LatePretermGuidelines Phillips ResArt 2013 PDF

Journal of Perinatology (2013) 33, S5S22
& 2013 The National Perinatal Association All rights reserved 0743-8346/13
www.nature.com/jp
PRACTICE GUIDELINES
Multidisciplinary guidelines for the care of late preterm infants

RM Phillips, M Goldstein, K Hougland, R Nandyal, A Pizzica, A Santa-Donato, S Staebler, AR Stark, TM Treiger and E Yost, on behalf of
The National Perinatal Association
Journal of Perinatology (2013) 33, S5S22; doi:10.1038/jp.2013.53
IN-HOSPITAL ASSESSMENT AND CARE

Late preterm infants (LPIs), like all other newborns, should have a
qualied 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 stafng
ratios during transition (112 h after birth) for this population of
infants is necessary.8 Because of their increased vulnerabilities, LPIs
require continued close monitoring throughout the rst 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 posttraumatic stress disorder in the postpartum period.
HEALTHCARE TEAM
FAMILY EDUCATION*
Initial
Assessment
References: 2, 7,
9, 10, 11, 12, 13,
14, 15
Establish gestational age (GA) prior to delivery, if possible.

Keep warm and dry, and stimulate per Neonatal
Resuscitation Protocol (NRP) guidelines.
Place stable infants skin to skin with mother as soon as
possible after delivery and cover with a warm blanket.
Do initial assessment and Apgar scores during infants
skin-to-skin contact with mother if infant remains stable.
After initial stabilization, assess newborn q 30 min until
condition has been stable for 2 h, then q 4 h for first 24 h,
then q shift until transition/discharge. * Assess respiratory
rate (RR), type of respirations, and work of breathing.
* Assess heart rate (HR) and rhythm, presence of murmur,
distal pulses, and perfusion. * Assess axillary temperature.
* Assess tone and activity. * Assess cord stump.
Support uninterrupted skin-to-skin contact by delaying
Vitamin K, eye care, and foot and hand prints until after the
first breastfeeding or until 12 h after birth (Vitamin K and
eye prophylaxis can be delayed up to maximum time
allowed by hospital protocol if there are no specific risk
factors.)
Obtain weight, length, and head circumference after first
breastfeeding unless needed to adjust care. * Plot
measurements on appropriate preterm growth curve.
* Determine if Small for Gestational Age (SGA), Appropriate
for Gestational Age (AGA), or Large for Gestational Age
(LGA).
Assess with New Ballard Score within 12 h of birth to
confirm GA.
Identify maternal risk factors that can affect infants initial
stability (e.g., diabetes, medications, or illicit drugs).
Communicate risks of late preterm birth (prior to delivery,

if possible), explaining that immature organ systems and
brain of LPI may lead to complications in the immediate
postpartum period (and beyond) that will require close
monitoring, including: * Respiratory distress
* Hypothermia * Sepsis * Hypoglycemia * Feeding
difficulties and dehydration * Hyperbilirubinemia
* Developmental, learning, and behavioral challenges.
Stress importance of immediate postpartum skin-to-skin
contact with mother to: * Stabilize infant and support
optimal transition after birth. * Promote physiological
stability in HR, RR, oxygen saturation, temperature, and
glucose levels. * Facilitate infants first breastfeeding.
Reducing Risks of
Respiratory
Distress
References: 2, 7,
13, 14
Monitor infants RR and work of breathing closely by

visual inspection during first hour after birth.
Maintain skin-to-skin contact if stable to decrease
infant stress, optimize respiration and oxygen saturations,
and protect from hypothermia-induced apnea.
Explain LPIs increased risk for respiratory distress and apnea,

including: * Immature lung development. * Decreased
surfactant level. * Immature control of breathing.
* Decreased airway muscle tone leading to decreased
ability to protect airway.
STABILITY
This supplement is modied and republished on behalf of the Late Preterm Infant Guidelines Steering Committee with permission from The National Perinatal Association.
Correspondence: Raylene M Phillips, MD, IBCLC, FAAP, Division of Neonatology, Loma Linda University Childrens Hospital, 11175 Campus Street, Suite 11121, Loma Linda,
CA 92354, USA.
E-mail: RPhillips@llu.edu
Multidisciplinary guidelines for the care of LPIs

RM Phillips et al
S6
HEALTHCARE TEAM
FAMILY EDUCATION*
If signs of respiratory distress are present and persist,

evaluate with pulse oximeter, stabilize infant, and
consult with next-level perinatal care provider about
transferring infant to higher level of care.
Teach how to recognize signs of respiratory distress and

apnea and when to alert healthcare provider for
immediate evaluation of infant.
Reducing Risks of
Hypothermia
References: 2, 7, 9,
14, 16
Maintain neutral thermal environment. * Dry infant gently

after birth. * Continue skin-to-skin care with parent
whenever possible. * Cover infants back with warmed
blanket. * Keep hat on infant when not in skin-to-skin
contact. * Use a pre-warmed blanket during weighing.
* Keep infants bed away from air vents and drafts.
Prevent heat loss when skin-to-skin care is not an option
or is ineffective in maintaining infants temperature.
* Swaddle with double wrap. * Increase ambient
temperature. * Use radiant warmer or incubator. * Assess
axillary temperature to ensure 97.799.51F (36.537.51C)
q 30 min 1 h, then q 4 h for first 24 h, then q shift
until transition/discharge.
Postpone bath until thermal, respiratory, and
cardiovascular stability is well established (typically 212
h after birth). * Consider partial rather than whole-body
bathing. * Dry infant immediately after bath and cover
infants head with dry hat. * Place infant in skin-to-skin
contact with mother, if possible, for optimal warming.
If temperature instability occurs, take actions to stabilize. If
instability persists, consult with next-level perinatal care
provider about transferring infant to higher level of care.
Explain LPIs increased risk for hypothermia: * Decreased

brown fat (thermogenesis) and white fat (insulation).
* Increased heat loss due to higher surface-area-to-mass
ratio.
Teach importance of skin-to-skin contact in keeping infant
warm.
Stress importance of adequate clothing when not in skinto-skin contact.
Teach how to take infants temperature accurately.
Reducing Risks of
Sepsis
References: 17, 18,
19
Identify maternal and neonatal risk factors: * Maternal

Group B Strep (GBS)-positive or unknown status with
inadequate antenatal antibiotic prophylaxis.
* Chorioamnionitis/maternal fever 4100.41F (38.01C).
* Maternal cold or flu-like symptoms. * Prolonged
(X18 h) rupture of membranes. * Fetal instability
during labor or delivery.
Assess and monitor for signs of infection:
* Respiratory distress, apnea. * Temperature instability.
* Glucose instability, jitteriness. * Pale, mottled, or
cyanotic color. * Lethargy. * Feeding problems.
* Abdominal distension, vomiting.
If signs of sepsis occur, stabilize infant, initiate septic
workup (CBC, blood culture), and start antibiotics.
Consult with next-level perinatal care provider about
transferring infant to higher level of care.
Explain LPIs increased risk for sepsis: * Immature immune

system. * Additional risk factors, if present.
Teach ways to reduce illness. * Wash hands, limit visitors,
avoid crowds, protect against contact with sick people.
* Breastfeed for as long as possible during the first year
after birth or longer.
Teach how to recognize early signs of infection.
Inform when to alert healthcare provider for immediate
evaluation of infant.
Reducing Risks of
Hypoglycemia
References: 7, 12,
20, 21
Review the antepartum/intrapartum history (as

described by the Association of Womens Health,
Obstetric, and Neonatal Nurses [AWHONN] Assessment
and Care of the Late Preterm Infant Evidence-Based
Clinical Practice Guidelines) for conditions that increase
the risk of hypoglycemia. * Maternal conditions:
Gestational or pre-existing diabetes mellitus, Pregnancyinduced hypertension, Maternal obesity, Tocolytic use for
preterm labor, Late antepartum/intrapartum
administration of IV glucose, Difficult/prolonged
delivery, Nonreassuring fetal heart rate pattern.
* Neonatal conditions: Prematurity, Intrauterine growth
restriction, Twin gestation, 5-minute Apgar score
o7, Hypothermia/temperature instability, Sepsis,
Respiratory distress, Polycythemia-hyperviscosity.
Follow American Academy of Pediatrics (AAP) 2011
guidelines for postnatal glucose homeostasis or established
hospital protocol for glucose monitoring of at-risk infants
(all LPIs); serum glucose nadir occurs 12 h after birth.
Monitor infant for symptoms of hypoglycemia.
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 1012 breastfeedings or 810 formula
feedings per day.
Provide intervention if required: * Offer feeding (at breast
if breastfeeding). * Recheck glucose 1 h after feeding. * If
Explain LPIs increased risk for hypoglycemia: * Low

glycogen stores. * Immature metabolic pathways to make
glucose.
Explain any additional risk factors for hypoglycemia that
may be present.
Stress importance of feeding infant frequently, at least
1012 breastfeedings or 810 formula feedings per day.
Teach how to recognize symptoms of hypoglycemia and
when to alert healthcare provider for immediate
evaluation of infant.
Journal of Perinatology (2013), S5 S22
& 2013 The National Perinatal Association

