The patient is a neonate with late prematurity: what it means, what it implies

By Cristiano Antonino On Jun 17, 2022

The neonate with late prematurity is a particularly delicate patient because, as his organs and systems are still immature, he is exposed to various perinatal pathologies

Newborn with late prematurity: approximately 1 in 10 preterm babies are born each year worldwide

Of these, 70% are defined as ‘late preterm’ or ‘late preterm’, i.e. gestational age between 34 and 36 weeks and 6 days.

The increasingly frequent obstetrical indication for birth before 39 weeks, for both maternal and fetal reasons (increased maternal age, chorioamnionitis, arterial hypertension, diabetes, thrombophilia, multiple gestations, alterations in flowmetry, intrauterine growth defect) has meant that this category of preterm babies has been on the increase in recent years.

The late preterm baby is a particularly delicate neonate

Although he or she is cardio-respiratory stable at the time of birth in the delivery room in most cases, with a birth weight of between 2 kg and 2.5 kg, he or she is more vulnerable than the full-term born, given the incomplete maturation of organs and systems, which exposes him or her to various perinatal pathologies and a higher risk of neurodevelopmental problems at a distance.

The perinatal pathologies to which late preterm infants are most frequently exposed are: perinatal suffering, thermoregulation defect with a tendency to hypothermia, hypoglycaemia, respiratory problems, hyperbilirubinaemia, feeding difficulties, infections.

The higher neurodevelopmental risk compared to term birth, which can also lead to distant outcomes, is due to the failure to complete the development of the nervous system in utero, which occurs in the last weeks of gestation: in fact, brain volume almost doubles in the last six weeks.

Babies born with late prematurity may in fact show typical early postnatal lesions on nuclear magnetic resonance imaging of the brain, such as the so-called ‘punctiform’ or ‘punctate’ periventricular leukomalacia, i.e. changes in the white matter.

Moreover, children in this category can develop all kinds of brain lesions, from those more characteristic of lower gestational ages, such as intraventricular haemorrhages, to those more characteristic of the term born, such as stroke.

Distant neurological outcomes during development can present with mild pictures such as learning disabilities, behavioural disorders and emotional disturbances and with severe pictures such as infant cerebral palsy and mental retardation.

For this reason, late preterm infants must be followed with special attention, both after birth during hospitalisation and after discharge and in the various growth stages.

Specialised, dedicated and multidisciplinary follow-up is necessary for the late preterm infant

In infants of gestational age < 35 weeks, rooming-in is only recommended if the infant demonstrates stability of body temperature, blood glucose and adequate ability to feed at the mother’s breast or with a bottle.

Glycaemic and bilirubin screening must be performed.

Early discharge, i.e. within 48 h, is not indicated.

Before discharge, full stability of cardio-respiratory parameters for at least 24 hours must be ascertained and the child must be metabolically stable (glycaemia, bilirubin).

He/she must be able to feed independently and maintain an adequate body temperature (axillary temperature between 36.5 and 37.4 °C).

Weight loss must not exceed 7% of birth weight; caloric intake between 100 and 130 Kcal/day and growth of at least 20 g per day.

The mother must be encouraged to breastfeed the baby; in the absence of breast milk, it must be fed with type 0 milk up to a weight of 2500 g.

Prior to discharge, the infant must be assessed by the physiotherapist, who provides the family with indications for motor, posture and care facilitation, which are useful for promoting neurodevelopment.

If necessary, motor rehabilitation, prescribed by the same physiotherapist, must be started during hospitalisation and then continued locally.

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Prevention of infections in the newborn with late prematurity

Prophylaxis with Palivizumab (monoclonal antibody) for respiratory syncytial virus (VRS) infection: Respiratory Syncytial Virus (VRS) bronchiolitis and pneumonia are the leading cause of hospitalisation under one year of age.

This infection is even more serious in preterm infants, the lower their gestational age. VRS is seasonal and highly contagious.

The epidemic can start in October-November and continue until April, with a peak in February.

Transmission occurs through contaminated hands and by air. Once the infection has passed, immunity is not permanent.

Infants between 32 and 35 weeks gestational age and younger than 6 months at the time of the onset of the seasonal VRS epidemic, if socio-environmental and demographic risk factors are present, should receive prophylaxis with Palivizumab, a monoclonal antibody directed against VRS.

Risk factors include: age of the child at the start of the epidemic season, older siblings/crowding, exposure to tobacco smoke, exposure to air pollutants, malnutrition.

The recommended dose is 15 mg/kg intramuscular, once a month during the epidemic period for up to 5 administrations.

Vaccinations: there are many temporary immune system deficits linked to preterm birth.

For this reason, these infants must be vaccinated according to their chronological age or as soon as clinical conditions make it possible.

They must follow the vaccination schedule provided by the National Health System.

Indirect protection through the upgrading (recovery) of the vaccine immunity of the family entourage is also crucial;

Environmental measures: once these infants arrive home, it is very important for the family to respect personal hygiene and to wash their hands thoroughly.

In addition, the mother herself must be encouraged to breastfeed her child for as long as possible.

Avoiding passive smoking is indispensable.

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