Preterm newborns are not able to tolerate the amount of stimuli that is usually involved with a newborn. This includes holding, stroking, sound, light, and pain. They require more uninterrupted sleep and an environment that is not brightly lit, quiet and less handling. What happens when a newborn arrives? Everyone wants to hold the baby, stroke the soft skin, talk loudly amongst themselves and stimulate the baby while he/she is trying to feed. They do not consider what effect all of this stimuli on their immature neurological system may have.
One consequence is failure to regulate. What does this mean? The baby is unable to calm himself/herself when over stimulation is occurs. They go into a overload mode that looks like they are asleep. They are actually removing themselves from the stimuli by shutting down their systems. The can go from crying to sound asleep in a minute. This is often seen with attempts at breast feeding when they are not ready for it or too tired to attempt. They resist, then basically "pass out." This article is an excellent discussion of regulation issues and other issues that are important with babies born prior to 37 weeks. Of course, the earlier, the more problems, but also the sicker the more problems. Click on the link to read this informative article. Premature Infants: A later look.
Parents must be educated on this issue if we are to prevent long term problems with self calming and behavior. As mentioned in the article, feeding problems, excessive crying and sleep disturbances can last for years, not just weeks. Consider the number of children diagnosed with ADHD or Attention Deficit Disorders. Some of this is related to their gestation at birth.
A familiar sign we see from preterm babies is the "how sign." You may wonder what this is. Regarding the old westerns with cowboys and Indians, when the Indians greeted the white man, they put up their and in a gesture of welcome. Preterm babies do this to signal "STOP." They are overstimulated and have recognized this. They are asking us to leave them alone, so that they can collect themselves and may breastfeed or bottle feed. Watch for their "cues."
Tuesday, February 21, 2012
Discharge to home
Association of Women's Health, Obstetrics and Neonatal Nurses (AWHONN) has a Late Preterm Infant Initiative with parental information that can be utilized to educate parents on the behavior, care, risks and breastfeeding of this group of newborns. Visit the site at AWHONN Late Preterm Infant Initiative
to view this great information to assist with your discharge instructions.
Prior to discharge, any newborn less than 37 weeks gestation should have a car seat pulse ox study completed. What this involves is strapping the baby in the car seat that will be used for the baby, monitoring their oxygen saturation using a pulse oximeter for a minimum of 1 hour. Because these newborns are usually smaller, with less developed neck muscle strength it is much easier for them to block their airway by the position of their head, either too much to the side, or sagging onto the chest. By checking their tolerance in a car seat, we can better assure the parents that the baby will be safe traveling for short distances, as for physician visits. Newborns in this category are not able to tolerate long road trips and should be allowed out of the car seat at least every 2 hours if this travel is necessary.
Many parents do not understand the risk of feeding a baby that is strapped in a car seat. It is important to discuss this prior to discharge. Demonstrating that it takes more steps to remove a bottle from the baby's mouth, unstrap the baby from the car seat and then pick him/her up to allow clearance of fluid when the baby chokes will help them to understand. Because these babies are not "expert" feeders, they can still have episodes of choking or apnea while feeding from a bottle especially.
We have helped to get these baby's this far, we do not want to see them return as a "rule out SIDS" in the emergency department.
to view this great information to assist with your discharge instructions.
Prior to discharge, any newborn less than 37 weeks gestation should have a car seat pulse ox study completed. What this involves is strapping the baby in the car seat that will be used for the baby, monitoring their oxygen saturation using a pulse oximeter for a minimum of 1 hour. Because these newborns are usually smaller, with less developed neck muscle strength it is much easier for them to block their airway by the position of their head, either too much to the side, or sagging onto the chest. By checking their tolerance in a car seat, we can better assure the parents that the baby will be safe traveling for short distances, as for physician visits. Newborns in this category are not able to tolerate long road trips and should be allowed out of the car seat at least every 2 hours if this travel is necessary.Many parents do not understand the risk of feeding a baby that is strapped in a car seat. It is important to discuss this prior to discharge. Demonstrating that it takes more steps to remove a bottle from the baby's mouth, unstrap the baby from the car seat and then pick him/her up to allow clearance of fluid when the baby chokes will help them to understand. Because these babies are not "expert" feeders, they can still have episodes of choking or apnea while feeding from a bottle especially.
We have helped to get these baby's this far, we do not want to see them return as a "rule out SIDS" in the emergency department.
Saturday, February 18, 2012
Sudden infant death syndrome (SIDS)
The risk for sudden infant
death syndrome (SIDS) is double for the Late-preterm newborn (LPT) (Bakewell-Sachs, 2007). Some risk factors cannot be eliminated such
as delivery prior to 37 weeks for specific medical complications, but there are
many risk factors that can be eliminated, such as exposure to smoke during pregnancy
and after birth. Small or preterm
newborn boys born to unmarried mothers in their teens that smoke or drink
alcohol are at the highest risk for SIDS.
