Abstract
OBJECTIVE
Late preterm infants represent nearly a quarter of a million infants born in the United States annually. There is a known variation in admission location for these infants. The objective of this study was to identify the timing and reasons for transfer for late preterm infants requiring an escalation in care during the birth hospitalization.
PATIENTS AND METHODS
This single-center retrospective cohort study examined the birth hospitalization for late preterm infants (34 + 0 to 36 + 6 weeks) born between 2019 and 2021, specifically focusing on infants requiring an escalation to a higher level of care. Infants with congenital anomalies expecting neonatal intensive care unit (NICU) admission were excluded. The analysis included descriptive and inferential statistics.
RESULTS
Of 1022 infants, 150 symptomatic infants were admitted to the level III/IV NICU at birth. Of the remaining 872 infants, 14% (n = 124) received escalation of care (n = 77 from level I to II, 25 from level I to III/IV, 22 from level II to III/IV). The most common reasons for escalation were need for respiratory support (n = 32, 26%), cardiorespiratory monitoring (n = 31, 25%), thermoregulation (n = 29, 23%), and dextrose-containing intravenous fluids (n = 27, 22%). Infants required escalation of care at a median of 12.5 hours after birth (IQR 4–40 hours, range 0–133), with 50% (n = 62) occurring within the first 12 hours and 67% (n = 83) within 24 hours.
CONCLUSIONS
Escalation of care for late preterm infants most frequently occurs in the first 24 hours after birth. The most frequent reasons for escalation were the need for respiratory support, followed by cardiorespiratory monitoring and thermoregulation.
INTRODUCTION
Late preterm infants, born between 34 and 36 weeks of completed gestational age, represent nearly a quarter million infants born in the United States annually.1 While some of these infants are developmentally mature enough to thrive in well newborn care within a mother-infant dyad, others require admission to a neonatal intensive care unit (NICU) for management of common morbidities such as respiratory distress, hypothermia, and hypoglycemia.2–4 Significant variability remains among hospitals in terms of admission location for late preterm infants. For example, our prior work showed nurseries use thresholds of 34 to 37 weeks’ gestational age and/or 1750 to 2500 g birth weight as minimum criteria for admission to well newborn care, and these thresholds were not correlated with the availability of medical interventions within well newborn care.5
Despite variability in admission practices and widespread lack of clinical practice guidelines standardizing care during the birth hospitalization, the landscape of late preterm infant care changed in the past decade, including the implementation of updated care practices for the evaluation and management of early onset sepsis, hyperbilirubinemia, and hypoglycemia, alongside emphasis on skin-to-skin care and early breastfeeding initiation.6–10 Literature on late preterm infants following these care practice changes is limited. The objective of this current study was to identify late preterm infants at a single institution who required escalation to a higher level of care during the birth hospitalization and examine the timing and reasons for transfer.
METHODS
This retrospective cohort study examined all late preterm infants born at a single tertiary university-based hospital from January 1, 2019, and December 31, 2021. Lucile Packard Children’s Hospital Stanford has approximately 4500 deliveries annually and provides both obstetric and neonatal care. We excluded infants prenatally designated for NICU admission because of suspected severe anomalies, such as those with complex congenital heart disease, from the analysis. A data query of the electronic health record captured demographic information, admission locations, and medical interventions rendered during the birth hospitalization. For infants transferred to a higher level of care, we completed a manual medical record review of the infant’s admission/transfer note to the higher level of care unit, progress notes, and discharge summary to delineate the reasons for transfer and subsequent events following the transfer to a higher level of care. We also examined the frequency of infants who had markers of disease severity (central line placement, intubation, exogenous surfactant administration, vasopressor support, seizures, positive blood culture, positive cerebrospinal fluid culture, extracorporeal membrane oxygenation).
The hospital setting included level I well newborn care, a level II Special Care Nursery (SCN), and a level III/IV NICU, all located within the same building. Infants born after 35 weeks of completed gestational age were eligible for level I well newborn care if well-appearing, with the option to escalate care to either the level II SCN or the level III/IV NICU. Infants born at 34 weeks were routinely admitted to the level II SCN if well-appearing, unless requiring a higher level of care (see the following section). The nursing staffing ratios in level I well newborn care are 1 nurse to 3 mother-infant dyads. Neonatal hospitalists are present in the house around the clock; they attend deliveries for all late preterm infants and are available for evaluation of any infants with clinical signs of illness. Clinically stable infants remain skin-to-skin with their mothers in the delivery room before the postpartum admission.
