Pediatric Primary Care Case Studies, 1st Ed.

Chapter 33. The Late-Preterm Baby Beginning Well-Child Care

Lori J. Silao

Late-preterm infants present a unique situation for the healthcare provider because these infants have higher morbidity and mortality rates than term infants. Thus, they need additional surveillance during their early health supervision visits. The healthcare provider needs to focus on both the infant’s gestational age and potential associated problems when examining such patients. In addition, the family must be educated about the need to watch for worrisome signs and symptoms of illness or failure to thrive. Potential problems must first be addressed with parents when their baby is discharged home from the hospital and then continue to be addressed at subsequent health supervision visits.

Educational Objectives

1.  Identify potential risk factors and apply management guidelines for the late-preterm infant.

2.  Consider the age of the infant’s primary caregivers and the impact of their maturity on the management plan developed.

3.  Address cultural and socioeconomic factors that may affect the management plan and adherence with the identified plan of care.

4.  Identify any infant health problems that may require further evaluation, and make appropriate referrals.

  Case Presentation and Discussion

Sandra Jones is a 17-year-old white female who presents to your clinic with her newborn infant boy, Bobby, born at 35 and 4/7 weeks gestation. Sandra and her infant are accompanied by the baby’s father who is also 17 years old and in his senior year of high school. They are here for the baby’s first visit since being discharged from the hospital 2 days ago. Sandra is concerned that her son does not seem to be eating well and sleeps all the time. Initially, you need to attend to the facts that this is a late preterm infant being cared for by teen parents.

The Late-Preterm Infant

A late-preterm infant is defined as a baby born between 34 and 36 and 6/7 weeks gestation (Engle, Tomashek, & Wallman, 2007). It is known that infants generally gain approximately ½ pound per week during the last 6 weeks of gestation, so an infant born even slightly premature may be at risk for a lower birth weight. Although some late-preterm infants may weigh as much as a term infant, the late-preterm infant is still premature and arrives with his or her own set of potential health risks. Traditionally there have been few studies in this population (Engle et al., 2007). However, because of the increased number of late-preterm births in recent years and the associated problems these infants experience due to their immature physiologic and metabolic systems, there has been a recent increase in the number of research studies focusing on this cohort of infants. Noteworthy, some interesting early data are beginning to surface regarding in-utero development and postnatal adaptation in this population (Wang, Dorer, Fleming, & Catlin, 2004). Most of the research data point to certain disease processes that seem to be prevalent or place such infants at increased risk for potentially life-threatening situations. Thus, the late-preterm infant must be closely monitored with careful follow-up by the healthcare provider. The most common problems facing this group of infants are discussed in this case study.

Lung Function

Because of the potential for immature pulmonary functioning, the lack of fully mature alveoli units, possible surfactant insufficiency, and delayed intrapul-monary fluid absorption, the late-preterm infant may need oxygen, positive pressure ventilation, and possibly surfactant therapy. Keep in mind that even if a late-preterm infant does not require pulmonary assistance after birth, he or she is still at risk for problems such as apnea that are associated with a potentially immature neurologic system. There are very few studies about apnea in this population, but one of the classic studies in this age population suggests that the incidence of apnea in a late-preterm infant is small, reported at 4–7%, compared to 1–2% for a term infant (Ramanathan et al., 2001). Nevertheless, this can be a life-threatening occurrence.

Sepsis

All infants are at risk for sepsis; however, the more preterm the infant is, the higher the risk factor due to the greater immaturity of their immune system. The late preterm infant is most at risk for group B streptococcal (GBS) sepsis; current American Academy of Pediatrics (AAP) recommendations include screening for GBS and sepsis, as well as monitoring the infant in the hospital for 48 hours after birth (AAP, 2004b; Engle et al., 2007).

Hyperbilirubinemia

Jaundice and hyperbilirubinemia occur more commonly in late-preterm infants than in term infants. This is due to a number of factors including the immaturity of the liver in which there are lower levels of the necessary enzymes to synthesize bilirubin, immature gastrointestinal function, and potential feeding difficulties that predispose infants to dehydration, decreased stooling, and subsequent hyperbilirubinemia. The two basic mechanisms that lead to unconjugated hyperbilirubinemia are increased bilirubin production and decreased bilirubin clearance (such as decreased hepatic clearance or increased enterohepatic circulation; Moerschel, Cianciaruso, & Tracy, 2008). Studies investigating the rates of and reasons for readmission to hospitals for the late-preterm infant note that the most common cause of readmissions in this population was hyperbilirubinemia (Engle et al., 2007).

