Neonatal intensive and special care is an expensive and limited health resource. Having a child in hospital is stressful and inconvenient for families, and may result in unbudgeted costs and loss of income; the home environment is most appropriate for normal infant development. For these reasons it is important that babies are discharged from neonatal units as early as is safely possible. Preterm infants take up the majority of neonatal hospital bed-days and our review will focus on this population.

There are three main parameters to consider: physiological maturity, parental readiness and home environment, and administrative/bureaucratic infrastructure. In a critical review of early discharge from the neonatal intensive care unit (NICU) for very-low-birthweight (VLBW) infants, Merritt et al1 summarised what has previously been published about discharge criteria. For physiological maturity, most would agree that adequate suckling to maintain weight gain, respiratory stability with freedom from apnoea, and ability to maintain body temperature in an open cot are important criteria. Despite this general consensus, there is marked variation in length of stay: the average for babies <1.5 kg birth weight discharged home from the 552 hospitals participating in the Vermont Oxford Database in 2005 ranged from ∼40 to ∼80 days (fig 1). Some of this variation reflects different gestational age distribution (fig 2) and some reflects differences in diagnoses and clinical outcomes—for example, chronic lung disease, necrotising enterocolitis requiring surgery, and more than two episodes of sepsis are associated with prolonged hospital stays.2 Some variation is due to different management policies for clinical issues such as apnoea and infant feeding.3 However, differences in the discharge process may also be important, as illustrated by the finding that moderately preterm infants cared for in the Kaiser Permanente Medical Care Program in California were discharged on average 4 days younger than similar babies cared for in the UK.4

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Figure 1 Variation in length of stay (LOS) for infants <1500 g (adjusted for various parameters of case-mix) in hospitals participating in the Vermont Oxford Network, 2005. Vertical bars represent 95% confidence intervals for the geometric means. Reproduced by kind permission of Dr J. Horbar, Director, Vermont Oxford Network.

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Figure 2 Variation in median length of hospital stay according to gestational age in hospitals participating in the Vermont Oxford Network, 2005. Dots represent overall median network values, and vertical bars represent quartiles at all data centres. Reproduced by kind permission of Dr J. Horbar, Director, Vermont Oxford Network.

We will explore how evidence-based management for the key clinical criteria may allow greater consistency between neonatal units and thus avoid unnecessary delays to discharge. We will then consider how innovative use of community and education resources may allow boundaries to be challenged, enabling earlier discharge with greater empowerment of families and better use of neonatal cots.

PHYSIOLOGICAL MATURITY

Respiratory

The two main respiratory conditions likely to prevent early discharge are bronchopulmonary dysplasia (BPD) and apnoea. Major advances in respiratory management of infants <1500 g over the last 20 years, including antenatal steroids, prophylactic surfactant and novel modes of ventilation, have had a sizeable impact on mortality, but have not significantly reduced the incidence of BPD or length of hospital stay.5^–7 Aly et al8 published data on 228 consecutive VLBW infants treated with early continuous positive airways pressure in the delivery room. Compared with benchmark values, both incidence of BPD and length of stay were significantly reduced: mean reduction of 5.1 days. The COIN study is currently investigating this question further in a large randomised controlled trial (information about this study can be found at www.bapm.org/trials). Postnatal use of corticosteroids has diminished in the last 8–10 years. Kumar9 evaluated the effect of this decrease on all infants born <1000 g between 1 January 1999 and 31 December 2000, and found a change in neither duration of assisted ventilation nor length of hospital stay.

Pinney and Cotton10 first described the use of home oxygen for babies with BPD in 1976, allowing discharge from hospital far earlier than had previously been possible. The impact on families and quality of life was significant, as were the cost savings in terms of shorter hospital stays. But the question remains, when is it safe to go home? Kotecha and Allen11 in 2002 reviewed oxygen therapy in infants with BPD. They concluded that babies should have pulse oximeter oxygen saturation readings of >94% while awake, asleep and feeding in a constant flow of oxygen. Many VLBW infants have coexisting medical problems including gastro-oesophageal reflux, stoma, hernias and pulmonary hypertension, and these should be appropriately managed.

The second respiratory condition affecting discharge is apnoea, particularly the fear that a baby may suffer an acute life-threatening event at home. “Periodic breathing” is normal in preterm and near-term infants, including pauses of 3–10 s, but is benign and self-limiting.12 Apnoea is usually defined as cessation of breathing of 10–30 s duration, and may be “central”, “obstructive” or “mixed”.12 It is likely to persist to a later postmenstrual age in infants born at <28 weeks gestation.13 Many infants at this gestation will have received caffeine as a respiratory stimulant, although, in the majority, this can be discontinued by 35 weeks corrected gestational age and certainly before discharge. Idiopathic apnoea episodes separated by as many as 8 days have been documented,13 so an 8-day apnoea-free period is wise. Caffeine has a long half-life, so this period should be off caffeine therapy. Apnoea monitors are only of use in infants with central apnoea and, in the vast majority of cases, are falsely reassuring.

Once ready for discharge, a safe journey is necessary. Ojadi et al14 monitored cardiorespiratory parameters in 42 preterm infants placed in car seats for 45 min. Periodic breathing, desaturation or bradycardia occurred in 35.7%. This appeared independent of gestational age but was increased in infants <2000 g at discharge. Symptoms improved in the majority when placed supine, resulting in the recommendation that infants undergo a period of “car seat testing” before discharge.

