Early NICU discharge of very low birth weight infants: a critical review and analysis

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Abstract

Early neonatal intensive care unit (NICU) discharge has been advocated for selected preterm infants to reduce both the adverse environment of prolonged hospital stay and to encourage earlier parental involvement by empowering parents to contribute to the ongoing care of their infant, and thereby reducing costs of care. Randomized trials and descriptive experiences of early discharge programs are critically reviewed over the last 30 years, and the key elements necessary for successful early discharge are reviewed and defined. Early discharge is clearly achievable for a large number of infants. Variations in neonatal care practices are reviewed since these variations have been documented to influence NICU stay. Management of apnea of prematurity and feeding practices is documented to significantly influence NICU length of stay, as is timing of discharge based on institutional factors. Developmentally centered care, use of nutritional supplements pre- and postdischarge, hearing screening programs, evaluation for retinopathy of prematurity, evaluation for apnea and bradycardia events, and cardiopulmonary stability while in a car seat all influence timing of discharge. Programs of early hospital discharge with home nursing and neonatologist support have been successful in lowering the length of NICU stay. However, trends in length of stay in NICUs indicate that for infants >750 g at birth over the last decade there have been insignificant reductions in length of hospital stay. Thus, because of the increase in the percentage of low birth weight infants in the US, there remain opportunities to improve on variations in care that will be translated to fewer NICU days in hospitals for selected infants. Several professional guidelines are summarized, and standards of care as related to discharge of premature infants are reviewed.

Introduction

Approximately 11.8% of all births in the US annually are premature, i.e. delivered prior to 37 weeks gestation.1 Of these infants in 1999, 57,000 weighed less than 1.5 kg at birth and have been designated as very low birth weight (VLBW). Because of discrepancies between maternal dating of the last menstrual period, the lack of universal ultrasonographic examination of all fetuses, and physical and neurologic characteristics at birth with gestational age assigned after birth, outcomes data collected on premature infants more often than not are based on birth weight. Outcomes among VLBW infants have been focused on by the Vermont–Oxford Network2 even though these outcomes may include fetuses with poor intrauterine growth as well as infants of shortened gestational age.National trends in the US indicate a steady increase in preterm delivery and in low birth weight infant rates from 1.3 to 1.5% between 1991 and 19973(Fig. 1). In the US, birth weight tends to be lower among African–American infants at all gestational ages, and there is a higher mortality among these groups with a disparity in low birth weight infants.4 The last decade has seen technological and pharmacological advances in perinatal and neonatal care, accompanied by improvements in mortality rate for infants of 24 or 25 weeks gestation and above.5, 6, 7, 8 However, the length of neonatal intensive care stays for survivors in their hospital of birth has changed only by a mean of 4 days since 1991 for infants 500–1500 g birthweight reporting to the Vermont–Oxford Network9 (Fig. 2). The provision of neonatal care in subspecialty and specialty neonatal intensive care units (NICUs), has estimated direct costs in the first year of life in excess of $4 billion annually in the US accounting for 35% of the total health care costs for the approximately 4.5 million births annually.10 This care is costly not only in monetary terms and consumption of medical resources, but in the context of parents coping with their baby's illness and their share of costs, which represents a ‘catastrophic illness that consumes parents' resources for many years’.11 Richardson et al.12 point out that the reasons for such high costs are clear: extremely premature infants are dependent on highly skilled personnel and extensive technology over prolonged lengths of hospital stay until they reach sufficient size and maturity for discharge. Further costs accrue from specialized care needs for many NICU graduates including pharmacy costs, medical equipment, and more frequent than usual visits to physicians and other care providers.

The special environment provided by NICUsbestows on VLBW infants a number of exposures with uncertain consequences. Evidence has accumulated regarding how the use of bright lights13, 14 may interfere with development while continuous exposure to reduced light afforded no benefit.15 The lack of day–night light cycling which has recently been advocated,16 excessive noise,17 lack of contingency-based developmental care,18, 19 and increased exposure to nosocomial infections20, 21 may have an adverse effect on convalescence and potentially on longer-term growth and development. Furthermore, prolonged hospitalization has been shown to correlate with poorer parent–infant relationships,22 failure to thrive, child abuse and/or abandonment,23 and grieving parents.24, 25 A number of reports in professional and lay press have described different approaches to enhance effectiveness of parent preparation before discharge from NICUs. Methodological flaws in these studies prevent definitive conclusions about their effect on long-term outcome. However, programs that incorporate parental care, participation in their infants' ongoing care, thorough preparation for discharge, and home nursing care visits with neonatologist supervision after discharge show promising results in terms of earlier discharge from the NICU and reduced infant readmission rates.

