In-Hospital Assessment and Care
Late preterm infants (LPIs), like all other newborns, should have a qualified healthcare provider assigned to their care during the immediate postpartum recovery period following birth.7 Late preterm infants may experience delayed or inadequate transition to the extra-uterine environment, so careful consideration of staffing ratios during transition (1–12 h after birth) for this population of infants is necessary.8 Because of their increased vulnerabilities, LPIs require continued close monitoring throughout the first 24 h after birth. Whenever possible, mother and infant should remain together, rooming in 24- h a day. Frequent, prolonged, skin-to-skin contact should be encouraged to promote optimal physiological stability. All LPIs are at risk for morbidities severe enough to require transition to a higher level of care. If an LPI is transitioned to a higher level of care, special attention should be paid to preparing the mother for going home without her newborn, and she should be monitored closely for signs of postpartum depression and post-traumatic stress disorder in the postpartum period.
Transition to Outpatient Care
Transition of care involves a set of actions designed to ensure continuity of care from inpatient to outpatient healthcare providers. Planning for transition of care should begin at the time of admission and requires a coordinated, multidisciplinary approach. The term “transition of care” is preferred to the term “discharge planning” in order to emphasize the active and dynamic nature of this process.
Optimal transition of care relies on accountable providers who ensure that accurate and complete information is successfully communicated and documented. The accountable sending provider sends the appropriate documents to the receiving provider in a timely manner, verifies the receipt of the information by the intended receiving provider, clarifies the receiving provider’s understanding of the information sent, documents the transaction, and resends information if not received by the intended recipient. The accountable receiving provider acknowledges having received the documents and asks any questions for clarification of the information contained therein, uses the information, and takes actions as indicated, ensuring continuity of the plan of care or services.43
Short-Term Follow-Up Care
Late preterm infants (LPIs) should be seen by their community primary care provider within 1–2 days after transition/discharge from the hospital; the provider should assess the infant’s continued stability, review screening results, ensure ongoing safety, and evaluate the adequacy of support systems. LPIs can appear deceptively vigorous on the first day or two after birth prior to transition/discharge. It is not unusual for morbidities common to LPIs to first appear a few days after transition/discharge. If not detected and managed early, these can quickly escalate and lead to re-hospitalization, increased family stress, and even permanent disability and death.2
It is especially important that breastfeeding LPIs be seen within a day after transition/discharge because of the feeding challenges so prevalent in this population. Immature feeding patterns, such as uncoordinated suck/swallow/breathe, ineffective milk transfer, and increased sleepiness because of immature brain/central nervous system (CNS) development, may not be apparent until the mother’s milk supply increases on postpartum days 2–5. Feeding failure, in both breastfed and formula-fed newborns, can be caused by other morbidities more common in LPIs, such as respiratory distress, cold stress, sepsis, hyperbilirubinemia, low muscle tone, and decreased stamina. Congenital heart disease and patent ductus arteriosis, also more common in LPIs, should be considered for any infant with feeding failure.
The community follow-up care provider should have received a copy of the transition/discharge summary from the in-hospital care provider prior to the initial follow-up visit. To guide evaluation, the follow-up care provider should carefully review maternal and infant history, as well as the infant’s hospital course, on the first follow-up visit. Because LPIs have many needs and because it is critically important to assess carefully the issues of continued stability, screening, safety, and support, it may be necessary to schedule extra time for follow-up visits of LPIs. Short-term follow-up care should include weekly assessments until the infant reaches 40 weeks of corrected gestational age (GA) (the infant’s due date) or is clearly thriving.25 More frequent visits may be necessary if weight or bilirubin checks are indicated.
Long-Term Follow-Up Care
There is no recognized endpoint to long-term follow-up care of late preterm infants (LPIs). Because research has documented increased morbidities for LPIs during infancy, childhood, adolescence, and through adulthood, follow-up care must begin at birth and continue, with varying degrees of surveillance and reflecting individual needs, throughout the lifespan.