Temperature Regulation and Metabolic Function

Late-preterm infants, like all premature infants, have less body fat present to maintain thermoregulation. Brown-fat accumulation is crucial in the last trimester of pregnancy, and peaks at term. Therefore, the preterm infant does not have this protective insulation and loses heat more rapidly than a term infant does. Cold stress may also lead to hypoglycemia. When combined with the fact that all infants have insufficient metabolic response time when the maternal glucose supply is abruptly cut off, hypoglycemia may be a more persistent problem in the late-preterm infant as opposed to the term infant, who quickly develops the necessary enzymes to combat hypoglycemia.

Immature Gastrointestinal Function and Feeding Problems

As stated previously, the late-preterm infant is at greater risk for gastrointestinal problems than the term infant due to the greater immaturity of his or her gastrointestinal system and slow production of certain enzymes necessary for digestion. In addition, these infants tend to have longer sleep cycles than term infants and must be awakened frequently to eat. They also may not be able to consume the same volume as a term infant, so smaller more frequent feedings become necessary to maintain weight gain and growth and minimize hyperbilirubinemia. These infants may also have issues in coordinating sucking and swallowing that can lead to a delay in successful breastfeeding (Raju, Higgins, Stark, & Leveno, 2006).

Epidemiology

Approximately 13% of all births in the United States result in preterm (less than 37 weeks gestation) deliveries (Davidoff et al., 2006). Interestingly, studies have shown that almost two thirds of all preterm births from the years 1992–2002 were judged to be late-preterm births (Davidoff et al.). Research studies demonstrate that the rise in late-preterm births correlates with the rise in births to women over age 30, the rise in induction rates, multiple births, and the rise in primary and repeat cesarean deliveries (Raju et al., 2006; Trofatter, 2006). Furthermore, various ethnic and sociodemographic subgroups in the United States differ in their rates of premature birth, a factor that is currently being investigated to examine the underlying variables. Factors such as low socioeconomic status, maternal age less than 18 years or advanced maternal age, lack of access to health care, and poor nutritional status all increase the risk of preterm delivery (Polin & Spitzer, 2001).

As reported by Chen and colleagues (2007) in the International Journal of Epidemiology, the number of teenage pregnancies in the United States had decreased over 10 years. However, this decline was short lived, with the birth rate for teenagers 15 to 19 rising from 40.5 to 41.9, and then to 42.5 births per 1,000 based on data collected in 2005, 2006, and 2007 respectively (Hamilton, Martin, & Ventura, 2009). Teenage pregnancy continues to be a major social, economical, and healthcare concern in the United States (Chen et al., 2007). Chen and colleagues reviewed multiple studies on teenage pregnancy, and one of the consistently identified adverse outcomes of teenage pregnancy was the increased risk for preterm birth.

In summary, the most common neonatal issues that arise include hyper-bilirubinemia, feeding issues, temperature instability, thermoregulation, potential breathing problems, and neonatal sepsis. Thus, prior to the infant’s discharge from the hospital, the healthcare provider must be assured that each of these areas of risk is no longer a threat to the infant and that the infant is stable enough to be discharged home. Furthermore, prior to the infant’s discharge home, the infant’s mother needs careful instructions about feeding and sleep issues, knowledge of signs and symptoms of illness indicating a need to immediately seek care, as well as the date of the first health supervision visit. Close follow-up during the subsequent weeks and the next few months is often necessary so the infant can be carefully evaluated for appropriate growth and development and a healthy progression from the newborn stage to that of the young infant. In addition, if the mother is a teen, her developmental level also needs to be factored into the care plan.

How will you begin your data collection with the information you have just learned? image

You introduce yourself to Sandra and José, the dad, and ask them how they would like to be addressed (e.g., Sandra and José). You begin by responding that you realize that the first few days and weeks home with a preterm infant are a challenging time for parents and go over the goals for today’s visits. You explain that the information you are collecting will provide you with an overview of how things progressed from pregnancy to today’s visit. You start by asking Sandra to tell you about how she, the baby, and dad are doing.

