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Taking care of baby

New research suggests that late preterm babies may be more vulnerable to certain health issues than previously thought. Now, staff at St. Boniface Hospital are using new guidelines to ensure these newborns get off to a healthy start

Taking care of baby
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Preterm babies by the numbers

Information on early delivery

Baby development timeline

BY JOEL SCHLESINGER
Winnipeg Health Region
Wave, November / December 2010

Karen Schnell-Hoehn and her husband, John Hoehn, looked on with concern as the nurse placed an oxygen mask over the mouth of their newborn baby.

It was shortly after 9 a.m. on Friday, Aug. 13 at St. Boniface Hospital. Their son, Rylan, had been delivered only a few minutes earlier by C-section.

"Not to worry," Schnell-Hoehn was told by the attending nurse. Sometimes babies born a few weeks early require a little extra help breathing in their first few hours of life.

At 36 weeks, Rylan was one week shy of being considered a full-term baby and is considered a late preterm newborn - those prematurely born between 34 weeks and 36 weeks and six days of gestation in the womb.

The fact that their son was born slightly early was nothing new for the couple. Two years earlier, their first child, Nora, was born at 35 weeks, weighing just over six pounds. Yet here was their newest addition, one week older at birth and one full pound heavier, and the nurses were paying much more attention to his condition than they did to their daughter's two years ago.

"I think both of us were a little bit nervous about things," says Schnell-Hoehn, a cardiac nurse. "You want everything to work out well and you just don't know."

But after some reassurance from the bedside nurse that this was indeed normal procedure, their worries subsided. And sure enough, by the time both mother and child were in the post-partum ward four hours later, the oxygen mask was no longer needed.

Still, Schnell-Hoehn found the experience markedly different this time around. The nurses were paying close attention to Rylan's temperature, checking it every half-hour. They monitored his breathing, and they emphasized that he needed to feed, either by breast or bottle, every three hours, for no longer than 45 minutes.

And before every feeding, a nurse would draw a drop of blood from Rylan's heel to measure his glucose levels. That struck Schnell-Hoehn as odd more than anything else.

"Is everything OK?" she asked, assuming all this extra attention meant something was amiss.

But again, the nurse reassured her. They were just monitoring his blood sugar - as they would any other late preterm baby.

It wasn't that Rylan was less healthy than their other child, the bedside nurse informed her. It was the late preterm infant protocols - the guidelines regarding care - that had changed.

The changes are part of a two year-long, North American-wide study of care for late preterm infants. St. Boniface's maternity ward was one of 15 sites chosen across North America to participate and help gather data.

The study is being conducted by the Association of Women's Health Obstetrics and Neonatal Nurses - or AWHONN for short - with support from the Johnson & Johnson Pediatric Institute, LLC. Called the Late Preterm Infant Research-Based Practice Project, a primary aim of the study is to help reinforce and improve the guidelines already in place for care of late preterm babies, an often overlooked population of newborns by researchers, says Barbara Wheeler, a clinical nurse specialist with St. Boniface Hospital's Woman and Child Program, which is part of the Winnipeg Health Region's Women's and Child health programs.

In addition, the study goals include educating health-care providers about prevention of possible complications late preterm infants may experience, and ensuring mothers are knowledgeable about special care needs of late preterm infants. Most importantly, Wheeler says, the study - which will be reviewed by Region staff and will inform practices in other facilities - will help maternal and newborn health-care providers optimize care in the coming years as the number of older women giving birth increases, giving rise to a corresponding jump in the number of preterm babies being delivered.

As a group, Wheeler says older mothers are more prone to certain illnesses and conditions during pregnancy, such as diabetes, hypertension and obesity. And they often tend to deliver earlier as a result.

"There have also been increases in fertility treatments, which means an increase in the number of multiple gestations. When you've got more than one baby, they tend to be delivered early as well," says Wheeler, who is leading the project.

Late preterm deliveries have been a common occurrence. But according to a 2009 study at Emory University School of Medicine in Atlanta, the number of late preterm infants has increased by 25 per cent in the last 20 years, even though preterm infants younger than 34 weeks at birth have increased only about 10 per cent during the same time period. Today, late preterm births make up about 75 per cent of all preterm births, Wheeler says.

In the past, a late preterm baby's good health may have been considered a foregone conclusion. Maybe they required a little extra care compared with full-term babies, but their morbidity and mortality rates had been considered to be consistently low.