Phototherapy, dextrose gel, short-term thermoregulatory support (radiant warmer up to 4 hours) and short-term cardiorespiratory monitoring (up to 4 hours) can be provided in level I well newborn care, however other interventions (antibiotics, ongoing thermoregulation, respiratory support, intravenous fluids, feeding tubes, continuous cardiorespiratory monitoring) required admission to a higher level of care. Respiratory support via nasal cannula can be provided in the level II SCN, but higher levels of respiratory support (ie, continuous positive airway pressure [CPAP]) necessitate admission to the level III/IV NICU. Of note, a level I nursery triage area is available to support the transitioning infant in need of brief periods of monitoring and support. This triage area allows for short trials of CPAP (usually less than 30 minutes), radiant warmth, continuous cardiorespiratory monitoring, and close nursing/physician observation. Any ongoing needs for continuous monitoring and/or intervention beyond this require transfer to either the level II SCN or the level III/IV NICU. Infants can receive up to 3 doses of dextrose gel in level I care prior to initiation of intravenous fluids for continued hypoglycemia. Thresholds for dextrose gel administration are glucose levels less than 35 mg/dL in the first 4 hours after birth, and less than 45 mg/dL after 4 hours. Infants undergo a serial clinical examination protocol for early onset sepsis risk stratification; no empirical antibiotics or laboratory testing occur in well-appearing infants. All infants have access to donor human milk for any supplementation needs. Small for gestational age was defined as birth weight less than the 10th percentile for gestational age and sex. At the time of this study, all infants born at late preterm gestation were required to pass a car seat screening test before discharge home, although this practice was discontinued in 2025.
Data were analyzed with descriptive and inferential statistics using SAS on Demand for Academics (SAS Version 9.4). Groups were compared using χ2 tests for categorical data and Kruskal-Wallis tests for continuous data. A P value of <0.05 was considered statistically significant. The study was approved by the Institutional Review Board at Stanford University.
RESULTS
During the study period, 1105 infants were born at late preterm gestation across 13540 live births (8.2%). Of these, 1022 (92.5%) met the inclusion criteria. We excluded 78 infants prenatally designated for NICU admission because of suspected severe congenital anomalies, and 5 infants for incomplete data availability. Of the 1022 included infants, 150 infants had clinical symptoms at birth that required admission from the delivery room to the level III/IV NICU. The remaining 872 infants were admitted to the level I well newborn nursery (n = 697) or level II SCN (n = 175). Infants admitted to the level II SCN included 157 infants born at 34 weeks (not eligible for level I care because of hospital policy), 7 infants at 35 weeks, and 11 infants at 36 weeks’ gestational age. The 18 infants born at 35 or 36 weeks were eligible for level I care based on their gestational age, but were admitted to level II SCN for clinical signs at birth requiring continuous monitoring and/or intervention, but not meeting level III/IV NICU care. A total of 124 (14.2%) infants of the 872 not requiring level III/IV admission at birth required escalation to a higher level of care during the birth hospitalization. This included 77 infants from level I to II care, 25 infants from level I to III/IV care, and 22 infants from level II to III/IV care. The overall rate of escalation from level I well newborn care was 14.6% (102/697 infants).
Demographic characteristics are shown in Table 1. Nearly half the cohort was born vaginally (n = 461, 45.1%). Infants had a median Apgar score of 8 at 1 minute, and 9 at 5 minutes. Infants born by Cesarean section were significantly more likely than infants born vaginally to be admitted to the NICU at birth (21.8% vs 6.1%, P < .001). When evaluating the 872 infants not requiring NICU care at birth, infants who were born by Cesarean section (13.7% vs 10.2% vaginal delivery, P < .001) or small for gestational age (SGA) (29% vs 11.2% non-SGA, P < .001) were more frequently escalated in care.
TABLE 1.
