ARTICLE

Role of the Pediatric Nurse

Practitioner in Promoting
Breastfeeding for Late
Preterm Infants in Primary
Care Settings
Azza H. Ahmed, DNS, RN, IBCLC, CPNP

ABSTRACT
The preterm birth rate has been increasing steadily during
the past two decades. Up to two thirds of this increase has
been attributed to the increasing rate of late preterm births
(34 to < 37 gestational weeks). The advantages of breastfeed-
ing for premature infants appear to be even greater than for
term infants; however, establishing breastfeeding in late-
preterm infants is frequently more problematic. Because of
their immaturity, late preterm infants may have less stamina;
difficulty with latch, suck, and swallow; temperature instabil-
ity; increased vulnerability to infection; hyperbilirubinemia,
and more respiratory problems than the full-term infant.
Late preterm infants usually are treated as full term and dis-
charged within 48 hours of birth, so pediatric nurse practi-
tioners in primary care settings play a critical role in
promoting breastfeeding through early assessment and
detection of breastfeeding difficulties and by providing antic-
ipatory guidance related to breastfeeding and follow-up. The
purpose of this article is to describe the developmental and
physiologic immaturity of late preterm infants and to high-
light the role of pediatric nurse practitioners in primary
care settings in supporting and promoting breastfeeding for
Azza H. Ahmed, DNS, RN, IBCLC, CPNP, Assistant Professor,
School of Nursing, Purdue University, West Lafayette, IN.
Correspondence: Azza H. Ahmed, DNS, RN, IBCLC, CPNP,
School of Nursing, Purdue University, 502 N University St, West
Lafayette, IN 47907; e-mail: ahmedah@purdue.edu.
0891-5245/$36.00
Published by Elsevier Inc. on behalf of the National Association
of Pediatric Nurse Practitioners.
doi:10.1016/j.pedhc.2009.03.005
late preterm infants. J Pediatr Health Care. (2010) 24, 116-
122.
KEY WORDS
Late preterm infant, breastfeeding, pediatric nurse practi-
tioner, primary care settings
With the increasing rate of prematurity (12.7% of live
birth infants) in the United States, the rate of late pre-
term births also has increased. A late preterm infant is
defined as an infant who is born 34 0/7 weeks (239
days) through and including 36 6/7 weeks (259 days)
after the beginning of the mother’s last normal men-
strual period (Raju, 2006). It is estimated that 71% of
all preterm births occurred at 34, 35, and 36 weeks of
gestation (Hamilton, Martin, & Ventura, 2007). Because
late preterm infants may look like term infants, their vul-
nerability to serious problems may be overlooked. Late
preterm infants are seven times more likely to have
newborn morbidity than are term infants (Shapiro-
Mendoza et al., 2008). According to Raju, Higgins, Stark,
and Leveno (2006), the newborn morbidity rate is dou-
bled in infants for each gestational week less than 38
weeks. Compared with term infants, late preterm in-
fants have higher frequencies of respiratory distress,
temperature instability, hypoglycemia, kernicterus, ap-
nea, seizures, and feeding problems, as well as higher
rates of rehospitalization.
The American Academy of Pediatrics (AAP) Com-
mittee on Fetus and Newborn (2004) recommends
that early postnatal discharge should be limited to in-
fants who are of singleton birth between 38 and 42

116 Volume 24  Number 2 Journal of Pediatric Health Care

weeks’ gestation; however, many late-preterm infants to lose heat more readily than term infants because of
are discharged early, and they are treated as term in- large surface area to weight. Preterm infants have im-
fants in regular maternity units. Preterm infants who mature hepatic glycogenolysis and adipose tissue lipol-
are being breastfed at discharge; who are firstborn; ysis, hormonal dysregulation, and deficient hepatic
and whose mothers are of Asian/Pacific Islander gluconeogenesis and ketogenesis that put them at
descent, have had labor and delivery complications, high risk for hypoglycemia. Hypothermia and hypogly-
or are recipients of public support are at risk for hos- cemia potentially can worsen pre-existing respiratory
pital re-admission (Shapiro-Mendoza et al., 2008). distress (Engle, Tomashek, Wallman, and the Commit-
Jain and Cheng (2006) also found that 36.9% of late tee on Fetus and Newborn, 2007). Late preterm infants
preterm infants seen in the emergency department have a higher metabolic rate and limited energy stores,
in the first month of life required re-admission to so any brief episodes of temperature instability can
the hospital. The top six diagnoses for late preterm deplete brown fat and other energy reserves and set
re-admission included apnea, hyperbilirubinemia, the stage for hypoglycemia (Meier, Furman &
fever, respiratory problems, feeding problems, and Degenhardt, 2007).
