Hospital Discharge of the High-Risk Neonate

This policy statement updates the guidelines on discharge of the high-risk neonate first published by the American Academy of Pediatrics in 1998. As with the earlier document, this statement is based, insofar as possible, on published, scientifically derived information. This updated statement incorporates new knowledge about risks and medical care of the high-risk neonate, the timing of discharge, and planning for care after discharge. It also refers to other American Academy of Pediatrics publications that are relevant to these issues. This statement draws on the previous classification of high-risk infants into 4 categories: (1) the preterm infant; (2) the infant with special health care needs or dependence on technology; (3) the infant at risk because of family issues; and (4) the infant with anticipated early death. The issues of deciding when discharge is appropriate, defining the specific needs for follow-up care, and the process of detailed discharge planning are addressed as they apply in general to all 4 categories; in addition, special attention is directed to the particular issues presented by the 4 individual categories. Recommendations are given to aid in deciding when discharge is appropriate and to ensure that all necessary care will be available and well coordinated after discharge. The need for individualized planning and physician judgment is emphasized. Pediatrics 2008;122:1119–1126 INTRODUCTION The decision of when to discharge an infant from the hospital after a stay in the NICU is complex.1 This decision is made primarily on the basis of the infant’s medical status but is complicated by several factors. These factors include the readiness of families for discharge, differing opinions about what forms of care can be provided at home, and pressures to contain hospital costs by shortening the length of stay. Insofar as possible, determination of the readiness for discharge should be based on peer-reviewed scientific evidence. Shortening the length of a hospital stay may benefit the infant and family by decreasing the period of separation of infant and parents; moreover, the infant may benefit from shortening its exposure to the risks of hospital-acquired morbidity. However, the overriding concern is that infants may be placed at risk of increased mortality and morbidity by discharge before physiologic stability is established. Infants born preterm with low birth weight who require neonatal intensive care experience a much higher rate of hospital readmission and death during the first year after birth compared with healthy term infants.2–5 Careful preparation for discharge and good follow-up after discharge may reduce these risks. It takes time for the family of a high-risk infant to prepare to care for their infant in a home setting and to obtain the necessary support services and mobilize community resources. With increased survival of very preterm and very ill infants, many infants are discharged with unresolved medical issues that complicate their subsequent care. Infants are often discharged requiring more care and closer follow-up than was typical in the past. In addition, societal and economic forces have come to bear on the timing and process of discharge and follow-up care. As a result, health care professionals need guidance in assessing readiness for discharge and planning for subsequent care. This policy statement, therefore, addresses 4 broad categories of high-risk infants: (1) the preterm infant; (2) the infant with special health care needs or dependence on technology; (3) the infant at risk because of family issues; and (4) the infant with anticipated early death. This policy statement updates a previous guideline published by the American Academy of Pediatrics in 1998.1 CATEGORIES OF HIGH-RISK INFANTS The Preterm Infant Historically, preterm infants were discharged only when they achieved a certain weight, typically 2000 g (5 lb). However, randomized clinical trials6–8 have shown that earlier discharge is possible without adverse health effects www.pediatrics.org/cgi/doi/10.1542/ peds.2008-2174 doi:10.1542/peds.2008-2174 All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.