Problems of late preterms lsd

Problems of Late Preterms

L S DeshmukhDM ( Neonatology )

Professor ( Pediatrics )GMC, Aurangabad

Term – 370/7 to 416/7 weeks gestation

“Near Term” – terms such as near term, early term, moderate preterm, mild preterm, borderline preterm, etc. have been used in the past to describe infants born anywhere between 32-37 weeks

Late Preterm – NICHD Workshop 2005 recommended the use of “Late Preterm” to describe infants born between 340/7 to 366/7 weeks, or 239—259 days counting from the first day of the LMP.

recommended discontinuing the use of the term “Near Term”.

Late Preterm Birth: Some Definitions

Gestational Age Terminology

Engle WA et al, Clin Perinatol 2008;35:325;

“Near-Term” conveys that these infants are almost term and therefore almost mature.

This may lead to false sense of security: - less rigorous assessment in first hours of life, - early discharge when infant is still at risk, - inadequate follow-up plans.

“Late Preterm” conveys the sense that they stillpremature and still vulnerable .

“All definitions are arbitrary, since maturation is a continuum”

Raju TNK et al, Pediatrics ,2006;118 1207-14

Why “Late Preterm” - not “Near Term”?

Of all preterm births, Late Preterm Births, 34 to 36 weeks, are both the largest and fastest growing subgroup

Since 1990, the rate of Very Preterm Birth (<32 weeks) has remained stable at 2% of live births

But between 1990 and 2003, Late Preterm Birth increased more than 20%, from 7.3% to 8.8% of live births, accounting for the majority of the increase in preterm birth rates over the last two decades.

As of 2005, Late Preterm Births represent 9.1% of live births

Based on 2005 Data from the CDC on singleton births, Late Preterm Births made up about 72% of all preterm births

2008 NCHS Data Brief: Recent Trends in Infant Mortality in the US

Late Preterm Birth Rates

Increase Most Striking in Late-Preterm Group

25% increase in Late Preterm Group

Slide courtesy of Dr. Tonse Raju, 2007 presentation

7%

5%

14%

13%

22%

40%<32 weeks

32 weeks

33 weeks

34 weeks

35 weeks

36 weeks

Source: NCHS, final natality dataPrepared by March of Dimes Perinatal Data Center, April 2006.

75% of singletonpreterm births

36 wks

35 wks

34 wks

Slide courtesy of Dr. Tonse Raju, 2007 presentation

Preterm Singleton Live Births

What are the Causes of Increasing Preterm and Late Preterm Births?

• Traditional Causes

– Maternal and fetal disorders

– Twins, triplets, and higher-order multi-fetal pregnancy

– Errors in gestational age assessment

What are the Causes of Increasing Preterm and Late Preterm Births?

•New causes

– Increasing Maternal Age

– Increasing maternal overweight/obesity

– Increasing rates of multi-fetal pregnancies

– Medical Interventions: earlier evaluation, diagnosis and deliveries ? efforts to reduce stillbirth rates

Non-Traditional Reasons/Causes?

• Some “indications” for preterm births in medical records :

– “Prevention of post-maturity” – “Impending labor” • “Softer” indications : – “borderline” non-reassuring fetal heart tracings • Mutual Convenience : – Maternal request• “We have a great NICU”—no worries : – “A little bit of huffing and puffing, can be treated

with a little bit of oxygen

Tonse N. K. Raju , 2012 AAP Workshop on Perinatal Practice Strategies

Transitional Respiratory Distress (RDS)

Temperature Instability

Hypoglycemia

Feeding difficulties

1 Late Preterm Birth: Every Week Matters, March of Dimes. March 2006.2NICHD Workshop: Optimizing Care and Long-term Outcome of Near-termPregnancy and Near-term Newborn Infant. July 18-19. Bethesda, MD, 2005.

Medical Issues in Late-Preterm Infants

First Week Neonatal jaundice

Apnea

Infection rate

Later Neonatal Period Poor feeding and dehydration

Readmission to hospital




Early Infancy SIDS risk

Later Outcomes Learning difficulties & School failures

Behavior problems


Risk factors for morbidity

• Multiple gestation

• ? Lack of antenatal corticosteroid administration

• cesarean delivery

• Complicated vaginal delivery

• Maternal diabetes

• ? insurance

Neonatal Morbidity

7 times greater in LPTI– 22% vs. 3%

10-14 times greater with

other risk factors

Shapiro-Mendoza, Pediatrics

2008

Neonatal morbidity Vs GA

Shapiro-Mendoza CK et al.Pediatrics 2008;121:e227

Gestational age was significantly correlated with morbidity risk

Neonatal Morbidity

Temperature instability– 10% (0%)

Hypoglycemia– 15% (6%)

RDS– 29% (4%)

Apnea– 6% (<0.1%)

Jaundice– 54% (38%)

Feeding difficulties– 32% (7%)

Shapiro-Mendoza, Pediatrics 2008

Engle W Clinics in Perinatology 2008

Rate of neonatal morbidity Vs GA

Obstet Gynecol 2009;114:258

clinical outcomes in near-term

Wang ML, Dorer DJ, Fleming MP, et al. Pediatrics 2004

Composite adverse neonatal outcome

Am J Obstet Gynecol 2008;199:367,e6.

