The near term infant is neither fish nor fowl when it comes to his medical status. Born at 34 to 37 weeks gestation, these babies may appear vigorous and well or may have trouble in the first days to weeks of life. Until they reach at least 40 weeks of corrected gestational age (the mother’s original “due date”) these babies should be observed and treated by their parents and health care practioners as vulnerable to some of the problems of prematurity. Those that started off with no problems may continue thrive or they may falter after a few hours, a few days or a week or two. Those that transitioned to extra-uterine life with some early difficulties may act like the typical full term infant within a day or two. Most of the problems encountered by near term infants are temporary and have no long term medical consequences if recognized and treated in a timely manner.
Physiologic issues that may be seen in the near term infant:
- May be low in stores of iron, vitamin D, brown fat (specialized fat cells that allow newborns to raise their body temperature without shivering)
- Suck immaturity – difficulty with suck, swallow
- Floppy
- Sleepy
- Less stamina
- Immature liver (delays bilirubin excretion)
- Immature temperature stability
- Less lactase
- More vulnerable to infection
- More respiratory instability
Medical problems that are more likely and we want to prevent:
Re-hospitalization of the near term infant in the first weeks after birth is frequently associated with inadequate feeding. Parents are sometimes stricken with grief and guilt when this happens. Parents, friends, family and
health care providers would do well to remember that these medical problems are a result of the infant’s immaturity not solely the parents’ lack of skill in parenting. That said, there are things that health care providers and parents can do to maintain and enhance the near term's health. Infants of first time parents are likely to suffer more frequently from inadequate transfer of breastmilk. This may be due partially to maternal lack of experience as breastfeeding is a learned skill but also may be due in large part to physiologic differences in the timing of the mature milk supply in the
multiparous mother vs. the first timer as well as the unique vulnerabilities of the near term infant.
Breastfeeding all babies is
important. The typical vulnerabilities of
preterm babies to infection and feeding intolerances are especially helped by being breastfed. Dr. Nancy Wight has pointed out that breastfeeding the near-term infant can be successful but that this success may be dependent upon proper understanding and recognition of the “special physical and developmental needs of near-term infants and their mothers”. Recognition of a problem is the first step in solving it. “Most common problems encountered when breastfeeding the near-term infant can be prevented and responded to appropriately."
The breastfeeding mother of a near term infant should know that:
- Colostrum may not be enough in the first few days of life because these babies may not have had the extra fat buffer that typically accumulates in the last trimester of pregnancy.
- supplementation may be medically indicated for a few days.
- Near term infants may not provide vigorous enough suckling to create an adequate milk supply on their own.
- Mothers of near term infants can use a breast pump or hand expression to increase the stimulation to their breasts in the early weeks in order to help assure an adequate long term milk supply
AWHONN, a US based nurses association has recently launched an initiative to improve care of the near term infant and to educate parents about their needs. “It is important for parents to understand that these near-term infants may face different and more serious health problems than most
full-term infants and to be alert for the special situations or needs that may arise because a baby is
just a few weeks early.”
They list five areas parents of a near-term infant should know and watch for:
- “Feeding. Because near-term infants tend to eat less, they may need to be fed more often. They also may have trouble coordinating sucking and swallowing and may need to be watched closely while they are eating. If a baby is not eating, even for less than a day, the parents or caregiver should contact the baby's nurse practitioner or pediatrician. Some near-term infants may have problems breastfeeding; a mother who chooses to breastfeed may need to ask for support from a nurse, physician or lactation consultant.
- Sleeping. Most healthy full-term babies will wake up when they need to eat. A near-term infant may be sleepier than most full-term infants and may sleep through needed feedings, in which case she or he should be awakened to eat. All infants, including near-term infants, should be placed on their backs to sleep.
- Breathing. Near-term infants may be at greater risk for respiratory distress. Problems in this area are most likely to be noticed and treated before discharge from the hospital since all newborns are closely screened after birth to ensure that they can breathe on their own. But if a baby seems to be having trouble breathing, parents or a caregiver should contact the baby's nurse practitioner or pediatrician immediately or dial 911 if it is an emergency.
- Temperature. Near-term infants, like all preemies, have less body fat and may be less able to regulate their own body temperature than full-term infants. Like all newborns, near-term infants should be kept away from drafts. They do not need to be overdressed, however.
- Infections and Jaundice. Near-term infants have immature immune systems and may be more likely to develop infections and, like all babies, should always be watched for signs of illness or infection such as high fever or difficulty breathing. These infants may also be more likely to develop jaundice, a symptom of a condition (hyperbilirubinemia) that can lead to severe nervous system damage if not identified and treated early. Parents should make sure that their infant is screened for jaundice prior to discharge. Infants should be seen by their nurse practitioner or pediatrician within 24 to 48 hours of discharge.” (AWHONN)
SOURCES:
Nancy Wight - Breastfeeding the Borderline (Near-Term) Preterm Infant – Pediatric Annals (May 2003)
Wang, M.L. - Clinical Outcomes of Near-Term Infants – Pediatrics August 2004
ABM protocol #10
http://www.bfmed.org/ace-files/protocol/near_term.pdf
San Diego County Breastfeeding Coalition newsletter
http://www.breastfeeding.org/pdf/newsletter12.pdf
AWHONN Near-Term Infant Initiative
http://www.awhonn.org/awhonn/?pg=872-18070
JOGNN, 34, 666-671; 2005
Paula Meier workshop notes and published articles