hypothermia. Transient tachypnea of the newborn and respiratory
According to the AAP, criteria for discharge of late distress syndrome in late preterm infants are related to
preterm infants should be based on evidence of physi- lack of clearance of lung fluid and/or relative deficiency
ologic maturity; feeding competency; thermoregula- of pulmonary surfactant. Escobar, Clark, and Greene
tion; maternal education; assessment and planned (2006) reported that acute respiratory distress was the
interventions for medical, family, environmental, and most common clinical problem for late preterm infants.
social risk factors; and follow-up arrangements They also found that the risk of experiencing respira-
(Landers, 2008). Parents of late preterm infants need tory problems in general rises greatly as gestational
special instruction and guidance before hospital dis- age falls below 38 weeks. Late preterm infants are
charge and close follow-up after discharge. also at a twofold higher risk for sudden infant death syn-
The AAP (2005) stressed that premature infants drome (1.4 cases per 1000 at 33 to 36 weeks’ gestation,
who are fed human milk receive significant benefits compared with 0.7 per 1000 at >37 weeks’ gestation)
with respect to host protection and improved devel- when compared with term infants (Raju et al., 2006;
opmental outcomes compared with formula-fed pre- Wang et al., 2004).
mature infants. Health benefits of mother’s milk are Late preterm infants also have immature gastrointes-
especially significant for the immunocompromised tinal function and feeding difficulties that predispose
and physiologically immature late preterm infant. them to an in-
The National Association of Pediatric Nurse Practi- crease in entero- Late preterm
tioners (NAPNAP), in agreement with the AAP, recog- hepatic circula-
nizes the nutritional and immunological benefits of tion, decreased infants.have
breastfeeding for term and preterm infants in addition stool frequency, immature gastroin-
to the developmental and psychological benefits dehydration, and testinal function and
(McCully et al., 2007). Primary care pediatric nurse hyperbilirubine-
practitioners (PNPs) can influence breastfeeding prac- mia. Feeding diffi- feeding difficulties
tices significantly by accurately assessing infant culties in late that predispose
breastfeeding behavior during an early clinic visit preterm infants them to an increase
and providing families with accurate and up-to-date that are associated
information and breastfeeding follow-up in primary with relatively low in enterohepatic
care settings. oromotor tone, circulation,
The purpose of this article is to describe the develop- function, and neu- decreased stool
mental and physiologic immaturity of late preterm in- ral maturation also
fants and to highlight the role of the PNP in predispose these frequency,
supporting and promoting breastfeeding in late pre- infants to dehy- dehydration, and
term infants. dration and hy- hyperbilirubinemia.
perbilirubinemia
DEVELOPMENTAL AND PHYSIOLOGICAL (Ludwig, 2007;
IMMATURITY OF LATE PRETERM INFANTS Raju et al., 2006; Wang et al., 2004).
Late preterm infants are at risk for hypothermia and During the last 6 to 8 weeks of gestation, more than
early hypoglycemia as a result of their immaturity. one third of the brain volume at term is acquired, and
Late preterm infants have less white adipose tissue for the white matter volume increases fivefold. Significant
insulation, and they cannot generate heat from brown maturation of brain structure occurs during this period,
adipose tissue as effectively as do infants who are including increases in neuronal connections and syn-
born at term. In addition, late preterm infants are likely aptic junctions. Therefore, late preterm infants may be

www.jpedhc.org March/April 2010 117

less prepared to respond to stimuli and regulate internal
processes, and they may be more vulnerable to brain in-
jury and permanent neurologic disabilities (Jorgensen,
2008; Raju et al., 2006). Ineffective milk removal during
breastfeeding may be affected by immature sleep-wake
behavior and temperature regulation, which can lead to
other morbidities such as hypoglycemia and hyperbilir-
ubinemia (Walker, 2008; Wight, 2004).
