Let Me Stay With Mom! – Safely Doing Less for 35-Week Infants

This case was modified slightly to prevent patient identification.A 35 3/7-week 2.7 kg infant was born by vaginal delivery after premature rupture of membranes and preterm labor. Pregnancy was complicated only by short cervix with one course of betamethasone at 28 weeks. Group B streptococcus status was unknown; there were no other sepsis risk factors, and the overall early onset sepsis score was 0.2 of 1000 live births. The infant emerged with low tone and weak cry that improved rapidly with routine measures. After 10 minutes of skin-to-skin (STS), the infant was transferred to the special care nursery (SCN) for 24 hours of continuous cardiorespiratory monitoring, as per current hospital guideline for infants born at 35 0/7 to 35 6/7 weeks’ gestation.The infant remained clinically well. He was bottle fed 15 to 20 mL of pasteurized donor human milk every 3 hours and breastfed once at 4 hours of life (HOL) with a LATCH score of 7 out of 10. Nurses documented coordinated feeding effort, and blood glucose levels were normal. At 21 HOL his temperature was 35.3°, which increased to 36.9° with radiant warming. He was then placed in an incubator without a trial of STS or open crib. He had no apneic, bradycardic, or desaturation (ABD) events during the first 24 HOL. However, because of neonatologist concern for insufficient oral intake and need for incubator, he remained in the SCN.On day of life (DOL) 1, the occupational therapist (OT) noted appropriate oral feeding. On DOL 2, the infant had an episode of coughing during bottle feeding with peripheral oxygen saturation of 85% to 91%. The neonatologist decided to continue observation in the SCN to determine if the event was related to prematurity or another etiology. A chest X-ray was normal. Nurses continued to document 20 to 40 mL feeds with intermittent coughing during bottle feeding, but none while breastfeeding. On DOL 3, the OT and the speech language pathologist (SLP) agreed that the oral feeding skills were appropriate and the coughing was not consistent with aspiration. The infant continued to have brief, self-resolved desaturation events (<20 seconds without apnea) and intermittent coughing with bottle feeding requiring pacing. He breastfed twice daily without concerns. His last desaturation event was documented on DOL 10.The infant had weight loss of −2% on DOL 1, −7.4% on DOL 2 (90th percentile on the Newborn Weight Tool [Newt] curve),1 and −7.6% on DOL 3 (50th percentile per Newt). He continued to have normal urine and stool output, but had weight loss of −10% on DOL 5, which prompted an increase in his intake goal to 160 ml/kg/d (52 mL every 3 hours). He was not able to meet that goal and a nasogastric tube was placed. He subsequently had daily weight gain. He achieved full oral feeds on DOL 11 and regained birthweight on DOL 12. He was discharged home on DOL 13.Late preterm infants (LPI) are those born between 34 0/7 to 36 6/7 weeks’ gestation and account for most preterm births in the United States.2 Although these infants are at risk for respiratory distress, hypothermia, hypoglycemia, poor feeding, and hyperbilirubinemia,3 there is variation in which hospital unit they are cared for. The American Academy of Pediatrics Policy Statement on Levels of Neonatal Care states that well newborn units can care for infants 35 to 37 weeks’ gestation who are physiologically stable.4 A survey of hospitals in the Better Outcomes through Research for Newborns Network found that 80% routinely admit 35-week infants to the well newborn unit,5 and Joshi et al found at their institution that 63% of 35-week infants remained in well newborn care for the entire birth hospitalization.6 In contrast, at our institution, of the 94 35-week infants delivered in 2023, only 35% were discharged from the well newborn unit, which raises a potential concern for overutilization of SCN care. The rooming-in model for 35-week infants requires increased nursing, lactation, and medical support to achieve optimal outcomes and ensure identification of infants needing additional support,7–9 but LPI who are rooming in with their parent(s) may have more breastfeeding success10,11 and a shorter length of hospital stay as compared with those who are cared for in the NICU or SCN.7,11 Additionally, NICU admissions can impact parental mental health and influence parental perception of their child’s vulnerability.12–14 In the following sections, we outline the aspects of this infant’s care that may demonstrate opportunities for safely reducing unnecessary interventions.The National Perinatal Association guideline for care of LPI recommends “immediate, uninterrupted, and extended skin-to-skin contact for stable infants until after the first breastfeeding (usually 1–2 hours).”15 The benefits of STS include decreased hypoglycemia, better thermoregulation, improved cardiopulmonary stabilization and increased breastfeeding success.16–18 There may also be benefits of STS for parent attachment and mental health.19 Despite his clinical stability after delivery, this infant received only 10 minutes of STS. Increased STS opportunities after delivery and during