Characteristics of Study Participants
| Characteristic n (%) or Median (IQR) | Initially Admitted to the Level III/IV NICU (n = 150) | Transferred to Higher Level of Care (n = 124) | No Higher Level of Care Needs (n = 748) | Total (n = 1022) |
|---|---|---|---|---|
| Sex | ||||
| Female | 71 (47.3) | 55 (44.4) | 369 (50.7) | 495 (48.4) |
| Male | 79 (52.7) | 69 (55.7) | 379 (49.3) | 527 (51.6) |
| Racea | ||||
| Asian | 25 (16.7) | 36 (29) | 231 (30.9) | 292 (28.6) |
| Black | 4 (2.7) | 1 (0.8) | 11 (1.5) | 16 (1.6) |
| Pacific Islander | 1 (0.7) | 0 | 7 (0.9) | 8 (0.8) |
| White | 59 (39.3) | 36 (29) | 172 (23) | 267 (26.1) |
| Other | 57 (38) | 45 (36.3) | 297 (39.7) | 399 (39) |
| Unknown | 4 (2.7) | 6 (4.8) | 30 (4) | 40 (3.9) |
| Ethnicitya | ||||
| Hispanic/Latino | 52 (34.7) | 37 (29.8) | 260 (34.8) | 349 (34.2) |
| Non-Hispanic | 95 (63.3) | 83 (66.9) | 461 (61.6) | 639 (62.5) |
| Unknown | 3 (2) | 4 (3.2) | 27 (3.6) | 34 (3.3) |
| Primary language | ||||
| English | 130 (86.7) | 108 (87.1) | 599 (80.1) | 837 (81.9) |
| Language other than English | 20 (13.3) | 16 (12.9) | 149 (19.9) | 185 (18.1) |
| Gestational age | ||||
| 34 weeks | 51 (34) | 19 (15.3) | 139 (18.6) | 209 (20.5) |
| 35 weeks | 41 (27.3) | 52 (41.9) | 170 (22.7) | 263 (25.7) |
| 36 weeks | 58 (38.7) | 53 (42.7) | 439 (58.7) | 550 (53.8) |
| Birth weight | ||||
| ≥2500 g | 75 (13.8) | 49 (9) | 418 (77.1) | 542 (53) |
| 2000–2499 g | 50 (14.2) | 52 (14.8) | 250 (24.5) | 352 (34.4) |
| 1500–1999 g | 21 (8) | 22 (18.8) | 74 (63.3) | 117 (11.5) |
| <1500 g | 4 (36.4) | 1 (9.1) | 6 (54.6) | 11 (1.1) |
| SGAb | ||||
| SGA | 21 (14) | 36 (29) | 84 (11.2) | 141 (13.8) |
| No SGA | 129 (86) | 88 (71) | 664 (88.8) | 881 (86.2) |
| Delivery type | ||||
| Cesarean section | 122 (81.3) | 77 (62.1) | 362 (48.4) | 561 (54.9) |
| Vaginal | 28 (18.7) | 47 (37.9) | 386 (51.6) | 461 (45.1) |
| 1 min Apgar score | 8 (7,8) | 8 (8,8) | 8 (8,8) | 8 (8,8) |
| 5 min Apgar score | 8 (8,9) | 9 (9,9) | 9 (9,9) | 9 (9,9) |
Abbreviations: NICU, neonatal intensive care unit; SGA, small for gestational age.
Race and ethnicity are self-reported by parents within the electronic health record.
Birth weight less than the 10th percentile for gestational age and sex.