Nutrition, feeding and growth

Achieving adequate nutrient intake in the early weeks is difficult in VLBW infants, and slow weight gain and nutritional deficiencies are common.15 Many fall below the tenth centile at term equivalent,16 and this may adversely affect readiness for discharge. Attention to nutrition is thus important throughout the baby’s whole NICU stay in order to minimise deficits and to promote growth and bone mineralisation. Most infants under 1.5 kg will have enteral feeds introduced using maternal breast milk, and then, when gut function is established, adequate nutrient intake will be achieved using fortified breast milk or preterm formula. Between 2 and 5 months of age is a period when many babies experience a peak of growth velocity,17 so optimising nutrient intake around the time of discharge is important. Nutrient-enriched “post-discharge formulas” meet the increased requirements of rapidly growing preterm infants—particularly for protein, calcium, phosphorus, trace elements and vitamins—within a tolerable volume. Weight gain is faster than on term formula, particularly in boys, with increase in lean body mass rather than fat, and a trend towards improved developmental scores.18 For babies fed on preterm formula, a change to a post-discharge formula shortly before discharge is appropriate. Duration of treatment should be guided by growth and overall dietary intake, but is recommended until at least 3 months post-term in growth-restricted preterm infants and at least 1 month post-term in others.15 For babies fed on fortified breast milk, discharge planning is less easy. Breast milk has many nutritional, immunological and developmental advantages,19 but has inadequate quantities of some nutrients. Once breast feeding is successfully established, this can often be combined with bottle feeds of fortified expressed milk if necessary. Vitamin and iron supplements should be provided, and for babies with serum phosphate <1.5 mmol/l a supplement should be given until ∼1 month post-term.15

PARENTAL READINESS

Although taking a preterm baby home is viewed by parents as an exciting and happy event, it is also a time when feelings of fear, helplessness and anxiety are common.20 It becomes apparent that the discharge process, although eagerly anticipated, can also be very stressful. Mothers who do not feel ready to take their preterm infant home show difficulty in establishing and maintaining relationships with their baby.21 Teaching and support to meet the emotional and physical demands of caring for these vulnerable infants is vital for the successful transition from hospital to home.

Planning needs to start early in the hospitalisation episode, and it has been emphasised that early discharge should not only be based on physiological stability but also the family’s ability to give competent care in the home.22 To develop competence in feeding, drug and oxygen administration, and “routine care”, parents need to be actively engaged in looking after their baby during the whole NICU stay. Units that incorporate principles of family-centred care have parents involved in care giving and decision-making and include early-discharge planning processes. Parents are taught resuscitation skills as a routine. This has led to parents experiencing increased competence and confidence.23

The Karolinska University Hospital in Stockholm and other Scandinavian units support early-discharge programmes.24 They have found that, in conjunction with gavage feeding at home, routine use of developmental care programmes such as NIDCAP (neonatal individualised developmental care and assessment programme) led to a shortened length of stay of at least 7 days. These programmes are designed to decrease stress for the preterm infant and allow parents to individualise care to the needs of their baby. The shortened length of stay liberated 10–12 out of every 100 beds, allowing NICU resources to be allocated to the increasing number of extremely preterm births. There was no increase in readmissions, no mortality after discharge, and a high satisfaction rate among parents.24

The benefits of rooming in before discharge are well known.21 Thus, in conjunction with parent education programmes, there should be a period when parents have the opportunity to care solely for their baby with the back up of NICU staff nearby. On-going support of families at home by community neonatal nurses provides emotional and physical support. Preterm infants often behave unpredictably and show unclear cues. They have special needs with regard to nutrition and growth and management of chronic lung disease with home oxygen; developmental progress must also be monitored. The community neonatal nurse provides a valuable resource of skilled expert care, maintaining a link with the NICU and the neonatologist while keeping the baby within the family unit. This should be considered a basic necessity, not only for the healthcare of the infant, but also to support the mother’s emotional and practical needs.25

LOOKING TO THE FUTURE?

Once “early” discharge is standardised, existing boundaries can be challenged. Some preterm infants achieve physiological stability and are gaining weight several weeks before full sucking feeds are sustained, and this period of hospitalisation may be particularly frustrating for families. Ortenstrand et al,26 in Stockholm, and Sturm,22 in Wisconsin, describe parents successfully gavage feeding babies at home. Adequate education and community follow-up were necessary, and, in each of these programmes, resulted in early discharge and good weight gain. Parents were overwhelmingly positive about having their baby home earlier. The most common problem encountered was accidental tube removal. No readmissions were related to the gavage feeding. A Cochrane review by Collins et al27 explored the small number of studies on home tube feeding, but concluded that, so far, there was insufficient evidence to support this as a recommendation for practice.

PRACTICAL STRATEGIES

Discharge home should be on the horizon as a clear goal from the point of NICU admission. The following strategies can help to make early discharge a reality.

1. Optimise acute neonatal care to reduce complications and avoidable delays

2. Identify specific personnel whose role is to expedite discharge; in our unit, neonatal community liaison nurses (NCLNs) perform this role (two whole time equivalent staff)

3. Allocate resources for parent support and education, including resuscitation training (NCLN role)

4. Establish responsive policy for rapid installation of home oxygen

5. Identify key members for discharge planning meeting—parents, consultant, neonatal intensive care nurse, NCLN, health visitor or general practitioner—and plan meeting at least 1 week ahead of expected discharge

6. Be receptive to the baby who has proven cardiorespiratory stability and who may be suitable for discharge with occasional tube feed