Jaundice and hyperbilirubinemia occur more com-
monly and are more prolonged among late preterm in-
fants than term infants, because late preterm infants
have delayed maturation and a lower concentration
of uridine diphosphoglucuronate glucuronosyltrans-
ferase (Jorgensen, 2008; Smith, Donze, & Schuller,
2007). Late preterm infants are two times more likely
than term infants to have significantly elevated bilirubin
concentrations and higher concentrations 5 and 7 days
after birth (Engle et al., 2007). Breastfeeding on dis-
charge is a predictor of pathological jaundice in late-
preterm infants (Bhutani & Johnson, 2006; Sarici et al.,
2004). A late preterm infant’s jaundice is mainly due
to inadequate milk intake, which leads to infrequent
stooling, exaggerated enterohepatic recirculation of
bilirubin, and increased intestinal reabsorption of bili-
rubin. The Box summarizes the most common morbid-
ities in late preterm infants attributed to immaturity.
WHY LATE PRETERM INFANTS HAVE
DIFFICULTY WITH BREASTFEEDING
Beside the physiological immaturity of late preterm in-
fants, mothers who deliver preterm infants are more
likely to have medical complications such as hyperten-
sion, prolonged rupture of membrane, chorioamnioni-
tis, pitocin induction, diabetes, or delivery by caesarian
section. These complications could lead to delayed lac-
togenesis II and expose the child to hypothermia,
hypoglycemia, dehydration, exaggerated jaundice,
kernicterus, fever secondary to hydration, rehospitali-
zation, and slow weight gain (Adamkin, 2006; Sha-
piro-Mendoza et al., 2008). Combining maternal
medical condition and late preterm birth greatly in-
creases the newborn morbidities compared with term
infants who were born without exposure to these risks.
Meier et al. (2007) describe a conceptual framework for
poor breastfeeding in late preterm infants (Figure 1).
The most important consideration in managing lacta-
tion for the late preterm infant is to recognize that inef-
fective breastfeeding may be a sign of underlying
morbidities that put the infant at risk (e.g., a sleepy in-
fant with difficulty arousing could be a sign of hypo-
thermia or hypoglycemia, which requires immediate
evaluation and treatment).
OVERCOMING POSTPARTUM MORBIDITIES
Although preventing late preterm morbidities should
start immediately after birth with the main goal to estab-
lish adequate feeding, PNPs in the primary care setting
118 Volume 24  Number 2
BOX. Common morbidities in late preterm
infant as a result of immaturity
d Hypoglycemia
d Hypothermia
d Transient tachypnea of the newborn and respiratory dis-
tress syndrome
d Hyperbilirubinemia
d Feeding difficulties and dehydration
d Vulnerability to brain injury and permanent neurological
disabilities
still have a major role in helping late preterm infants
overcome these morbidities. Engle et al. (2007) stressed
that the timing of discharge should be individualized
and based on feeding competency, thermoregulation,
and absence of medical illness and social risk factors.
Late preterm infants usually do not meet these criteria
in 48 hours. In addition, feeding before hospital dis-
charge may be transiently successful but not sustained
after discharge. According to the Academy of Breast-
feeding Medicine (2004), a pre-written individualized
feeding plan order should be communicated to the staff
and discussed with the mother before discharge. Adam-
kin (2006) highlighted that there are times when an in-
fant’s condition deteriorates in the interval between
discharge and first office visit. Therefore, timely evalu-
ation of the late preterm infant after discharge is critical.
FIRST OFFICE VISIT
Mother/infant Assessment and Feeding History
The first outpatient office visit should be when the infant
is 3 to 5 days old or 1 or 2 days after discharge from the
hospital. The PNP should revise the inpatient maternal
and infant records including prenatal, perinatal, and in-
fant feeding history (e.g., the need for supplement in
the hospital and problems with latch). Gestational age,
birth weight, and weight at discharge should be recorded
in the infant record. A review of breastfeeding since dis-
charge should be conducted, including frequency, du-
ration of feedings, and how the baby is being fed (e.g.,
at the breast or with expressed breast milk via supple-
mental devices such as a supplemental nursing system,
finger feeds, or a bottle with an artificial nipple) (Acad-
emy of Breastfeeding Medicine, 2004).
Information about stool and urine output, color of
stools, and the baby’s state (e.g., crying, not satisfied af-
ter feeding, or sleepy and difficult to keep awake at the
breast during feeding) should be obtained. Accurate in-
fant weight without clothes and calculation of change in
weight from birth and discharge should be obtained.