rooming-in care may have resulted in improved thermoregulation, more breastfeeding, and possibly avoided incubator use. Joshi et al found that although 68% of 35-week infants had hypothermia, only 36.5% required an incubator, which suggests that less intensive measures work for many of these infants.6LPI are known to be at risk for feeding difficulties that may delay hospital discharge and result in lower rates of breastfeeding than their full-term counterparts.20 The European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) notes a lack of nutritional guidelines for LPI, strongly recommends breastmilk as the optimal feeding method, and emphasizes the need for extended lactation support.20 The standard volume goal of 160 ml/kg/d used in our institution is derived from the ESPGHAN guidelines for enteral nutrition for the preterm infant that are intended for infants weighing 1000 to 1800 g and may not be appropriate for LPI.20 Studies have shown that tube feeding and nutritional support among LPI are most common in 34-week infants and for those weighing less than 2 kg.6,21 Over the first 24 HOL, this infant maintained normal blood glucose levels and took 15 to 20 mL per feed by bottle, which is over the recommend 2 to 10 mL supplement recommended by the National Perinatal Association Guideline and the Academy of Breastfeeding Medicine (ABM).15,22 However, his SCN stay was extended in part because of concern of poor feeding. Kumar et al found first feeding volumes of more than 8 ml/kg increased emesis 2.5-fold in LPI, and concluded that nonphysiologic feeding significantly contributes to feeding intolerance.23 This infant’s SCN stay was further prolonged by weight loss and feeding tube placement. Recommendations on maximum weight loss for late preterm infants range from −7% recommended by the ABM to −10% by the National Perinatal Association.15,22 This infant’s nadir weight loss of −10% on DOL 5 prompted an increase in his feeding goal and subsequent nasogastric tube placement. Although increased nutritional support is likely needed for this infant, less invasive measures, including caloric fortification of breastmilk and/or more frequent feedings, may have been equally successful.This infant’s SCN stay was also extended because of coughing and brief, self-resolved desaturation events with bottle feeds; neither were documented during breastfeeding. Monitoring for ABD events is a frequent justification for empirical admission of all 35-week infants to a higher level of care. Although recent studies around car seat testing have demonstrated opportunities to safely reduce monitoring for subclinical ABDs in this population,24 the clinical significance of feeding-related events in late preterm infants is unclear and has been demonstrated to prolong hospital stay.25,26 Studies have shown increased oxygenation while breastfeeding when compared with bottle feeding.27,28 Ultrasound imaging shows that a vacuum between the tongue and palate is the primary mechanism of milk removal during breastfeeding, and ratios of sucking, swallowing, and breathing likely change in response to flow rates during milk ejection.29 A higher rate of swallowing may be seen with bottle feeding, which results in more disruption of breathing and thus desaturations associated with bottle feeds.27,28 Concern for cough with feeds resulted in OT and SLP evaluation for this infant, as well as a chest X-ray, all of which did not suggest aspiration. The laryngeal cough reflex develops around 1 to 2 months.30 Before the cough reflex, the laryngeal chemoreflex is the primary method of airway protection that is manifested by repeated swallowing and apnea, which were not observed in this infant.30 Both the cough and feeding desaturations may be attributable to the volumes of milk this infant was taking by bottle and potentially could have been avoided with a focus primarily on breastfeeding. Literature describing the clinical significance of feeding-related events in the late preterm population is sparse; however, given the lack of evidence demonstrating harm and the potential stress of prolonged hospitalization on the infant and family, perhaps closer consideration of the risks and benefits of ABD monitoring in this population is warranted.Schroeder et al describe “minimization of overtesting and overtreatment as a core initiative of the patient safety movement.”31 Some of the issues discussed previously could additionally be considered overdiagnosis—when a true abnormality is discovered, but detection of that abnormality does not benefit the patient.32 Enhanced monitoring of otherwise healthy LPI may uncover true abnormalities, but whether these have clinical relevance is not always clear. When resources permit, allowing 35-week infants who are medically stable after delivery to receive rooming-in care in the well newborn unit could help reduce overmedicalization and increase opportunities for family bonding, breastfeeding, and possibly improve parental mental health. Although ongoing vigilance is needed to identify infants requiring additional support, discontinuing routine admissions of 35-week infants to the SCN may help us achieve the goal of safely doing less.