RM Phillips et al
S7
HEALTHCARE TEAM
FAMILY EDUCATION*
glucose is still low or infant is unable to adequately feed,

provide IV glucose and consult with next-level perinatal care
provider about transferring infant to higher level of care.
Reducing Risks of
Feeding
Difficulties
References: 7, 12,
22, 23
Identify maternal risk factors that may affect successful

breastfeeding: * Multiple gestation. * Diabetes.
* Pregnancy-induced hypertension. * Chorioamnionitis.
* Cesarean delivery.
Provide assistance as needed to ensure adequate
feeding frequency, at least 1012 breastfeedings or
810 formula feedings per day.
Maintain nursing staff lactation competencies consistent
with scope of practice and responsibilities.
Provide a dedicated lactation consultant, ideally an
International Board Certified Lactation Consultant
(IBCLC), whenever possible.
Provide (or refer to) a feeding specialist (occupational
or physical therapist or speech/language pathologist) to
evaluate infants with persistent feeding difficulties.
Adopt the Baby Friendly Hospital Initiatives Ten Steps
to Successful Breastfeeding whenever possible
(www.babyfriendlyusa.org/eng/10steps.html).
Explain LPIs increased risk for inadequate feeding:

* Immature suck/swallow/breathe coordination.
* Inadequate breastmilk transfer due to low muscle tone,
ineffective latch, and decreased stamina. * Low milk
supply due to inadequate breast emptying.
Stress the value to mother and baby of exclusive breastmilk
feeding. * Explain the value of colostrum in providing
immune protection and nutrition. * Reassure mothers that
small amounts of colostrum are usually adequate in the first
few days if baby is feeding frequently enough.
Teach how to recognize early 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
LPIs immature brain and increased sleepiness. * Infant will
transition to full cue-based feeds when closer to term
gestational age.
Encourage mothers to ask for assistance as needed with
breastfeeding or formula feeding.
First
Breastfeeding
References: 7, 12,
24
Assess mothers desire to breastfeed as well as her

knowledge and level of experience.
Facilitate immediate, uninterrupted, and extended
skin-to-skin contact for stable infants until after the
first breastfeeding (usually within first 12 h).
Remind mother that babies are born to breastfeed. * Review

benefits of breastfeeding for baby: decreased risk of infection,
diarrheal illness, Sudden Infant Death Syndrome (SIDS), and
obesity. * Review benefits for mother: decreased risk of breast
cancer, ovarian cancer, and osteoporosis. * Review risks of
formula feeding, e.g., increased risk of infection due to
increased gastric pH and change in gut flora, risk of cow
protein allergy, increased risk of SIDS (www.health-elearning.com/articles/JustOneBottle.pdf).
Explain reasons for formula use if formula is medically
indicated.
Explain the importance of early and prolonged skin-to-skin
contact: * Promote optimal physiological stability.
* Facilitate the first breastfeeding.
Continued
Breastfeeding
References: 25, 26
Monitor and document breastfeeding frequency.

A healthcare professional with appropriate education and
experience in lactation support, such as a RN, midwife and/
or certified lactation consultant, should assess
breastfeeding at least twice per day by evaluating:
* Coordination of suck, swallow, and breathing. * Mothers
breastfeeding position and comfort. * Babys latch and milk
transfer. * Mothers questions regarding breastfeeding.
Consider use of ultrathin silicone nipple shield if infant has
ineffective latch or milk transfer. * Use of shield requires
close follow-up by knowledgeable healthcare professional.
Assess mothers level of fatigue and coping.
Refer mother to a qualified lactation specialist if feeding
difficulties persist.
Provide written and verbal information about

breastfeeding and ensure mothers understanding.
Stress the importance of frequent breastfeedings, at least
1012 times every 24 h, waking baby if necessary, and
encourage recognition of and response to early feeding
cues.
Educate about the size of a newborns stomach and the
adequacy of frequent, small-volume feedings of
colostrum. * Use the phrase when your milk supply
increases rather than when your milk comes in to avoid
implying that no milk is present during the colostrum
phase.
Stress the value of exclusive breastfeeding.
Encourage mother to ask for assistance if needed.
Monitoring
Breastfeeding
Success
References: 25
Monitor weight daily, ideally when the baby is unclothed

(taking care to maintain a neutral thermal environment).
* Weight loss of more than 3% per day or 7% by day 3
merits further evaluation and close monitoring.
Document voiding and stool patterns.
Explain importance of tracking voids and stools to

determine adequate feeding intake: * 3 voids and 3 stools
by day 3. * 4 voids and 4 stools by day 4. * 6 voids and 4
stools by day 6 and thereafter.
Supplementation
References: 12, 25
Supplement feeds only if medically indicated.

Maternal antenatal IV fluids may lead to infant diuresis in
the first 24 h, increasing infants urine output and apparent
weight loss and should be taken into consideration when
evaluating the need for supplementation.
If indicated, supplement with (in order of preference)
expressed breastmilk, donor human milk, hydrolyzed
formula, or formula.
Supplement using one of the following: * Feeding tube at
breast. * Cup feeding. * Finger feeding. * Bottle feeding.
Explain reasons for supplementing breastfeeding if

indicated.
Explain options for providing supplementation, methods
of delivery, and volumes to be given.
Stress value of exclusive breastmilk feeding if possible and
risks of introducing formula.
Explain feeding plan. * Explain that supplementation may
be needed until the baby appears to be growing
adequately but will likely be discontinued when baby
matures and adequate growth is ensured.

RM Phillips et al
S8
HEALTHCARE TEAM
FAMILY EDUCATION*
Supplement no more than recommended volumes

(if breastfeeding is inadequate): * 210 mL per feed
(first 24 h). * 515 mL per feed (2448 h). * 1530 mL
per feed (4872 h). * 3060 mL per feed (7296 h).
Evaluate continued need for supplementation with daily
feeding plan.
Evaluate mothers understanding of feeding plan.
Breast Pumping
References: 27
Provide hospital-grade electric breast pump if pumping

is needed.
Assist with milk expression as soon as possible (ideally
no later than 6 h after birth) if mother and infant are
separated.
Evaluate milk transfer and help mother hand express or
pump after each feeding if milk transfer during
breastfeeding is inadequate.
Refer mother to a qualified lactation specialist if she has
difficulty expressing milk or using breast pump.
Explain the importance of early and frequent milk

expression if one of the following is present: * Mother and
infant are separated. * Breastfeeding is inadequate due to
infants prematurity or illness.
Address the importance of reassuring/informing the
mother that despite having to initially use a breast pump,
she can go on to successfully breastfeed.
Teach techniques of milk expression: * Hand expression.
* Mechanical milk pump use. * Hands-on pumping.
Explain the importance of complete breast emptying at
least 1012 times per day to: * Reduce Feedback Inhibitor
of Lactation (FIL). * Ensure adequate milk supply.
Teach proper handling and storage of expressed milk.
Reducing Risks
of Hyperbilirubinemia
References: 2, 7,
20, 28, 29, 30, 31,
32, 33
Identify known maternal/infant/family risk factors that

