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
Sue Omel RN, MS, MPH
Nursing Program Supervisor; Washington County DHHS;
Public Health Division; Field Team
Why Prematurity is an Important Public Health Issue
Public Health focuses on promoting health
and preventing disease
Decreasing the Rate of Preterm Births
Determining the Factors that Impact Preterm Birth
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
Other Risk Factors
Smoking, use of alcohol, other substance use
Chronic health conditions like diabetes or high blood pressure
History of repeated miscarriages or spontaneous abortions
Despite a good understanding of risks, there has been little reduction in the rate of prematurity in the US
Improving the Outcome of Premature Infants
Preterm infants are at higher risk for poor health outcomes than infants born at term
Preterm birth and low birth weight are the leading cause of death in infants younger than one year.
Infants born before 34 weeks are at greatest risk of death and long term morbidities
Late Preterm Infants
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
Late Preterm Infants
The fetal brain at 34 weeks weighs only about 65% of that of a full term infant brain
The Costs of Prematurity
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
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
What is the Role of the Public Health Nurse?
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.
What skills do you need to provide services to premature infants and their families?
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
Growth, Nutrition, Feeding
The CaCoon Nurse’s Role in Screening, Assessment and Intervention
to Identify Risks and Improve Infant Outcomes
Height, weight, head circumference, and height/weight ratio
Use standardized tools
Other standardized screening
Nursing Systems ASSESSMENT
Helping the family access and utilize other services
Referral and Follow Up
The Cacoon Nurse’s Role in Screening, Assessment and Intervention
to Identify Risks and Improve Infant Outcomes
Screening for Physical Development
Standardized screening tools—must look at all areas of development
Adjust for Prematurity!
Gross motor risks in early screening
Looking at more than milestones
Use the Infant Motor Screen
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
Identify and remove barriers
Referrals to EI, SSI, OT/PT, Speech, Developmental clinics or pediatricians
Infant massage, infant sign language, library programs, swimming classes
Educational staff, medical, neurologist, ophthalmologist, audiologist, developmental disabilities
Family’s understanding of developmental issues
Family resources and strengths
Social Emotional Development
Preterm infants are at significant risk for later relationship issues. These risks are related to:
Infant’s experience in the NICU
Infant cues and behaviors
Ongoing stress when infant transitions to the home
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
Immature brain and nervous system
Unusual stimulation and pain
Cues and behavior patterns may be difficult for caregiver to understand
Difficulty developing social relationships
Increased risk for abuse and neglect
The longer the NICU stay, the higher the likelihood of issues related to maternal infant interaction
ASQ-SE; screening for maternal depression; screening for attachment issues
Maternal infant interaction; parents knowledge of cues, behaviors, infant state
Improve Parent Understanding
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.
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
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
Maintaining and Ensuring Continuity and Predictability
Support the parents in their efforts to maintain consistency in the in infant’s routine and daily activities.
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.
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
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
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
Care conferences with other in home programs, services, child care provider to
explore ways to foster and support attachment
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
Repeat screenings and assessments
Follow up with referrals
Skills building behaviors
Nursing Systems ASSESSMENT
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
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?
The Triple Aim of your Local CCO
Better Health Care
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?
How will CaCoon services to premature infants fit into your Early Learning Hub?
What are you doing to improve kindergarten readiness?
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.
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.
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