Feeding Challenges in the Late Preterm Infant

From Neonatal Network
Karen Cleaveland, MSN, APRN, NNP-BC

Abstract
A late preterm infant is defined as one born between 34 and 36 6/7 weeks of completed gestation. The rate of late preterm births has risen 18 percent since the late 1990s. Data are beginning to emerge concerning morbidity rates and the risks these newborns face with regard to feeding difficulties, temperature instability, hypoglycemia, and hyperbilirubinemia.
Feeding challenges place these vulnerable infants at risk for prolonged hospital stays and readmission after discharge. To better address the unique needs of late preterm infants, providers should establish individual feeding orders. This article offers research-based suggestions for caring for these infants in the newborn nursery and the postpartum unit as well as parent teaching guidelines.

Introduction
Late preterm infants represent the most rapidly growing segment of preterm births in the U.S., accounting for 72 percent of the 12.7 percent preterm birth rate in 2005. This population of preterm infants is often cared for within the general newborn setting using the feeding guidelines for healthy term infants.

The staff of the newborn nursery often regards these infants as being term because they are usually of normal size and have a more mature appearance than preterm infants born after shorter gestations.

Compared with term infants, however, late preterm infants are at higher risk for excessive weight loss, feeding intolerance, hyperbilirubinemia, hypoglycemia, hypothermia, respiratory distress, apnea of prematurity, and a weak suck.

And, because of the increased risks these infants face, they also have higher morbidity and mortality than term infants. It is therefore necessary to recognize and treat this late preterm infant population with its own feeding and care guidelines instead of using guidelines for term infants. It is also vital to formulate a specific set of discharge planning teaching guidelines for them.

Feeding Challenges

Feeding challenges in the late preterm infant have been shown to be related to immature sucking and swallowing reflexes, which lead to improper latch-on for the breastfeeding infant as well as inadequate intake in the bottle-feeding infant.
As noted earlier, sucking, swallowing, and breathing must synchronize smoothly and effectively, with highly accurate timing and coordination, for safe and efficient oral feeding.[11]
Late preterm infants often have fewer awake-alert periods and less postural stability than their full-term counterparts, which often results in inadequate caloric intake. Decreased feeding combined with low energy stores and high energy demands place these infants at risk for inadequate hydration.

Health care providers and mothers may assume that the infant has ingested an adequate volume of milk when he falls asleep at the breast, when in reality the infant has exceeded his energy stores and has shut down without adequate caloric intake. Parents need to be educated regarding their infant's feeding cues, sleep-wake cycles, and how to promote postural stability.

Behaviors such as rooting, mouthing, and finger sucking indicate feeding readiness. Ensuring that the hips are flexed and the head and neck are aligned with the trunk provides appropriate postural stability, improving feeding success in the late preterm infant.

Immature brain development in late preterm infants is often overlooked because they are considered stable compared with extremely low birth weight premature infants. During the final few weeks of gestation, movements become smoother, oral motor skills more coordinated, and states of alertness more predictable.

This relates directly to why late preterm infants fail at feeding when they are discharged without the proper instructions being given to their caregivers. It is necessary that the nursing staff and parents, as well as the pediatric providers, receive education in achieving safe and effective oral feedings in late preterm infants.

The medical issues described earlier also make late preterm infants more susceptible to having a decreased state of arousal as well as poor endurance, resulting in early fatigue during feeding.