66: Is the Infant Ready for Discharge?

An infant in the neonatal intensive care unit (NICU) is ready to be discharged home. How can we ensure that discharge from the NICU or newborn nursery is smooth, safe, and complete?

1. Does the infant meet discharge criteria? The decision to discharge the high-risk infant after hospitalization in the NICU is complex. Careful consideration must be given to infant safety as well as the family's readiness at home.

   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 postconceptional age of 36 weeks is a prime time for consideration for discharge.

   2. 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/d. Sustained weight gain is more important than specific weight criteria for discharge. 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.

   3. 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.

   4. Is the infant feeding satisfactorily? The ability of the infant to breast- or bottle-feed satisfactorily, taking in an adequate number of calories (120 cal/kg/d) in reasonable frequency (every 3–4 hours), with each feed not taking >30–40 minutes, is important.

   5. Are the vital signs stable? 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. If infants are being discharged with technological support, parental training in monitor use and cardiopulmonary resuscitation must be verified before discharge.

2. Is the family ready for the infant's discharge? The housing environment, caregiver comfort level, and access to community resources all play an important part in the successful transition to home.

   1. Has the family received discharge training? Before discharge home, at least 2 caregivers should have received training in basic infant care, techniques to identify acute illness, and review of infant safety guidelines (ie, sleep safety, smoke-free environment).

   2. Are there medications that need to be continued after discharge? Infants discharged on medications usually have the first prescription filled before discharge. Before the infant leaves the hospital, the parents should be trained in safely administering the medications. Parents are briefed on the duration of administration, importance of the medication, and probable duration of treatment, as well as side effects and risks of discontinuing too soon.

   3. Are any special feeding techniques necessary? 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. Training on the specific method of feeding with the actual equipment the caregivers will be using at home is essential for safe discharge.

   4. Will the infant be discharged with technological support? If infants have bronchopulmonary dysplasia/chronic lung disease (BPD/CLD), a history of bradycardia, or other complications associated with prematurity, they may be sent home with a monitoring device, home oxygen, or both. Parents must have completed training on the specific devices they will be using in the home, and proper use of the devices should be verified before discharge. Rarely, infants will be discharged with much more technological support (ie, ventilators). The home environment must be safe for and supportive of all levels of support. If necessary, a home environmental assessment can be done to ensure appropriateness before discharge.

   5. Have the parents received training in cardiopulmonary resuscitation? All caregivers should be aware of the procedures for emergency intervention. Parents of high-risk infants being discharged from the NICU should have infant cardiopulmonary resuscitation reviewed with them before discharge.

3. Is the community ready for the infant's discharge? Identification of key local providers and support systems for both the infant and family is necessary before discharge of the high-risk neonate.

   1. Has a primary care provider been identified? Information on the name, location, and choice of follow-up physician should be available at the time of discharge. In any given case, the specialty physician should personally contact the primary care physician by telephone to discuss the patient or to make arrangements for a preliminary discharge summary to be faxed to the primary physician. Most infants should be seen within 48 hours of discharge from the NICU.

   2. Will specialists be involved in outpatient care? Parents should be made aware of all the clinical conditions that require outpatient follow-up as well as given specific names and contact information for making follow-up appointments. In many cases, the inpatient team may be more successful at arranging follow-up than the caregivers, and every attempt should be made to solidify appointments before discharge. It is imperative that parents understand the importance of follow-up with subspecialists (ie, ophthalmologists, pediatric surgeons, pulmonologists).

   3. Is the infant at high risk for neurodevelopmental disability? Early intervention is extremely important to beneficial long-term outcome in those infants at highest risk for disability. Many states have early intervention programs that are available to NICU graduates at high risk. These resources should be accessed before discharge in preparation for outpatient follow-up. Appointments at a neonatal follow-up clinic for monitoring growth and development, with input from a dietitian, social worker, physiotherapist, and developmentalist, are mandatory for very high-risk infants.

   4. Is the infant a candidate for in home health visits? At the request of the physician, follow-up house visits by a home health nurse to check clinical status, to repeat tests, and to ensure weight gain should be arranged for finite periods, depending on the needs of the individual infant and family.

4. Have all screening tests, laboratory evaluations, radiologic evaluations, and appropriate immunizations been completed?

