, if feasible; they should receive empiric antibiotic therapy.
  4. Continue to monitor the LPI for signs of infection for at least 48 hours before discharging the infant from hospital.

Discharge Planning

  1. Provide education to the family and assess learning regarding strategies to prevent infection:
    1. Signs of infection
    2. Meticulous and frequent handwashing
    3. Avoidance of crowds and public places
    4. When to call the health care provider

Jaundice and Hyperbilirubinemia

Assessment

  1. Recognize that the LPI is at increased risk for developing hyperbilirubinemia.
  2. Recognize that the LPI is more susceptible to severe hyperbilirubinemia and kernicterus:
    • Identify risk factors for severe hyperbilirubinemia (see Appendix A in the original guideline document).
  1. Assess the quality and adequacy of breastfeeding, and provide ongoing encouragement and support for breastfeeding mothers.
  2. Assess for the presence of jaundice in the first 24 hours, and initiate immediate screening of total serum bilirubin (TSB) if visible jaundice is present.
    • Visual assessment of jaundice alone is not recommended
  1. Evaluate bilirubin levels prior to discharge using transcutaneous (TCB) or total serum bilirubin levels.
    • Consider obtaining transcutaneous bilirubin levels from both the mid-sternum and forehead.

Intervention

  1. Plot TSB levels on an hour-specific bilirubin nomogram and identify the infant's risk of developing severe hyperbilirubinemia (see Appendix B in the original guideline document).
  2. Ensure that phototherapy is initiated when the infant's bilirubin level reaches the threshold for treatment presented in Appendix B in the original guideline document.

Discharge Planning

  1. Perform a systematic assessment of the infant prior to discharge to help determine for the risk of severe hyperbilirubinemia.
  2. Provide parents with written and verbal information and validate their understanding about newborn jaundice, including the following:
    1. Signs and symptoms of jaundice
    2. Importance of contacting their health care provider if their infant becomes jaundiced
    3. Importance of maintaining adequate hydration
    4. Importance of contacting their health care provider if their infant is not eating well
  1. Ensure that an appointment for a follow-up visit is made with the primary pediatric care provider within 24-48 hours of hospital discharge.

    If this post-discharge visit does not coincide with the time frame when the LPI's bilirubin levels are likely to peak (day 5 to day 7), an additional follow-up visited should be planned for between day 5 and day 7 of life.

Feeding Challenges

Assessment

  1. Assess the LPI's readiness to feed before initiating oral feeding and at regular intervals during hospitalization:
    1. Evaluate the coordination of sucking, swallowing, and breathing. Behaviors demonstrating success include smooth, regular respirations and hand activity near the face with good posture. Behaviors demonstrating stress include increased respiratory rate, coughing, and choking.
    2. Behavioral feeding cues may include:
      • Rooting
      • Hand-to-mouth movements
      • Sucking movements/sounds
      • Opening of mouth in response to tactile stimulation
      • Transition between behavioral states from sleep to drowsy and quiet alert
    1. Evaluate infant's sleep-wake cycle prior to feedings.
  1. Monitor the LPI for physiologic stability during early feedings.
  2. Evaluate the mother's position for breastfeeding, latch, and milk transfer at least twice per day after birth.
  3. Evaluate the infant for potential complications associated with poor feeding, such as hypoglycemia, hyperbilirubinemia, and increased weight loss.

Intervention

  1. Facilitate early infant feeding as soon as possible after birth.
  2. Observe, educate, and validate the mother's knowledge about feeding behaviors seen in LPIs, such as the following:
    1. Patterns of sucking, including coordination of sucking, swallowing, and breathing
    2. Need to wake before feedings
    3. Need for frequent feedings
    4. Importance of monitoring milk intake
  1. Educate the mother who is breastfeeding and validate her knowledge about methods to facilitate milk transfer, such as proper latch, prepumping her breast prior to breastfeeding, milk expression, and other measures, such as the following
    1. Ensuring proper positioning and head support
    2. Using a breast pump
    3. Using nipple shields
    4. Seeking support from a lactation consultant

