This document summarizes the management of late preterm infants. Key points include monitoring infants for common complications like respiratory distress, hypoglycemia, and feeding difficulties. Supplementation with expressed breastmilk or formula is often needed due to challenges with exclusive breastfeeding. Close follow-up is important to assess growth, development, and prevent future health issues that late preterm infants are at higher risk for. Lifestyle changes and interventions during pregnancy can help prevent preterm births.

1. Symposium
Late Preterm - Management
Dr Andrea Josephine R,
1st year MD PG,
Dept of Pediatrics,
ESI- PGIMSR, Chennai.

2. Topics Covered
• Neonatal Management:
Prevention & Management of Complications
• Discharge criteria
• Follow-up
• Prevention of late preterm

3. Neonatal Management – Initial assessment
• Perform routine resuscitation by NRP
guidelines.
• Place stable infants in Kangaroo Mother Care
• Cover with a warm blanket.
- Vitals and temperature
- System examination
• Initiate breast-feeding as early as possible.
• Infant’s Ht,Wt,HC plotted in Fenton’s chart.
• Assess GA by New Ballard Score.
• Keep assessing the newborn continuously.

4. Complications:
Respiratory disorders
A. Respiratory distress syndrome:
i. Supplemental Oxygen: Target saturation
range (88-95%), ABG monitoring
ii. Continuous positive airway pressure
(CPAP)- Simple, May obviate need for
ventilation;
iii. Surfactant replacement: Prophylactic or
Rescue therapy, Prophylactic more
efficacious, +AN steroids
iv. Mechanical ventilation: Surfactant therapy,
Respiratory acidosis, PCO2>55mmHg,
PO2<50mmHg, spO2<90% with FiO2>0.50.

5. Respiratory disorders
B. Transient Tachypnea of Newborn (TTN):
Supplemental oxygen and CPAP as needed.
C. Persistent Pulmonary Hypertension of the Newborn(PPHN):
Supplemental oxygen –Target SpO2-90-98%
Mechanical ventilation: HFOV/HFJV when a/w Pulmonary
parenchymal ds
iNO: Selective pulmonary vasodilation
ECMO; Sedation, analgesia

6. Respiratory disorders
D. Apnea:
• Treat the cause
• Oxygen supplementation
• Positioning of infant: Avoid extreme neck flexion/extension
• Nasal CPAP
• Caffeine
• SIDS: Avoid prone position, Sleeping separate from but near
mother(AAP), Avoid smoking, Avoid excess wrapping/overexposure to
heat, Breastfeeding

7. 2. Hypothermia
Prevention:
• Dry baby gently after birth.
• Continue skin-to-skin care with mother and
cover baby’s back with a blanket.
• If not, swaddle the baby with warm blanket.
• Keep baby’s cot away from open windows,
AC vents.
• Use radiant warmer on servo mode.
• Assess axillary temperature regularly

8. Hypoglycemia
• Monitor infant for signs of
hypoglycaemia
• Institute glucose monitoring
and management as per AAP
guidelines
• Facilitate feeding at breast
during first hour after birth if
mother and infant are stable.
• Monitor to ensure frequent
ongoing feedings on demand,
at least 10–12 breastfeeds

9. Feeding difficulty
• Early unrestricted breastfeeding: Access to baby
• Educate the mother about breastfeeding her infant:
Position, latch, duration, early feeding cues,
breast compressions
• Feeding cues:
Opening eyes, Moving head back and forth, Opening mouth, tongue
thrusting, rooting, or sucking on hands/fingers; Crying (a late hunger cue
often leading to difficulty with latch due to infant frustration)
• Explain the probable need to awaken infant for feeds due to LPI’s
immature brain and increased sleepiness.

