Hyperbilirubinemia in the late preterm newborn

Today we are taking a closer look at another complications experienced by the late preterm newborn: hyperbilirubinemia.  As  you remember we were talking about hypos: too little of something; now we are looking in the other direction, at too much bilirubin in the blood stream and in the brain.  Kernicterus is the condition that can lead to encephalopathy and long term neurological damage. 

A few reasons why this population is at a higher risk are the late development of the hepatic and neurological systems.  Even at term, the neurological system is not totally developed.  This opens the brain to damage more easily than a brain that is fully developed.  The immaturity of the liver is also a factor; it is inefficient in filtering the blood and removing the bilirubin.

Here we have a small baby that usually does not feed well, so is a bit more dehydrated, with a higher risk of hyperbilirubinemia and a higher risk of brain injury and add into it bruising from birth and incompatible blood types between mother and baby.  This scenario will result in a prolonged hospitalization.

Another concern with hyperbilirubinemia is when phototherapy is required, smaller babies with less fat stores have more difficulty maintaining  a normothermic state without the use of external heart sources.  Think about all of the consequences that you may not have considered when caring for a full term newborn with the same diagnosis.

The best way to prevent this is monitoring of serum bilirubin levels, assuring that there is an adequate intake with a supplementation of mother's pumped breast milk or donor breast milk, monitoring output as bilirubin is excreted in the urine and stool and accurate assessments of the newborns color and activity levels.  There is always another worry as well; pain during frequent heelsticks for bilirubin monitoring.

Tomorrow we will look at pain in the late preterm newborn, the effects that repeated pain has on an underdeveloped brain and interventions that can help prevent this stress and pain.

Late preterm newborns

Let's look at some of the most common problems seen with this population. Glucose homeostasis is not only important for brain function, it also plays a role in thermoregulation.

When a newborn becomes hypoglycemic, it utilizes brown fat stores to maintain homeostasis; with this is the attempt to maintain thermoregulation. This results in more glucose utilization.

It becomes a cycle of cold, hypoglycemia, and the requirement to take in nutrition such as breast feeding, which again requires energy expenditure.

Today, I would like you to consider other consequences of hypoglycemia in the late preterm newborn.

Why was the term "late preterm birth" conceived?

There are probably many reasons why we now have a category of newborn, the "late preterm"; those that have been born in this grey area between premature and term.  Research over the past decade has noted a trend with an increase in births during this time period as well as long term consequences for children that were born during this stage of development.  It was not until the two were put together, that specialists in Obstetrics and in particular Neonatology and Pediatrics realized that this group needed to be singled out and monitored more closely.  The Association of Women's Health, Obstetrics, and Neonatal Nurses (AWHONN) has been instrumental in leading the way when they developed the guidelines for "Assessment and care of the late preterm infant.  Evidence-based clinical practice guideline" in 2010.  Visit this site and review the guideline.
http://www.guideline.gov/content.aspx?id=24066&search=late+preterm+infants

We will be discussing this guideline this week, share what you have learned and questions that you have about this group of newborns.

Designing a nursing course

 

Designing a new nursing related course.  What an opportunity; design a course that I feel will be beneficial to nursing students for the next decade.  I can think of a few that I would like to redesign, but starting from scratch, oh my!

I have been a nurse for almost 40 years; now this I cannot believe.  I still enjoy caring for my patients in the Neonatal ICU (NICU) and forming relationships with their families.  This area of nursing is seldom covered in nursing school; they do touch on newborn care.  So, I am leaning towards a course that goes into more detail in the care of a premature or ill newborn.  They frequently start out in the newborn nursery, but soon are transferred to the NICU when complications are detected.

The Late preterm or Near term newborn is a group of newborns of major concern these days with the increased number of babies that are born in this gray area between premature and term; 35-38 weeks gestation.  Usually newborns 35 weeks or older are given a chance to "prove themselves" in the newborn nursery.  All this means is that they are monitored more closely and given the chance to prove that they can maintain their temperature, feed adequately and not lose more than 9 % of their birth weight by 3 days of life.

This is sounding more promising already.  I am eager to begin this assignment.  Check out these website for information regarding this newly designated population.

http://www.uptodate.com/contents/late-preterm-infants
http://preemies.about.com/od/preemiehealthproblems/a/LatePretermBirth.htm