Sandra looks tired and says that having the baby early was very scary for her, and motherhood is much more challenging than she thought it would be. She starts to cry and says she is concerned that her son does not seem to be eating as well as he did in the hospital and that he sleeps all the time. You acknowledge her feelings and notice that the father has put his arm around her shoulders as she hugs the baby. Sandra quickly replies, “I’m OK now, I was just upset because I had trouble filling out these forms. We need you to help me and José do them right.” She hands you the pregnancy, labor and birth history, and family medical history forms that she completed while waiting to be seen. You decide to go over the forms first to give you some time to dialogue with Sandra and José and to relieve her stress about completing the forms correctly. You will address her obvious stress and emotional needs later during the visit.

What questions will you ask Sandra regarding the pregnancy, labor and delivery, and birth history? image

Obtaining a complete prenatal and birth history will be a key factor in evaluating subsequent health risk factors for this infant. Starting with the hospital stay, it will be important to find out as much as possible about Bobby’s course of hospitalization. You begin with the pregnancy and ask about whether there were any complications other than the prematurity. After birth, was the infant in the neonatal intensive care unit (NICU) or did he remain with the mother or in the newborn nursery? Was he treated with antibiotics and, if so, does she remember their names? Did he have hyperbilirubinemia and/or did he receive treatment; if so, what? Did he have any breathing problems during the hospitalization? What was he fed, how much, and how often, and what was his birth weight?

According to the mother, she and José weren’t planning on having Bobby but “things just got out of hand.” Bobby was conceived the first time they had sex. She started prenatal care at 5 months gestation and had problems with her blood pressure “going real high” and her feet and hands swelling. She had to see the obstetrician frequently because of her blood pressure and needed to take blood pressure medication, which she is still taking. She went into labor early and delivered Bobby vaginally after a 6-hour labor. He cried right away, and the doctor said he was small but that was expected since he was early. She and the infant stayed in the hospital for 4 days without complications. She can’t remember how much he weighed when he went home but “the nurse said he lost a little weight from birth, but that was expected.” Bobby is now 6 days old, and this is his first visit to you for follow-up care.

What has been Bobby’s course since being discharged home with Mom? image

The following discussion will help you review common problems seen in the late preterm infant and to determine whether this infant has experienced any of these problems or associated sequelae.

You explain to Sandra that you will check Bobby’s weight today and compare it to her discharge papers that she has brought with her. You ask her if she is breastfeeding or bottle feeding, and if bottle feeding, what type of formula she is using; how much does the baby take (or if breastfeeding, how many minutes at the breast and inquire if she switches sides); how often is the infant feeding; how many wet diapers per day and frequency of stooling; how long does the baby sleep; and does the infant have any trouble with breathing, feeding, rashes, or any other concerns she has.

Sandra states that she is trying to breastfeed Bobby, but she isn’t very good at it. She states that the nurses told her to feed him every 2–3 hours. She is trying her best but is frustrated that she doesn’t seem to have very much milk. She tells you that the baby gets cranky when she tries to put him to breast and that she is so tired now. She tries to switch to both breasts but feels awkward. She says that the nurses told her not to give him anything else but breastmilk, so she hasn’t given him a bottle. They did show her how to pump while in the hospital, but she doesn’t have a pump at home. Sandra tells you that he seems to have quite a bit of poop, almost every diaper change, so she guesses that there is urine in the diaper as well. She says that Bobby doesn’t seem to have any other issues in general, but that he does seem to sleep all the time and she has to wake him up to feed, and then he starts crying because, according to Sandra, he isn’t getting very much milk. She is frustrated because she has been told that breastfeeding is best, but José’s mother keeps telling her to give the baby a bottle. Before moving on to further discussion, you take this moment to encourage her with the breastfeeding and inform her that you will arrange for a lactation consultant to come to her home to assist her and arrange for her to get a breast pump.

Social and Emotional History

As you begin to obtain a complete history from Sandra regarding her baby, you ask her about home life: her biologic parents, current living arrangements, and future plans for education or a career (both Sandra and José). How are they supporting themselves and the baby (food, shelter, clothing, medical insurance)? What were the issues surrounding the conception and the use of birth control? The possibility of postpartum depression (maternal and paternal) should be assessed using a brief assessment tool such as the Beck Depression Scale (Mancini, Carlson, & Albers, 2007; Whooley, Avins, Miranda, & Browner, 1997).