It is recommended that PNPs screen for hyperbiliru-
binemia using standardized nomograms to assess the
risk of hyperbilirubinemia and plan for follow-up test-
ing based on the infant’s results. Assessment for jaun-
dice with a transcutaneous bilirubin screen and/or
Journal of Pediatric Health Care
 FIGURE 1. Conceptual framework for poor lactation outcomes in late preterm infants. Reprinted with
permission from Meier, P., Furman, L., & Degenhardt, M. (2007). Increased lactation risk for late
preterm infants and mothers: Evidence and management strategies to protect breastfeeding.
Journal of Midwifery & Women’s Health, 52, 579-587.
serum bilirubin determination should be done if indi-
cated (AAP Subcommittee on Hyperbilirubinemia,
2004; Kelly,2006). Data from the Pilot Kernicterus Reg-
istry (2003-1992) revealed that in breastfed late preterm
infants, especially those who were large for gestational
age, kernicterus developed significantly more fre-
quently than in term infants (Bhutani & Johnson, 2006).
Pumping
Late preterm infants can vary in their sucking pattern
and intensity of sucking. Some late preterm infants
are capable of stimulating the mother’s breasts effec-
tively, but others are not able to do so. If the infant is
not able to maintain at least 15 minutes of effective
suckling 8 to 10 times in a 24-hour period, the mother
should be advised to use a hospital-grade breast
pump to ensure effective breast stimulation (Meier
et al., 2007; Walker, 2008). For the purpose of effective
establishment of milk supply, the mother should be ad-
vised to pump after feeding for at least 2 weeks
(Walker). Studies have shown the importance of ideal
target milk volumes for mothers of preterm infants,
which should be around 750 to 1000 mL per day by
day 7 to 10 (Meier, Engstrom, Mingolelli, Miracle, &
Kiesling, 2004). Mothers also should be assessed for
timing of lactogenesis II and ongoing milk supply
(Walker; Wight, 2004). All the causes of preterm birth
are risk factors for delayed lactogenesis II, including un-
scheduled cesarean section birth, hypertension, diabe-
tes, stressful labor and delivery, and obesity (Hurst,
2007).
Test Weighing and Signs of Ineffective
Breastfeeding
Pre- and post-breastfeeding weighing using an elec-
tronic scale is a reliable method for assessing effective
www.jpedhc.org
milk transfer (Meier et al., 1994). Mothers can rent an
electronic scale if one is not available at home. Mothers
have found that in-home test weighing helps them
achieve their breastfeeding goals and decreases stress
levels (Hurst, Meier, Engstrom, & Myatt, 2004).
Frequent monitoring is needed for weight change,
stool and urine output, and milk transfer to avoid exces-
sive weight loss or dehydration. Losses of greater than
3% of birth weight by day 1 or greater than 7% by day
3, continued weight loss after postbirth day 3, no audi-
ble swallowing from the baby, fewer than six diaper
changes per day after day 4, fewer than three stools
per day after day 4, an irritable, restless, or sleepy infant,
minimal or no breast changes by day 5 after birth, or ex-
aggerated jaundice all are signs of ineffective breast-
feeding and require further evaluation and
intervention (Hurst, 2007). The infant’s diet may need
to be supplemented after breastfeeding with small
quantities of expressed breast milk or pasteurized hu-
man breast milk if available. Other choices, beyond
pasteurized human milk, are elemental formulas, regu-
lar formulas, and then soy formulas (Academy of
Breastfeeding Medicine, 2003). Supplemented
amounts should be 5 to 10 mL per feeding on day 1,
10 to 20 mL on day 2, and 20 to 30 mL on day 3 as sug-
gested by Stellwagen, Hubbard, and Wolf (2007).
Mothers may supplement using a supplemental nursing
device at the breast, cup feeds, finger feeds, syringe
feeds, or bottle depending on the clinical situation
and the mother’s preference (Walker, 2008; Wight,
2004).
Positioning
Mothers should be educated about effective position-
ing that provides good head support. Clutch or cross
cradle are the positions of choice for late-preterm
March/April 2010 119

FIGURE 2. Dancer hand position. Reprinted
with permission from Wilson-Clay, B., &
Hoover, K. The Breastfeeding Atlas (4th ed.)
Austin, TX: Lactnews Press. This figure is
available in color online at www.jpedhc.org.
infants (Meier et al., 2007; Walker, 2008). In addition,
mothers should also be taught the dancer hand position
(Figure 2) to prevent the infant from slipping off the
breast during pauses between sucking (Isaacson,
2006; Walker, 2008).