add to increased risk of LPI.
Assess adequacy of feeding (especially breastfeeding),
voiding, and stooling.
Evaluate for visible jaundice within first 24 h. * If present,
obtain either transcutaneous (TcB) or serum (TSB)
bilirubin level.
Obtain TcB or TSB at 24 h after birth or at the time of
metabolic screening for all infants regardless of presence
or absence of visual jaundice (visual assessment alone is
not reliable).
Plot bilirubin levels on hour-specific Bhutani Nomogram
to determine risk category and intervention threshold(s)
for infants 435 weeks GA. For infants o35 weeks GA,
consult next-level perinatal care provider.
Obtain repeat bilirubin level prior to transition/discharge
to determine rate of rise.
If rate of rise is 40.5 mg /dL/h, consider initiating
phototherapy.
If bilirubin levels checked prior to transition/discharge
are higher than threshold for age in hours, initiate
phototherapy. * Provide phototherapy in mothers room,
if possible. * Monitor repeat bilirubin levels per hospital
protocol. * Transfer to higher level of care if infant does
not respond to phototherapy in expected manner.
Plan for repeat bilirubin testing within 2448 h if
indicated for infants transitioned/discharged prior to
72 h of age. Additional testing may be needed to
coincide with peak bilirubin levels which may occur on
days 5-7 in LPIs.
Explain LPIs increased risk for hyperbilirubinemia: * Delay

in bilirubin metabolism and excretion. * Peak bilirubin
levels at days 57 after birth. * Twice as likely to have
significantly high bilirubin levels and more susceptible to
bilirubin toxicity.
Provide written and verbal information about jaundice,
risks of kernicterus, and possible need for phototherapy to
treat hyperbilirubinemia.
Teach how to recognize signs and symptoms of
hyperbilirubinemia and when to alert healthcare provider
for immediate evaluation of infant.
Stress importance of adequate feeding to minimize the
risk of dehydration and hyperbilirubinemia.
Stress importance of follow-up for all LPIs.
Optimizing
Neurologic
Development
References: 34
Assess parents understanding of LPI brain immaturity

and implications for apnea risks, feeding and sleeping
behaviors, tone, and development.
Explain immaturity of LPIs brain and central nervous system

(CNS). * Fetal brain cortical volume increases by 50% between
34 and 40 weeks GA, with great increase in surface area.
Review implications of immature brain for apnea risks,
feeding and sleeping behaviors, tone, and development,
including: * Apnea of prematurity and periodic breathing.
* Poor coordination of suck/swallow/breathe and need for
pacing if bottle feeding. * Increased sleep needs and need to
wake for feeds. * Decreased muscle tone and need for
positioning support for airway and feeding/swallowing.
Ensure familiarity with requirements of individual states

newborn screening mandates (www2.aap.org/
healthtopics/newbornscreening.cfm).
Document date and time of state-required newborn
screening. * Screening should be done 24 h after feeding
Explain reasons for newborn screening.

Stress importance of asking primary care provider about
results of newborn screening.
Stress importance of any follow-up that is indicated:
* Date, time, and location of follow-up appointment.
SCREENING
Newborn
Screening
References: 55, 56,
73, 74, 75

RM Phillips et al
S9
HEALTHCARE TEAM
FAMILY EDUCATION*
is initiated. * Document plan to repeat test if screening

performed earlier. * Document results, if available.
Report abnormal results or plans for repeat testing to
primary care provider. * Document that intended recipient
received information sent.
Hearing
References: 2
Perform hearing screen prior to transition/discharge.

Document hearing screening date and results.
Make referral to audiology service if indicated.
Explain reasons for hearing screening.

Reinforce understanding of hearing screening procedure.
Explain that screening does not always diagnose a hearing
deficit and that the need for follow-up does not always
mean that the infant is impaired.
Anomalies
References: 93
Evaluate infant for congenital anomalies.

Consider pulse oximetry screening for congenital heart
defects per hospital protocol.
Explain any physical or internal anomalies found.

Stress importance of any follow-up that is indicated.
Maternal
Screening
References: 36, 37,
38, 39, 40, 41, 42
Review maternal blood type.

Review prenatal lab results and risk factors. * Be aware of
Centers for Disease Control and Prevention (CDC)
recommendations for HIV screening and treatment.
Review ingestion of illicit and prescription drugs or other
substances during pregnancy and refer mother to drug
or alcohol rehabilitation program, if indicated.
Review use of prescription or herbal medications or
supplements of concern, if identified.
Review smoking history (present or past use). * Refer
family members who smoke to smoking cessation
program. * Encourage mothers who quit smoking
during or just prior to pregnancy to avoid relapse (high
risk during the postpartum period).
Screen for psychiatric illness or perinatal mood disorders
(including postpartum depression and post-traumatic
stress disorder). * Parents separated from the infant at
birth (e.g., due to cesarean delivery or NICU admission)
are at higher risk for perinatal mood disorders. * Mothers
of infants born prematurely are at increased risk for
mood disorders in the first 6 months postpartum (three
times higher than mothers of term infants). * Make
referrals for treatment if indicated.
Evaluate mothers understanding of any referrals made.
Provide referrals to smoking cessation, drug or alcohol

treatment, psychiatric, or support services, if indicated.
Explain risks of secondhand smoke exposure. * Stress
importance of providing a smoke-free environment for all
infants and children, especially those born prematurely.
* Secondhand smoke exposure is associated with apnea,
SIDS, behavior disorders, hyperactivity, oppositional defiant
disorder, sleep abnormalities, and upper respiratory
infections.
Explain risks and benefits of prescription and herbal
medications and supplements, if indicated. * Where
medications are indicated, encourage use of medications
compatible with breastfeeding, if possible. Reference
LactMed at http://toxnet.nlm.nih.gov/cgi-bin/sis/
htmlgen?LACT.
Provide information about the signs and symptoms of
postpartum depression and post-traumatic stress disorder,
and encourage parents to seek help if needed.
Model proper hand hygiene when handling baby or

feeding equipment.
Model proper equipment, positioning, and monitoring
of the newborn for bathing, diapering, and routine care.
Model safe sleeping practices when placing baby in bed.
Teach importance of handwashing before handling baby

or feeding equipment.
Teach proper use of: * Bulb syringe to suction nares, if
needed. * Thermometer to take auxiliary temperature.
Teach about safe bathing procedures, bath temperature,
and maintaining a neutral thermal environment during
bathing and care.
Stress importance of placing babies on their backs to
sleep in hospital and at home.
Staff Support
Assess adequacy of staff support for physicians, midwives,

nurses, lactation and feeding specialists, social workers,
occupational therapists, physical therapists, case managers,
transition/discharge planners, and home health services,
including: * Availability of staff to support level of services
offered. * Staffing ratios. * Competencies and skills.
* Availability of referral services.
Explain roles of multidisciplinary staff.

Provide case manager evaluation to initiate transition/
discharge planning process.
Family Support
Assess adequacy of family support including: * Partners

presence, involvement, and coping. * Grandparents
and/or friends.
Provide social worker evaluation of special needs as
indicated.
Provide contact information for support resources as

indicated.
Reinforce potential challenges of caring for LPI at home
and encourage use of any needed resources.
SAFETY
In-Hospital
Safety
References: 7
SUPPORT
*When communicating with families and providing education as listed in the Family Education column, concepts should be shared in a manner appropriate
for the needs of the family including those whose first language is not English.

RM Phillips et al
S10
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, veries the receipt of
the information by the intended receiving provider, claries the
receiving providers 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 clarication of the information contained therein, uses the information, and takes
actions as indicated, ensuring continuity of the plan of care or
services.43
HEALTHCARE TEAM
FAMILY EDUCATION*
STABILITY
General
References: 2, 44
Delay transition/discharge until the late preterm

infant (LPI) is at least 48 h of age.
Document infant stability for at least 24 h:
* Successful feeding for at least 24 h without
excessive weight loss. * Stable vital signs for at least
12 h either while in skin-to-skin care or in an open
crib with appropriate clothing. * No significant
emesis. * Adequate voiding. * At least 1 stool/24 h.
* No signs of sepsis.
Reinforce understanding of LPIs increased risks

compared with term infant: * Respiratory distress.
* Hypothermia. * Sepsis. * Hypoglycemia.
* Inadequate feeding and dehydration.
* Hyperbilirubinemia. * Immature brain.
Feeding
References: 2, 18, 23, 25, 50,
51, 52, 53, 54, 55, 56, 57, 58,
59, 60, 61, 62
For breastfeeding infants: * Provide formal

assessment by breastfeeding specialist at least twice
before transition/discharge. * Provide prescription
for breast pump if indicated.
For formula feeding infants: * Provide formal
assessment by feeding specialist if intake is
inadequate or weight loss is abnormal.
For all infants: * Document adequate infant feeding
competency for at least 24 h. * Evaluate parents
understanding of home feeding plan.
Provide written and verbal infant feeding

information: * Recognizing early hunger cues.
* Breastfeeding frequency and technique.
* Supplemental feeding only if indicated (review
indications, such as signs of dehydration). * Breast
pumping, hand expression, and milk storage.
* Formula mixing if indicated. * Assessing adequate
intake. * Knowing how many wet diapers and stools
to expect. (3 voids and 3 stools by day 3, 4 voids and
4 stools by day 4, 6 voids and 4 stools by day 6 and
thereafter). * Understanding significance of
decreased urine and stool output.
Teach how to give Vitamin D drops; explain that
Vitamin D deficiency is widespread in pregnant and
breastfeeding mothers, leading to increased risk of
rickets in infants.
Teach how to give supplemental iron; explain that
lack of iron transfer from mother (normally occurs in
the third trimester) leads to increased risk of infant
anemia.
Provide detailed home feeding plan.
Provide contact information for community
breastfeeding support.
Hyperbilirubinemia
References: 31, 63, 64, 65, 66,
67, 68, 69
Document maternal and infant risk factors.