She reveals that she got pregnant by her Hispanic boyfriend, José, also 17 years of age, and, as a result, Sandra’s mother “disowned” her. She is now living with her boyfriend and his family, a large Mexican family. José’s mother, father, and four younger siblings are all living in a small three-bedroom house. She and José have no space to themselves. José’s parents speak minimal English. Sandra says she feels stressed because she cannot easily communicate with them and has to rely on her boyfriend to translate for her. José’s mother tries to help with the baby and has been very helpful with changing diapers and rocking the baby when he cries. She says that she has been happy overall about the pregnancy, although she had no idea about how difficult it was to be a new mom, but that she plans on finishing school because José’s mother can help with the baby. She and José have talked about marriage, but are waiting for now. She says she is on WIC and does have Medicaid for insurance.

You use the two-question depression screen that the U.S. Preventive Services Task Force (Gaynes et al., 2005) recommends as a quick screen for adults. The two-question screen is as effective as longer screening tools. The two simple questions to ask are: During the past month have you been bothered by 1) feeling down, blue, depressed, or hopeless? and 2) feelings of little interest or pleasure in doing things? Sandra answers no to both, and you decide that at this point in time she does not have postpartum depression.

Cultural and Teenage Dynamics

Cultural/socioeconomic factors must always be considered when evaluating patients. The healthcare provider working with ethnically diverse patients must reach out to patients and learn about their cultures, beliefs, and values as well as addressing the dynamics of teenage parenting. Sociodemographic risk factors of teenage pregnancy include poverty, low education level, inadequate prenatal care, and unmarried status (Chen et al., 2007). Thus, one of the most important issues to address in teenage parents is their lack of support as well as the lack of access to resources. Some perceptions of teenage parents include that they lack emotional and mental maturity, lack the ability to provide financial stability due to education interruption or to qualify for particular jobs due to their age, lack preparation for motherhood or fatherhood, and a general feeling that teenagers are unsuitable to be parents because they are still children themselves. This often leads to social abandonment when they become parents and worsens the already turbulent adolescent period (Hanna, 2001).

Cultural diversity can also add to difficulties in teenage parenting. In this particular discussion, the father of the baby is Hispanic, and typically Hispanic households are male-dominated and take great pride in their sons. There may be alternative healthcare practices that affect the care of a newborn and influence when to access traditional medical care. During this past decade great emphasis has been placed on developing family-centered care management strategies. This translates to all aspects of health care, including private physician offices and community clinics. Thus, it is critical to include the family in all decisions regarding care as well as recognizing cultural differences that may affect the delivery of care at home. Explanations should be sensitive to cultural issues and potential barriers to effective communication. Language translators or cultural brokers (individuals who are fluent in the language and sensitive to customs and nuances) may be very helpful. Careful wording of health and social questions is essential as well as explaining the content of the questions and why the healthcare provider needs such information. Identifying cultural beliefs and integrating appropriate management plans is important to the success of the treatment and management plan for the infant and his or her mother. In this case, there may be cultural differences operating between the mother and her Hispanic surrogate family as well as between the mother and the healthcare provider.

What information will be especially important to obtain on this newborn examination? image

Physical Examination

On physical examination, you find a sleeping male infant who appears comfortable with regular respirations. Vital signs for this age are within normal limits, and auscultation of lungs and heart sounds are also normal. The infant’s weight at birth was 5 lbs 5 oz. Current weight is 4 lbs 12 oz (approximately 11% weight loss). This places the infant at approximately the 10th percentile on a premature growth chart for boys, but the current weight loss is the more concerning issue. You notice milia on the infant’s nose, and the anterior fontanel is open, of normal size, and flat but not depressed. His skin is slightly jaundiced in color and the mucous membranes are wet. The infant’s abdomen is soft and flat with active bowel sounds; the umbilical cord is drying without redness or other abnormalities. The infant’s genitalia is Tanner stage 1 with both testicles descended, the penis uncircumcised, and the anus patent. Tone appears to be within normal limits; however, the infant is slightly difficult to awaken but when he does awaken he has a robust cry and is easily soothed.

Making the Diagnosis

The differential diagnoses for assessing a late-preterm infant include carefully evaluating for each of the previously discussed problems that can occur in this population. In this particular case study, the infant’s jaundiced skin, slight lethargy, and the poor feeding are red flags that require further evaluation. The healthcare provider should evaluate Bobby for three key potential problems:

1. Hyperbilirubinemia: Total and direct bilirbubin levels and the feeding history should provide you with information to distinguish between conjugated versus unconjugated hyperbilirubinemia.