Nipple Shields
Correct and effective use of an ultra-thin silicone nipple
shield facilitates milk intake and breast stimulation. Sev-
eral studies with term and preterm infants indicated that
ultra-thin silicone nipple shields increase rather than
decrease milk transfer to the infant and lengthen rather
than shorten duration of breastfeeding (Meier et al.,
2000). Chertok, Schneider, and Blackburn (2006), in
their pilot study, found that nipple shields do not affect
maternal hormonal levels or infant breast milk intake.
Mothers also were satisfied with ultra-thin nipple
shields. Walker (2008) explained that the mothers
may need to moisten the shield with warm water and
turn it almost inside out when applying it to help the
shield stay in place. Nipple shields can be used until
approximately the infant’s expected due date (Isaac-
son, 2006).
Observing a Breastfeeding Session
Observing a breastfeeding session during the first visit
to assess the infant’s ability to latch, suck, swallow,
and transfer milk is essential, if possible (Smith et al.,
2007; Walker, 2008; Wight, 2004). The PNP should as-
sess the mother’s breast for nipple shape, pain and
trauma, engorgement, and mastitis. The mother’s emo-
120 Volume 24  Number 2
tional status and degree of fatigue should be consid-
ered, especially when considering supplemental
feeding routines (Campbell, 2006). Because observing
a breastfeeding session in a primary care setting is
time consuming, PNPs need to be familiar with the com-
monly used ICD-9-CM codes related to lactation and
feeding problems (AAP, 2008).
For infants with latch difficulties, the baby’s mouth
should be examined for anatomic abnormalities (e.g.,
ankyloglossia, cleft palate), and a digital suck examina-
tion should be performed. A referral to a trained profes-
sional lactation specialist in the case of ankyloglossia or
a referral to someone trained in frenotomy may be indi-
cated (Academy of Breastfeeding Medicine, 2004).
Vitamin D and Iron Supplementation
According to the new recommendations of AAP, the di-
ets of breastfed and partially breastfed infants should be
supplemented with 400 IU/day of vitamin D beginning
in the first few days of life (Wagner, Greer, and the Sec-
tion on Breastfeeding and Committee on Nutrition,
2008). Iron supplementation should be considered be-
cause iron stores in preterm infants are less than those
of term infants. The AAP Committee on Nutrition recom-
mends 2 mg/kg/day of elemental iron drops for preterm
breastfed infants from 1 to 12 months of age (AAP, 2005).
Follow-up
Late preterm infants should have weekly weight checks
until 40 weeks’ postmenstrual age or until full breast-
feeding is established with no supplements. Infants
who are not gaining weight well and for whom adjust-
ments are being made to the feeding plan may need
a visit 2 to 4 days after each adjustment (Academy of
Breastfeeding Medicine, 2004).
The mother’s ability to cope with and manage the
feeding plan needs to be evaluated at each visit. If the
mother is not coping well, the PNP should work with
her to find help and to modify the feeding plan so it is
more manageable. After the first week, infants should
be monitored for adequate growth and evidence of nor-
mal biochemical indices. Weight gain should average
more than 20 g/day, and length and head circumfer-
ence each should increase by an average of more
than 0.5 cm/week (AAP, 2005). The Table summarizes
points for assessment and teaching during the first of-
fice visit for late preterm infants.
CONCLUSION
Late preterm infants are more likely than term infants to
have temperature instability, hypoglycemia, respiratory
distress, jaundice, and feeding problems and to require
rehospitalization in the first 2 weeks postpartum. Opti-
mizing feeding, especially for breastfed babies, reduces
these morbidities and hospital re-admissions. PNPs in
the primary care setting not only need to be supportive
of breastfeeding but also need to know how to manage
Journal of Pediatric Health Care
 TABLE. First office visit (within 2 days after infant discharge)
Assessment/teaching topics Intervention
Assessment Assess prenatal and perinatal history and feeding history; assess timing of lactogenesis II;
screen for hyperbilirubinemia
Pumping Encourage mother to pump after each feeding for 2 weeks; monitor weight change
Positioning Encourage mothers to use clutch or cross cradle positioning
Nipple shields Advise mother than ultrathin nipple shields can be used until infant’s expected due date if
infant has difficulty with latching
Observe breastfeeding session Assess the infant’s ability to latch, suck, swallow, and transfer milk; assess the mother for
nipple problems
Vitamin and iron supplementation Suggest 400 IU/day of vitamin D and 2 mg/kg/day of elemental iron
Follow-up Perform weight check weekly until 40 weeks; evaluate and revise breastfeeding plan; monitor
weight gain; refer to lactation consultant in a timely manner; refer to home care if available

uncomplicated breastfeeding problems in late preterm American Academy of Pediatrics. (2005). Breastfeeding and the use
infants. Follow-up visits after discharge from the hospital of human milk. Pediatrics, 115, 496-506.