Escalation to a higher level of care happened at a median of 12.5 hours after birth (IQR 4–40 hours), shown in Figure 1. Escalation of care was most frequent in the first 24 hours; half of all transfers (n = 62, 50%) occurred by 12 hours and 66.9% (n = 83) by 24 hours after birth. The most frequent reason for escalation of care was the need for respiratory support (n = 32, 25.8%). Other reasons for escalation of care included need for cardiorespiratory monitoring (n = 31, 25%), thermoregulation (n = 29, 23.4%), dextrose-containing intravenous fluids (n = 27, 21.8%), antibiotics (n = 10, 8.1%), supplemental tube feeds (n = 8, 6.5%), and other reasons (n = 12, 9.7%). Table 2 shows reasons for escalation of care by gestational age, and Supplemental Table 1 shows the median time for transfer by reason for escalation. Of note, more than half of infants escalated to a higher level of care for cardiorespiratory monitoring were due to a failed car seat screening in level I well newborn care (n = 17/31, 55%). The remaining infants escalated for cardiorespiratory monitoring had clinical symptoms (ie, dusky episodes) necessitating closer observation. Case descriptions for infants escalated to a higher level of care for “other” reasons are detailed in Table 3. Median length of stay did not differ between infants admitted to the NICU from birth for respiratory support compared with infants receiving escalation to higher level of care for respiratory support (237 vs 263 hours, P =.28). For infants receiving escalation because of a failed car seat screening, the median time between transfer to higher level of care and discharge was 168 hours (IQR 67–245). All infants transferred to the level II SCN or level II/IV NICU receive continuous cardiorespiratory monitoring per hospital policy; for 18 infants (14.5%) escalated to a higher level of care, monitoring was the only medical intervention.
FIGURE 1.
Reasons for transfer to a higher level of care by hours after birth.
TABLE 2.
Reasons for Transfer to a Higher Level of Care by Gestational Age
| Reason and Location for Transfer | 34 wk, n (%) | 35 wk, n (%) | 36 wk, n (%) | Total, n (%) |
|---|---|---|---|---|
| Respiratory support | 17 (89.5) | 10 (19.2) | 5 (9.4) | 32 (25.8) |
| Level I to II | 0 | 2 | 2 | 4 |
| Level I to III/IV | 0 | 8 | 3 | 11 |
| Level II to III/IV | 17 | 0 | 0 | 17 |
| Cardiorespiratory monitoringa | 0 | 10 (19.2) | 21 (39.6) | 31 (25)b |
| Level I to II | 9 | 16 | 27 | |
| Level I to III/IV | 1 | 3 | 2 | |
| Level II to III/IV | 0 | 2 | 2 | |
| Thermoregulationa | 0 | 22 (42.3) | 7 (13.2) | 29 (23.4) |
| Level I to II | 20 | 6 | 28 | |
| Level I to III/IV | 2 | 1 | 1 | |
| Level II to III/IV | 0 | 0 | 0 | |
| Dextrose-containing intravenous fluidsa | 0 | 11 (21.2) | 16 (30.2) | 27 (21.8) |
| Level I to II | 10 | 11 | 26 | |
| Level I to III/IV | 1 | 4 | 0 | |
| Level II to III/IV | 0 | 1 | 1 | |
| Need for antibioticsa | 0 | 4 (7.7) | 6 (11.3) | 10 (8.1) |
| Level I to II | 1 | 3 | 5 | |
| Level I to III/IV | 3 | 3 | 5 | |
| Level II to III/IV | 0 | 0 | 0 | |
| Supplemental tube feedsa | 0 | 3 (5.7) | 5 (9.4) | 8 (6.5) |
| Level I to II | 3 | 5 | 8 | |
| Level I to III/IV | 0 | 0 | 0 | |
| Level II to III/IV | 0 | 0 | 0 | |
| Otherc | 2 (10.5) | 4 (7.7) | 6 (11.3) | 12 (9.7) |
| Level I to II | 0 | 2 | 1 | 5 |
| Level I to III/IV | 0 | 2 | 4 | 4 |
| Level II to III/IV | 2 | 0 | 1 | 3 |
| Total infantsd | 19 | 52 | 53 | 124 |
Per hospital protocol, all infants under 35 weeks’ gestational age require empiric admission to a minimum level II special care nursery. Accordingly, interventions for these clinical concerns are available at baseline for 34-week infants and do not require transfer to a higher level of care.
17/31 (55%) infants admitted for cardiorespiratory monitoring were secondary to a failed car seat challenge. The remaining infants had clinical concerns (ie, dusky spell) that led to the need for cardiorespiratory monitoring.
See Table 3 for descriptions of “other” reasons for transfer.
Infants can have one or more reasons for transfer.
TABLE 3.
