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Transition of the Premature Infant from Hospital to Home

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child and parent hands photography

In 1963, President John F. Kennedy’s wife Jacqueline delivered an infant at 34 weeks’ gestation. The President’s child must have received the most advanced medical care but was unable to survive because of severe lung disease caused by surfactant deficiency. Today, medical technology has dramaticallyimproved the survival rate of premature infants, and now almost 100% of infants born at 34 weeks’ gestation survive. At the same time that more premature infants are surviving, the rate of premature deliveries has increased to the point that almost 500,000 infants are born premature each year, accounting for “=12% of all births in the United States.’ A significant number of these premature infants are born between 34 and 37 weeks’ gestation. This rise of premature births is partly attributable to a greater number of multiple pregnancies, which, in turn, is due to the increased number of older women who are interested in having children. Older women are more inclined to seek assisted reproductive methods that often result in multiple births, many of which are preterm. In fact, approximately half of twin pregnancies and nearly all pregnancies of triplets (or greater) lead to deliveries before 37 weeks’ gestation. Other causes of prematurity include cervical incompetence, placental or uterine anomalies, trauma, advanced maternal illness,chorioamnionitis, and subclinical infection.P In spite of the increased understanding of the various factors leading to preterm deliveries, in most cases an etiology for the premature birth remains unknown. Even though physicians cannot always identify the cause of premature delivery, medical advancements in obstetric and neonatal care have led to dramatically greater chances for survival of extremely premature infants. Infants born at 24 weeks’ gestation currently have a survival rate of approximately 40% to 60%.4 Unfortunately, the morbidities ofthese extremely premature infants have not decreased significantly. Indeed, gestational age at birth is inversely correlated with the chance that the infant will experience physical, developmental, and/or psychosocial sequelae. Because of the increased number of premature deliveries and the greater number of extremely premature infants who are surviving, primary care providers are taking care of a growing population of former premature infants. Therefore it is critical that primary care providers understand the special difficulties facing these infants and their families. Depending on the infant’s degree of prematurity and the number of complications the infant encounters in the neonatal intensive care unit (NICU), he or she is at risk for a wide variety of physical and developmental problems. Some of these medical problems may be identified in the NICU and require further monitoring for a significant period oftime, whereas others may manifest clinically later in infancy or in childhood.’ Thus the primary care provider should understand both how to follow problems that NICU clinicians have already identified and how to be attentive to new issues that may develop

Discharge Planning

Before discharge from the NICU, the premature infant must demonstrate physiologic maturity by predefined criteria (Table 1-1). Whereas the premature infant usually meets these requirements at an approximate postmenstrual age (PMA) of 40 weeks, infants who are born closer to 24 weeks’ gestation usually are discharged later, and infants born closer to 37 weeks’ gestation often are discharged before 40weeks’PMA.The premature infant is not required to attain a certain weight before being discharged to home; rather, the infant should demonstrate a sustained pattern of weight gain. The infant’s transition from the NICU to home should correspond with a shift in parental thinking from viewing their infant as receiving “illness care” to “primary care.” In addition to teaching families about this change, the NICU staff is responsible for discharge teaching, ensuring that specific tests are completed prior to discharge, developing a home care plan, and arranging for the appropriate followup appointments and/or referrals for surveillance and support services (Table 1-1). The NICU staff should provide families with a copy of the infant’s discharge summary, immunization record, growth curve, medication list, and contact numbers. Primary Care Provider Role Primary care providers often are responsible for directly managing the “late preterm” infant, previously known as the “near-term” infant, in the newborn nursery. These infants are born between 34 and 36 6/7 weeks’ gestation, which accounts for the majority of all singleton preterm births. This population of infants has a broad range of potential short-term morbidities, including respiratory distress, jaundice, feeding difficulties, hypoglycemia, temperature instability, and sepsis.’ Although these infants may be admitted directly to the NICU, some may be admitted to the newborn nursery under the supervision of the primary care physician. Some infants in this latter group may develop complications and require subsequent transfer to the NICU for management of their medical issues. Those infants who are not transferred to the NICU and are discharged to home directly from the newborn nursery still have a higher rate of rehospitalization, within the first 2 weeks after discharge, than do full-term infants, mostly because of feeding difficulties and jaundice.” Table 1-2 provides guidelines for the primary care clinicianin caring for these late preterm infants, both in the hospital and after discharge. Becauseprimary care providers are the principal clinicians for the premature infant and the infant’s family, they are in a unique position to help families normalize their childbirth experience.Therefore it is important that clinicians provide continuity of care with an emphasis on a team approach. Indeed, the premature infant whose family uses a large pediatric practice might benefit from a core team of providers. During the first office visit, the primary care provider should focuson the issueslistedin Table1-3.

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