But recent studies suggest this group of infants may not be as healthy as once thought.

Last year, doctors at the neonatal division of McMaster University in Hamilton published findings suggesting that late preterm babies are at significantly higher risk of respiratory problems and readmission to hospital in the first few weeks of life as compared with full-term babies. And late preterm infants, as a group, have a 12-fold mortality risk compared to full-term infants.

While the mortality rate for late preterm babies remains low, Wheeler says health-care professionals working in this field have long suspected that late preterm babies are at higher risk of a number of complications that may not be apparent to these newborns' parents.

"Although they're bigger and look more mature than tiny, younger preterm infants, they're quite vulnerable and at higher risk of some problems ," says Wheeler. And some of those problems can seem relatively innocuous to parents at first.

One of the biggest challenges is simply keeping them warm. A chilled baby may not sound like such a big deal to new parents, but Wheeler says it can lead to bigger problems very quickly in the first few days of life.

Late preterm babies may be as large as full-term babies, but they do not have the same amount of body fat to help keep them warm. They are long, thin and lack muscle tone. "A full-term baby has flexed arms and legs and can be curled up for days after birth, but these preterm babies aren't like that," Wheeler says. "They tend to have straighter limbs and expose much of their bodies to the environment so they chill more quickly."

When their temperature drops below normal, babies start to breathe more quickly as they increase their metabolic rate to warm up. "In breathing more quickly, they can tire out and actually have lapses in breathing, which obviously is not a good thing," she says.

Furthermore, as their breathing changes, and fat and starch stores are metabolized, the blood chemistry may change. "Also, blood vessels in the skin may clamp down in an effort to keep the baby warm, and the baby may develop a condition called pulmonary hypertension," she says. "This is a dangerous condition where the baby doesn't receive the oxygen he or she needs, and it can be difficult to reverse. Prevention is critically important."

Basically, something as seemingly innocent as a slight chill can potentially result in much more serious consequences. "We know if a baby doesn't breathe well or oxygenate well, complications can happen unless the situation is corrected," she says. If parents notice their baby's breathing is laboured, or their colour is very pale or bluish, they need to get help immediately. In fact, researchers are also looking at potential long-term consequences, such as whether serious stresses early in life can lead to such problems as learning disabilities a few years later, Wheeler says.

While more research is needed to better understand long-term effects of neonatal respiratory distress and related problems in late preterm infants, the short-term effects are already a familiar sight at hospitals across North America. Some preterm babies will develop respiratory distress despite receiving excellent care, and they may then need a ventilator or intravenous fluids, which means the length of hospital stay can be long and may include a variety of complications. Although most preterm infants who end up in the neonatal intensive care unit go home after a few days or weeks, their presence in NICU is often very stressful for families."Prevention of things like a severe drop in temperature can decrease the risk of other potentially serious complications," she says.

Michele Carruthers, an NICU nurse at St. Boniface Hospital with more than two decades of experience, says the number of late preterm infants has increased in the last few years for a number of reasons, including the increased use of fertility drugs and the average age of mothers.

Health-care providers have always been faced with a dilemma in treating late preterm babies. "It becomes a question of what do we do with these babies and where do they belong?" she says. "They don't always belong in the intensive care unit, but then they may need more support than is available in the post-partum ward."

While the new care protocols impress upon nursing staff the importance of closely monitoring babies for respiratory distress and low body temperature, she says the end goal is that the changes will mean fewer babies require care in NICU and can stay with their moms.

"It used to be that we would routinely put 35-week infants in NICU," says Carruthers. Today, only those late preterm infants who struggle with breathing immediately after birth - or those with an obvious condition like a heart defect - are taken immediately to the NICU's observation unit.

There, they are kept warm in specially heated Plexiglas bassinets; their heart and breathing rates are monitored, as well as body temperature and blood glucose levels. If their respiratory condition is stable, they will be fed; if not, they may need intravenous fluids.

But after about four to six hours, most of the babies with early respiratory difficulty stabilize. Their breathing becomes normal, less than 60 times per minute. Their heart rate stabilizes at 120 to 140 beats per minute, and their blood sugar reaches a level where they have energy to do those three essential acts of early life - breathe, suck and swallow.

Late preterm babies often struggle with muscle coordination to feed early on, so just the simple act of feeding, in which they must breathe, suck and swallow, can be difficult, Carruthers says. Still, once temperature and respiration stabilizes, the likelihood of successful feeding increases. "And if they can maintain all those things, there's no reason for them to be away from their mom and in intensive care," says Michelle Jones, a clinical resource nurse for NICU, who has helped implement the new late preterm protocols.