2. Sepsis: A complete blood count (CBC) with differential should serve for sepsis screening. Some practitioners may obtain a blood culture at the same time, but usually a CBC is sufficient initially. Infection is also a differential diagnosis for hyperbilirubinemia (Moerschel et al., 2008). The CBC should be similar to a term, healthy infant, which often has an elevated white blood cell (WBC) count for the first 2 weeks of life (up to 30,000 leukocytes), and then decreases to normal adult levels. Of concern would be a low WBC count, a persistently elevated WBC level, or an elevation in the segmental band count on the differential (Polin & Spitzer, 2001).

3. Dehydration: Comparison of the infant’s current weight compared to birth weight, feeding history including volume and frequency of feedings, as well as the number of wet diapers will help with this assessment. Do a 24-hour recall of feedings, number of wet diapers, and stooling pattern. Normal weight loss for newborns is 5–10% of birth weight for the first week of life. Watch the mother breastfeed her infant to assess proper latch on and sucking by the infant; encourage 10–15 minutes of breastfeeding on both sides. Approximate the amount of breastmilk the infant is receiving by comparing to how much she pumps in 10–15 minutes. And, of course, make appropriate referrals to lactation consultants as needed.

Do you need to do anything to confirm the diagnosis, such as laboratory studies?image

Laboratory studies are needed to confirm the diagnosis, and to monitor the degree of hyperbilirubinemia and the response to treatment. According to the AAP, bilirubin levels should be obtained within the first 24 hours of life, then repeat the test based on identified risk factors from every 4 hours to every 24 hours. When suspecting hyperbilirubinemia, a total serum bilirubin level should be obtained for baseline diagnosis. It is generally accepted that a rise of greater than 5 mg/dL per day of life is concerning. And any level greater than 15 mg/dL requires further investigation and possible intervention (AAP, 2004a). If elevated, but within normal limits for age/gestation, a follow-up level should be obtained the next day. Depending on the severity of hyperbilirubinemia, levels may need to be obtained as frequently as every 4 hours, in which case an infant would need to be hospitalized for the frequent lab draws and management such as phototherapy. Generally, a daily total serum bilirubin level is adequate to monitor the low-risk infant. In addition, a set of electrolytes would be warranted in this infant due to the dehydration. The fractionated bilirubin test is helpful to rule out any other issues that could cause a cholestatic hyperbilirubinemia; however, current guidelines suggest evaluation only if the jaundice persists beyond the normal physiologic period (2 weeks) in newborns. Also, if it had not been obtained in the newborn nursery or neonatal intensive care unit, a direct Coombs test would be necessary to rule out Rh hemolytic disease (Moerschel et al., 2008).

You order the following tests:

image  Neonatal bilirubin

image  Complete blood count with differential

The indirect bilirubin level comes back at 15 mg/dL on day 6 of life, and the CBC is within normal limits. Fortunately, the mother had a discharge summary from the birth hospital, and the direct Coombs test is negative. With the information that Bobby has had only three wet diapers in the last 24 hours, is not taking adequate amounts of fluids, and has had an excessive weight loss (approximately 11%) within the first few days of life, in combination with the elevated bilirubin level, you decide that this infant’s hyperbilirubinemia is exaggerated by poor feeding and mild dehydration with no other signs of sepsis.

Management

How do you plan to treat the hyperbilirubinemia and dehydration? What specifically will you do to bring the bilirubin level to within acceptable range? image

The most important therapy to initiate after making the diagnosis will be one that increases bilirubin excretion and includes improved hydration and stooling. Increasing the number of feedings per day will be necessary with possible supplemental breastmilk or formula, usually adding about one additional ounce of formula or breastmilk to each feeding as tolerated. Some infants may even “request” more, and as long as the infant does not have emesis, choking, or overt resistance, he or she can be fed with an ad lib volume. Breastfed infants should continue to be breastfed, optimally 8–12 times per day, 10–15 minutes on each breast. If there is difficulty with breastfeeding, a lactation consult may be initiated. Water or dextrose water supplementation is not recommended (Moerschel et al., 2008). If the mother is still having trouble breastfeeding or her milk production seems low, encourage her to stay hydrated herself and to eat healthy meals. Many new mothers feel that once the baby is born it is a good time to go on a diet, but this is not appropriate for breastfeeding mothers. Also, support her if she chooses not to breastfeed. There is a lot of pressure from society to breastfeed, and many new mothers feel like failures if they are unsuccessful or overwhelmed with the difficulties and frequency of feeding necessary with a poor feeder.