Being Native American or black with minimal education also contribute to
the risks (Hitti, 2006).
Did you know?
When mom or dad puffs on a cigarette, their infants may inhale the resulting
second-hand smoke. Now, researchers have detected cancer-causing chemicals associated
with tobacco smoke in the urine of nearly half the babies of smoking parents.
"The take home message is, 'Don't smoke around your kids,'" said
Stephen S. Hecht, Ph.D., professor and Wallin Chair of Cancer Prevention at The
Cancer Center at the University of Minnesota ("Carcinogens in urine,"
2006).
Links for sids information for parents
References
Friday, February 17, 2012
MindView concept map for Late-Preterm Newborns
This mindmap is an overview of the problems that we have been discussing regarding the LPT newborn. Notice the inter-relationships between poor feeding and 3 other problems and the long term consequences that are common to more than one problem.
Developing a mindmap such as this is an excellent method for students to participate in their learning from numerous perspectives. They are the researcher, the author, designer and writer (Asthana, n.d.).
Download a free trial of MindView, and try this out. Select a topic in Obstetrics that we have covered that relates to the early delivery of newborns in this LPT category. See how many factors you can relate and what the interrelationships between those factors are. Use your new knowledge acquired so far in this course, do some research and be creative.
Wednesday, February 15, 2012
Respiratory complications in the late-preterm (LPT) newborn
During
development of the respiratory system, the lungs begin production of a
substance called surfactant at 32-33 weeks gestation. Neonates that are
born at or before this time are at a significantly higher risk for respiratory
distress because of the absence of surfactant. This lubricant is
responsible for providing the elasticity of the lungs. Maximum levels of
surfactant are reached between 38-40 weeks gestation Engle, Tomashek, &
Wallman, 2007). Morbidity related to respiratory distress syndrome (RDS)
has decreased significantly since the introduction of manufactured surfactant,
such as Survanta® in 1991. http://abbottnutrition.com/Products/Survanta.aspx
Other issues that contribute to respiratory problems in the LPT newborn are related to gas exchange that is less effective than that of a more mature newborn. Alveoli are lined with epithelial cells that thin with maturity improving gas exchange and fluid absorption; the last few weeks of pregnancy. Transient tachypnea of the newborn (TTN) is seen more often in the LPT newborn especially if delivered by C section. For 6-24 hours, occasionally longer, the newborn is breathing at rates of 80-100/minute due to this increase in retained fluid (Bakewell-Sachs, 2007).
Apnea is a complication in 4-7% of LPT newborns. Besides causing anxiety in the parents, this can lead to bradycardia and ultimately hypoxia. Some reasons for this apnea include poor sensitivity to stimulation of the larynx and poor response to an increase in carbon dioxide levels due to a decrease in the sensitivity to the gas while there is an increase in the response to irritants. Poor muscle tone in the upper airway and central nervous system immaturity also play a role (Engle, Tomashek, & Wallman, 2007).
Environments
where the newborn is exposed to smoking increased the respiratory problems for
these newborns. This includes contact
with clothing worn in the presence of smokers.
Third hand smoke is causing more than just respiratory problems in these
newborns; it is also dangerous to their more sensitive brain . Read more in this article. http://www.scientificamerican.com/article.cfm?id=what-is-third-hand-smoke
Every day that the fetus remains in the uterus improves lung maturity and decreases the risks for prolonged hospitalization and long term respiratory problems. Morbidity related to respiratory complications has been reported to be between 4 and 29% (Engle, Tomashek, & Wallman, 2007).
Other issues that contribute to respiratory problems in the LPT newborn are related to gas exchange that is less effective than that of a more mature newborn. Alveoli are lined with epithelial cells that thin with maturity improving gas exchange and fluid absorption; the last few weeks of pregnancy. Transient tachypnea of the newborn (TTN) is seen more often in the LPT newborn especially if delivered by C section. For 6-24 hours, occasionally longer, the newborn is breathing at rates of 80-100/minute due to this increase in retained fluid (Bakewell-Sachs, 2007).
Apnea is a complication in 4-7% of LPT newborns. Besides causing anxiety in the parents, this can lead to bradycardia and ultimately hypoxia. Some reasons for this apnea include poor sensitivity to stimulation of the larynx and poor response to an increase in carbon dioxide levels due to a decrease in the sensitivity to the gas while there is an increase in the response to irritants. Poor muscle tone in the upper airway and central nervous system immaturity also play a role (Engle, Tomashek, & Wallman, 2007).
