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PREMATURITY. Sue Omel RN, MS, MPH Nursing Program Supervisor; Washington County DHHS; Public Health Division; Field Team. PREMATURITY. Why Prematurity is an Important Public Health Issue. PREMATURITY. Public Health focuses on promoting health and preventing disease Primary Prevention

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prematurity
PREMATURITY

Sue Omel RN, MS, MPH

Nursing Program Supervisor; Washington County DHHS;

Public Health Division; Field Team

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Why Prematurity is an Important Public Health Issue

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Public Health focuses on promoting health

and preventing disease

Primary Prevention

Secondary Prevention

Tertiary Prevention

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Primary Prevention

Decreasing the Rate of Preterm Births

Determining the Factors that Impact Preterm Birth

Social

Biologic

Environmental

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At Risk Populations

Low income women

Women of color

Women younger than 20 and older than 40

Women who were born preterm

Women with a history of previous preterm delivery

Women with multiple pregnancy

Women with uterine/cervical abnormalities

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Other Risk Factors

Smoking, use of alcohol, other substance use

Infection

Stress

Trauma

Unintended pregnancy

Chronic health conditions like diabetes or high blood pressure

In-vitro conception

History of repeated miscarriages or spontaneous abortions

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Despite a good understanding of risks, there has been little reduction in the rate of prematurity in the US

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Secondary Prevention

Improving the Outcome of Premature Infants

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Preterm infants are at higher risk for poor health outcomes than infants born at term

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Increased Mortality

Preterm birth and low birth weight are the leading cause of death in infants younger than one year.

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Infants born before 34 weeks are at greatest risk of death and long term morbidities

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Increased Morbidity

  • Respiratory distress and long term respiratory issues; asthma
  • Delayed brain development/developmental delay
  • Cerebral palsy
  • Epilepsy
  • Cognitive delay
  • SIDS/SUIDS
  • Feeding problems
  • NICU admission and re-hospitalization
  • Vision and hearing problems
  • Autism
  • Behavior and learning problems
  • Depression, anxiety, and other mental health issues
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Late Preterm Infants

Mortality

Late preterm infants (34-37) weeks are 6 X more likely to die in the first week of life and 3X more likely to die in the first year

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Late Preterm Infants

Morbidity

  • Respiratory distress
  • Hypothermia
  • Sepsis
  • Hypoglycemia
  • Inadequate feeding/dehydration
  • Hyperbilirubinemia
  • Growth and developmental issues
  • Immature brain
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The fetal brain at 34 weeks weighs only about 65% of that of a full term infant brain

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The Costs of Prematurity

  • Physical/Medical
  • Developmental
  • Emotional
  • Financial
  • Psychosocial
  • Educational
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Costs

According to the Institute of Medicine

The annual costs to society are $26.2 billion dollars

$51,600 per infant

$49,033 to employer

The costs are 11 X greater than those of a normal newborn

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The average 1st year costs for a preterm infant are 10X than that of a term infant

($32,325 vs $3,235)

The average hospital stay is 9 X longer if the infant is born preterm

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What is the Role of the Public Health Nurse?

  • Improve the health and developmental outcomes of the premature infant by identifying the physical, developmental and social/emotional risks
  • Implement nursing interventions to reduce the risks
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  • Reduce costs
  • Reduce disparities

The differences in the rates of disease; incidence, prevalence, morbidity, mortality, or survival rates in one population compared to the health of the general population.

the cacoon nurse s role in providing services to preterm infants
The CaCoon Nurse’s Role in Providing Services to Preterm Infants

Screening

Assessment

Education/Information

Case Management

Care Coordination

Support/Advocacy

Monitoring

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What skills do you need to provide services to premature infants and their families?

  • Know how to adjust for prematurity
  • An understanding of the growth and development of the pre-term infant
  • Understand common medical issues and treatments
  • Understanding of normal vs abnormal course
  • Understand infant states, cues, and behaviors
  • Knowledge of community resources
  • Ability to provide family centered approach to care
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Adjusting for Prematurity

Determine gestational age in weeks

Subtract the gestational age from 40 weeks

Subtract the weeks of prematurity from the chronological age

Example: JA was born at 32 weeks gestation. Subtract 40-32= 8 weeks premature

Today JA is 12 weeks old chronologically

12 weeks (actual age) -8 weeks = 4 weeks adjusted age

Adjustment for prematurity should be done until at least 24 months of age

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Growth, Nutrition, Feeding

The CaCoon Nurse’s Role in Screening, Assessment and Intervention

to Identify Risks and Improve Infant Outcomes

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Screening

Growth

Height, weight, head circumference, and height/weight ratio

Development

Use standardized tools

Other standardized screening

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Nursing Systems ASSESSMENT

  • Cardiovascular
  • Respiratory
  • Gastrointestinal
  • Urinary
  • Neuro-motor
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Risk Assessment