   1. Is the audiology screen complete? A newborn hearing screen (either an otoacoustic emissions [OAE], measuring the sound waves in the inner ear, or an auditory brainstem response [ABR], measuring how the brain responds to sound) is recommended before discharge. Results are recorded in the patient's record and the discharge summary and are also mailed to each state's Newborn Hearing Screening Program. Brainstem auditory evoked response assessment is essential in other clinical conditions in which there is an increased risk for hearing loss and for which progressive losses are possible. Risk factors for hearing loss include family history of hearing loss, in utero TORCH (toxoplasmosis, other infections, rubella virus, cytomegalovirus [CMV], and herpes simplex virus [HSV]) infection, ear and craniofacial anomalies, high bilirubin requiring exchange transfusion, birthweight <1500 g, bacterial meningitis, low Apgar scores of 0–3 at 5 minutes or 0–6 at 10 minutes, respiratory distress, mechanical ventilation >10 days, ototoxic medication given >5 days, and physical features of a syndrome that includes hearing loss.

   2. Is the newborn metabolic screen completed? If so, is it valid and is a repeat test needed? (See Chapter 15.) The content of the newborn metabolic screen varies among states. Screening at birth for phenylketonuria, hypothyroidism, and galactosemia is almost universal. Other tests, such as sickle cell screen and cystic fibrosis screen, vary regionally based on prevalence. All initial newborn screens should be done per state protocol but essentially at 48 hours after birth and preferably after 24 hours of protein feeding. The thyroid screen is invalid if done before 48 hours because of the surge of thyroid-stimulating hormone (TSH) at birth. The galactosemia test is valid at birth and invalid after blood transfusion for at least 60 days. Any borderline values or abnormal initial metabolic screen results are repeated with more definitive tests (eg, serum thyroxine, TSH, free thyroxine, and thyroxine-binding immunoglobulin).

   3. Have all required laboratory studies been completed and documented?

      1. Hematocrit and reticulocyte count. Hematocrit at the time of discharge should be >22% (controversial), and the reticulocyte count should be >5% (controversial ), with adequate supplementation of iron and multivitamins added to the normal dietary intake. Folic acid, B₁₂, and fat-soluble vitamin supplementation may be necessary in infants with short-gut syndrome or loss of distal ileum, including ileocecal valve during surgery. Anemia of prematurity must be noted and followed.

      2. Serum calcium, phosphorus, and alkaline phosphatase. Extremely premature infants and low birthweight infants must have these parameters checked during inpatient stay and at discharge, along with radiographs of the bones to rule out rickets of prematurity. Vitamin D₃ (1,25-dihydroxycholecalciferol) supplementation may be considered in these infants, often as part of a multivitamin (controversial).

      3. Drug levels. Infants being discharged home on medications such as phenobarbital or theophylline should have levels tested before discharge, and the results should be recorded with dose adjustment as necessary.

   4. Have all required radiologic studies been completed and documented?

      1. Chest radiograph. A copy of the most recent radiograph should be sent with the parents to the primary physician for follow-up care of chronic lung disease (eg, BPD/CLD).

      2. Head ultrasound scan. Clearly record the findings of the scans in chronologic order, with emphasis on hemorrhage, ventricular size, and areas of echogenicity suggestive of periventricular leukomalacia and porencephalic cysts.

      3. Computed tomography or magnetic resonance imaging. If performed to evaluate any area in the infant's body, comment on the findings and interpretation

   5. Are any immunizations due before discharge? (See Appendix E for immunization table.) Preterm infants should be immunized at the normal chronologic age with the same vaccine doses as term infants (Note: Birthweight does not matter). If the infant is discharged at ≥2 months of age, give DPT (diphtheria-pertussis-tetanus), Hib vaccine (Haemophilus influenzae vaccine), and IPV (polio vaccine inactivated) at the appropriate time. All of these, DPT, Hib, and IPV can be given as early as 6 weeks of age. All newborns should be vaccinated against hepatitis B before discharge from the hospital. Preterm infants (<2000 g) born to HBsAg-negative women usually receive the first hepatitis B vaccine at 1 month of age, regardless of gestational age or birthweight. Infants whose mothers are positive for hepatitis B virus surface antigen or core or “e” antigen (HBsAg, HBcAg, or HBeAg, respectively) need to be given both hepatitis B immunoglobulin and hepatitis B vaccine (high dose) in the first 12 hours of life. Preterm infants with BPD/CLD should be considered for respiratory syncytial virus immunoglobulin administration throughout the winter months and influenza vaccination at 6 months of age.

