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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

Prematurity
Late Preterm Infants
Morbidity

Respiratory distress
Hypothermia
Sepsis
Hypoglycemia
Inadequate feeding/dehydration
Hyperbilirubinemia
Growth and developmental issues
Immature brain

Prematurity
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 Nurses 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 preterm 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 Nurses 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 familys 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 Nurses Role in Screening,
Assessment and Intervention
to Identify Risks and Improve Infant Outcomes

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Screening for Physical Development
Standardized screening toolsmust 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
Familys 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
Infants 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 doesnt 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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Infants 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 parents role is to meet the infants
needs. Parents who are empathetic and
responsive foster a sense of trust which
strengthens the infants attachment and
sense of security.

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Modifying the
Environment
Help the parent learn to
respond sensitively to the
infants ability to handle
various levels of light,
noise, and activity and
adjust the infants
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 infants 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 infants
routine and daily activities.

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Supporting the Infants Attempts at Self
Regulation
Help the parent learn to recognize the
infants fatigue levels.
Assist parent to develop skills that support
and facilitates the infants 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 Infants Management of
Sleep Wake Cycles
Teach normal sleep wake cycles and help
the parent develop positive behaviors that
facilitate the infants level of alertness,
smooth state changes, engagement
opportunities, and opportunities for selfcalming

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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 supportschurch, work, school
Empathy for the familys 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?

Prematurity
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