In this review, we report on the criteria for NICU discharge in terms of physiological stability and parental preparation for most premature infants with a special emphasis on those reports finding success with ‘early’ discharge. Other articles in this journal edition focus on specialized needs of those infants with ongoing technological support, infants with special needs owing to ongoing neurologic or respiratory illness, and those infants who are anticipated to have limited survival potential soon after discharge.

Section snippets

Variations in neonatal practice and discharge

Variations in the practice of neonatal medicine account for differences in the readiness for hospital discharge for many infants. Differences in the length of NICU stay for infants 500–1500 g birth weight is illustrated inFig. 3reproduced from the years 1997–2000 annual reports from the Vermont–Oxford Network. In 2000, the average length of stay was 61±31 (mean±95% confidence interval (CI)) days for infants discharged home from their hospital of birth. However, among 349 reporting centers the

Early discharge programs and developmentally centered care

In the US, estimates on the percent of low birth weight infants in 1999 varied greatly from a high of 13.1% in the District of Columbia to a low of 5.4% in Oregon.39 The critical care environment of the NICU that has provided for unparalleled survival of these premature infants has also raised concerns regarding some of the adverse environmental stimuli, including separation from parents and extended family when transport from the birth hospital is required, increased risks for nosocomial

Feeding the VLBW infant in preparation for home discharge

The 2001 report from the NICHD Neonatal Network regarding VLBW infants documents that survival for infants between 501 and 1500 g continues to improve, especially for infants weighing ≤1000 g at birth. This improvement in survival was not associated with an increase in major morbidities, because the incidence of chronic lung disease, proven necrotizing enterocolitis, and severe intracranial hemorrhage has not changed over the last several years. Growth failure, defined as weight less than the

Issues of apnea and discharge

Apnea of prematurity frequently persists beyond the time that infants might otherwise be considered ready for discharge from the NICU. This delay in ‘respiratory maturity’ may lead to longer hospitalization, especially among the most premature infants. Among infants 24–26 weeks gestation at birth, 68% continued to experience clinically significant apnea and bradycardia beyond 37 weeks postconceptional age. Presence of gastro-esophageal reflux, chronic lung disease, and male gender were

Car seat use in the premature infant at discharge

The premature infant is at risk for oxygen desaturation and apnea when placed in upright car seats.87, 88, 89, 90 For this reason, the American Academy of Pediatrics has recommended that premature infants undergo screening for events such as apnea, bradycardia, or oxygen desaturation while in car seats prior to discharge.16, 91 Current data support the screening of all infants born at <37 weeks of gestational age for both cardiorespiratory stability and appropriate fit of the car seat.16, 91, 92

Discharge of the infant with retinopathy of prematurity

The premature infant who is at risk for developing, or who already has been diagnosed with, retinopathy of prematurity requires special attention at discharge. Either lack of a clear plan at discharge or failure of the caregiver to comply with discharge plans can place the infant at risk for the development of complications of retinopathy of prematurity, including blindness.97 Poor outcomes in circumstances where outpatient follow-up has been neglected increase the risk of a successful

Hearing screening

Universal screening of all infants for hearing loss prior to hospital discharge has been made a national priority by the Early Hearing Detection and Intervention position statement 2000 sponsored by the U.S. Public Health Service, and mandated by law in several states. The urgency of hearingimpairment identification for early intervention with hearing augmentation to assist in acquisition of language skills by age 3 has been convincingly documented by Youshinaga-Itano et al.113 Premature, low

Guidelines for discharge of premature infants

Based on clinical observation, randomized, and nonrandomized trials of NICU discharge, the following guidelines and generalized criteria have emerged as necessary milestones of achievement prior to discharge of premature infants from the NICU. These recommendations have been published by various committees of the American Academy of Pediatrics,123, 124, 125, 126, 127 National Association of Neonatal Nurses,128, 129 California Association of Neonatologists,130 and the National Health and Medical

Summary

The unparalleled survival rate of premature infants brought about by advances in fundamental knowledge regarding human development, perinatal physiological adaptations after birth, technological and pharmacological advances, and dedication of neonatal health care providers has created new challenges. These challenges primarily focus on two competing goals: the provision of ventilatory, nutritional, and supportive therapies that promote survival and ongoing growth and development after preterm

Acknowledgments

Funded in part by a grant to T.A.M. from the American Academy of Pediatrics CATCH Grant, 2001.

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