Early Neonatal Outcome in Late PretermsIndian data Femitha P et al ,

Indian J Pediatr (August 2012) 79(8):1019–1024

Significantly higher odds of developing morbidity• Respiratory distress (12.4% vs. 5.6%, OR 2.21, 95%CI

1.21,4.11) • need for non invasive (17.3% vs. 5.7%, OR 3.05 95% CI• 1.69, 5.47) • invasive ventilation (14.6% vs. 1.7%, OR 8.62, 95% CI

3.09, 24.04), • Sepsis (20.8% vs. 5.2%, OR 5.20, 95% CI 2.71, 9.99), • Seizures (22.8% vs. 4.8%, OR 4.75 95%CI 2.61, 8.63), • Shock (17.6% vs. 4.4%, OR 4.00 95% CI 2.12,7.56), • Jaundice (26% vs. 6%, OR 4.3395%CI 2.54, 7.39).

Mortality 0-28 days (forest plot)

Teune. Am J Obstet Gynecol 2011

Mortality 0-365 days (forest plot)

Teune. Am J Obstet Gynecol 2011

Respiratory Problems

Epithelial sodium (Na) absorption in the fetal lung near birth

Perinatol 2008;25(2):75–8

Respiratory morbidity according to gestational age

Hibbard JU, Wilkins I, Sun L, et al. JAMA 2010;304:423

Respiratory Morbidity In Late PretermsJAMA, July 28, 2010—Vol 304,

feeding issues

• Vulnerabilities

1. Respiratory Instability

2. Immature state regulation

3. Hypotonia and Immature Feeding Skills

4. Insufficient milk (delayed lactogenesis)

Late Preterm Infant Risk Factors for feeding problems

• Initially, may feed well with small volumes• Unable to take larger volumes after discharge

- Great Pretenders• Skin-to-skin in delivery room not done• Separation from mother• Delayed initiation of feeding• Infrequent feeding• Sleepy, non-demanding behavior, needs to be

awakened for feedingsAdapted from Tomashek et al; Sem Perinatol 2006; 30:61

Hypoglycemia in the Late Preterm Infant

• The incidence of hypoglycemia inversely proportional to GA

• Glucose levels fall 1-2 hrs after birth

• Late preterm infants:

- Immature hepatic glycogenolysis

- Decreased adipose tissue lipolysis

- Deficient hepatic gluconeogenesis and ketogenesis

Hyperbilirubinemia

• Readmission due to jaundice–7 to 13 fold increased risk

• Slower meconium passage

• Low milk intake

• Decreased activity of bili-conjugating enzyme

• Bilirubin peak levels typically occur around 5 to 7 days of life

• Kernicterus is seen more frequently in LPT

Risk zones of near-term newborns according to the percentile tracks based on the hour-specific serum bilirubin values

Pediatrics 2004

Hyberbilirubinemia

• Preventative goals–Optimize milk intake

–Promote rapid meconium clearance and increase stool volume

–Prevent excessive weight loss

• more structured approach to management and follow-up (predischarge bilirubin , GA, and other clinical risk factors ) Bhutani VK , Indian Pediatr, 2012

Kernicterus in Late Preterm Infants Cared for as Term Healthy Infants.

125 cases in US, 1979 – 2002 “healthy at discharge” Sources – parents, MDs RNs, literature, med-legal 69% male Nearly all breastfed [follow up scheduled for 2 weeks] 97% discharge <72 h (58% < 48 h) 25% Late Preterm infants LGA with kernicterus

35% Late Preterm infants were LGA* 25% Term infants were LGA*

Bhutani, Semin Perinatol 2006; 30:89-97

Kernicterus Registry Incidence & Patient Profile

Kernicterus in Late Preterm Infants

Largest group on Kernicterus Registry

Late Preterm Infants due to :

Suboptimal milk intake

Bilirubin binding to albumin less than term

Delayed follow-up visits

Signs of kernicterus may be more subtle

- Hypertonia, irritability Posturing,

Neurological Issues

Neurologic Immaturity

Decreased awake state

Low tone

Poor coordination of suck/swallow/breathe

Death and/or severe neurologic disorder and gestational age.

