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
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
"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
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
"Is everything OK?" she asked, assuming
all this extra attention meant something
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,
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
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
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
But recent studies suggest this group
of infants may not be as healthy as once
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
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
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
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,"
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
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
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
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.
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
Despite having some difficulty breathing,
Rylan did not end up in the NICU
observation unit. Instead, he stayed with
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
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
Still, it's important for mothers to be
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
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 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.
Read the November / December 2010 issue of Wave