Going home: Facilitating discharge of the preterm infant

Question 1

What percentage of preterm infants <37 weeks are discharged home directly from tertiary NICUs?

Answer 1

50%

Question 2

What is prolonged hospitalization associated with?

Answer 2

1. Poor parent-child relationships
2. Failure to thrive
3. Child abuse
4. Parental grief
5. Feelings of inadequacy in parents

Question 3

What is the usual GA at discharge for infants born at <34 weeks GA?

Answer 3

37-40 weeks GA

Question 4

What are the four physiological competencies required for discharge?

Answer 4

1. Thermoregulation
2. Control of breathing
3. Respiratory stability
4. Feeding skills and weight gain

Question 5

What is a risk of overheating?

Answer 5

SIDS

Question 6

Does transfer to a cot before 1700g have an adverse effect on temperature stability or weight gain?

Answer 6

No

Question 7

What is apnea of prematurity?

Answer 7

Cessation of breathing for >20s or 10-20s if accompanied by bradycardia (HR <80bpm) or oxygen saturation <80% in infants <37 weeks PMA

Question 8

How late can apnea of prematurity persist until?

Answer 8

44 weeks PMA

Question 9

What is the half life of caffeine in neonates?

Answer 9

100h

Question 10

When is home cardiorespiratory monitoring occasionally considered?

Answer 10

Infants with unusually prolonged and recurrent apnea, bradycardia, and hypoxemia

Question 11

What are risk factors for recurrence of apneas of prematurity?

Answer 11

<30 weeks GA

Last spell occurred at > 36 weeks PMA

Question 12

At what time period from the last spell did 96% of preterm infants not experience recurrence of apnea or bradycardia?

Answer 12

Seven days

Note that 13 days were required in infants <26 weeks GA

Question 13

What percentage of surviving preterm infants with birthweights <1500g receive oxygen beyond 36 weeks PMA?

Answer 13

25%

Question 14

What complications are associated with high oxygen targets (95-99%) in preterm infants vs. low targets (89-94%)?

Answer 14

1. No difference in growth
2. No difference in neurodevelopment
3. Higher respiratory morbidity (pneumonia, acute exacerbations of CLD, rehospitalizations for pulmonary causes, need for diuretics, methylxanthines and/or oxygen)
4. Longer duration of oxygen therapy
5. Nonspecific reduction in progression to threshold ROP
6. Modest decrease in retinal ablative therapy for severe ROP

Question 15

What do most centres recommend as a target SaO2 for infants with BPD?

Answer 15

90-95%

Question 16

What does offering non-nutritive sucking during gavage feeding do?

Answer 16

Significantly shorten LOS and facilitate transition from tube to oral feeding

Question 17

How does supplementation with cup feeds affect discharge?

Answer 17

Increases the number of babies discharged home fully breastfeeding
Delays discharge by approximately 10 days

Question 18

What additional nutritional support is required in preterm infants?

Answer 18

1. May require hypercaloric feedings
2. Iron supplementation for the first year of life
3. Vitamin D 400-1000IU/day

Question 19

What is the recommendations regarding GER?

Answer 19

Usually physiologic with minimal clinical consequences

Question 20

What factor increase risk of neglect, FTT, and adverse developmental outcomes?

Answer 20

1. Low educational level
2. Poor SES
3. Young maternal age
4. Language barriers
5. Inadequate housing
6. Inadequate prenatal care
7. Use of illicit substances or alcohol
8. Depression
9. Isolation
10. Lack of family support
11. Unstable parental relationships
12. Infrequent family visiting during NICU stay

Question 21

What should nurseries do re: parents of preterm infants?

Answer 21

1. Educate parents about their infant
2. Promote parental involvement
3. Prepare parents for infant’s transition to home

Question 22

What factors must be attained for physiologic maturity?

Answer 22

1. Maintenance of normal body temperature (~37 degrees) when fully clothed in an open cot
2. An apnea-free period of sufficient duration (at least 5-7 days suggested)
3. Maintenance of SaO2 >90-95% on RA
4. Sustained weight gain
5. Successful feeding by breast and/or bottle without major cardiorespiratory compromise

Question 23

What evaluations must be completed on the preterm infant prior to discharge?

Answer 23

1. Provincial newborn screening
2. Assessment for RSV prophylaxis and administration as indicated
3. Cranial imaging at near term if indicated by GA
4. ROP screening, if indicated by GA or BW
5. Hearing screening
6. Immunizations according to chronological age and provincial/territorial schedule
7. Predischarge physical exam incld. wt, lt, HC

Question 24

What should parents be able to do prior to discharge of a preterm infant?

Answer 24

1. Independently and confidently care for their infants
2. Provide medications, nutritional supplement, and any special medical care
3. Recognize signs and symptoms of illness and respond appropriately, esp. in emergency situations
4. Understand the importance of infection control and smoke-free environment

Question 25

What follow-up should be arranged prior to discharge of a preterm infant?

Answer 25

1. identification of and communicatio with the identified primary care MD and providing written or electronic summary of each infants’ birth history and care
2. f/u by qualified HCP within 72h
3. medical and surgical appointments as required, incld. ROP screening
4. Neonatal neurodevelopmental f/u if indicated
5. f/u of hearing and newborn screening results
6. RSV prophylaxis, if required
7. Community resources and supports
8. A neonatologists or pediatricians advice and support to PCP as needed