Case Descriptions of “Other” Reasons for Transfer
| Gestational | Transfer | Reason for Transfer |
|---|---|---|
| Age (week) | Location | |
| 34 | II to III/IV | Exposure to COVID-19, needed airborne isolation room in NICU |
| 34 | II to III/IV | Bilious emesis necessitating surgical evaluation |
| 35 | I to II | Neonatal opiate withdrawal syndrome with excessive weight loss |
| 35 | I to II | Placed in incubator empirically for small size (1792g) |
| 35 | I to III/IV | Large cleft palate necessitating closer feeding support, also needed airborne isolationroom in NICU for exposure to COVID19 |
| 35 | I to III/IV | Harsh cardiac murmur and oxygen desaturations, transfer for cardiac evaluation |
| 36 | I to II | Syphilis evaluation and treatment |
| 36 | I to III/IV | Hemolytic anemia requiring blood transfusion |
| 36 | I to III/IV | Abnormal movements with concern for seizures |
| 36 | I to III/IV | Abnormal neurological examination and dysmorphic features with concern for seizures |
| 36 | I to III/IV | Bradycardia concerning for heart block |
| 36 | II to III/IV | Lethargy, hypotonia, desaturation events with prenatal history of ventriculomegaly |
Abbreviation: NICU, neonatal intensive care unit.
Most infants were transferred to a higher level of care for a single (n = 102, 82.3%) or 2 (n = 19, 15.3%) documented reasons. However, once transferred to a higher level of care, further NICU-level interventions in addition to the admission needs were common (Supplemental Figure 1). For example, 29 infants (23.4%) had a reason for transfer including hypothermia; however, 83 infants (66.9%) were placed in an incubator at some point in their hospitalization. Eight infants (6.5%) were transferred for feeding challenges with the intention of initiating supplemental tube feeds; only 2 of 8 infants (25%) were ultimately tube fed from this group, and the remaining received feeding education and support only. Comparatively, 57 (46%) transferred infants were ultimately tube fed; this included 26 infants (45.6%) in whom tube feeding was initiated because of concurrent respiratory support. Of the 17 infants escalated in care because of a failed car seat screening, 7 (41%) received only cardiorespiratory monitoring on escalation. The remaining infants escalated for a failed car seat screen received respiratory support (n = 1, 6%), phototherapy (n = 5, 29%), thermoregulation (n = 9, 53%), supplemental tube feeds (n = 3, 18%), or dextrose-containing intravenous fluids (n = 1, 6%). None of these infants received antibiotics.
For infants transferred to a higher level of care, the frequency of severity markers is shown in Table 4. Notably, no transferred infant developed seizures, required pressor support, had positive blood or cerebrospinal fluid cultures, or required extracorporeal membrane oxygenation. Thirteen infants, or 10.5% of all transferred infants, underwent central line placement. For 8 of these 13 infants, this central line placement was for higher concentrations of dextrose-containing fluids for refractory hypoglycemia. An additional 4 central lines were used for parenteral nutrition and/or antibiotics, and 1 infant had its central line quickly discontinued. Three infants (2.4%) were intubated and received exogenous surfactant.
TABLE 4.
Frequency of Severity Markers Following Transfer to a Higher Level of Care
| Severity Marker | n (%) |
|---|---|
| Central line placementa | 13 (10.5) |
| Intubationb | 3 (2.4) |
| Surfactant administrationb | 3 (2.4) |
| Vasopressor support | 0 |
| Seizuresc | 0 |
| Positive blood culture | 0 |
| Positive CSF culture | 0 |
| ECMO | 0 |
| Otherd | 3 (2.4) |
| None | 107 (86.3) |
Abbreviations: CSF, cerebrospinal fluid; CPAP, continuous positive airway pressure; EEG, electroencephalogram; ECMO, extracorporeal membrane oxygenation.
Eight of 13 infants with central line placement needed it for higher dextrosecontaining fluids for refractory hypoglycemia. 1 infant had line placement just for monitoring and discontinued the next day. The remaining central lines were for nutrition and/or antibiotics.
Infants receiving surfactant were born at 34w0d, 36w3d, and 36w3d. All infants who received surfactant were additionally intubated.
Two infants were transferred to the NICU for concern for seizures; video EEGs were negative on both infants, and no diagnosis of seizures was made.
