Chapter 59

1. Problem. The infant in the neonatal intensive care unit (NICU) or newborn nursery is ready to be discharged home. How can we ensure that this discharge is smooth, safe, and complete? The three essential factors for discharge are maintaining a normal body temperature in an open crib; ability to grow at a normal rate; and ability to eat, without respiratory compromise while taking an appropriate volume of feeding.

2. Immediate questions

1. What is the corrected age of the infant? Most preterm infants are discharged 2–4 weeks before their "due date," but there are variations among hospitals. Infants staying beyond their due date are usually on prolonged assisted ventilation, have severe malformations, or are status post–major surgery. The postconceptual age of 36 weeks is a prime time for consideration for discharge.

1. Is the infant showing consistent weight gain? At discharge, the infant should be gaining weight steadily on breast- or bottle-feeds. Most healthy preterm or term infants with no ongoing problems show an average weight gain of 15–30 g/day. If possible, multiple-gestation infants should be discharged home together, which may necessitate extra allowance on weight criteria. A specific weight requirement at discharge is controversial. Recent recommendations state that a sustained weight gain is more important than a specific weight. Some institutions require that an infant must weigh at least 1800–2000 g at discharge. Others base discharge more on maturity: ability to feed, gain weight, and keep warm.

1. Is the infant maintaining body temperature in an open crib? The ability to maintain thermal homeostasis without an external source of heat in an open crib with comfortable clothing is a key determinant of fitness for discharge.

1. Is the infant feeding satisfactorily? Are any special feeding techniques necessary? The ability of the infant to breast- or bottle-feed satisfactorily, taking in an adequate number of calories (120 cal/kg/day) in reasonable frequency (every 3–4 h), with each feed not taking >30–40 min, is important. If clinical grounds indicate the need for prolonged tube feeding or gastrostomy tube feeding, the parents must be trained to carry out the feedings at home.

1. Are the vital signs stable? Is there a need for home monitoring? Have arrangements been made for parental training in monitor use and in cardiopulmonary resuscitation? Episodes of apnea of prematurity along with associated bradycardia and desaturation resolve at about the postconceptional age of 36 weeks. If such episodes persist at 36 weeks of age or at discharge, the infants are usually sent home on varying combinations of cardiopulmonary event monitoring, respiratory stimulants (eg, theophylline or caffeine), and supplemental oxygen. Infant cardiopulmonary resuscitation training is arranged for the parents. If theophylline is still being used, then serum levels should be checked before discharge and monitored during follow-up visits; this is not usually necessary with caffeine. If home oxygen therapy is needed, pulse oximetry saturations in room air and in oxygen (supine and in a car seat) are recorded before discharge and checked during each follow-up visit.

1. Are there medications that need to be continued ...

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