American Academy of Pediatrics, & , Committee on Fetus and New-
are essential and
born. (2004). Hospital stay for healthy newborns. Pediatrics,
should include a re- Follow-up 113, 1434-1436.
view of the current American Academy of Pediatrics, & , Subcommittee on Hyperbiliru-
feeding regimen,
visits.are essential binemia. (2004). Clinical practice guideline: Management of
information re- and should include hyperbilirubinemia in the newborn infant $35 weeks of gesta-
tion. Pediatrics, 114, 297-316.
garding feeding a review of the Bhutani, V. K., & Johnson, L. (2006). Kernicterus in late preterm
progression, and
reinforcement
current feeding infants cared for as term healthy infants. Seminars in Perinatol-
ogy, 30, 89-97.
about changing regimen, Campbell, S. (2006). A case study: Challenges of breastfeeding pre-
term infants. Journal of Obstetric, Gynecologic, and Neonatal
infant behaviors as information Nursing, 10, 490-497.
the preterm infant
approaches 40
regarding feeding Chertok, I., Schneider, J., & Blackburn, S. (2006). A Pilot study of ma-
ternal and term infant outcomes associated with ultrathin nipple
weeks postmenst- progression, and shield use. Journal of Obstetric, Gynecologic, and Neonatal
rual age. It is crucial reinforcement about Nursing, 35, 265-272.
to be able to refer Engle, W., Tomashek, K., Wallman, C. & Committee on Fetus and
mothers and in-
changing infant Newborn. (2007). ‘‘Late-Preterm’’ infants: A population at
risk. Pediatrics, 120, 1390-1401.
fants immediately behaviors as the Escobar, G., Clark, R., & Greene, J. (2006). Short-term outcome of
to a trained lacta- preterm infant infants born at 35 and 36 weeks gestation: We need to ask
tion professional more questions. Seminars in Perinatology, 30, 28-33.
for more compli-
approaches 40 Hamilton, B.E., Martin, J.A., & Ventura, S. J (2007). Births: Prelimi-
cated breastfeeding weeks nary data for 2006. National Vital Statistics Reports, 56(7), 1-18.
Hurst, N. M. (2007). Recognizing and treating delayed or failed Lacto-
problems. A lacta- postmenstrual age. genesis II. Journal of Midwifery and Women’s Health, 52, 588-
tion referral should 592.
be viewed with the same medical urgency as any other Hurst, N., Meier, P., Engstrom, J., & Myatt, A. (2004). Mothers per-
acute medical referral (Adamkin, 2006). Home care forming in-home measurement of milk intake during breast-
feeding of their preterm infant: Maternal reactions and feeding
should be arranged if available for early detection and outcomes. Journal of Human Lactation, 20, 178-187.
management of neonatal morbidities. Jain, S., & Cheng, J. (2006). Emergency department visits and reho-
spitalization in late preterm infants. Clinics in Perinatology, 33,
REFERENCES 935-945.
Adamkin, D. H. (2006). Feeding problems in the late preterm infant. Jorgensen, A. (2008). Late preterm infants: Clinical complications
Clinics in Perinatology, 33, 831-837. and risk. Nursing for Women’s’ Health, 12, 317-329.
American Academy of Breastfeeding Medicine. (2004). Clinical pro- Isaacson, L. (2006). Steps to successfully breastfeeding the prema-
tocol #10: Breastfeeding the near-term infant (35-37 weeks ture infant. Neonatal Network, 25, 77-86.
gestation). Retrieved October 30, 2008, from http://www. Kelly, M. (2006). Primary care issues in healthy preterm infant. Journal
bfmed.org/ace-files/protocol/near_term.pdf of Pediatric Health Care, 20, 293-299.