10. Feeding difficulty
Breastfeeding positions: Cross-cradle and football hold, Support head & neck

11. Feeding difficulty
• Assess breastfeeding at least twice per day:
- Coordination of suck, swallow, and breathing
- Mother’s breastfeeding position and comfort
- Baby’s latch and milk transfer
- Mother’s questions regarding breastfeeding
• Consider use of ultrathin silicone nipple shield if infant
has ineffective latch or milk transfer
• Monitor weight daily: Weight loss of more than 3% /day
or 7% by day 3 merits further evaluation and close
monitoring.
• Document voiding and stool patterns.
• Develop individualized care plan
• Follow-up

12. Feeding difficulty
• Many late preterm infants need to be supplemented with EBM/formula.
• BFHI for healthy term infants; Supplements and temporary lactation aids
often needed in LPIs.
• Use of breast pumps: Create and maintain milk production in critical
transition period to Lactogenesis II
• Triple feeding: Breastfeeding f/b Use of breast pump and feeding EBM (or
formula) to infant; Exhausting, High failure rates.
• Alternative: Split day into breastfeeding(Mother and baby rested) and
EBM feeds by pumping(night)
• Discontinue above methods 40-42wks PMA or when gaining adequate
weight on exclusive DBF

13. Feeding difficulty
Elements of an Effective Feeding
• The baby is awake and stays awake throughout the feeding
• Latches on to the breast and stays on, creating suction
• Suckles vigorously, both non-nutritive and nutritive suckles
• Demonstrates swallowing that can be seen and heard
• The baby lets go of the breast by himself
• The baby is relaxed and content after feeding
• Report of maternal uterine contractions

14. Feeding difficulty
Is Baby Getting Enough Milk?
• All elements of an effective feeding
• Many late preterm infants are not able to consistently feed effectively
until they reach term age
• Monitor urine and stool output
• Monitor weight gain and loss
• Check mother’s LOG
• Pre- and post-feeding weights (Test feed)

15. Feeding difficulty
Prevent and promptly recognize frequently encountered problems in
breastfed late preterm infants:
• Hypoglycemia
• Hypothermia
• Hyperbilirubinemia
• Dehydration or excessive weight loss
• Failure to thrive

16. Neonatal hyperbilirubinemia
• Identify additional known maternal/infant/family risk factors.
• Assess adequacy of feeding, voiding, and stooling.
• Evaluate for visible jaundice within first 24 h.
• Obtain TcB or TSB at 24 h after birth for all infants (±visual jaundice).
• Plot bilirubin levels on hour-specific Nomogram.
• Additional testing may be needed to coincide with peak bilirubin levels
which may occur on days 5-7 in LPIs
• Provide phototherapy in mother’s room, if possible.
• Monitor repeat bilirubin levels per hospital protocol.
• Exchange transfusion: When phototherapy fails to prevent rise to toxic
levels, Hemolytic disease, Correct anemia.

17. Neonatal hyperbilirubinemia

18. AAP guidelines for neonatal
hyperbilirubinemia
Bilirubin-Albumin Molar Ratio
(BAMR):
Total serum bilirubin (mg/dL)
Serum albumin (g/dL)
More predictive of BIND
(Cut-off >8mg/g).

19. Screening
1. Congenital anomalies – Internal and external; SpO2 screening for CHD
(>10% difference suggestive)
2. Hearing screening prior to discharge in all newborn (AAP)
• Risk factors- F/h/o SNHL, In utero infections, NNH requiring Exchange
transfusion, Ototoxic medication>5d/+loop diuretics, Mech ventilation>10d
• OAE- Simpler, Middle & inner ear assessed, all ages.
• ABR- Can diagnose auditory neuropathy(dyssynchrony), recommended for
high-risk infants admitted in NICU, within 1st 3mo.
3. Visual impairment: ROP screening using indirect ophthalmoscopy at PN
age of 3wks in high risk infants: Severe RDS, Hypotension req vasopressors,
Surgery in 1st several wks

20. Discharge criteria
1. Accurate gestational age determined
2. At least 48h old
3. Successful feeding for at least 24 h with <7% weight loss
4. Stable vitals for at least 12 h either while in skin-to-skin care or in
an open crib with appropriate clothing(HR, RR and Temperature)
5. No significant emesis
6. Adequate voiding
7. At least 1 stool/24 hr
8. Follow-up visit scheduled 24-48h from discharge.

21. Nutritional Supplements
• Iron 2mg/kg/day, from 1 to 12 months of life
• Calcium 200mg/kg/day
• Vitamin D 400IU/day, beginning in first few days of life until
adolescence.
• Phosphorus 100mg/kg/day
• Human milk fortifier: For all infants <2kg, Infants 2-2.5kg if SGA/IUGR,
intiate when tolerating feed >25ml breast milk/day

22. Follow-up – 1st visit:
Ask for h/o apnea
Look for signs of respiratory distress, cyanosis.
Signs of Sepsis
Hyperbilirubinemia:
• Assess infant for jaundice 1–2 d discharge.