JB,Vintejoux A, Sagot P, et al. Int J Epidemiol 2010;39:772

The risk of death

severe neurologic disorder defined by is

chemic encephalopathy, grade 3or 4 IVH,

cystic PVL, and/or seizures

Developmental delay, CP, & GA

Petrini JR et al, J Pediatr 2009;154:174

Discharge Criteria

• not be considered before 48 hours after birth.• Vital signs should be within normal range for

the 12 hours proceeding discharge.• Passage of one stool spontaneously.• Adequate urine output.• 24 hours of successful feeding: ability to

coordinate sucking, swallowing and breathing while feeding.

• If weight loss greater than 7% in 48 hours, consider further assessment before discharge.

• Risk assessment plan for jaundice for infants discharged within 72 hours of birth.

Ramachandrappa A et al, Pediatr Clin N Am 56 (2009) 565–577

Readmission

• LPIs are readmitted 2 to 3 times more often than term infants

• Common reasons:

– Jaundice, infection, feeding issues, failure to thrive

• Risk factors:

– Primigravida mother, breastfeeding, maternal complications

Readmission after NICU Discharge

Group (LOS) n Rehospit. %

≥ 37 wk (< 96 h) 2593 2.2

≥37 wk (≥ 96 h) 1133 2.8

33-36 wk (< 96 h) 545 5.7

33-36 wk (≥ 96 h) 1196 2.2

< 32 wk (all LOS) 587 3.4

Escobar et al., Pediatrics 1999

Readmission Diagnoses

• Dehydration, Weight Loss

• Hypernatremia

• Severe Hyperbilirubinemia

Comparison of frequency of different methods of therapy

Archives of Perinatal Medicine 16(2), 83-85, 2010

Early School Age Outcomes

Morse SJ et. al: Pediatrics, 2009

Linnet KM et al., Arch Dis Child 2006

Is There an Expanded Role forAntenatal Steroids at > 34 weeks?

• Late preterm infants have been excluded

from most randomized studies; or the number randomized is too few to study accurately.

• In the majority of studies utilizing a single

course of Betamethasone, the benefit seems

to outweigh the risk.

Antenatal Steroids for Term Cesarean SectionASTECS study group

• 1995 –2002

• 10 centers in the UK; N= 998 women

• Randomized to receive Betamethasone

• 48 hours prior to elective c/s > 37 wks

• # Adm to SCU with respiratory distressStutchfield et al BMJ 2005

Antenatal Steroids for Term Cesarean SectionASTECS study group

• Combined respiratory morbidity

5.1% vs. 2.4% ( 0.46, CI 0.23-0.93)**

• Respiratory distress syndrome

1.1% vs 0.2% ( 0.21, CI 0.03 –1.32 )

• Transient tachypnea of the newborn

4.0% vs. 2.1% ( 0.54, CI 0.26 – 1.12 )

Stutchfield et al BMJ 2005

Antenatal Steroids ?

• Cochrane Database , 2009- results from the single trial promising

- larger samples are needed

• Effectiveness of antenatal corticosteroids in reducing respiratory disorders in late preterm infants: randomised clinical trial Porto AMF et al, BMJ. 2011; 342: d1696.

• - No effect on RDS

• - decreased need for PT for jaundice

Late preterm infants: the known and the unknown

What’s known

a. Mortality rises with each week lost in gestation below 39 weeks.

b. Excess morbidity, mostly transient, is related to global immaturity.

c. Birth at earlier gestations has an impact on health and mortality beyond the neonatal period.

d. Long-term neurologic outcomes are a cause of concern.

Mohan SS et al , Clin Perinatol 38 (2011) 547–555

Late preterm infants: the known and the unknown

What’s unknowna. Are adverse outcomes due to early delivery or due to

the events preceding late preterm birth?

b. Are outcomes after preterm labor, preterm rupture of membranes, or medically indicated late preterm birth different?

c. Can late preterm births and iatrogenic prematurity be safely reduced?

d. Can interventions, such as antenatal steroids, improve outcomes?

Mohan SS et al , Clin Perinatol 38 (2011) 547–555

Conclusions

• All preterm deliveries need to be indicated (medical or obstetric indications only)

• Understand and watch for specific medicalcomplications

Respiratory Distress Hypoglycemia Temperature instability/hypothermia Feeding difficulties Jaundice/ hyperbilirubinemia Keep a low threshold for NICU transfer

Conclusions Early discharge should not occur in these infants and

diligent follow up is important, both in the post neonatal period and for continued long-term care.

Long- term Problems :

- Learning difficulties, school failures;

– Medical, psychological, and behavioral problems into adult lives

They need to be treated as preterm infants

Knowledge is Power

Educate yourselves

Educate your colleagues

Educate your patients

Together we can make a big impact on the number of late preterm infants born with just a little knowledge

and prevention…

Conclusion

Questions?

Healthcare

Problems of late preterms lsd