Academy of Breastfeeding Medicine. (2003). Clinical protocol #3: Hos- Landers, S. (2008). Guidelines on care of late preterm infants empha-
pital guidelines for the use of supplementary feedings in the size importance of feeding competency before discharge. AAP
healthy term breastfeeding neonate. Retrieved January 9, News, 29, 17.
2009, from http://www.bfmed.org/ace-images/ProtocolSuppl3 Ludwig, S. (2007). Oral feeding and the late preterm infant. Newborn
rev.pdf and Infant Nursing Review, 7, 72-75.
American Academy of Pediatrics. (2008). Coding for breastfeeding McCully, M., Johnson Balkam, J., Butkus, S., Frantz, K., Karen, H.,
and lactation services. Retrieved December 26, 2008, from Leslie, L., et al. (2007). NAPNAP position statement on breast-
http://coding.aap.org/content.aspx?aid=10852 feeding. Journal of Pediatric Health Care, 21, 39A-40A.

www.jpedhc.org March/April 2010 121

Meier, P. P., Engstrom, J. L., Spanier Mingolelli, S., Miracle, D. J., &
Kiesling, S. (2004). The Rush mothers’ milk club: breastfeeding
interventions for mothers with very-low birth-weight infants.
Journal of Obstetric, Gynecologic and Neonatal Nursing, 33,
164-174.
Meier, P., Furman, L., & Degenhardt, M. (2007). Increased lactation
risk for late preterm infants and mothers: Evidence and man-
agement strategies to protect breastfeeding. Journal of Mid-
wifery & Women’s Health, 52, 579-587.
Meier, P., Brown, L., Hurst, N., Spatz, D., Engstrom, J., Borucki, L.,
et al. (2000). Nipple shields for preterm infants: Effect on milk
transfer and duration of breastfeeding. Journal of Human Lac-
tation, 16, 106-114.
Meier, P., Engstrom, J., Crichton, C., Clark, D., Williams, M., Man-
gurten, H., et al. (1994). A new scale for in-home test-weighing
for mothers of preterm and high risk infants. Journal of Human
Lactation, 10, 163-168.
Raju, T. (2006). Epidemiology of late preterm (near-term) births.
Clinics in Perinatology, 33, 751-763.
Raju, T., Higgins, R., Stark, A., & Leveno, K. (2006). Optimizing care
and outcome for late-preterm (near-term) infants: A summary of
the workshop sponsored by the National Institute of Child Health
and Human Development. Pediatrics, 118, 1207-1214.
Shapiro-Mendoza, C., Tomashek, K., Kotelchuck, M., Barfield, W.,
Nannini, A., & Declercq, E. (2008). Effect of late-preterm birth
122 Volume 24  Number 2
and maternal medical conditions on newborn morbidity risk.
Pediatrics, 121, e223-e232.
Sarici, S., Sedra, M., Korkamaz, A., Erdem, G., Oran, O., Tekinalp,
G., et al. (2004). Incidence, course, and prediction of hyperbilir-
ubinemia in near-term and term newborns. Pediatrics, 113,
775-780.
Smith, J., Donze, A., & Schuller, L. (2007). An evidence-based review
of hyperbilirubinemia in late preterm infant, with implications for
practice: Management, follow-up, and breastfeeding support.
Neonatal Network, 26, 395-405.
Stellwagen, L.M., Hubbard, E.T., & Wolf, A. (2007). The late preterm
infant: A little baby with big needs. Contemporary Pediatrics. Re-
trieved December 24, 2008, from http://www.modernmedicine.
com/modernmedicine/CME+showcase/The-late-preterm-infant-
A-little-baby-with-big-nee/CME/Article/detail/522990
Wagner, C. L., Greer, F. R. & Section on Breastfeeding & Committee
on Nutrition. (2008). Prevention of rickets and vitamin D defi-
ciency in infants, children, and adolescents. Pediatrics, 122,
1142-1152.
Walker, M. (2008). Breastfeeding the late preterm infant. Journal of
Obstetrics, Gynecologic and Neonatal Nursing, 37, 692-701.
Wang, M., Dorer, D., Fleming, M., & Catlin, E. (2004). Clinical out-
comes of near-term infants. Pediatrics, 114, 372-376.
Wight, N. (2004). Breastfeeding the borderline (near-term) preterm
infant. Breastfeeding Review, 12, 17-23.
Journal of Pediatric Health Care