Key points

Introduction

Initial hospital discharge of the infant is a time of great excitement and anxiety for the family. Health care provider and family anxiety may be heightened by any combination of actual or perceived medical and/or social risks. Preparation of the infant and family for discharge is an involved process that is best done through a consistent approach from all members of the health care team perceptive to the needs of the infant and family. Although most hospitals have routine patterns of newborn care, medical documentation, and discharge order sets, it is important that each relevant aspect of care is applied appropriately to each child at discharge. The optimal time for discharge of the apparently healthy newborn depends on several factors including the infant’s condition, risk for evolving problems (eg, infection, poor feeding, jaundice, and drug withdrawal), the ability of the family to provide appropriate care for the infant, and the timely availability of appropriate follow-up.

Nursing, medical, and support staff should be attuned to the interaction of the infant and family throughout the initial hospital course to recognize concerns about the ability of the family to provide appropriate care. Additionally, variations from normal in an infant’s health and behavior should be documented and communicated effectively by all health care providers. Discharge examination of the newborn should be thorough with documentation of adequate transition from the intrauterine environment to include establishment of normal respirations, normal circulatory status, adequate feeding, normal voiding and stooling patterns, and adequate thermoregulation. Infants who fail to meet these criteria should not be discharged home and additional assessment may be needed. Before hospital discharge, physical examination should include assessment for the presence of a red reflex from the eyes bilaterally and for any evidence of developmental dysplasia of the hip. The red reflex should be bilateral, symmetric, and without dark spots or white opacity. Female infants, infants born with breech presentation, and infants with a family history of this disorder are at highest risk for developmental dysplasia of the hip. When definite dislocation of the hip is noted, prompt referral to an orthopedist is warranted; when the examination is equivocal, serial follow-up examinations are warranted. If necessary, further assessment for developmental dysplasia of the hip can be performed with hip ultrasound. The efficacy of these traditional recommendations for screening for developmental dysplasia of the hip and common interventions has more recently been questioned.

Introduction

Initial hospital discharge of the infant is a time of great excitement and anxiety for the family. Health care provider and family anxiety may be heightened by any combination of actual or perceived medical and/or social risks. Preparation of the infant and family for discharge is an involved process that is best done through a consistent approach from all members of the health care team perceptive to the needs of the infant and family. Although most hospitals have routine patterns of newborn care, medical documentation, and discharge order sets, it is important that each relevant aspect of care is applied appropriately to each child at discharge. The optimal time for discharge of the apparently healthy newborn depends on several factors including the infant’s condition, risk for evolving problems (eg, infection, poor feeding, jaundice, and drug withdrawal), the ability of the family to provide appropriate care for the infant, and the timely availability of appropriate follow-up.

Nursing, medical, and support staff should be attuned to the interaction of the infant and family throughout the initial hospital course to recognize concerns about the ability of the family to provide appropriate care. Additionally, variations from normal in an infant’s health and behavior should be documented and communicated effectively by all health care providers. Discharge examination of the newborn should be thorough with documentation of adequate transition from the intrauterine environment to include establishment of normal respirations, normal circulatory status, adequate feeding, normal voiding and stooling patterns, and adequate thermoregulation. Infants who fail to meet these criteria should not be discharged home and additional assessment may be needed. Before hospital discharge, physical examination should include assessment for the presence of a red reflex from the eyes bilaterally and for any evidence of developmental dysplasia of the hip. The red reflex should be bilateral, symmetric, and without dark spots or white opacity. Female infants, infants born with breech presentation, and infants with a family history of this disorder are at highest risk for developmental dysplasia of the hip. When definite dislocation of the hip is noted, prompt referral to an orthopedist is warranted; when the examination is equivocal, serial follow-up examinations are warranted. If necessary, further assessment for developmental dysplasia of the hip can be performed with hip ultrasound. The efficacy of these traditional recommendations for screening for developmental dysplasia of the hip and common interventions has more recently been questioned.