Document 24-h bilirubin level and repeat level prior
to transition/discharge.
Document follow-up plan for bilirubin check within
2448 h of transition/discharge. Additional testing
may be needed to coincide with peak bilirubin
levels, which may occur on days 57 in LPIs.
Teach how to recognize signs and symptoms of

worsening hyperbilirubinemia: * Deepening yellow
skin and eye color (visual assessment alone is not
reliable). * Sleepiness and lethargy. * Decreased
feeding. * Increased irritability and high-pitched cry.
Inform when to call primary care provider.
Explain follow-up plan for bilirubin check when
indicated.
Circumcision
References: 70, 71, 72
Monitor for at least 2 h after procedure to assess for

bleeding.
Document parents understanding of postcircumcision care.
Explain and demonstrate post-circumcision care.

Explain and demonstrate care of intact penis if infant
is not circumcised.
Newborn Care
Assess parents understanding about general

newborn care and issues specific to LPIs.
Provide written and verbal education about general

newborn care and issues specific to LPIs: * Bathing
and diaper changing. * Cleaning and caring for
umbilical cord. * Value of skin-to-skin holding.
* Need for increased clothing to keep warm when
not in skin-to-skin contact.
Developmental Care
References: 45, 46, 47, 48, 49
Assess parents understanding about developmental

care of preterm/LPI.
Explain the differences between corrected

gestational age (GA) and chronological age.

RM Phillips et al
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HEALTHCARE TEAM
FAMILY EDUCATION*
Model recognition of and sensitivity to infants

behavioral cues.

* Developmental milestone expectations are based

on corrected GA rather than chronological age.
Stress importance of close monitoring of corrected
GA developmental milestones by primary care
provider.
Provide written and verbal education about
developmental care of preterms (including LPI):
* Need for protection from overstimulation.
* Need for positional support if low muscle tone.
* Normal sleep/wake cycles and need for extra
sleep.
Teach signs (behavioral cues) of stress and
overstimulation, including: * Limb extension, finger
or toe splaying. * Twitches or startles. * Arching or
limpness. * Facial grimace or scowl. * Abrupt color
changes. * Irregular breathing. * Gaze aversion.
* Crying.
Teach signs of relaxation and readiness for
engagement, including: * Limb flexion, relaxed
fingers and toes. * Smooth movements. * Rounded,
flexed trunk and back. * Relaxed face and mouth.
* Normal color. * Regular breathing. * Eyes open and
engaged. * Quiet-alert state.
Stress the importance of skin-to-skin holding for
optimal brain development.
SCREENING
Newborn Screening
74, 75
Ensure familiarity with requirements of individual

states newborn screening mandates.
Document date and time of state-required newborn
screening. * Ensure that screening is be done 24 h
after feeding is initiated. * Document plan to repeat
test if screening performed earlier.
* Document results, if available.
Report abnormal results or plans for repeat testing
to primary care provider. * Document that intended
recipient received information sent.
Reinforce reasons for newborn screening.

Stress importance of asking primary care provider
about results of newborn screening tests.
Hearing
References: 2
Review hearing screen test date and results.

Make referral to audiology service if indicated.
Reinforce understanding of hearing screening

procedure.
Explain that screening does not always diagnose a
hearing deficit and that the need for follow-up does
not always mean that the infant is impaired.
Anomalies
References: 93
Document any congenital anomalies.

Consider pulse oximetry screening for congenital
heart defects per hospital protocol. If screen is done,
document results.
Explain any physical or internal anomalies found.

Maternal Screening
References: 36, 37, 38, 39, 40,
41, 42
Review maternal blood type, prenatal lab results,

and risk factors.
Review ingestion of illicit and prescription
drugs or other substances during pregnancy and
any referrals for drug or alcohol rehabilitation
program.
Review smoking history (present or past use)
* Refer family members who smoke to smoking
cessation program. * Encourage mothers who
quit smoking during or just prior to pregnancy to
avoid relapse (high risk during the postpartum
period).
Screen for psychiatric illness or perinatal mood
disorders (including postpartum depression and
post-traumatic stress disorder). * Parents separated
from the infant at birth (e.g., due to cesarean
delivery or NICU admission) are at higher risk for
perinatal mood disorders. * Mothers of infants born
Provide referrals to smoking cessation, drug or

alcohol treatment, psychiatric, or support services,
if indicated.
Explain risks of secondhand smoke exposure.
* Stress importance of providing a smoke-free
environment for all infants and children, especially
those born prematurely. * Secondhand smoke
exposure is associated with apnea, Sudden Infant
Death Syndrome (SIDS), behavior disorders,
hyperactivity, oppositional defiant disorder,
sleep abnormalities, and upper respiratory
infections.
Explain risks and benefits of prescription and
herbal medications and supplements, if indicated.
* Where medications are indicated, encourage use
of medications compatible with breastfeeding,
if possible. Reference LactMed at http://toxnet.
nlm.nih.gov/cgi-bin/sis/htmlgen?LACT.
Provide information about the signs and symptoms
of postpartum depression and post-traumatic

RM Phillips et al
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HEALTHCARE TEAM
prematurely are at increased risk for mood disorders
in the first 6 months postpartum (three times higher
than mothers of term infants). * Make referrals for
treatment if indicated.
Evaluate mothers understanding of any referrals
made.
FAMILY EDUCATION*
stress disorder and encourage parents to seek help if
needed.
Assess family, home, and social risk factors that may

affect bonding.
Assess signs of attachment: * Infants ability
to demonstrate cues. * Parents ability to
recognize and respond appropriately to infants
cues.
Reinforce parents understanding of infant cues.

Encourage frequent and prolonged skin-to-skin
contact with both parents.
Family Risk Factors

References: 41, 57, 76, 77
Document screening done and referrals made for

the following: * Drug or alcohol use in home.
* Smokers in home. * Domestic violence.
* Mental health issues. * Social services
involvement.
Evaluate parents understanding of any referrals made.

available support services, if indicated.
Home Environment
Assess parents knowledge of how to make the

home environment safe for infants.
See Tips and Tools, Safety for Your Child
(www.healthychildren.org/English/tips-tools/Pages/
default.aspx).
Document screening and referrals made for the
following: * Adequate housing/shelter. * Utilities.
* Phone. * Fire alarms. * Transportation.
Teach ways to make the home environment safe for

infants.
Stress importance of adequate shelter for infant.
available support services, if indicated.
Review familys plan for communication with and
transportation to primary care provider for infant
follow-up visits.
Safe Sleep
References: 24, 94, 95, 96, 97,
98, 99
Document education about safe infant sleep

practices provided.
See Ages & Stages, A Parents Guide to Safe Sleep
(www.healthychildren.org/English/ages-stages/
baby/sleep/pages/ A-Parents-Guide-to-SafeSleep.aspx)
Reinforce the LPIs increased risk for SIDS.

placing infant on his/her back to sleep and on
tummy to play.
Explain unsafe sleeping practices.
Recommend use of pacifier after first month after birth.
Infection & Immunizations

References: 2, 18, 53, 54, 57,
78, 79, 80, 81, 82, 83
Document education provided.