  • Feeding and Nutrition
  • Infection
  • Unintentional Injury
  • Intentional Injury
  • Exposure to toxins (second hand smoke)
  • Dental
  • Attachment and Bonding
  • Parenting
  • Coping
  • Basic Needs
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Case management

Helping the family access and utilize other services

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Referral and Follow Up

  • Well Child Care and Immunizations
  • Early Intervention
  • Head Start/Early Head Start
  • Healthy Start
  • WIC
  • Speciality Services ie, OT, PT, Developmental Clinics
  • Community Services to meet basic needs
  • Services for family ie, counseling, primary care, etc
  • Services to provide financial support, ie SSI
  • Respite care
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Care Coordination

  • Primary care provider
  • Vision-ophthalmologist
  • Hearing-audiologist/ENT
  • Cardiologist
  • Pulmonologist
  • Gastroenterologist
  • Neurologist
  • Home Health
  • Equipment supplier
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Family Support

  • Understanding family’s experience and needs
  • Provide opportunity for family to share feelings
  • Identification of support systems
  • Role model and support advocacy efforts
  • Encourage healthy coping strategies
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Monitoring

Constantly re-evaluating

  • Repeating screening and assessment
  • Trying new interventions
  • Gathering outcome data
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Development

The Cacoon Nurse’s Role in Screening, Assessment and Intervention

to Identify Risks and Improve Infant Outcomes

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Screening for Physical Development

Standardized screening tools—must look at all areas of development

RDSI

ASQ

CAT/CLAMS

Adjust for Prematurity!

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Gross motor risks in early screening

Looking at more than milestones

Use the Infant Motor Screen

  • Symmetry
  • Presence or absence of reflexes
  • Tone
  • Protective responses
  • Vestibular responses
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Interventions

Education/Information

Case Management

Care Coordination

Support

Monitoring

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Education and Information

Current development and what to expect next –normal progression of development

Activities to foster development

Modifying activities based on infants needs, behaviors, and cues

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Case Management

Identify and remove barriers

Referrals to EI, SSI, OT/PT, Speech, Developmental clinics or pediatricians

Community services

Infant massage, infant sign language, library programs, swimming classes

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Care Coordination

Educational staff, medical, neurologist, ophthalmologist, audiologist, developmental disabilities

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Support

Family’s understanding of developmental issues

Family resources and strengths

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Social Emotional Development

Preterm infants are at significant risk for later relationship issues. These risks are related to:

Maternal/family experience

Infant’s experience in the NICU

Financial impact

Infant cues and behaviors

Ongoing stress when infant transitions to the home

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Maternal Experience

Interrupted pregnancy leads to crisis birth

Crisis leads to anxiety and fear

May also experience feelings of guilt, grief or loss

Attachment behaviors are developed in a technical environment that doesn’t foster nurturing

Infant is probably less socially responsive and harder to soothe

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Maternal outcomes

  • Depression
  • Disengagement
  • Symptoms similar to PTSD
  • Over-involved and protective
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Infant’s Experience

Immature brain and nervous system

NICU environment

Unusual stimulation and pain

Cues and behavior patterns may be difficult for caregiver to understand

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Infant Outcomes

Insecure attachment

Anxiety

Internalizing problems

Difficulty developing social relationships

Increased risk for abuse and neglect

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The longer the NICU stay, the higher the likelihood of issues related to maternal infant interaction

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Interverventions

Screening

ASQ-SE; screening for maternal depression; screening for attachment issues

Assessment

Maternal infant interaction; parents knowledge of cues, behaviors, infant state

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Education

Improve Parent Understanding

  • Cues
  • Behaviors
  • Infant states
  • Temperament
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Variations in behavior, sleep states, and cues should guide all parent interactions.

The parent’s role is to meet the infant’s needs. Parents who are empathetic and responsive foster a sense of trust which strengthens the infant’s attachment and sense of security.

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Modifying the Environment

Help the parent learn to respond sensitively to the infant’s ability to handle various levels of light, noise, and activity and adjust the infant’s environment as needed for the infant

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Providing Appropriate Timing

Foster positive interactions by helping the parent learn to adjust to the infant’s needs by pacing interactions and avoiding activity that overwhelms the infant

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Maintaining and Ensuring Continuity and Predictability

Support the parents in their efforts to maintain consistency in the in infant’s routine and daily activities.

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Supporting the Infant’s Attempts at Self Regulation

Help the parent learn to recognize the

infant’s fatigue levels.

