D i s c h a r g e Pl a n n i n g Brian M. Barkemeyer,
MD
KEYWORDS Neonatal intensive care unit Discharge planning Screening test Circumcision Late preterm infant High-risk infant KEY POINTS Hospital discharge is a time of transition for infants and families that requires oversight of common postnatal adaptations, screening tests, and establishment of necessary follow-up care. Preterm infants face additional medical problems that vary in complexity by degree of prematurity, with infants born at lowest gestational age (10% of birthweight). Breastfed infants should receive supplemental vitamin D, 400 IU per day. Infants who are not breastfed need to have their intake, output, and weight monitored, although most infants quickly adapt to an ad lib intake. Mothers who decide against or are unable to breastfeed their child should be supported in this process. Formula-fed infants should receive an iron-fortified cow’s milk–based formula unless there is a defined need for an alternative. There is no need for routine additional vitamin D supplementation of formula-fed infants. CIRCUMCISION
Circumcision of newborn male infants has been a topic of great discussion and passion for several years. Although some medical benefits of circumcision are definite,
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4
Barkemeyer
opponents view any such benefits as limited given the risks and potential pain of the procedure. Proponents have argued that the procedure affords lifelong benefits with limited risk and can be safely done with appropriate anesthesia. In 2012, the American Academy of Pediatrics issued a Circumcision Policy Statement that stated, “preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure.” Additionally, the policy states that circumcision lowers the risk of urinary tract infection (UTI) and acquisition of HIV and other sexually transmitted diseases, but these benefits are not so great to warrant routine circumcision for all male infants; if a family desires circumcision for medical and cultural reasons, the procedure should be safely done. In addition to familiarity with the policy statements, such as that of the American Academy of Pediatrics, health care providers should be prepared to answer a family’s questions about this procedure. The three primary benefits of circumcision are a reduced incidence of UTI, sexually transmitted diseases, and penile cancer. The number needed to treat for reduction of male UTI is 100, meaning that for every 100 circumcisions performed, one male UTI is prevented. Circumcision lowers transmission rates for HIV, herpes simplex virus type 2, and human papilloma virus. Penile cancer is rare, and current data to assess the impact of circumcision on risk are limited. Opponents to circumcision question the supportive data indicating reduction in sexually transmitted diseases and penile cancer are benefits of the procedure. Circumcision done in the newborn period is generally safer and better-tolerated than in older males. Circumcision should be done by an appropriately trained provider using sterile technique. Appropriate anesthesia may include sucrose solution in addition to topical anesthetic or injectable local nerve block. There is no clear advantage to any of the three most commonly used techniques (Plastibell device, Gomco clamp, or Mogen clamp). Bleeding is the most frequent complication of circumcision, but it is usually limited. Significant complications are reported in 0.2% of all circumcisions. There is no evidence for diminished sexual pleasure or performance as a result of circumcision. Poor cosmetic outcome is a concern for some parents, but concerned parents should be advised that appearance will likely evolve to a more acceptable one over time. Despite the available medical data, the decision for circumcision for most families is most strongly influenced by religious, cultural, and personal motives. At present, payment for the procedure by many third-party payors is limited.10–13 DISCHARGE OF THE LATE PRETERM INFANT
Lacking the physiologic maturity of the term infant, the late preterm infant is at higher risk of problems, such as feeding difficulty, hypoglycemia, hyperbilirubinemia, hypothermia, apnea, and respiratory distress. Because these infants lack some of the more obvious acute problems of infants born at earlier gestation and they are often managed in a regular nursery with full-term infants, a lack of awareness by caretakers and families of the potential for these problems may result in ever greater risks of morbidity and mortality. Additionally, there may be interplay between these problems, such as a late preterm infant with hypothermia with resulting tachypnea and further worsening of immature feeding processes, thus placing the infant at higher risk for hypoglycemia and hyperbilirubinemia. The problems of the late preterm infant may not fully resolve at the time of discharge, and infants may regress in what initially seemed to be a normal feeding pattern. Sooner and more frequent outpatient follow-up may reduce the increased risk for readmission that these infants face. Ideally, the late preterm infant should be seen as an outpatient within 48 hours of discharge. At follow-up, close monitoring