Give hepatitis B vaccine prior to transition/discharge.
* If parents defer until 2-month vaccine schedule or
defer entirely, document the decision.
Give respiratory syncytial virus (RSV) prophylaxis and
recommendations for repeat dosing as indicated.
See Talking with Parents about Vaccines for
Infants (www.cdc.gov/vaccines/spec-grps/hcp/
conv-materials.htm#talkpvi)
Review ways to reduce illness. * Wash hands,

limit visitors, avoid crowds, protect against
contact with sick people. * Breastfeed for as long
as possible during the first year after birth or
longer.
Stress importance of infant immunizations.
Stress importance of flu shots and pertussis boosters
for family and care providers.
Provide written and verbal information about RSV
prophylaxis and prevention.
Car Seat Safety

References: 84
Ensure parents have a car seat or assist them in

procuring one.
Ensure car seat testing is done in the same car seat
infant will use after transition/discharge. * A trained
professional should teach proper use of car seat.
Arrange for a car bed if the infant fails the car seat
test.
Instruct parents to bring their own car seat in for

testing.
Provide written and verbal instruction on proper use
of car seat: * Correct way to secure car seat in car.
* Correct way to secure infant in car seat. * Age of
transition to front-facing car seat
Shaken Baby Prevention

Education
References: 117
Provide shaken baby syndrome information and

explanation using visual aids and document viewing
prior to transition/discharge.
Provide written and verbal instruction about risks of

shaking baby.
Teach ways to calm infant.
Teach ways to cope with crying infant.
When To Call 911 or Local

Emergency Number
Assess parents understanding of when to call 911.
Teach how to recognize life-threatening events and

when to call 911, including: * Apnea. * Choking.
* Difficulty breathing. * Cyanosis
Teach CPR.
When To Call Primary Care

Provider
Assess parents understanding of when to call

primary care provider.
Teach how to recognize signs of illness and when to

call primary care provider, including: * Lethargy.
* Fever, hypothermia. * Poor skin color. * Decreased
Parent-Infant Bonding
References: 77
SAFETY

RM Phillips et al
S13
HEALTHCARE TEAM
FAMILY EDUCATION*
urine output. * Abdominal distension. * Vomiting.
* Bloody stool. * Inconsolable infant. * Uncertainty
about significance of infants symptoms.
SUPPORT
Staff Support
Assess adequacy of staff support for physicians,

midwives, nurses, lactation and feeding specialists,
social workers, occupational therapists, physical
therapists, case managers, transition/discharge
planners, and home health services. * Availability of
staff to support level of services offered. * Staffing
ratios. * Competencies and skills. * Availability of
referral services.
Explain roles of multidisciplinary staff.
Family and Social Support
Evaluate support needs and address barriers to care:

* Family/Social support network. * Communitybased services (e.g., WIC, lactation support, social
services). * Home health care referral. * Ongoing
infant care education.
Ask parents if they have any questions or concerns
that have not already been addressed.
Provide a call-back number for general questions
that come up after when family is home.

available resources, if indicated.
Reinforce potential challenges of caring for LPI at
home and encourage use of needed resources.
Primary Care Provider

References: 85, 86
Identify community primary care provider and

document name, address, phone, fax, and email
address.
Document plan for first follow-up appointment.
Review name, place, time, and purpose of first

follow-up appointment.
Stress importance of initial and subsequent followup appointments.
Discharge Summary &

Checklist
References: 43, 77
Complete transition/discharge summary: * Maternal

history, prenatal lab results, labor and delivery
course. * Birth events, Apgar scores, measurements.
* Hospital course, lab results, procedures,
medications. * Immunizations given. * Feeding
history and detailed feeding plan. * Growth chart
with birth and transition/discharge weights.
* Follow-up appointments planned.
Send copy of transition/discharge summary to
community primary care provider. * Document
acknowledgment that the intended recipient
received and understood the information sent.
* Resend information if not received.
Give copy of transition/discharge summary to
parents (in person) and evaluate parents
understanding of content.
Evaluate and assist with transportation issue(s),
as needed.
Explain content of transition/discharge summary.

* Stress importance of bringing transition/discharge
summary to all follow-up appointments.
Explain infants growth curve, immunization record,
list of medications, feeding plan, and follow-up.
* Ensure parents understanding of information
explained. * Ask parents if they have any questions
or concerns that have not already been addressed.
* Provide a call-back number for general questions
that come up after the family is home.
TRANSFER OF CARE
SHORT-TERM FOLLOW-UP CARE

Late preterm infants (LPIs) should be seen by their community primary care provider within 12 days after transition/
discharge from the hospital; the provider should assess the
infants continued stability, review screening results, ensure
ongoing safety, and evaluate the adequacy of support systems.
LPIs can appear deceptively vigorous on the rst day or two after
birth prior to transition/discharge. It is not unusual for morbidities
common to LPIs to rst 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 mothers milk supply increases on postpartum days 25.
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 infants hospital
course, on the rst follow-up visit. Because LPIs have many needs

RM Phillips et al
S14
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 asse-
ssments until the infant reaches 40 weeks of corrected gestational

age (GA) (the infants due date) or is clearly thriving.25 More
frequent visits may be necessary if weight or bilirubin checks are
indicated.
HEALTHCARE TEAM
FAMILY EDUCATION*
Respiratory Distress
References: 87
Assess infant for current signs of respiratory distress.

Ask parents if infant has had any history of apnea,
cyanosis, or respiratory distress.
Reinforce LPIs increased risk for apnea and

respiratory instability, especially when in car seat and
upright devices.
Sepsis
References: 88
Assess infant for current signs of sepsis.

Ask parents about any recent symptoms of sepsis.
Ask parents if the infants care givers or any of the care
givers family members have signs of illness.
Reinforce LPIs increased risk for sepsis and rehospitalization.

Review ways to reduce illness: * Wash hands, limit
visitors, avoid crowds, protect against contact with
sick people. * Breastfeed for as long as possible
during the first year after birth or longer.
Review signs and symptoms of sepsis:
* Difficulty in breathing or feeding, increased or
decreased temperature, decreased energy level.
Review how to take infants temperature.
If temperature 4100.41F (381C), take infant to primary
care provider.
Weight Loss
References: 2, 25, 89, 90
Assess weight 12 days after hospital transition/discharge

using appropriate preterm growth curves and compare
with infants transition/discharge weight.
In addition to weight loss, take into account the number
of wet diapers and stools when evaluating adequacy of
intake (3 voids and 3 stools by day 3, 4 voids and 4 stools
by day 4, 6 voids and 4 stools by day 6 and thereafter).
Evaluate feeding practices if weight loss greater than
appropriate for age. * Ask mother about any pain with
breastfeeding. * Do oral exam and check for
abnormalities, such as ankyloglossia, cleft palate, or thrush.
* Observe infant feeding (breast or bottle). * Modify
feeding and supplementation appropriately. * If unable to
observe infant feeding, immediately refer mother to
lactation consultant or feeding specialist. * Make
appointment for repeat infant weight check.
Reinforce LPIs increased risk for excessive weight loss.

Review normal weight-loss parameters: * No more
than 3% per day or total of 10% loss. * Regained by
14 days after birth.
Review and validate understanding of feeding plan.
* Explain need for supplementation of breastmilk if
infant has excessive weight loss.
* Explain need to prevent infant dehydration by
ensuring infant has adequate fluid intake.
Stress importance of follow-up for weight check:
* Date, time, and location of follow-up appointment
Feeding
References: 23
Determine family understanding of post-discharge

feeding plan and assess adherence to plan (including
iron and Vitamin D supplementation).
Assess current feeding practices, including type of milk,
length of time feeding, amount taken (if formula fed).
Assess urine output, stool color, and frequency and
symptoms of gastroesophageal reflux disease (GERD),
colic, or oral aversion.
Modify feeding and supplementation plan if indicated.
* Encourage pumping and supplementing with
expressed breastmilk if supplementation is needed for
breastfed infants. * Provide prescription for breast pump,
if indicated. * Supplement with formula only as last resort.
Encourage and support breastfeeding.
* Congratulate mother about choosing to breastfeed.
* Ask about pain with breastfeeding or any other
concerns. * Observe breastfeeding if concerns or
pain are described by mother (evaluate for
ankyloglossia). * Make immediate referral to lactation
consultant if needed.
Reinforce LPIs increased risk for failure to thrive and

re-hospitalization: * Immature feeding skills.
* Ineffective sucking/swallowing. * Uncoordinated
suck/swallow/breathe; may not be noticed until after
increase in breastmilk supply. * Longer sleep cycles,
may need to wake for feedings.
Review normal feeding frequencies: * 1012 times/
day for breastfeeding infants. * 810 times/day for
formula-fed infants.
Review normal urine output and stool frequency and
color as indicators of adequate feeding intake (and
lack of normal urine/stool as signs of dehydration):
* At least 6 wet diapers/24 h by day 5 after birth. * At
least 1 yellow seedy stool daily by day 4 after birth.
Review benefits of breastfeeding/breastmilk for all
infants and their mothers.
Provide contact information for lactation specialist
and community breastfeeding support.
Hyperbilirubinemia
66, 91
Assess infant for jaundice 12 days after transition/

discharge.
Assess for any feeding difficulties or dehydration,
especially if infant is breastfeeding exclusively.
Follow-up maternal and infant blood type and Direct
Coombs tests if available.
Review 24-h bilirubin level and repeated evaluation
done prior to transition/discharge.
Reinforce LPIs increased risk for jaundice requiring

hospitalization and/or phototherapy. * Stress
increased risk for kernicterus
Review delayed peak in bilirubin levels for LPIs (at
days 57 after birth) and possible need for additional
testing to coincide with this peak.
Review signs and symptoms of worsening
hyperbilirubinemia: * Deepening yellow skin and eye
STABILITY