23. Follow-up: Feeding
• Assess current feeding practices, including type of milk,
length of time feeding,
frequency,
amount taken (if formula fed).
Observe infant feeding
• Assess urine output and stool colour
• Symptoms of gastroesophageal reflux disease (GERD).
• Encourage pumping and supplementing with expressed breastmilk.
• Assess for any feeding difficulties or dehydration

24. Follow-up
1. Growth:
• Monitor (weight, length, and head circumference) at
each visit
• If infant failing to thrive consider need for fortification
or supplementation of breastmilk.
• Recommend introducing solid foods no earlier than 6
months corrected gestational age (GA)

25. Respiratory illness
Increased risk for recurrent respiratory infections and reactive airway
disease
• Advise on how to reduce
Keep area smoke free and away from crowds,
Breastfeeding as long as possible
Adequate nutrition
Immunization
Consistent adequate hand hygiene.

26. Developmental screening
LPIs at increased risk for:
Psychomotor delay,
Cerebral palsy,
Cognitive delay,
Delay in school readiness,
Increased need for special educational services,
Increased disability (74% of total disability associated
with preterm birth)
• Perform regular developmental screening using
valid and reliable assessment tools and schedule
for follow-up

27. Behavioral screening
Increased risk for:
Attention disorders,
Hyperactivity,
Internalizing disorders,
Autism,
Schizophrenia.
• Parents questioned about any signs of behavioral or emotional
disturbances in their child.
• Assess family’s support system and coping abilities.
• Make referrals as indicated

28. Prevention
• Interventions proven useful:
1. Smoking cessation
2. Elective dly only after 39wks GA unless indicated
3. Antenatal progesterone supplementation in women with h/o
previous preterm dly and in women with short cervix (≤15mm in
<24wks GA) with present singleton pregnancy

29. Prevention
Other potentially useful interventions:
• Avoiding undernutrition
• Adequate spacing between pregnancies
• Avoiding physical exertion and emotional stress in mother.
• Screen for and treat asymptomatic bacteriuria and bacterial vaginosis
• Tocolytics to delay labour by up to 48hrs to allow for AN steroids
• Cervical cerclage in women with h/o previous preterm birth and short
cervical length
• Avoiding multiple pregnancies from ART .

30. Preparing for delivery
• Accurate estimation of gestational age
• Better evaluation of the fetal outcome by USG and Fetal lung maturity
test to assess the risk-benefit ratio to decide on termination of pregnancy
• Antenatal steroids in elective caesarean section prior to 39+0 weeks of
gestation.
• Antenatal steroids in all women at risk of iatrogenic or spontaneous
preterm birth up to 34+6 weeks of gestation

31. Summary
• Monitoring & Anticipation key to management of complications.
• Exclusive breastfeeding often not sufficient.
• Lactation aids & special care needed.
• Supplement with EBM/formula
• Follow-up equally important to neonatal management

32. References
1. Multidisciplinary Guidelines for the Care of Late Preterm Infants, by
National Perinatology Association.
2. Assessment and care of the late preterm infant. Evidence-based
clinical practice guideline. The National Guideline Clearing House.
3. “Late-Preterm” Infants: A Population at Risk. American Academy of
Pediatrics.
4. ABM Clinical Protocol #10: Breastfeeding the Late Preterm Infant
(340/7 to 366/7 Weeks Gestation) (First Revision June 2011)
5. Late Preterm Infants: Near Term But Still in a Critical Developmental
Time Period. A Kugelman, AA Colin. Pediatrics.

33. References
6. Clinics in perinatology.
7. Calcium and Vitamin D Requirements of Enterally Fed Preterm
Infants. American Academy of Pediatrics.
8. Antenatal Corticosteroids to Reduce Neonatal Morbidity and
Mortality. Green–top Guideline No. 7, October 2010. Royal College
of Obstetricians and Gynaecologists.
9. Late preterm birth. Reviews in Obstetrics and Gynaecology.
10. ACOG Practice Bulletin No. 31: Assessment of Risk Factors for
Preterm Birth.

34. Thank You