Screening tests

Routine screening of mothers and infants for a variety of common and uncommon conditions has allowed for timely recognition and intervention resulting in ongoing significant improvements in perinatal outcomes. Many of these screening tools are discussed in greater detail elsewhere in this issue, and appropriate follow-up of abnormal results and pending studies is essential at hospital discharge. Follow-up of all relevant maternal screening tests requires effective communication between obstetric and newborn care providers. Timely identification of infants at risk for infection based on maternal screening tests (including gonorrhea, syphilis, HIV, hepatitis B, and group B streptococcus) should be accomplished in the immediate neonatal period, and follow-up on all such tests and their impact on the infant should be done at the time of discharge.

Although newborn metabolic screening results may not be available at the time of hospital discharge, it is important that specimens are obtained before discharge with proper follow-up mechanisms established. A hearing screen should be obtained before hospital discharge with awareness of ongoing factors, such as infection, ototoxic drug exposure, and severe jaundice, which may alter results. At-risk infants should be identified with appropriate follow-up testing in place at discharge.

Screening for congenital heart disease should be performed with pulse oximetry after the first 24 hours of life in all infants, with infants with oxygen saturations less than 90% being evaluated immediately for potential cardiac malformation if there is no other obvious cause. Infants with oxygen saturations greater than or equal to 95% and less than 3% difference in saturation between right hand and either lower extremity are considered to have passed this screen.

Because it is known that preterm and other infants may have apnea, bradycardia, and/or oxygen desaturation when placed semiupright in a car seat, it is recommended that infants of gestational age less than 37 weeks and other at-risk infants (eg, Down syndrome, hypotonia, congenital heart disease) undergo a period of observation in their car seat before discharge. This period of observation should be 90 to 120 minutes, or more if travel duration is longer. Infants who experience problems during this screen should be reassessed with changes in support or position to ensure safety. Family members should be educated in the importance of proper use of car restraints.

Jaundice is a common problem in newborn infants during the first few days of life, which typically is self-limited or easily treated, but can put the infant at significant risk for adverse neurologic outcome if not monitored appropriately for timely intervention. Awareness of risk factors for excessive jaundice, such as hemolysis, excessive bruising, or poor feeding, is important along with visual screening and transcutaneous bilirubin determination. Transcutaneous bilirubin screening is noninvasive; relatively inexpensive; and avoids inadequacies of visual screening, such as poor lighting, poor color perception, or a newborn with darker skin tone. Comparison of screening bilirubin values with available time-dependent bilirubin nomograms helps identify higher-risk infants before hospital discharge. When transcutaneous bilirubin screening suggests a need for therapy, serum bilirubin should be promptly obtained to make appropriate clinical decisions. Infants who do not require intervention for hyperbilirubinemia and are otherwise ready for discharge may be safely discharged if timely follow-up of subsequent bilirubin levels is available.

Feeding

It is commonly accepted that exclusive breastfeeding is the optimal feeding method for infants for the first 6 months of life, and breastfeeding can continue beyond that up to 12 months or longer as mutually desired by the mother and infant. Achievement of higher sustained breastfeeding rates has significant medical benefits for infants and their mothers along with significant economic benefits for families and society. There are several barriers to effective breastfeeding including many within the birth hospital. Common hospital practices that have a negative influence on successful breastfeeding initiation include a lack of emotional and practical support for breastfeeding mothers, delays in initiation or limitations on duration of breastfeeding, and early introduction of supplemental formulas and pacifiers. Pacifiers have been associated with a lower incidence of sudden infant death syndrome (SIDS), so if desired, their use should be restricted until after breastfeeding is well-established.

Throughout the hospital stay and at the time of discharge, the adequacy of the mother’s ability to breastfeed her infant should be assessed. Mothers with prior breast surgery, flat or inverted nipples, or difficult delivery are at greatest risk for problems in establishing adequate breastfeeding. Assessment of the mother’s milk production, infant feeding practices, voiding and stooling patterns, and serial infant weight are needed. Because the establishment of breastfeeding is an ongoing process that typically continues after discharge, close monitoring of this evolution is necessary, especially for mother-infant pairs with suspicion or evidence of delays. Supplementation of breastfeeding should be limited in duration and for defined conditions (persistent hypoglycemia, dehydration as evidenced by inadequate voiding and stooling, and excessive weight loss >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, 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.

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 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.