RM Phillips et al
S15
HEALTHCARE TEAM
FAMILY EDUCATION*
If concerned about elevated bilirubin, obtain Total

Serum Bilirubin (TSB) or Transcutaneous Bilirubin (TcB)
level (visual assessment is not reliable).
Arrange for repeat bilirubin check, home phototherapy
with follow-up, or hospital admission, as indicated.
color (visual assessment alone is not reliable).

* Sleepiness and lethargy. * Decreased feeding.
* Increased irritability with high-pitched cry.
Stress critical importance of follow-up with primary
care provider if infant has signs or symptoms of
worsening jaundice.
Explain that breastfed infants are at higher risk for
jaundice and need close monitoring of feedings to
reduce risk of hyperbilirubinemia. * Infant may need
supplementation. * Expressed breastmilk is ideal first
choice. * If mothers own milk or donor human milk is
not available, cows-milk-based formula may be used
for supplementation.
Circumcision
Assess circumcision site for healing.
Review normal course of healing and care of

circumcised penis.
Review care of intact penis if infant is not
circumcised.
Newborn Care
References: 2, 7
Evaluate appropriateness of infants clothing for

warmth and general cleanliness.
Evaluate evidence for proper care of umbilicus and
diaper area.
Assess parents knowledge and skill regarding routine
newborn care.
Review parents understanding of all routine newborn

care procedures, e.g., taking temperatures,
appropriate clothing, bathing, and diapering.
Developmental Care
48, 49
Evaluate parents level of understanding about the

special developmental care needs of the LPI.
Explain the differences between corrected gestational

age (GA) and chronological age.
* Developmental milestone expectations are based on
corrected GA rather than chronological age.
Stress importance of close monitoring of
developmental milestones by primary care provider.
Provide written and verbal education about
developmental care of preterms (including LPI):
* Need for protection from overstimulation.
* Need for positional support if low muscle tone.
* Normal sleep/wake cycles and need for
extra sleep
Teach signs (behavioral cues) of stress and
overstimulation, including: * Limb extension, finger or
toe splaying. * Twitches or startles. * Arching or
limpness. * Facial grimace or scowl. * Abrupt color
changes. * Irregular breathing. * Gaze aversion.
* Crying.
Teach signs of relaxation and readiness for
engagement, including: * Limb flexion, relaxed
fingers and toes. * Smooth movements.
* Rounded, flexed trunk and back. * Relaxed face and
mouth. * Normal color. * Regular breathing.
* Eyes open and engaged. * Quiet-alert state.
Stress the importance of skin-to-skin holding for
optimal brain development.
Newborn Screening
74, 75
Ensure familiarity with requirements of individual

states newborn screening mandates.
Follow-up on state-specific newborn screening
mandates as indicated.
Make referral or follow-up plan, if indicated.
Respond to parents questions about newborn

screening results.
Explain any abnormalities found during newborn
screening results.
* Date, time, location of follow-up appointment.
Hearing
References: 92
Within the first 3 months after birth, order brainstem

auditory evoked response (BAER) for any infant with
Total Serum Bilirubin (TSB) X20 mg/dL.
Explain reason for BAER if ordered: * Vulnerability of

hearing to high bilirubin levels. * Importance
of normal hearing for speech development.
Stress importance of following-up on any hearing
screening ordered: * Date, time, and location of
follow-up appointment.
Anomalies
References: 93
Identify physical or internal anomalies requiring further

assessment or follow-up care.
Assess parents understanding of anomalies if present.
Make follow-up plan for family.
Respond to any questions about infants anomalies.

* Date, time and location of follow-up appointment
SCREENING

RM Phillips et al
S16
HEALTHCARE TEAM
FAMILY EDUCATION*
Maternal Screening
References: 36, 37, 38, 39,
40, 41, 42
Review maternal prenatal lab results and risk factors.

Review ingestion of illicit and prescription drugs or
other substances during pregnancy and referrals to
drug or alcohol rehabilitation program.
Review smoking history (present or past use). * Refer
family members who smoke to smoking cessation
program. * Encourage mothers who quit smoking
during or just prior to pregnancy to avoid relapse (high
risk during the postpartum period).
disorders (including postpartum depression and posttraumatic stress disorder). * Parents separated from the
infant at birth (e.g., due to cesarean delivery or NICU
admission) are at higher risk for perinatal mood
disorders. * Mothers of infants born prematurely are at
increased risk for mood disorders in the first 6 months
postpartum (three times higher than mothers of term
infants). * Make referrals for treatment if indicated.
Evaluate mothers understanding of any referrals made.

alcohol treatment, psychiatric, or support services, if
indicated.
hyperactivity, oppositional defiant disorder, sleep
abnormalities, upper respiratory infections.
Explain risks and benefits of prescription and herbal
medications and supplements, if indicated. * Where
medications are indicated, encourage use of
medications compatible with breastfeeding, if
possible. Reference LactMed at http://
toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT.
Provide information about postpartum depression
and post-traumatic stress disorder and encourage
parents to seek help if needed.
Review increased risk for postpartum mood disorders
in mothers of infants born prematurely: * Nearly three
times higher risk during first 6 months postpartum.
Parent-Infant Bonding
References: 77
Assess family, home, and social risk factors that may

affect bonding.
Assess maternal health and parents ability to cope with
challenges of newborn care and monitoring that can
affect healthy bonding.
Assess signs of bonding and attachment: * Infants
ability to demonstrate cues. * Parents ability to
recognize and respond appropriately to infants cues.
Review parents understanding of infant cues.

Encourage skin-to-skin contact of LPI with both
parents.
Encourage parents to verbalize feelings about caring
for their LPI and challenges they face that may affect
healthy bonding and attachment.
Family Risk Factors

References: 41, 57,
76, 77
Assess and address family risk factors and make

referrals if needed: * Drug or alcohol use in home.
* Smokers in home.
* Domestic violence. * Mental health issues. * Social
services involvement. * Provide additional education as
needed.
Evaluate parents understanding of any referrals made.
Provide verbal and written information about where

to get professional and community support.
Home Environment
Assess and address parents knowledge of how to

make the home environment safe for infants. * See Tips
and Tools, Safety for Your Child (www.healthychildren.org/
English/tips-tools/Pages/default.aspx). * Provide additional
education as needed.
Document screening and referrals made for the following:
* Adequate housing/shelter. * Utilities. * Phone. * Fire
alarms. * Transportation.
Teach ways to make the home environment safe for

infants.
Stress importance of adequate shelter for infant.
Provide written and verbal information about available
support services, if indicated.
Review familys plan for communication with and
transportation to primary care provider for infant
follow-up visits.
Safe Sleep
References: 24, 94, 95, 96,
97, 98, 99
Assess and address parents understanding of safe

sleep practices. * Provide additional education as
needed.
Reinforce LPIs increased risk for SIDS.