The importance of establishing a medical home for each LPI cannot be overemphasized. A medical home is necessary to ensure that appropriate screening and assessments are completed, referrals are made, continuity of care is coordinated and implemented by a multidisciplinary team, and duplication of services is avoided. At each follow-up visit the continued stability, screening, safety, and support of LPIs and their families should be assessed.
Ongoing follow-up care should continue to be culturally, developmentally, and age-appropriate, taking into account families’ preferences and ensuring that parents are active participants in making informed decisions about follow-up testing and therapeutic interventions. Communication should occur and education should be provided in ways that are appropriate for families with limited or no English proficiency or health literacy and in ways that are developmentally appropriate for the target audience (e.g., teen parents).
If an LPI was transitioned to a higher level of care during the initial or subsequent hospitalizations, or if the mother and infant were separated at birth, both mother and father/partner should be monitored closely for signs of postpartum depression and post-traumatic stress disorder during the postpartum period and the first year of the infant’s life. Because optimal infant development is so influenced by the mental health of the infant’s primary caregivers, especially that of the mother, referrals should be made for professional help and community support whenever indicated.100, 101, 102, 103
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Acknowledgements
The Steering Committee gratefully acknowledges Amy Akers for her exceptional skills in communication, coordination and creativity, without which this project would have been nothing more than a great idea that never reached fruition.
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The Steering Committee members disclosed no relevant financial relationships that might create a conflict of interest in the development of the Multidisciplinary Guidelines for the Care of Late Preterm Infants. The development of the guidelines and funding for this supplement were supported through sponsorships from Philips Mother & Child Care and GE Healthcare Maternal-Infant Care. These organizations had no input or editing rights to the content included in the guidelines.
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This supplement is modified and republished on behalf of the Late Preterm Infant Guidelines Steering Committee with permission from The National Perinatal Association.
Appendices
Collaborative Partners
Thank you to the following individuals and organizations for their participation in the initial development and review of the Multidisciplinary Guidelines for the Care of Late Preterm Infants.
Academy of Neonatal Nursing
Jan Thape, MSN, RNC NIC
American Academy of Pediatrics
American College of Nurse-Midwives
Association of Women’s Health, Obstetric and Neonatal Nurses
Case Management Society of America
Council of International Neonatal Nurses, Inc.
Carole Kenner, PhD, RNC, FAAN
March of Dimes
National Association of Neonatal Nurses
National Association of Neonatal Therapists
Sue Ludwig, OTR/L, NTMTC
National Association of Pediatric Nurse Practitioners
Jane K. O’Donnell RN, MS, PNP-BC
National Association of Perinatal Social Workers
Debby Segi-Kovach, LCSW
National Healthy Mothers, Healthy Babies Coalition
Judy Meehan
NPA Board Member
Diane Bolzak, MPH
NPA Board Member
Mothers & Babies Perinatal
Network of SCNY
Sharon Chesna, MPA
NPA Board Member
Newborn Associates
Christina Glick, MD, FAAP, IBCLC
NPA Board Member
Neonatal Nurse Practitioner Program, Vanderbilt University School of Nursing
Karen D’Apolito, PhD, APRN, NNP-BC, FAAN
Nurse-Family Partnership
Oklahoma Infant Alliance
Endorsing Organizations
Thank you to the following organizations for their review and endorsement of the Multidisciplinary Guidelines for the Care of Late Preterm Infants.
Academy of Neonatal Nursing
American Academy of Pediatrics
American College of Nurse-Midwives
Association of Women’s Health, Obstetric and Neonatal Nurses
Council of International Neonatal Nurses, Inc.
Hand To Hold
National Association of Neonatal Nurses
National Association of Neonatal Therapists
National Association of Perinatal Social Workers
National Healthy Mothers, Healthy Babies Coalition
Nurse-Family Partnership
Oklahoma Infant Alliance
Preemie Parent Alliance
Zoe’s New Beginnings
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Phillips, R., Goldstein, M., Hougland, K. et al. Multidisciplinary guidelines for the care of late preterm infants. J Perinatol 33 (Suppl 2), S5–S22 (2013). https://doi.org/10.1038/jp.2013.53
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DOI: https://doi.org/10.1038/jp.2013.53
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