In extreme cases of hyperbilirubinemia or dehydration, hospitalization will be required for intravenous fluid therapy and aggressive monitoring of total serum bilirubin levels. A minimum of daily total serum bilirubin levels is recommended. Home phototherapy could be considered if the infant is close to requiring intensive phototherapy. You will need to order the phototherapy equipment for the mother from a local home healthcare equipment vendor if you decide to use it. The old wives’ tale of placing a jaundiced infant near the sunlight still holds true to a certain extent to help assist with mild jaundice. However, issues such as “heat, excessive water loss and dehydration, and unnecessary exposure to ultraviolet light (prevented by window glass) need to be considered” (Polin & Spitzer, 2001, pp. 196–197).

Patient Education

The goals of patient education should be holistic and include addressing the socioeconomic factors/home stresses as well as the infant’s medical condition. They are as follows:

1. Feeding: The most important thing for this infant’s hyperbilirubinemia and mild dehydration is to increase the feedings/intake. The mother is young and is probably lacking support at home in caring for the infant. A lactation consultant should be included if the mother wishes to continue breastfeeding successfully. Sandra should be taught that the infant needs to be fed every 3 hours and to supplement with extra breastmilk or formula as needed due to the hyperbilirubinemia. The mother should contact the healthcare provider if the infant is refusing feedings. Tell her that she should observe improvement in intake in the next 12 hours. If not, Bobby must be seen immediately for the first morning appointment or taken to the emergency department if he is listless or she is concerned about his general well-being. Instruct the mother to keep a journal to log feeding times, volume and length of feedings, and the number of wet diapers and bowel movements each day.

2. Jaundice: Sandra needs to be taught what jaundice/hyperbilirubinemia is and the potential risks of elevated bilirubin levels, such as kernicterus. She should be taught to call the healthcare provider immediately if Bobby shows signs of increased irritability, hypertonia alternating with lethargy, arching, fever, and high-pitched cry (Moerschel et al., 2008).

3. Infection/thermoregulation: Instruct the mother that often newborns do not have fevers when they become ill, and may actually have a low temperature. Instruct the mother in how to take the infant’s temperature if she has not been taught, good handwashing techniques, and to keep the infant away from ill contacts. Regarding temperature, the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) recommends that a good rule of thumb is to dress the infant in one more layer than the mother is wearing (AWHONN, 2007).

4. Sleeping: Most infants sleep 18–20 hours per day in the newborn period, and it is not uncommon for infants to sleep through feedings. For newborns, the typical length of sleep between feedings is 2–4 hours, then usually a 30-minute feeding, then back to sleep. Most healthcare providers do not recommend sleeping longer than 4 hours without a feeding, and not exceeding 30 minutes for a feeding. Encourage the mother to wake the infant up for feedings and teach her to always place the infant on his back to sleep.

5. Referrals: Due to the mother’s young age, it is important to get her the appropriate referrals such as WIC (Women, Infants, and Children) programs, lactation consultants, referral to a teen mom clinic if you have one in your practice setting, and any community organizations (such as the YWCA or YMCA) that help young mothers. Encouraging her to network with other mothers and even other teen mothers is important because her resources may be limited. Web sites such as http://www.youngmommies.comhttp://www.teenmotherchoices.org, and http://www.mops.org all offer resources to teenage parents. She should be provided phone numbers for questions and for poison control, and told in case of emergency to call 911. AWHONN has a worksheet for parents on its Web site that helps parents keep information organized for doctor visits (http://www.awhonn.org).

6. Immunization: Bobby received his first hepatitis B immunization at birth. You will emphasize Sandra’s role in having her son receive all recommended childhood vaccinations on schedule. Tell her that immunization is the most effective way to avoid vaccine-preventable diseases and to protect her child’s health. The AAP and the Centers for Disease Control and Prevention have excellent immunization information for parents. Their Web sites are http://www.aap.org and http://www.cdc.gov, respectively.

You discuss each of these six major areas of patient education with Sandra and provide pamphlets or written information regarding the key points outlined under each patient education point.

When do you want to see Sandra and Bobby back again? image

You want to see Bobby the next day for a follow-up total serum bilirubin level and to evaluate feedings and stooling. Encourage Sandra to bring her journal with her to the appointment to help quantify this information and include both José and his mother at the appointments, if possible, for additional support to Sandra. Including the grandmother at the appointments and translating information into Spanish for her may improve stress encountered at home from different ideas on how to care for Bobby.