Discharge Planning
of feeding, voiding, and stooling is essential with serial weight measurements and observation of jaundice also necessary. Ultimately, the late preterm infant is at increased risk for developmental delays; close developmental follow-up is needed to provide timely allied health therapy interventions.14,15 DISCHARGE OF THE PRETERM INFANT AFTER NEONATAL INTENSIVE CARE UNIT STAY
Discharge of the preterm infant after neonatal intensive care unit (NICU) stay requires close attention to health care maintenance and follow-up for specific problems of prematurity that may require visits to several physicians and therapists. Timing of discharge for the complex infant is determined by the current stability and needs of the infant; the ability of caregivers to meet those needs in the home setting; and increasingly, outside pressures to limit duration of hospital stay. Thoughtful and thorough discharge planning may help reduce the high risks for morbidity, mortality, and hospital readmission these infants face. In general, the preterm infant can be safely discharged from the NICU when the infant is able to feed adequately to allow for appropriate weight gain; is able to maintain appropriate body temperature without external heat sources; is able to receive any additional necessary medical care or therapy in the home setting; and is able to be cared for in a home with capable caretakers properly equipped with all necessary nutrition, medications, and equipment. Determining the readiness of a particular infant to meet each of these criteria depends on several variables in addition to gestational age and weight. Infants may meet one criteria (eg, adequate thermoregulation) but not another (eg, poor feeding); thus, it is not possible to routinely discharge a preterm infant at a given gestational age and weight. Although most infants are able to be safely discharged by 36 to 37 weeks postmenstrual age, some may be ready as early as 33 to 34 weeks, whereas others may require hospitalization well beyond these postmenstrual ages. Infants of lowest gestational age and birthweight are more likely to require discharge at a later gestational age.16–18 Oral feedings are typically introduced to preterm infants around 33 to 34 weeks postmenstrual age with appropriate maturation of the ability to coordinate sucking, swallowing, and breathing. Gaining proficiency at oral feedings varies by infant and depends on neurodevelopment and associated health problems; preterm infants with neurologic impairment or chronic lung disease may have significant delays in achieving proficiency at oral feeding. Gastroesophageal reflux is common in preterm infants; for most preterm infants without other comorbidities, gastroesophageal reflux is self-limited and typically does not require specific treatment. For preterm infants with comorbidities, such as neurologic impairment, chronic lung disease, or apnea, a variety of therapies for gastroesophageal reflux have been used including positional maneuvers, thickened feedings, acid-suppression medication, or prokinetic medication. There is no consensus among a variety of pediatric specialists for the optimal management of significant gastroesophageal reflux, but therapy should be provided in stepwise fashion with ongoing assessment for improvement. A pattern of adequate growth on a specific feeding regimen that can be mimicked at home should be established before discharge. Breast milk is the optimal nutrition for preterm infants throughout the hospital stay and after discharge. Breast milk typically requires supplementation to augment calories, protein, sodium, and calcium intake in the preterm infant. In the hospital setting, this is often accomplished through the addition of commercial human milk fortifiers. Postdischarge, supplementation if necessary may be accomplished more economically by the addition of postdischarge formula to human milk intake. For the preterm infant not feeding breast milk, a fortified 22 calorie/
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Barkemeyer
ounce preterm infant formula should be used after discharge. The duration of time postdischarge to use fortified human milk or 22 calorie/ounce preterm infant formula is variable and depends on degree of prematurity, growth, and associated medical problems, such as osteopenia. Infants born at less than 28 weeks gestation with ongoing medical problems may benefit for 12 months adjusted age, whereas infants of higher gestational age with few associated medical problems and steady growth may limit duration to 6 to 9 months adjusted age. Weight, length, and head circumference of the preterm infant after NICU discharge should be plotted regularly on growth curves designed for preterm infants. Infants born at lower gestational ages (