Provide written and verbal information about placing
infant on his/her back to sleep and on tummy to play.
Explain unsafe sleeping practices.
Recommend use of pacifier after first month
after birth.
Immunizations
References: 2, 18, 53, 54,
57, 78, 79, 80, 81, 82, 83
Assess and address parents views and understanding

about importance of immunizations for infant and
family members. * Provide additional education as
needed.
Reinforce importance of immunizations for infant: *

Scheduled immunizations as recommended by
American Academy of Pediatrics (AAP). * Flu shots
during flu season. * Respiratory syncytial virus (RSV)
prophylaxis as indicated.
Stress importance of flu shots and pertussis boosters
for family and care providers.
Car Seat Safety

References: 84
Determine whether parents have an appropriate car

seat and refer for help as needed. * Refer for assistance
in obtaining appropriate car seat as needed.
Assess and address parents understanding of proper
Review proper use of car seats: * Correct way to

secure car seat in car. * Correct way to secure infant in
car seat * Age of transition to front-facing car seat.
SAFETY

RM Phillips et al
S17
HEALTHCARE TEAM
FAMILY EDUCATION*
use of car seats. * Provide additional education/training

in proper car seat use as needed.
Shaken Baby
Prevention Education
References: 117
Assess and address parents understanding of risks of

shaking baby. * Provide additional education as needed.
Assess and address parents knowledge of ways to calm
infants and cope with infant crying. * Provide
additional education as needed.
Assess and address parents coping and stress levels as
risks for shaken baby syndrome. * Provide additional
education as needed.

When To Call 911 or

Local Emergency
Number
Assess and address parents understanding of when to

call 911. * Provide additional education as needed.
Review how to recognize life-threatening events and

when to call 911, including: * Apnea. * Choking.
* Difficulty breathing. * Cyanosis.
Review CPR.
When To Call Primary

Care Provider
Assess and address parents understanding of when to

call a primary care provider for urgent evaluation of
infant.
* Provide additional education as needed.
Teach how to recognize signs of illness and when to

call primary care provider, including:
* Lethargy. * Fever, hypothermia. * Poor skin color.
* Decreased urine output. * Abdominal distension.
* Vomiting. * Bloody stool.
* Inconsolable infant. * Uncertainty about
significance of infants symptoms.
Evaluate support needs and address barriers to care:

* Family/Social support network. * Community-based
services (e.g., WIC, lactation support, social services).
* Home health care referral. * Ongoing infant care
education
Ask parents if they have any questions or concerns that
have not already been addressed.
Provide a call-back number for general questions that
come up after when family is home.
Provide verbal and written information about where

to find support if needed.
Reinforce potential challenges of caring for LPI at
home and encourage utilization of resources as
needed.
Review risks of shaking any baby.

Review ways to calm crying infants.
Review ways to cope with infant crying.
Provide information about community or professional
resources as needed for support.
SUPPORT
Family and Social
Support
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 reecting
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 prociency 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 posttraumatic stress disorder during the postpartum period and the
rst year of the infants life. Because optimal infant development is
so inuenced by the mental health of the infants primary
caregivers, especially that of the mother, referrals should be made
for professional help and community support whenever
indicated.100,101,102,103
HEALTHCARE TEAM
FAMILY EDUCATION*
STABILITY
Growth
References: 52, 104
Monitor growth parameters (weight, length, and

head circumference) at each well-child visit.
Consider need for fortification or
supplementation of either breastmilk or formula if
infant is failing to thrive per appropriate preterm
Assess parents knowledge and reinforce

importance of good nutrition.
Reinforce the health benefits of exclusive
breastfeeding with appropriate fortification or
supplementation if indicated, until 6 months of

RM Phillips et al
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HEALTHCARE TEAM
FAMILY EDUCATION*
growth curves. * Assess both volume of intake

and also caloric density of feeds when planning
fortification or supplementation. * Reassess at
each visit to determine continued need for
fortification or supplementation to maintain
normal growth. * Encourage fortification/
supplementation in ways that encourage
suckling at the breast, if possible, such as higher
calorie transitional formula given at separate
feeds from breastfeeding. This is preferable to
giving fortified expressed milk in a bottle at each
feeding, which discourages feeding at the breast.
Recommend introducing solid foods no earlier
than 6 months corrected gestational age (GA)
and when infant demonstrates developmental
readiness.
age. * Decreased incidence in gastrointestinal

illnesses. * Possible delay in onset of eczema
allergies. * No decrease in growth.
Provide verbal and printed information about
appropriate introduction of healthy solid foods
after 6 months of age. * Assess parents ability to
choose and obtain healthy baby food.
* Encourage continued breastfeeding until at
least 1 year of age or longer in addition to solid
foods.
Reinforce the importance of continuing to
monitor growth.
Assess parents understanding of ways to reduce

upper respiratory infections throughout the first
few years after birth.
Ask about signs or symptoms of asthma.
Reinforce increased LPIs risk for asthma,

respiratory infection and re-hospitalization during
the first year after birth: * Respiratory syncytial
virus (RSV) is the most common infectious
etiology. * High morbidity is similar to that of
extremely preterm infants if admitted to the PICU.
Review ways to avoid respiratory illness: * Keep
immunizations current. * Avoid crowds and
contact with sick people. * Careful and consistent
handwashing. * Protect from secondhand smoke.
* Breastfeed for as long as possible during the
first year after birth or longer. * Maintain good
nutrition on a long-term basis. * RSV prophylaxis
as indicated.
Sensory Screening
References: 105, 106, 107, 108
Evaluate for sensory impairments, including

hearing, sight, and sensory integration.
Follow-up brainstem auditory evoked response
(BAER) results if referral had been made.
Monitor for syndrome of auditory neuropathy/
auditory dyssynchrony (normal otoacoustic
emission (OAE) with abnormal auditory brain
response (ABR)).
Provide education about increased risk for sensory

impairments: * Hearing impairment or deafness.
* Visual impairment or blindness. * Disorders of
sensory integration. * Auditory and visual
processing delay.
Stress importance of hearing or vision follow-up.
* Review date, time, and location of follow-up
appointments.
Stress importance of alerting primary care provider
of any concerns about hearing, vision, or speech.
Developmental Screening
References: 2, 4, 10, 47, 75, 77, 85,
106, 109, 110, 111, 112, 113, 114,
115, 116
Perform regular developmental screening using

valid and reliable assessment tools, such as:
* Modified Checklist for Autism in Toddlers
(MCHAT). * American Academy of Pediatrics (AAP)
Bright Futures, including Pediatric Symptom
Checklist (ages 4 years and up). * Brief Infant
Toddler Social Emotional Assessment (BITSEA), for
age 1236 months; parent can fill out in 710 min
See the AAPs websites for more tools
(www.medicalhomeinfo.org) and (www.aap.org/
sections/dbpeds).
Make referrals as indicated.
Teach about LPIs increased risk for developmental

delays: * 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).
Stress importance of developmental follow-up.
* Review date, time, and location of follow-up
appointments.
Behavioral Screening
References: 77, 86, 106
Ask parents about any signs of behavioral or

emotional disturbances in toddler or child.
Assess familys support system and coping
abilities.
Make referrals as indicated.
Educate about LPIs increased risk for behavioral

and emotional disturbances: * Attention disorders.
* Hyperactivity. * Internalizing behaviors. * Autism.
* Schizophrenia.
Stress importance of alerting primary care
provider regarding abnormal behaviors.
Maternal Screening
References: 36, 37, 38, 39, 40,
41, 42
Review ingestion of illicit and prescription drugs

or other substances during pregnancy and refer
mother to drug or alcohol rehabilitation
program, if indicated.
Review use of prescription or herbal medications
or supplements of concern, if identified.
Review smoking history (present or past use).
* Refer family members who smoke to smoking

alcohol treatment, psychiatric, or support
services, if indicated.
Respiratory Illness
References: 105, 118
SCREENING

RM Phillips et al
S19
HEALTHCARE TEAM
FAMILY EDUCATION*
cessation program. * Encourage mothers who quit

smoking during or just prior to pregnancy to avoid
relapse (high risk during the postpartum period).
disorders (including postpartum depression and
post-traumatic stress disorder). * Parents
separated from the infant at birth (e.g., due to
cesarean delivery or NICU admission) are at
higher risk for perinatal mood disorders.
* Mothers of infants born prematurely are at
increased risk for mood disorders in the first
6 months postpartum (three times higher than
mothers of term infants). * Make referrals for
treatment if indicated.
Evaluate mothers understanding of any referrals
made.

hyperactivity, oppositional defiant disorder,
sleep abnormalities, and upper respiratory
infections.
Explain risks and benefits of prescription and
herbal medications and supplements, if
indicated. * Where medications are indicated,
encourage use of medications compatible with
breastfeeding, if possible. Reference LactMed at
http://toxnet.nlm.nih.gov/cgi-bin/sis/
htmlgen?LACT.
Provide information about postpartum
depression and post-traumatic stress disorder
and encourage parents to seek help if needed.
Provide contact information for local professional
and community resources as appropriate to
provide assistance for parenting support,
substance abuse, domestic violence, and mental
health issues
Family Risk Factors