Environments
where the newborn is exposed to smoking increased the respiratory problems for
these newborns. This includes contact
with clothing worn in the presence of smokers.
Third hand smoke is causing more than just respiratory problems in these
newborns; it is also dangerous to their more sensitive brain . Read more in this article. http://www.scientificamerican.com/article.cfm?id=what-is-third-hand-smoke Every day that the fetus remains in the uterus improves lung maturity and decreases the risks for prolonged hospitalization and long term respiratory problems. Morbidity related to respiratory complications has been reported to be between 4 and 29% (Engle, Tomashek, & Wallman, 2007).
References
Sunday, February 12, 2012
The Big late-preterm baby
Not all late-peterm newborns are small. Some can be the size of a full term newborn, especially if the mother has diabetes. Infants of diabetic mothers (IDMs) are a category in themselves for increased risks. Type II or gestational does not seem to make a difference. The increased glucose level in the mothers blood stream provides more glucose than the fetus needs. A consequence of this is that these newborns are at a higher risk for respiratory distress because their lungs do not mature at the same rate as a fetus with normal levels of glucose during development.
The lungs of an IDM newborn of 36 weeks gestation could have the same maturity as one that is 34 weeks. Add onto this a larger body to oxygenate and you have a large baby with respiratory distress that very well may need ventilatory support. Assessments of all newborns is important; there are many unexpected complications that could be missed without a thorough assessment. Respiratory assessments are no different. If the newborn has obvious respiratory distress with grunting and retracting, no matter what color it is, this baby will be monitored more closely with pulse oximiters for oxygen saturation. There can also be an oxygen requirement with normal respirations, just because of the immaturity.
Relying on the color of a newborn is a very inaccurate means to evaluate oxygenation. Any newborn can have a blue face from bruising, a white face from a tight nuchal cord or some short term shock and perfusion issues, but the tongue and gums are usually a good visual indicator of oxygenation. Think about babies that you have seen during the frist 24-48 hours of life. Sometimes their color is not at all what is expected. Start paying attention to newborn pictures and their color, skin tone, bruising, jaundice.
The lungs of an IDM newborn of 36 weeks gestation could have the same maturity as one that is 34 weeks. Add onto this a larger body to oxygenate and you have a large baby with respiratory distress that very well may need ventilatory support. Assessments of all newborns is important; there are many unexpected complications that could be missed without a thorough assessment. Respiratory assessments are no different. If the newborn has obvious respiratory distress with grunting and retracting, no matter what color it is, this baby will be monitored more closely with pulse oximiters for oxygen saturation. There can also be an oxygen requirement with normal respirations, just because of the immaturity.
Relying on the color of a newborn is a very inaccurate means to evaluate oxygenation. Any newborn can have a blue face from bruising, a white face from a tight nuchal cord or some short term shock and perfusion issues, but the tongue and gums are usually a good visual indicator of oxygenation. Think about babies that you have seen during the frist 24-48 hours of life. Sometimes their color is not at all what is expected. Start paying attention to newborn pictures and their color, skin tone, bruising, jaundice.
Thursday, February 9, 2012
This little boy will be subjected to numerous heelsticks to check his blood glucose, bilirubin levels and possibly for a sepsis evaluation. Without measures to control pain, he will have long term consequences including behavioral (Jong, 2010) and his future responses to pain will be increased (Grunau, 2006). Future temperament, poor adaptability to changes, easy distractability and an overreaction to touch are some of the long-term consequences noted by research.
There are very effective pain control measures for him, if they are utilized and used correctly.
A 24% sucrose solution (Tootsweet®, Sweetease®) has been determined by numerous research studies to decrease pain perception and response in newborns by stimulating the brain to release endorphins. This is most effective if given 2 minutes prior to the painful intervention. What this means, is that the baby will be sucking on a pacifier or finger, which also helps to decrease pain perception, while this solution is squirted into the corner of his mouth. He may then not even realize that he has sustained a heelstick and that the nurse is obtaining the blood sample. The same is true for a venipuncture (Gal, 2005).
Imagine no crying and thrashing about; the baby is happy, the parents are happy and are often allowed to remain with the baby during the blood testing.
References:
Grunau, R. H. (2006). Long-term consequences of pain in human neonates. Seminars in Fetal & Neonatal Medicine, 11, 268-275.
Harrison, D. L. (2009). Repeated doses of sucrose in infants continue to reduce procedural pain during prolong hospitalizations. Nursing Research, 21(6), 491-498.
Jong, J. (2010). Can temperament be understood at birth? The relationship between neonatal pain cry and their temperament: A preliminary study. Infant Behavior & Development, 33, 266-272.
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