(1) Fevers, respiratory support, infiltrate on chest imaging: infant treated for neonatal pneumonia. (2) Necrotizing enterocolitis in an infant born at 35w4d and 2454g birth weight. (3) Transferred for respiratory distress and started on CPAP. Initial imaging at admission with interstitial fluid, pneumomediastinum, and potential pneumonia. The infant developed worsening respiratory distress on CPAP and was found to have a tension pneumothorax requiring needle decompression. The infant additionally with refractory hypoglycemia due to hyperinsulinism and was started on diazoxide.
DISCUSSION
In this cohort of over a thousand late preterm infants, we found that 14.2% of infants required escalation of care during the birth hospitalization. Late preterm infants represent a large group of infants born annually in the United States, and are often caught in the Goldilocks paradox between preterm infants and term infants. Compared with term infants, late preterm infants are at higher risk for needing medical intervention during the birth hospitalization and are more likely to have long-term neurodevelopmental delays, yet do not usually need the same level of medical care and support as preterm infants.3 With limited contemporary literature describing the care of late preterm infants, this study describes the topology of resource needs for this group.
Keeping infants safely together within a mother-infant dyad in well newborn care has benefits to the infant and family in terms of breastfeeding success, maternal and paternal mental health, and bonding. Successful dyadic well newborn care additionally benefits the health care system in terms of lower costs compared to a NICU admission.11–13 However, some late preterm infants require a higher level of support than the well newborn nursery can provide. Appropriate identification and the ability to safely transfer in a timely manner infants who need a higher level of care allows for hospital systems to trial late preterm infants within dyadic care, knowing that many will thrive and benefit, while those needing more support will safely receive it. The percentage of infants that a system can sustainability accommodate transfers for is likely to differ among hospital systems of varying resources. The 14.2% transfer rate in our study cohort is, therefore, nested within our center’s individual resources and system of care setup. Transfer to a higher level of care occurs within the same building; this proximity allows transfers to occur quickly when needed and potentially allows for a lower threshold to trial infants in well newborn care. A triage area with the ability to provide thermoregulation via a radiant warmer, continuous cardiorespiratory monitoring, and frequent assessments by nurses and physicians for up to 4 hours allows for the management of late preterm infants with transient symptoms without needing a full SCN/NICU admission. Identification of infants needing escalation was likely helped by 24/7 in-house neonatal hospitalist availability, and the presence of the same neonatal hospitalist team at each late preterm infant delivery allowed for an assessment of which infants were well-appearing enough to be trialed in care outside the NICU. The percentage of infant transfers the system can sustainably accommodate at a high resource site, as in this study, is likely to be higher than at a site where resources are limited or may require longer to access.
Half of all escalations in care occurred within the first 12 hours after birth, and more than two-thirds by 24 hours after birth. Early transfers were most frequently due to the need for respiratory support, which fits with the pathophysiology of transient tachypnea of the newborn and respiratory distress syndrome. Transfers beyond the first day were most often due to a need for cardiorespiratory monitoring, such as following a failed car seat screening or a dusky spell noted during feeding. Some hospitals require a minimum observation period in the NICU before allowing late preterm infants into dyadic well newborn care, most commonly for 35-week infants. Our institution does not require such a monitoring period. Our findings support this approach, maximizing the number of infants able to remain with their mother, and show that infants who required escalation received so without clinical decompensation. While this single-site data provide some understanding of late preterm infant care needs, future multisite work should compare escalation of care needs and NICU intervention rates among hospitals with varying admission policies. Understanding late preterm infant care patterns across varying sites can then set the foundation toward standardizing admission practices, developing clinical benchmarks, and identifying quality markers to ultimately discriminate among late preterm infant care performance across institutions.
More than half of the escalations for continuous cardiorespiratory monitoring followed failed car seat screening. Routine car seat screening was originally intended as a practical attempt to reduce cardiorespiratory events following discharge; however, concerns surrounding the limited efficacy and reliability as a screening tool have led to the de-implementation of its use in some nurseries.14,15 The Canadian Paediatric Society issued a position statement recommending against routine car seat screening in 2016.14 De-implementation in a large integrated California health care system found no differences in 30-day postdischarge adverse outcomes.15 Similarly, a retrospective cohort study found that car seat screening failure was associated with longer post-test hospitalization, but no changes in 30-day mortality or readmission.16 Infants in our study underwent car seat screening when otherwise ready for discharge, and following the failed result, remained admitted for a median of 168 hours. While it is possible that this failed test uncovered developmental immaturity that benefited from further inpatient admission, it is also possible that this represented overdiagnosis and subsequent overutilization of NICU care. As more nurseries de-implement car seat screening, it will be important to continue to critically evaluate postdischarge outcomes.