MD
KEYWORDS Neonatal intensive care unit Discharge planning Screening test Circumcision Late preterm infant High-risk infant KEY POINTS Hospital discharge is a time of transition for infants and families that requires oversight of common postnatal adaptations, screening tests, and establishment of necessary follow-up care. Preterm infants face additional medical problems that vary in complexity by degree of prematurity, with infants born at lowest gestational age (10% of birthweight). Breastfed infants should receive supplemental vitamin D, 400 IU per day. Infants who are not breastfed need to have their intake, output, and weight monitored, although most infants quickly adapt to an ad lib intake. Mothers who decide against or are unable to breastfeed their child should be supported in this process. Formula-fed infants should receive an iron-fortified cow’s milk–based formula unless there is a defined need for an alternative. There is no need for routine additional vitamin D supplementation of formula-fed infants. CIRCUMCISION
Circumcision of newborn male infants has been a topic of great discussion and passion for several years. Although some medical benefits of circumcision are definite,
3
4
Barkemeyer
opponents view any such benefits as limited given the risks and potential pain of the procedure. Proponents have argued that the procedure affords lifelong benefits with limited risk and can be safely done with appropriate anesthesia. In 2012, the American Academy of Pediatrics issued a Circumcision Policy Statement that stated, “preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure.” Additionally, the policy states that circumcision lowers the risk of urinary tract infection (UTI) and acquisition of HIV and other sexually transmitted diseases, but these benefits are not so great to warrant routine circumcision for all male infants; if a family desires circumcision for medical and cultural reasons, the procedure should be safely done. In addition to familiarity with the policy statements, such as that of the American Academy of Pediatrics, health care providers should be prepared to answer a family’s questions about this procedure. The three primary benefits of circumcision are a reduced incidence of UTI, sexually transmitted diseases, and penile cancer. The number needed to treat for reduction of male UTI is 100, meaning that for every 100 circumcisions performed, one male UTI is prevented. Circumcision lowers transmission rates for HIV, herpes simplex virus type 2, and human papilloma virus. Penile cancer is rare, and current data to assess the impact of circumcision on risk are limited. Opponents to circumcision question the supportive data indicating reduction in sexually transmitted diseases and penile cancer are benefits of the procedure. Circumcision done in the newborn period is generally safer and better-tolerated than in older males. Circumcision should be done by an appropriately trained provider using sterile technique. Appropriate anesthesia may include sucrose solution in addition to topical anesthetic or injectable local nerve block. There is no clear advantage to any of the three most commonly used techniques (Plastibell device, Gomco clamp, or Mogen clamp). Bleeding is the most frequent complication of circumcision, but it is usually limited. Significant complications are reported in 0.2% of all circumcisions. There is no evidence for diminished sexual pleasure or performance as a result of circumcision. Poor cosmetic outcome is a concern for some parents, but concerned parents should be advised that appearance will likely evolve to a more acceptable one over time. Despite the available medical data, the decision for circumcision for most families is most strongly influenced by religious, cultural, and personal motives. At present, payment for the procedure by many third-party payors is limited.10–13 DISCHARGE OF THE LATE PRETERM INFANT
Lacking the physiologic maturity of the term infant, the late preterm infant is at higher risk of problems, such as feeding difficulty, hypoglycemia, hyperbilirubinemia, hypothermia, apnea, and respiratory distress. Because these infants lack some of the more obvious acute problems of infants born at earlier gestation and they are often managed in a regular nursery with full-term infants, a lack of awareness by caretakers and families of the potential for these problems may result in ever greater risks of morbidity and mortality. Additionally, there may be interplay between these problems, such as a late preterm infant with hypothermia with resulting tachypnea and further worsening of immature feeding processes, thus placing the infant at higher risk for hypoglycemia and hyperbilirubinemia. The problems of the late preterm infant may not fully resolve at the time of discharge, and infants may regress in what initially seemed to be a normal feeding pattern. Sooner and more frequent outpatient follow-up may reduce the increased risk for readmission that these infants face. Ideally, the late preterm infant should be seen as an outpatient within 48 hours of discharge. At follow-up, close monitoring
