66: Is the Infant Ready for Discharge?

I. PROBLEM

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?

II. IMMEDIATE QUESTIONS

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 ...