Sandra and her baby return the next day for the follow-up appointment and the total serum bilirubin level is 13 mg/dL. She brings her journal with her with detailed entries on feeding times, volume, and intake/output and has done a good job in increasing the feedings. She quietly tells you that when she left the hospital she did not know she was supposed to wake the baby up to feed and before yesterday’s visit had been supplementing formula in between breastfeedings. She also tells you that the lactation consultant is coming over to her house today to help assist with breastfeeding, because she “isn’t very good at it,” and hopes this will help. You congratulate her on a job well done and encourage her and José to continue doing a great job. You decide to see Bobby again tomorrow to check another bilirubin level and tell Sandra to continue with current management of increased volume intake. At that time you will also expand on your anticipatory guidance discussions, including appropriate car seat positioning and size for a preterm infant, placing Bobby on his back to sleep, and making sure they have a crib that meets current safety standards, among other newborn safety issues.

It will also be important to continue to monitor Sandra’s mental health because most mothers do not see their obstetricians for 4–6 weeks postpartum. You encourage José to be at each visit and be involved with activities such as diaper changes, bathing, learning how to give any medications, and participating in feedings as able. You also discuss with José the importance of finishing his high school education and ask him whether he has considered college or vocational school as part of his future plans.

Above all, the healthcare provider must serve as an advocate for these young parents and assist them in not only raising a happy, healthy child, but also continuing their own growth to reach their full potential.

Key Points from the Case

1. Late-preterm infants are more at risk for potentially serious health problems than term infants and require special observations.

2. Hyperbilirubinemia is one of the most common causes of rehospitalization in the late-preterm infant population and needs to be identified early with appropriate management to prevent negative sequelae.

3. Teenage parents often have limited resources and thus need to be supported and encouraged by providing information and teaching from experts such as the nurse practitioner, the physician, physician assistant, and various members of the healthcare team.

4. Appropriate referrals should be made to assist the parents. Finding ways to include the family in planning care and providing education will be key in assuring success at home.

REFERENCES

American Academy of Pediatrics. (2004a). Clinical practice guideline: management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Subcommittee on Hyperbilirubinemia. Pediatrics, 114(1), 297–316.

American Academy of Pediatrics. (2004b). Policy statement: hospital stay for healthy term newborns. Committee on Fetus and Newborn. Pediatrics, 113(5), 1434–1436.

Association of Women’s Health, Obstetric and Neonatal Nurses. (2007). Late preterm infant initiative. Retrieved August 7, 2008, from http://www.awhonn.org

Chen, X., Wen, S. W., Fleming, N., Demissie, K., Rhoads, G. G., & Walker, M. (2007). Teenage pregnancy and adverse birth outcomes: a large population based retrospective cohort study. International Journal of Epidemiology, 36(2), 368–373.

Davidoff, M. J., Dias, T., Damus, K., Russell, R., Bettegowda, V. R., Dolan, S., et al. (2006). Changes in the gestational age distribution among U.S. singleton births: impact on rates of late preterm birth, 1992–2002. Seminars in Perinatology, 30, 8–15.

Engle, W. A., Tomashek, K. M., & Wallman, C. (2007). “Late-preterm” infants: a population at risk. Pediatrics, 120(6), 1390–1401.

Gaynes, B. N., Gavin, M., Meltzer-Brody, S., Lohr, K. N., Swinson, T., Gartlehner, G., et al. (2005). Perinatal depression: prevalence, screening accuracy, and screening outcomes. Evidence Report/Technology Assessment No. 119. (Prepared by the RTI-University of North Carolina Evidence-Based Practice Center, under Contract No. 290-02-0016. AHRQ Publication No. 05-E006-2.) Rockville, MD: Agency for Healthcare Research and Quality.

Hamilton, B. E., Martin, J. A., & Ventura, S. J. (2009). Births: preliminary data for 2007. National Vital Statistics Reports, 57(12), 1–23.

Hanna, B. (2001). Negotiating motherhood: the struggles of teenage mothers. Journal of Advanced Nursing, 34(4), 456–464.

Mancini, F., Carlson, C., & Albers, L. (2007). Use of the postpartum depression screening scale in a collaborative practice. Journal of Midwifery and Women’s Health, 52(5), 420–434.

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