Chapter 71: Is the Infant Ready for Discharge?

I. PROBLEM

An infant in the newborn nursery or the neonatal intensive care unit (NICU) is ready to be discharged home. How can we ensure that discharge from the hospital is smooth, safe, and complete? The American Academy of Pediatrics (AAP) has developed specific guidelines for discharge for the following infant types: high risk, late preterm, and healthy term. The following section reviews the evaluation of infants prior to discharge.

II. IMMEDIATE QUESTIONS

1. What is the gestational age of the infant? Does the infant fit in a high-risk category? It is important to accurately determine the gestational age of an infant to use the correct AAP guidelines. The guidelines for the late preterm infant differ from those for the healthy term infant. High-risk category guidelines are very specific for 4 subcategories: preterm infant, infant with special care needs or who is dependent on technology, infant at risk because of family issues, or infant with anticipated early death.

2. Does the infant meet discharge criteria (infant readiness)? The decision to discharge any infant is often a very complex decision. Careful preparation for discharge by ensuring infant readiness and other factors may decrease the incidence of readmission and reduce the risks of morbidity and mortality. These guidelines are only a framework for guiding decisions, as the final decision should be individualized for each infant. Historically, preterm infants were only discharged when they achieved a specific weight; now preterm infants are discharged based on physiologic criteria and not weight. In fact, the first, most important factor in deciding on discharge is infant readiness. Other considerations include family, community, and healthcare provider readiness; risk factors of the mother and infant; and safety concerns, among others.

   1. Are the vital signs stable? Most discharge criteria require vital signs be documented within normal reference ranges for the infant for 12 hours preceding discharge. For late preterm and term infants, this includes a respiratory rate <60 breaths/min, a heart rate of 100 to 160 beats/min, and an axillary temperature of 36.5°C to 37.4°C in an open crib. For high-risk neonates, criteria include physiologic mature and stable cardiorespiratory function and adequate maintenance of normal body temperature in an open bed with normal ambient temperature. Most preterm infants are able to maintain normal body temperature at home between 36 and 37 weeks of postmenstrual age (PMA) but lag in achieving maturation of respiratory control, sometimes until up to 44 weeks of PMA.

   2. Have there been any recent episodes of apnea and bradycardia? Episodes of apnea of prematurity along with associated bradycardia and desaturation typically resolve at approximately postconception age of 34 to 36 weeks, although infants born less than 28 weeks gestation may have prolonged apnea beyond term. If such episodes persist at 36 weeks of age, the infants may not yet be safe for discharge. Many NICUs will wait for an event-free period of time (typically 5–7 days) before considering these infants ready for ...