Despite having some difficulty breathing, Rylan did not end up in the NICU observation unit. Instead, he stayed with his mother.

Although Schnell-Hoehn and her husband were concerned at first by all the attention nurses were paying to their son's vital signs, they soon realized the increased vigilance was for both their son's and their benefit. "It helped that they explained the importance of close monitoring for Rylan," she says.

And along the way they learned plenty of helpful tips to ensure their baby's wellbeing in the first few weeks of life, such as the importance of making sure Rylan wears a little cotton hat at all times. "The baby has to have a hat because that's the first place a baby will lose heat, through the head," Jones says. "It used to be you had the hat when you were first born, and then after the first bath, it was off." Now, late preterm babies wear a hat for at least the first few weeks of life, especially if they are in a cool or drafty space.

The couple also learned about the importance of skin-to-skin contact.

This helps the baby maintain a warm temperature, which helps maintain normal breathing. In turn, they spend less energy, able to devote more of it toward feeding rather than keeping warm.

"We like Mom best in that instance because we know skin-to-skin contact helps with milk production and breastfeeding," Wheeler says, adding fathers are also encouraged to do skin-to-skin care.

Having the baby feed within the first hour of life is another priority made clear by the nurse to mothers. Wheeler says late preterm babies may not be good feeders at first because they tend to be sleepier and less energetic than full-term babies. "The act of feeding is often rather difficult for these infants because some of them would rather sleep than feed," she says. Feeding late preterm babies as early as possible helps them increase their energy and maintain body heat.

Of course, breastfeeding is encouraged, but it's not always possible early on because mothers' milk production may be delayed or the baby's muscle tone and energy level may render him or her unable to breastfeed effectively at first. "Our goal is to begin feeding as soon as it is safe to do so," says Wheeler. "Ideally, that's with human milk because we know that's best for many reasons."

Once feeding has been established, mothers are reminded to feed often, every two to three hours, to ensure the baby's blood sugar stays elevated. If the level drops, so too will their energy and ability to feed and stay warm.

After the first 24 hours in hospital, Rylan was keeping warm by skin-to-skin contact and feeding every couple of hours. During the first few hours, the nurse drew a blood sample, using a lancet on the heel of his foot, before every feeding. This was to test his blood sugar levels. But as his levels stabilized, the blood tests became infrequent. Once nurses were confident his levels were stabilizing, they stopped the tests.

Before Rylan left hospital, a nurse did another blood test, but this time it was to check him for jaundice.

Jaundice occurs when babies have elevated levels of bilirubin, a natural byproduct that occurs in the body when red blood cells die off and break down.

"For babies, there's often a bit of time in the first few weeks of life that those cells are dying off faster than the body can clean them up," Wheeler says.

Jaundice is common in late preterm infants because their liver is underdeveloped and is not efficient in clearing the bilirubin from the blood. With proper feeding, however, bilirubin levels will usually fall.

Still, it's important for mothers to be aware that bilirubin levels peak five to seven days after birth - later than the three to five days of age when full-term babies reach their peak, which means it usually happens after the baby has gone home, Jones says. "If Mom isn't in tune to what the baby has taken in or the signs of dehydration, the baby may suddenly appear extremely yellow," she says. "And that can lead to a readmission into the unit for treatment."

While some jaundice is common in late preterm babies, extremely high bilirubin levels are concerning as they can result in brain damage in some instances if left untreated, Wheeler says. "Again, we believe that's fairly rare and we do everything to prevent it, but it's really important for families to know jaundice can escalate to dangerous levels quickly if babies aren't feeding well."

Although Rylan's levels were checked, they weren't elevated enough to prevent him from going home." They said to make sure that I tried to wake him up for feedings and then to let him really rest between feedings," Schnell-Hoehn says.

For the next few days, she and her husband did just that. They kept Rylan warm, ensuring his hat was on at all times, and they fed him regularly.

When the public health nurse came to visit a few days later, she found Rylan was progressing nicely. His weight hadn't increased dramatically, something to be expected in the first week after birth, but he was feeding well - a reassuring sign of a healthy newborn.

Most importantly, the nurse's advice helped reinforce what Schnell-Hoehn had learned in hospital.

Joel Schlesinger is a Winnipeg writer.

Wave

About Wave

Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books.

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