Transition of the Premature Infant
from Hospital to Home
Ma. Teresa C. Ambat, MD
Neonatology-TTUHSC
10/7/2008
Introduction

PCPs are taking care of a growing population of former
premature infants

PCPs should understand the special difficulties facing
these infants and their families

PCPs should understand how to follow problems
identified in the NICU and be attentive to new issues that
may develop
Terms Commonly Used to Describe
Premature Infants
Premature
Born < 37 weeks’ estimated GA
Late preterm
Previously referred to as “near
term”. Born between 34 -36 6/7
wks
Low birth weight (LBW)
BW <2500g (5 lbs 8oz)
Very low birth weight (VLBW)
BW <1500g (3lb 5oz)
Extremely low birth weight
(ELBW)
BW <100g (2lb 3oz)
Terms Commonly Used to Describe
Premature Infants
Gestational age
Age based on time elapsed between the 1st day
of LMP and the day of delivery
Chronological age
Age based on time elapsed after birth =
postnatal age
Postmenstrual age
Age based on time elapsed bet the 1st day of
LMP and birth + chronological age
Ex. 26 wk GA who is 10 wks chronological age
would have postmenstrual age of 36wks
Corrected age
Age of the infant based on expected delivery
date (Chronological age - number of weeks
born before 40 wks)
Ex. 12 month old former 28 wks has corrected
age of 9 months
Late Preterm

Potential short term morbidities: respiratory distress,
jaundice, feeding difficulties, hypoglycemia, temperature
instability and sepsis

Higher rate of rehospitalization within the first 2 weeks
after discharge
Guidelines for PCP Caring for
Late Preterm Infant

Newborn nursery care
– Monitor for feeding difficulties, respiratory distress, jaundice,
temperature instability, hypoglycemia and sepsis
– Lower threshold for supplementing breastfeeding and obtaining
lactation consultant who can continue to advise the mother after
discharge
– Car seat safety screening
– Determine need for RSV prophylaxis
– Educate family about differences between late preterm and full
term
Guidelines for PCP Caring for
Late Preterm Infant
Family education
 Feeding
– Usually eat less and may need to be fed more often
– Difficulty coordinating sucking, swallowing, and breathing
during the feeding needs to be observed closely while
eating
– May feed well initially at the hospital  become tired and
feed poorly contact PCP if the infant has decreased oral
intake
– 5-6 wet diapers in every 24 hour period
Guidelines for PCP Caring for
Late Preterm Infant
Family education
 Sleeping
– Sleepier than full term and sleep through feedings  should
awaken the infant to feed
– Should sleep on their backs

Thermoregulation
– Difficulty regulating body temperature (decreased subq fat)
– Should wear hats to decrease heat loss, if environmental
temperature is cool

Jaundice
– Greater risk for jaundice. Families should be taught how to look
for jaundice and need for close-ffup
Guidelines for PCP Caring for
Late Preterm Infant
Family education
 Infection
– Greater risk for infections  watch for signs of
infection (fever, difficulty breathing, lethargy)
– Minimize exposure to crowded places
– Practice good handwashing

Car safety seat
– Minimize time in car seats until good head control is
achieved
Guidelines for PCP Caring for
Late Preterm Infant
Follow up
 Schedule appointments in 1-2 days after discharge
 At first visit, PCP should:
–
–
–
–
–
Assess dehydration with weight check and P.E.
Evaluate for jaundice
Arrange for continued ff-up
Reemphasize educational points
Record results of the newborn screening
Guidelines for PCP Caring for
Premature Infant

Manage complications of prematurity
Monitor for potential new problems
Support the family

Coordinate various medical and social services needed


– Determine whether an Infant follow up program is needed
– Refer infant to an early intervention program as needed (in most
states NICU graduates are eligible for this program)

Educate the family by providing anticipatory guidance
and a list of resources
Discharge Criteria
Thermoregulation
Ability to maintain a normal body
temperature when clothed in an
open crib
No apnea or bradycardia for a
defined period
Observational days that are spell
free varies by unit
Exclusively taking oral feedings
with adequate weight gain
Should demonstrate a sustained
pattern of weight gain
Discharge Teaching
Teach good handwashing and
minimize exposure to crowded
places
Antibacterial solution in case soap and
water are not easily accessible
Infant must sleep on their backs
AAP recommends that infants sleep on
their backs to decrease SIDS
When to call PCP
Instruct parents to contact PCP if with any
abdominal issues, breathing problems,
feeding intolerance, fever, decreased
activity that could represent illness.
Medication administration
Fill prescriptions before discharge. Teach
family how to administer medications.
Caloric supplementation
Written instructions for formula/milk
preparation.
Discharge Checklist
Car seat safety screen
Assessed in all infants <37 wks
Phone contact with PCP
Phone contact
Written summary of medical course for
PCP
Newborn hearing screen
Perform prior to discharge and if needed
arrange for out-patient follow-up
Newborn state screening
PT often have initial NBS results that are
“out of range” requiring ff-up
Immunizations
Routine immunizations
Assess need for RSV prophylaxis
CPR
Ideally, all care providers should learn CPR
Discharge Planning


Follow-up appointments/referrals
Arrange discharge appointments at times that would decrease
exposure to children with infections
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–
–
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–
PCP
Early childhood intervention (ECI)
Visiting nurse
Ophthalmologist
High-risk clinic
Other consultants
Discharge Planning


Discharge paper works to families
Supply the family with a copy of infants’ discharge summary
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–
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Discharge summary (recent weight, length, HC)
Immunization record
Growth curve
List of medications and doses
Appointments and contact numbers of consultants, including
lactation consultant
Potential Medical Problems for
Premature Infants

Respiratory
– BPD, ventilator dependent with need for tracheostomy
tube, apnea of prematurity

Growth and Nutrition
– Inadequate nutrition and growth, difficulty with
breastfeeding, nutritional deficiencies, complications of
IUGR

GI
– GER, colic, oral aversion, constipation, need for enteral
tubes, NEC, SBS, direct hyperbilirubinemia
Potential Medical Problems for
Premature Infants

Neurologic
– IVH, post hemorrhagic HCP, white matter injury, CP, delayed
neurodevelopment

Hematologic
– Anemia of prematurity, indirect hyperbilirubinemia

Endocrine
– Hypothyroidism, osteopenia

Neurosensory
– ROP, other ophthalmologic issues, hearing loss

Surgical
– Cryptorchidism, inguinal or umbilical hernia