Infants escalated in care frequently received medical interventions beyond the original reason(s) for escalation in care. There can be multiple reasons for this discrepancy. It may reflect a limitation with the methodology—that physicians documenting reasons for escalation in care may not have thoroughly listed all possible reasons. This discrepancy may also suggest that the need for escalation was only “the tip of the iceberg,” and that once escalated, infants show multiple areas of needing support for their prematurity. It is also important to consider that this discrepancy may represent overuse. This current study did not allow us to evaluate the necessity of each received intervention. However, our prior study showed, for example, that 23.7% of late preterm infants receiving thermoregulatory measures never had documented hypothermia. We know that physician practices for low acuity infants are variable and that significant variation exists in NICU level care, suggesting that overutilization of care can occur.17,18 Subsequent studies can be designed to better understand causal links between escalation in care and receipt of medical interventions to help clarify the discrepancies noted here.
When infants require escalation of care during the birth hospitalization, clinicians and families themselves often ask if the infant should have been placed in a higher level of care to begin with. The answer to this question is nuanced and needs to incorporate patient safety, systems-based care, and family-centered care perspectives. While some infants had severity markers, such as needing central line placement or mechanical ventilation following transfer to a higher level of care, the retrospective cohort nature of this study did not allow for a comparison group to help understand if any severity markers could have been prevented with an earlier empirical higher level of care admission. Reassuringly, no infants transferred to a higher level of care required vasopressor support, extracorporeal membrane oxygenation, or had seizures. From a clinician’s perspective, an infant’s admission to well newborn care, even if for a limited time before transfer, can offer the benefits of bonding and breastfeeding initiation. However, future studies of parental perspectives need to be conducted to identify whether parents prefer a trial of well newborn care, knowing the risk for needing transfer, or prefer empirical higher-level of care admission for their infants with downgrading to well newborn care following a set timeframe for observation of symptoms.
This study should be viewed in light of its design, including a single quaternary care hospital setting with potential lack of generalizability to other hospital settings with differing resources, and inability to define causality given the retrospective cohort design. Future work should include diversity in hospital settings, including community hospitals where newborn care commonly occurs, and yet are underrepresented within the literature. Incorporating parental perspectives in future prospective work is needed to first define and then implement patient-centered care for late preterm infants.
CONCLUSIONS
This study describes care patterns for late preterm infants requiring escalation of care during the birth hospitalization at a quaternary care children’s hospital. Infants most frequently required escalation within the first 24 hours after birth. Need for respiratory support, cardiorespiratory monitoring, and thermoregulation were the most common reasons for escalation in care. Late preterm infants represent a large number of infants born annually in the United States; this study provides insight into their admission patterns and care use needs.
Supplementary Material
FUNDING
The work in this manuscript was supported by the Stanford Maternal and Child Health Research Institute (Joshi), the National Institutes of Health (1F32HD106763, 1K23HD114878), and the Society for Pediatric Research. The contents of this manuscript are solely the responsibility of the authors and do not necessarily represent the official views of Stanford University, the National Institutes of Health, or the Society for Pediatric Research. Sponsors were not involved in the study design, data collection, data analysis, interpretation of data, writing of the report, or the decision to submit the article for publication. Dr Joshi is supported by the National Institutes of Health (1K23HD114878-01A1, formerly 1F32HD106763), the Stanford Maternal and Child Health Research Institute, and the Society for Pediatric Research. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, Stanford University, or the Society for Pediatric Research.
ABBREVIATIONS
- CPAP
continuous positive airway pressure
- ECMO
extracorporeal membrane oxygenation
- NICU
neonatal intensive care unit
- SCN
special care nursery
- SGA
small for gestational age
Footnotes
CONFLICTS OF INTEREST DISCLOSURE: The authors have no conflicts of interest relevant to this article to disclose.
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