When a “high-risk infant” who has spent the first weeks to months of his life in an intensive care nursery is preparing for discharge to the home environment, it does not matter whether the child was born extremely premature or at term with a complex list of medical diagnoses. While it seems obvious that a 600-g infant born at 25 weeks’ gestation requires successful transition through several stages of maturation prior to being deemed ready for discharge, it is less recognized that a 4.5-kg infant born at 41 weeks’ gestation with persistent pulmonary hypertension who required treatment with ECMO must satisfy many of the same requirements for discharge.

With advances in neonatal intensive care increasing survival rates for sicker newborns, a concomitant rise in complex morbidities present at the time of discharge has occurred. The process of moving from hospital to home will only be successful if it starts early and several transitions occur along the way. These transitions are not only required of the baby, but “minigraduations” must occur for the parents and providers as well.

1. 
   

   Delivery room

   
   

   Successfully moving from the mother’s womb to the outside world is required of all infants, whether they are admitted to the NICU or stay in the well-baby nursery. In the very low birthweight infant, “the golden hour” protocol of care along with the American Heart Association guidelines for neonatal resuscitation (NRP) has become a standard in the initial treatment of this high-risk population, in attempts to minimize the likelihood of poor long-term outcomes. This dogma, originating from the “golden hour of trauma,” suggests that the first hour of life in the sickest of neonates can have a lifetime impact. And, as the philosophy has been carried over to the treatment of adult patients with stroke and myocardial infarction, it is probably applicable not only for extremely preterm infants but also for very sick term infants who poorly transition in the delivery room. This critical hour of care starts in the DR and finishes in the NICU, and key areas of concern include those that, if not successfully addressed, could worsen acute stress.

   
   
   
   
   1. 
      

      Appropriate resuscitation

      
      
   2. 
      

      Maintenance of thermoregulation

      
      
   3. 
      

      Treatment of sepsis

      
      
   4. 
      

      Prevention of hypoglycemia

      
      
   5. 
      

      Proper administration of fluids

      
      
   6. 
      

      Completion of admission process

   
   

   This transition is accomplished through teamwork, consistency, and application of evidenced-based medicine. Along with the necessary individualization of care, proper support of this initial transition can significantly influence short-and long-term outcomes.

   
   
2. 
   

   Intensive to intermediate care

   
   

   Movement from neonatal intensive care to intermediate care requires that the infant meet several medical milestones. The baby must be medically ready for the next important transition.

   
   
   
   
   1. 
      

      Minimum weight. Suggest 1200 g.

      
      
   2. 
      

      Minimum gestational age. Suggest 32 weeks PMA.

      
      
   3. 
      

      Minimal respiratory support required.

      
      
      
      
      1. 
         

         Nasal cannula oxygen at most.

         
         
      2. 
         

         Infants nearing discharge with a tracheostomy or requiring an increased level of respiratory support at baseline, but are stable, should move to the intermediate nursery/care team prior to discharge.

      
      
   4. 
      

      “Stable” medical status.

      
      
      
      
      1. 
         

         No current acute diagnoses requiring intensive level of care (NEC, sepsis, significant apneic or bradycardic events, etc).

   
   
3. 
   

   Hospital to home

   
   

   Preparing for discharge requires that the infant no longer requires an acute hospital environment for observation or medical treatment and that their medical stability is no longer determined to be at unacceptable risk in the home environment.

   
   
   
   
   1. 
      

      Minimum weight. Suggest 1800 g.

      
      
   2. 
      

      Minimum gestational age. Suggest 34 weeks PMA.

      
      
   3. 
      

      Proper thermoregulation.

      
      
   4. 
      

      No significant cardiorespiratory events.

      
      
   5. 
      

      Established feeding regimen.

      
      
   6. 
      

      “Stable” medical status.

      
      
   7. 
      

      Infants who are technology dependent must have transitioned to home equipment.