Parent Teaching and Support

  1. Teach parents and validate their understanding about the special health needs of LPIs affecting their care at home. These include but may not be limited to the following:
    1. Maintain NTE and dress the infant appropriately.
    2. Help prevent the spread of infection by good handwashing, limiting contact with ill family members, limiting contact with visitors, and breastfeeding when possible.
    3. Maintain adequate nutritional and fluid intake to promote adequate growth and development.
    4. Ensure frequent monitoring by a pediatric health care provider and contact the primary pediatric care provider immediately if the following conditions arise:
      • Temperature below 97° F (36.1° C) or above 100.4° F (38° C)
      • Difficulty breathing or turning blue (instruct parents to call for emergency services [911] in this case)
      • Jaundice
      • Difficulty feeding
      • Vomiting
      • Failure to void for 12 hours
      • Lack of stooling for 24 hours
      • Lethargy
      • Irritability
      • Changes in the baby's typical behaviors
    1. Place the infant in supine position (e.g., on his back) for sleep and avoid soft mattresses or blankets under the infant. Avoid exposure to secondhand smoke.
  1. Support the establishment of the parental role:
    1. Encourage rooming in whenever possible.
    2. Encourage KC (skin-to-skin care) and minimize hospital-associated constraints, such as staff interruptions and infant unavailability.
      • Assess all vital signs, pulse oximetry, and pain score before KC and 15 minutes after transfer to KC.
      • Assess parental readiness and teach them about skin-to-skin holding.
      • To facilitate KC, the mother should wear a front-button blouse or patient gown and remove her bra.
      • Assist the parent with transferring infant to KC.
      • Position the infant chest-to-chest, upright, inclined about 30 degrees, with the infant’s nose slightly above the mother's nipples.
      • Monitor the infant's vital signs, pulse oximetry, and pain scores as needed during skin-to skin holding. Vital signs should be monitored every 10–15 minutes during skin-to-skin holding for ventilated newborns.
      • KC can be usually be maintained for 1 hour or more.
    1. Help parents identify infant behaviors, especially alertness, hunger, and satiety cues.
    2. Model appropriate responses to infant cues during routine caregiving, such as responding quickly to infant cries or fussiness and talking and maintaining eye contact when the infant is alert.
  1. Assess the mother for emotional distress, especially depression and posttraumatic stress symptoms.
  2. Encourage parents to spend time interacting with their infant at home.
  3. Help parents identify a primary pediatric care provider and community follow-up resources before discharge.
  4. Ensure that an appointment for a follow-up visit is made with the primary pediatric care provider within 24-48 hours of hospital discharge. If this post-discharge visit does not coincide with the time frame when the LPI's bilirubin levels are likely to peak (day 5 to day 7), an additional follow-up visited should be planned for between day 5 and day 7 of life.
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the original guideline document for referenced rationale and specific quality of evidence ratings for each recommendation).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

The guideline describes evidence-based approaches to accomplish the following:

  • Identify the late preterm neonate at risk for complications during the continuum from birth through hospital discharge.
  • Recognize the physiologic limitations and challenges of a late preterm infant (LPI) that place him or her at increased risk.
  • Describe emerging research regarding potential neurodevelopmental consequences of late preterm birth.
  • Perform a risk assessment of perinatal events that may adversely impact the LPI.
  • Validate the LPI's gestational age.
  • Assess respiratory status and intervene to minimize the risk of respiratory distress.
  • Implement interventions to promote thermoregulation.
  • Assess and intervene to help prevent and manage hypoglycemia.
  • Assess the risk for sepsis and implement appropriate interventions.
  • Assess the risk and implement interventions for hyperbilirubinemia.
  • Address feeding challenges and promote successful breastfeeding.
  • Incorporate elements of the Guideline into nursing interventions, discharge planning, and parent education.
Potential Harms