Discharge Planning
of feeding, voiding, and stooling is essential with serial weight measurements and observation of jaundice also necessary. Ultimately, the late preterm infant is at increased risk for developmental delays; close developmental follow-up is needed to provide timely allied health therapy interventions.14,15 DISCHARGE OF THE PRETERM INFANT AFTER NEONATAL INTENSIVE CARE UNIT STAY
Discharge of the preterm infant after neonatal intensive care unit (NICU) stay requires close attention to health care maintenance and follow-up for specific problems of prematurity that may require visits to several physicians and therapists. Timing of discharge for the complex infant is determined by the current stability and needs of the infant; the ability of caregivers to meet those needs in the home setting; and increasingly, outside pressures to limit duration of hospital stay. Thoughtful and thorough discharge planning may help reduce the high risks for morbidity, mortality, and hospital readmission these infants face. In general, the preterm infant can be safely discharged from the NICU when the infant is able to feed adequately to allow for appropriate weight gain; is able to maintain appropriate body temperature without external heat sources; is able to receive any additional necessary medical care or therapy in the home setting; and is able to be cared for in a home with capable caretakers properly equipped with all necessary nutrition, medications, and equipment. Determining the readiness of a particular infant to meet each of these criteria depends on several variables in addition to gestational age and weight. Infants may meet one criteria (eg, adequate thermoregulation) but not another (eg, poor feeding); thus, it is not possible to routinely discharge a preterm infant at a given gestational age and weight. Although most infants are able to be safely discharged by 36 to 37 weeks postmenstrual age, some may be ready as early as 33 to 34 weeks, whereas others may require hospitalization well beyond these postmenstrual ages. Infants of lowest gestational age and birthweight are more likely to require discharge at a later gestational age.16–18 Oral feedings are typically introduced to preterm infants around 33 to 34 weeks postmenstrual age with appropriate maturation of the ability to coordinate sucking, swallowing, and breathing. Gaining proficiency at oral feedings varies by infant and depends on neurodevelopment and associated health problems; preterm infants with neurologic impairment or chronic lung disease may have significant delays in achieving proficiency at oral feeding. Gastroesophageal reflux is common in preterm infants; for most preterm infants without other comorbidities, gastroesophageal reflux is self-limited and typically does not require specific treatment. For preterm infants with comorbidities, such as neurologic impairment, chronic lung disease, or apnea, a variety of therapies for gastroesophageal reflux have been used including positional maneuvers, thickened feedings, acid-suppression medication, or prokinetic medication. There is no consensus among a variety of pediatric specialists for the optimal management of significant gastroesophageal reflux, but therapy should be provided in stepwise fashion with ongoing assessment for improvement. A pattern of adequate growth on a specific feeding regimen that can be mimicked at home should be established before discharge. Breast milk is the optimal nutrition for preterm infants throughout the hospital stay and after discharge. Breast milk typically requires supplementation to augment calories, protein, sodium, and calcium intake in the preterm infant. In the hospital setting, this is often accomplished through the addition of commercial human milk fortifiers. Postdischarge, supplementation if necessary may be accomplished more economically by the addition of postdischarge formula to human milk intake. For the preterm infant not feeding breast milk, a fortified 22 calorie/
5
6
Barkemeyer
ounce preterm infant formula should be used after discharge. The duration of time postdischarge to use fortified human milk or 22 calorie/ounce preterm infant formula is variable and depends on degree of prematurity, growth, and associated medical problems, such as osteopenia. Infants born at less than 28 weeks gestation with ongoing medical problems may benefit for 12 months adjusted age, whereas infants of higher gestational age with few associated medical problems and steady growth may limit duration to 6 to 9 months adjusted age. Weight, length, and head circumference of the preterm infant after NICU discharge should be plotted regularly on growth curves designed for preterm infants. Infants born at lower gestational ages (
