Neonatal Discharge

1. Before Neonatal Discharge
Raafat Salama
Neonatologist

2. How can we ensure that discharge from the
hospital is smooth, safe, and complete?

3.  Historically, preterm infants were only discharged when they achieved a specific
weight; now preterm infants are discharged based on physiologic criteria and
not weight.
 The American Academy of Pediatrics (AAP) has developed
specific guidelines for discharge for the following infant types: high risk, late
preterm, and healthy term.
 High-risk category guidelines are very specific for 4 subcategories: preterm
infant, infant with special care needs, infant at risk because of family issues, or
infant with anticipated early death.

4. The important factors in deciding on discharge
A- infant readiness
B-Family, community, and healthcare provider readiness.
C-Risk factors of the mother and infant.
D-screening tests, laboratory evaluations, radiologic evaluations, and appropriate
immunizations been completed.
E-the mandatory pulse oximetry screening for critical congenital heart disease.
F-Developmental Dysplasia of the Hip.
G- Red reflex.

5. 1- the vital signs
-Most discharge criteria require vital signs be documented within
normal reference ranges for the infant for 12 hours preceding
discharge .
• -For late preterm and term infants, this includes a respiratory
rate<60 breaths/min, a heart rate of 100 to 160 beats/min, and an
axillary temperature of 36.5°C to 37.4°C in an open crib.
• For high-risk neonates, criteria include :
-physiologic mature and stable cardiorespiratory function and
adequate maintenance of normal body temperature in an open bed
with normal ambient temperature. Most preterm infants are able to
maintain normal body temperature at home between 36 and 37
weeks of postmenstrual age.

6. 2-Recent episodes of apnea and bradycardia
• Apnea of prematurity typically resolve at approximately postconception
age of 34 to 36 w.
• Infants born less than 28 weeks gestation may have prolonged apnea
beyond term. If such episodes persist at 36 weeks of age, the infants may
not yet be safe for discharge.
• Many NICUs will wait for an event-free period of time (typically 5–7
days) before considering these infants ready for discharge home.
• Home monitors do not prevent sudden infant death syndrome and
should not be used to justify discharge of an infant with apnea or at risk
of apnea

7. 3- Feeding satisfactorily
• To be able to coordinate sucking and swallowing and breathing while taking in
an adequate number of calories [120 kcal/kg/d] in reasonable frequency
[every 3–4 hours], with each feed not taking >30–40 minutes) is of major
importance.
• Gavage feeding and gastrostomy tube are alternative feeding practices that
are used in infants who are not able to feed by breast or bottle.
• many premature infants require fortification of their milk to provide adequate
nutrition even after discharge from the NICU.

8. 4-sufficient weight gain
-Most healthy preterm or term infants with no ongoing problems
show an average weight gain of 15 to 30 g/d. Sustained weight gain is
more important than specific weight criteria for discharge.
5-The late preterm and term infant passed 1 stool spontaneously and
urinated regularly.
6-Active bleeding from the circumcision site . no active bleeding for a
minimum of 2 hours prior to discharge

9. pulse oximetry screening(CCHD)

13. Meta-analysis of POS studies
shows that overall, the test has
moderate sensitivity (∼75%)
and high specificity (99.8%)

14. pulse oximetry screening (CCHD)

18. Developmental Dysplasia of the Hip
 Developmental dysplasia of the hip, sometimes termed congenital
dysplasia or dislocation of the hip, is a chronic condition present from
early childhood which can cause permanent disability if not identified
and treated early.
 Developmental Dysplasia of the Hip is a disorder of abnormal
development resulting in dysplasia, subluxation, and possible
dislocation of the hip secondary to capsular laxity and mechanical
instability.
 Diagnosis can be confirmed with ultrasonography in the first 4
months and then with radiographs after femoral head ossification
occurs (~ 4-6 months).

19. Treatment varies from Pavlik bracing to surgical reduction and
osteotomies depending on the age of the patient, underlying etiology,
and the severity of dysplasia.
Screening for DDH
• Barlow :dislocates a dislocatable hip by adduction and depression of
the flexed femur.
• Ortolani :reduces a dislocated hip by elevation and abduction of the
flexed femur.

20. • Screening for DDH
The Galeazzi test

21. Who is affected?
-One in 1000 live births are affected. It runs in families. It can be
in one or both hips. The left hip is mostly affected. High risk
factors include being female, first born or breech position at birth.
When is the baby screened for DDH?
-Babies are screen at birth and at well baby check ups by the
Pediatrician. If the Pediatrician has concerns, he/she should refer the
baby and parents to an orthopedic surgeon.
What if DDH is left untreated?
-If DDH is left untreated, it can lead to pain and osteoarthritis in early
adulthood.

22. Red reflex
• The red reflex from the retina is a quick and non-invasive test used to identify
opacities in the visual axis, such as a corneal abnormality or cataract, as well as
abnormalities in the posterior segment of the eye, such as retinoblastoma.
• Currently, the American Academy of Pediatrics policy recommends eye
examinations for all neonates.
• Normal red reflex: red reflex should appear red, orange, or yellow and be
symmetric across both pupils.

23. Abnormal red reflex requires urgent referral to an ophthalmologist.
An abnormal or absent red reflex can indicate sight and life-
threatening pathology, including congenital cataracts, retinal
abnormalities, retinoblastoma, strabismus, or refractive errors

24. conclusion
• Discharge neonate based on full fit certain criteria not only gain
specific weight.
• If you want discharge your baby within 48 hour of age ,you should do
pulse oximetry CCHD.
• There is no excuse to not doing RED reflex for your discharged baby.
• Don’t forget DDH screen while you examine your baby before
discharge especially if she is female ,breach,and you suspect left hip.

25. Thanks