Assist parent to develop skills that support and facilitates the infant’s ability to calm itself.

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Supporting Movement and Positioning and Providing Appropriate Support During All Handling

Assist the parent to learn how to provide smooth, gentle, slow handling, how to move in rhythm with the infant, and how to effectively position the infant

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Supporting the Infant’s Management of Sleep Wake Cycles

Teach normal sleep wake cycles and help the parent develop positive behaviors that facilitate the infant’s level of alertness, smooth state changes, engagement opportunities, and opportunities for self-calming

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Case Management

Referral for maternal mental health support

Referral to programs that support positive attachment-mother baby group

Infant mental heath programs ???

Referrals to services to reduce stressors

Financial referrals SSI/DD programs

Parenting support programs

Respite

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Care Coordination

Care conferences with other in home programs, services, child care provider to

explore ways to foster and support attachment

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Support

Help family identify support systems

Assist family to find other community supports-church, work, school

Empathy for the family’s situation/beliefs

Active listening to the parent

Activities to support attachment, ie, kangaroo care, infant massage, breastfeeding

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Monitoring

Repeat screenings and assessments

Follow up with referrals

Skills building behaviors

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Nursing Systems ASSESSMENT

  • Cardiovascular
  • Respiratory
  • Gastrointestinal
  • Elimination
  • Vision and Hearing
  • Neuromuscular
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Risk Assessment

  • Feeding and Nutrition
  • Infection
  • Unintentional Injury
  • Intentional Injury
  • Exposure to toxins (second hand smoke)
  • Dental
  • Attachment and Bonding
  • Parenting
  • Coping
  • Basic Needs
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Resources for Interventions

Premature Infant Standards

Multidisciplinary Guidelines for the Care of the Late Preterm Infant

Getting to Know Your Baby

Infant Cues and Infant States

Coming Home from the NICU

Understanding My Signals

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Prematurity is a public health issue

Public health nurses understand prematurity at both the level of individual and community

How do the services provided through the Cacoon program and targeted toward preterm infants integrate with health care transformation efforts in your community?

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The Triple Aim of your Local CCO

Better Health

Better Health Care

Lower Costs

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When you, as the Cacoon nurse, targets premature infants, how are your services contributing to the Triple Aim.

Are you improving the health outcomes of a disparate population? How?

Are you improving health care to this population of vulnerable infants? How?

Are you lowering costs? How?

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How will CaCoon services to premature infants fit into your Early Learning Hub?

What are you doing to improve kindergarten readiness?

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References

Coming Home from the NICU. A Guide for Supporting Families in Early Infant Care and Development. VandenBerg, K.A.; Hanson, Marci. Paul.H.Brookes Publishing. 2013.

Understanding My Signals. Help for Parents of Premature Infants. Hussey-Gardner, Brenda. Vort Corporation. 2013.

March of Dimes. www.marchofdimes.com

American Academy of Pediatrics:

Modified Recommendations for Use of Palivizumab for Prevention of Respiratory Syncytial Virus Infections. Committee on Infectious Diseases. Pediatrics. 2009

Perinatal Origins of First-Grade Academic Failure: Role of Prematurity an Maternal Factors. Pediatrics. 2013

Early Childhood Development of Late Preterm Infants. A Systematic Review. Pediatrics. 2011.

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References

American Academy of Pediatrics

Persistence of Morbidity and Cost Differences Between Late-Preterm and Term Infants During the First Year of Life. Pediatrics. 2009.

Safe Transportation of Preterm and Low Birth Weight Infants at Hospital Discharge. Bull, Marilyn J. and Engle, William A. Pediatrics. 2009.

“Late Preterm “ Infants. A Population at Risk. Engel, William A., Tomashek, Kay M., and Wallman, Carol. Pediatrics. 2007.

Use of Soy Protein-Based Formulas in Infant Feeding. Bhatia, Jatinder, and Greer, Frank. Pediatrics. 2008.

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References

Getting to Know Your Baby. A Developmental Guide for Community Service Providers and Parents of NICU Graduates. VandenBerg, K.; Browne, J.;Perez, L. 2003. www.wonderbabies.org

Multidisciplinary Guidelines for the Care of Late Preterm Infants. National Perinatal Association.2012. www.nationalperinatal.org/lptguidelines.php

Infant Cues. Infant States. WIC California Baby Behavior Campaign. California WIC Program. www.cdph.ca.gov/programs/wicworks/Pages/WICCaliforniaBabyBehaviorCampaign.aspx

Your Premature Baby. Volume 1, 2, 3. Injoy Videos. www.injoyvideos.com

The Effects of Prematurity on Development. Bell, M. www.prematurity.org