References: 41, 57, 76, 77
Assess family risk factors and make referrals if

needed: * Drug or alcohol use in home.
* Smokers in home. * Domestic violence.
* Mental health issues. * Social services
involvement.
Evaluate parents understanding of any referrals
made.
Provide verbal and written information about

where to get professional and community
support.
Developmental Risk Factors
Assess for fine and gross motor development

and behaviors that may lead to potential safety
risks.
Review LPIs increased risk for fine and gross

motor development and behaviors that may lead
to potential safety risks: * Hyperactivity. * Seizure
disorder.
Infant Support
Assess and address specialized support needs

and make referrals, if indicated: * Physical,
occupational, or speech therapy. * Subspecialty
care. * Early childhood intervention (03 years).
* School disability programs (ages 3 years
and up).
Use resources such as Child Find (free
screenings, available in all states) to identify
children who may need early intervention
services (www.childfindidea.org).
Use resources such as the National
Dissemination Center for Children with
Disabilities (www.nichcy.org).
Reinforce LPIs increased risk for need of

specialized support and resources.
how to find state and community resources.
Family Support
Assess adequacy of familys support system.

Identify familys support needs: * Parent support
groups for specific disabilities. * State parent-toparent groups or other parenting support
groups. * State parent training and information
Ask parents if they have any questions or
concerns that have not already been addressed.
Provide a call-back number for general questions
that come up when family is home.
Reinforce increased risk of need for specialized

family support due to special needs of infants
born prematurely.
how to find state and community resources for
families of infants born prematurely.
SAFETY
SUPPORT
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
The Steering Committee members disclosed no relevant nancial relationships

that might create a conict 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.
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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This work is licensed under a Creative Commons AttributionNonCommercial-NoDerivs 3.0 Unported License. To view a copy of
this license, visit http://creativecommons.org/licenses/by-nc-nd/3.0/

RM Phillips et al
S22
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 Womens 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. ODonnell 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 DApolito, 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 Womens 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
Zoes New Beginnings

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Journal of Perinatology (2013) 33, S5S22

Multidisciplinary guidelines for the care of late preterm infants

Journal of Perinatology (2013) 33, S5S22; doi:10.1038/jp.2013.53

IN-HOSPITAL ASSESSMENT AND CARE

birth. Whenever possible, mother and infant should remain together,

 Establish gestational age (GA) prior to delivery, if possible.

 Communicate risks of late preterm birth (prior to delivery,

 Monitor infants RR and work of breathing closely by

 Explain LPIs increased risk for respiratory distress and apnea,

Multidisciplinary guidelines for the care of LPIs

 If signs of respiratory distress are present and persist,

 Teach how to recognize signs of respiratory distress and

 Maintain neutral thermal environment. * Dry infant gently

 Explain LPIs increased risk for hypothermia: * Decreased

 Identify maternal and neonatal risk factors: * Maternal

 Explain LPIs increased risk for sepsis: * Immature immune

 Review the antepartum/intrapartum history (as

 Explain LPIs increased risk for hypoglycemia: * Low

Journal of Perinatology (2013), S5 S22

& 2013 The National Perinatal Association

Multidisciplinary guidelines for the care of LPIs

glucose is still low or infant is unable to adequately feed,

 Identify maternal risk factors that may affect successful

 Explain LPIs increased risk for inadequate feeding:

 Assess mothers desire to breastfeed as well as her

 Remind mother that babies are born to breastfeed. * Review

 Monitor and document breastfeeding frequency.

 Provide written and verbal information about

 Monitor weight daily, ideally when the baby is unclothed

 Explain importance of tracking voids and stools to

 Supplement feeds only if medically indicated.

 Explain reasons for supplementing breastfeeding if

& 2013 The National Perinatal Association

Journal of Perinatology (2013), S5 S22

Multidisciplinary guidelines for the care of LPIs

 Supplement no more than recommended volumes

 Provide hospital-grade electric breast pump if pumping

 Explain the importance of early and frequent milk

 Identify known maternal/infant/family risk factors that

 Explain LPIs increased risk for hyperbilirubinemia: * Delay

 Assess parents understanding of LPI brain immaturity

 Explain immaturity of LPIs brain and central nervous system

 Ensure familiarity with requirements of individual states

 Explain reasons for newborn screening.

Journal of Perinatology (2013), S5 S22

& 2013 The National Perinatal Association

Multidisciplinary guidelines for the care of LPIs

is initiated. * Document plan to repeat test if screening

 Perform hearing screen prior to transition/discharge.

 Explain reasons for hearing screening.

 Evaluate infant for congenital anomalies.

 Explain any physical or internal anomalies found.

 Review maternal blood type.

 Provide referrals to smoking cessation, drug or alcohol

 Model proper hand hygiene when handling baby or

 Teach importance of handwashing before handling baby

 Assess adequacy of staff support for physicians, midwives,

 Explain roles of multidisciplinary staff.

 Assess adequacy of family support including: * Partners

Establish gestational age (GA) prior to delivery, if possible.

Communicate risks of late preterm birth (prior to delivery,

Monitor infants RR and work of breathing closely by

Explain LPIs increased risk for respiratory distress and apnea,

If signs of respiratory distress are present and persist,

Teach how to recognize signs of respiratory distress and

Maintain neutral thermal environment. * Dry infant gently

Explain LPIs increased risk for hypothermia: * Decreased

Identify maternal and neonatal risk factors: * Maternal

Explain LPIs increased risk for sepsis: * Immature immune

Review the antepartum/intrapartum history (as

Explain LPIs increased risk for hypoglycemia: * Low

Identify maternal risk factors that may affect successful

Explain LPIs increased risk for inadequate feeding:

Assess mothers desire to breastfeed as well as her

Remind mother that babies are born to breastfeed. * Review

Monitor and document breastfeeding frequency.

Provide written and verbal information about

Monitor weight daily, ideally when the baby is unclothed

Explain importance of tracking voids and stools to

Supplement feeds only if medically indicated.

Explain reasons for supplementing breastfeeding if

Supplement no more than recommended volumes

Provide hospital-grade electric breast pump if pumping

Explain the importance of early and frequent milk

Identify known maternal/infant/family risk factors that

Explain LPIs increased risk for hyperbilirubinemia: * Delay

Assess parents understanding of LPI brain immaturity

Explain immaturity of LPIs brain and central nervous system

Ensure familiarity with requirements of individual states

Explain reasons for newborn screening.

Perform hearing screen prior to transition/discharge.

Explain reasons for hearing screening.

Evaluate infant for congenital anomalies.

Explain any physical or internal anomalies found.

Review maternal blood type.

Provide referrals to smoking cessation, drug or alcohol

Model proper hand hygiene when handling baby or

Teach importance of handwashing before handling baby

Assess adequacy of staff support for physicians, midwives,

Explain roles of multidisciplinary staff.

Assess adequacy of family support including: * Partners

Provide contact information for support resources as

Delay transition/discharge until the late preterm

Reinforce understanding of LPIs increased risks

For breastfeeding infants: * Provide formal

Provide written and verbal infant feeding

Document maternal and infant risk factors.

Teach how to recognize signs and symptoms of

Monitor for at least 2 h after procedure to assess for

Explain and demonstrate post-circumcision care.

Assess parents understanding about general

Provide written and verbal education about general

Assess parents understanding about developmental

Explain the differences between corrected

Model recognition of and sensitivity to infants

Ensure familiarity with requirements of individual

Reinforce reasons for newborn screening.

Review hearing screen test date and results.

Reinforce understanding of hearing screening

Document any congenital anomalies.

Explain any physical or internal anomalies found.

Review maternal blood type, prenatal lab results,

Provide referrals to smoking cessation, drug or

Assess family, home, and social risk factors that may

Reinforce parents understanding of infant cues.

Document screening done and referrals made for

Provide written and verbal information about

Assess parents knowledge of how to make the

Teach ways to make the home environment safe for

Document education about safe infant sleep

Reinforce the LPIs increased risk for SIDS.

Document education provided.

Review ways to reduce illness. * Wash hands,

Ensure parents have a car seat or assist them in

Instruct parents to bring their own car seat in for

Provide shaken baby syndrome information and

Provide written and verbal instruction about risks of

Assess parents understanding of when to call 911.

Teach how to recognize life-threatening events and