   6. Does the infant require a car seat study? Use infant-only car safety seats with 3-point harness systems or convertible car safety seats with 5-point harness systems. Blanket rolls may be placed on both sides of the infant, and a rolled diaper or blanket can be used between the crotch strap and the infant to reduce slouching. Parents need to bring the car seat before discharge for training on seating the infant, proper positioning, and support. While the infant is in the car seat, check for oxygen saturation in supine and car seat positions, especially for premature infants sent home on oxygen and monitoring for apnea (per the American Academy of Pediatrics' (AAP's) “Safe Transportation of Preterm and Low Birth Weight Infants at Hospital Discharge” 2009 policy statement).

   7. Are there other studies that need to be completed or documented?

      1. Electroencephalogram. Record the results, if done more than once, in chronologic order, indicating assessment of cerebral function in infants with seizures.

      2. Electrocardiogram. Documentation is useful in cases of congenital heart defect, supraventricular tachycardias, or metabolic problems.

      3. Echocardiogram. Useful to note results in case of persistent murmurs or the need for follow up.

      4. Other tests. Record the findings and recommendations on pneumograms, barium contrast studies, and so on.

1. Discharge diagnoses. A concise list of all the diagnoses for a patient, listed in chronologic order of occurrence, including procedures, should be generated.

2. Database. Review the initial history, NICU hospital course, and physical examination at discharge. Compose an organized discharge summary by systems or by problems.

   1. History. Inclusive of maternal–fetal conditions (including prenatal diagnostic tests and medications), labor and delivery information, birth history (Apgar scores, head circumference, length, and weight).

   2. Physical examination. List any significant abnormal findings noted at birth. Perform a complete physical examination, paying careful attention to note any significant changes or findings. See Chapter 6 for details on the newborn physical examination.

1. Ophthalmologic examination. An eye examination for evaluation of retinopathy of prematurity (ROP) is recommended for all infants ≤32 weeks and selected infants with an unstable clinical course. Any infants who are believed to have a high risk should also have an examination. Parents need to be told the importance of follow-up examinations and the possible consequences of serious ROP. The examination schedule is initially determined by the neonatologist based on the AAP policy statement from the Section on Ophthalmology, and then follow-up examinations are usually scheduled by the examining ophthalmologist.

2. Audiologic follow-up

   1. If an infant passes the ABR. No follow-up screen is required, but the pediatrician should follow-up per standard practice.

   2. If the infant fails the ABR. Rescreen in 2 weeks.

   3. If the infant passes but has high risk. Reevaluate in 3 months for ABR/OAE.

3. Developmental assessment, including occupational therapy and physiotherapy. The initial examination and evaluation is done in the NICU before discharge to assess the need for early interventional services.

4. Bilirubin assessment in late preterm and term infants

   1. Before discharge, every infant should be assessed for the risk of developing severe hyperbilirubinemia. The AAP recommends either doing a predischarge bilirubin using total serum bilirubin (TSB) or transcutaneous bilirubin (TcB) and/or do a clinical assessment of risk factors or both. Use the predischarge TSB and plot the results on the nomogram (see Figure 100–1) to assess the risk of subsequent hyperbilirubinemia. Clinical judgment should be used. If there are many risk factors, it is best to see those infants earlier and more frequent. If follow-up cannot be done and there is significant risk, it may be best not to discharge the infant.

   2. Follow-up recommendations are as follows:

      1. Infant discharged <24 hours should be seen by age 72 hours.

      2. Infant discharged between 24 and 47.9 hours should be seen by age 96 hours.

      3. Infant discharged between 48 and 72 hours should be seen by age 120 hours.

5. Follow-up immunizations. Except hepatitis B, which should be given before discharge unless the mother is HBsAg positive, follow-up immunizations need to start at 2 months of age.

6. Circumcision. Performed at parental request and with their consent before discharge. The procedure is elective, requires analgesia, and should not be done on small infants, on infants with BPD/CLD on oxygen, or on those with ongoing apnea or bradycardia problems or anomalies of the external genitalia (eg, hypospadias, ambiguous genitalia where reconstruction may be needed at a later date). Older infants require formal anesthesia and analgesia.

7. Social services input. Determine whether this service has been required, including the family's need for housing, financial stability, or other assistance.