Not stated

Qualifying Statements

Qualifying Statements
  • The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) requires authors and planners to identify investigational products or off-label uses of products regulated by the U.S. Food and Drug Administration at first mention and whenever appropriate in the content. No off-label drugs or devices are presented in the guideline.
  • The planners have ensured that the educational activity is free of any commercial bias by participating in development and review of the evidence-based guideline and by developing its associated continuing education activity.
  • The Evidence-Based Clinical Practice Guideline was developed for AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses, as an informational resource for nursing practice. The Guideline does not define a standard of care, nor is it intended to dictate an exclusive course of management. It presents general methods and techniques of practice that AWHONN believes to be currently and widely viewed as acceptable, based on current research and recognized authorities.
  • Proper care of individual patients may depend on many individual factors to be considered in clinical practice, as well as professional judgment in the techniques described in the original guideline document. Variations and innovations that are consistent with law, and that demonstrably improve the quality of patient care, should be encouraged. AWHONN believes that the drug classifications and selections set forth in the guideline are in accordance with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check information available in other published sources for each drug for potential changes in indications, dosages, warnings, and precautions. This is particularly important when a recommended agent is a new or infrequently employed drug. In addition, appropriate medication use may depend on unique factors such as individuals' health status, other medication use, and other factors that the professional must consider in clinical practice.
  • The information presented is not designed to define standards of practice for employment, licensure, discipline, legal, or other purposes.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Foreign Language Translations
Patient Resources
Quick Reference Guides/Physician Guides
Staff Training/Competency Material
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). Assessment and care of the late preterm infant. Evidence-based clinical practice guideline. Washington (DC): Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN); 2010. 57 p. [109 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2010 Jul 30
Guideline Developer(s)
Association of Women's Health, Obstetric, and Neonatal Nurses - Professional Association
Source(s) of Funding

Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN)

Publication of the guideline was supported through an educational grant from Johnson & Johnson Pediatric Institute, LLC.

Guideline Committee

Late Preterm Infant Guideline Development Team

Composition of Group That Authored the Guideline

2008–2010 Late Preterm Infant Guideline Development Team: M. Terese Verklan, PhD, CCNS, RNC, (Guideline Development Team Leader); Debbie Fraser Askin, MN, RNC; Catherine Hill, MSN, RN; Diane Holditch-Davis, PhD, RN, FAAN; Jane Lamp, RN-BC, MS, CNS; Barbara Medoff-Cooper, PhD, FAAN; Anne Santa-Donato, RNC, MSN

Financial Disclosures/Conflicts of Interest

The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) requires authors, planners, and reviewers in a position to control content of an Evidence-Based Clinical Practice Guideline to disclose all relevant financial relationships with any commercial interest. Diane Holditch-Davis, PhD, RN, FAAN discloses that she owns common stock in Proctor and Gamble and General Electric. Julie Solomon, PhD, (Science Team representative and reviewer) discloses that she is a consultant for Johnson & Johnson Corporate Contributions on behalf of its philanthropic corporate giving programming. Other authors and planners for this Evidence-Based Clinical Practice Guideline disclosed no relevant financial relationships that might create a conflict of interest.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Not available at this time.

Print copies: Available by contacting the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN), 2000 L Street, N.W. Suite 740, Washington, D.C. 20036; Phone: (800) 354-2268; Web site: www.awhonn.org/store External Web Site Policy.

Availability of Companion Documents

The following is available:

  • Quick care guide: Assessment and care of the late preterm infant. Washington (DC): Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN), 2010. 4 p.

Print copies: Available with purchase of the evidence-based guideline by contacting the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN), 2000 L Street, N.W. Suite 740, Washington, D.C. 20036; Phone: (800) 354-2268; Web site: www.awhonn.org/store External Web Site Policy.

Also, the appendices of the original guideline document contain a continuing nursing education credit application, post-test questions, and an evaluation form.

Patient Resources

The following is available:

Additional prematurity patient education materials are available from the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) Web site External Web Site Policy.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This summary was completed by ECRI Institute on December 17, 2010. The information was verified by the guideline developer on February 15, 2011.

Copyright Statement

This summary is based on the original guideline which is copyrighted by the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) and protected by copyright law. This summary is available for public use and may be downloaded from the NGC Web site and/or transferred to an electronic storage and retrieval system for personal use. Notification of AWHONN for any use of the summary is appreciated but not required.

Requests for use of the original full text guideline should be directed to Rights and Permissions, Association of Women's Health, Obstetric and Neonatal Nurses, 2000 L Street, NW Suite 740, Washington, DC 20036 or permissions@awhonn.org.

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