Healthy term infants and their mothers should receive individualized care during their hospital stay, but pediatricians, obstetricians, nurses, and other health care providers should work together to determine the optimal time for hospital discharge for each mother-infant dyad, according to a policy statement issued by the American Academy of Pediatrics.
“There have been new studies since [the previous policy statement was published in 2004] to find out if there are better ways to assess the readiness for discharge of a healthy term infant, and these studies have shown that perceptions of readiness or unreadiness at the time of discharge often differ among pediatricians, obstetricians, and mothers,” said lead author and neonatologist Praveen Kumar of Northwestern University, Chicago.
The new statement recommends that “the hospital stay of the mother and her healthy term newborn infant should be long enough to allow identification of early problems and to ensure that the family is able and prepared to care for the infant at home.”
Dr. Kumar and eight other members of the AAP's Committee on Fetus and Newborn wrote the statement, which recommends following a set of 16 minimum criteria before discharging a term newborn (Pediatrics 2010;125:405-9).
“It is our recommendation that all hospitals should develop guidelines in collaboration with appropriate community agencies and third-party payers, to establish hospital-stay and follow-up programs for healthy term infants that implement these recommendations,” Dr. Kumar said in an interview.
The statement also recommends that physicians use the AAP's Safe and Healthy Beginnings toolkit, which contains a discharge readiness checklist that can aid clinicians with the preparation of a newborn for discharge (http://practice.aap.org/public/Newborn_Discharge_SAMPLE.pdf
In making discharge assessments, the committee advises determining that the clinical course and physical examination of the newborn reveal no abnormalities that require additional hospitalization; vital signs are within normal ranges; and there is a history of successful feedings, urinations, and bowel movements and a lack of significant circumcisional bleeding. Other examinations should assess for the clinical risk of hyperbilirubinemia, and for sepsis based on maternal risk factors and in accord with guidelines for preventing perinatal group B streptococcal disease.
Testing of newborns' blood type as well as their cord blood should be performed as clinically indicated. Hospital protocols and state regulations may call for other metabolic and hearing screenings. The initial hepatitis B vaccine also should be administered to the newborn according to the current immunization schedule.
Mothers should have certain blood tests performed, including screening tests for syphilis and hepatitis B surface antigen and other tests required by state regulations, such as HIV testing. Other assessments need to be made of the mother's knowledge, ability, and confidence to provide adequate care for her infant—including barriers to adequate follow-up care for the newborn—as well as any family, environmental, and social risk factors.
“One of the take-home messages is that the length of stay should accommodate the unique characteristics of each mother-infant dyad, including the health of the mother, the health and stability of the infant, the ability and confidence of the mother to care for her infant, the adequacy of support systems at home, and access to appropriate follow-up care.
To accomplish this, a pediatrician's decision to discharge a newborn should be made jointly with input from the mother, her obstetrician, and other health care providers who are involved in the care of the mother and her infant, such as nursing staff and social workers,” Dr. Kumar said.
“Everything should be considered as a mother-infant dyad rather than independently for the mother and infant. Just looking at the baby and making a decision that the baby can go home” is not adequate, he added.
Once a medical home for the newborn has been identified and a plan for timely communication of pertinent clinical information to the medical home is in place, the committee recommends making a follow-up appointment for the infant within 48 hours of discharge, but no later than 72 hours, if the infant was discharged less than 48 hours after delivery.
“It is very important for all babies to have a medical home, and it should be in place before a baby goes home,” Dr. Kumar said.
Disclosures: None was reported.
The new policy recommends following 16 minimum criteria before discharge.
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