The Committee on Fetus and Newborn of the American Academy of Pediatrics (AAP) has released a policy statement on the length of hospital stays for healthy term newborns. “Hospital Stay for Healthy Term Newborns” appears in the May 2004 issue of Pediatrics and is available online at http://pediatrics.aappublications.org/cgi/content/full/113/5/1434.
The hospital stay of the mother-infant dyad 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. Many cardiopulmonary problems related to the transition from an intrauterine to an extrauterine environment become apparent during the first 12 hours after birth. However, detection of jaundice, ductal-dependent cardiac lesions, gastrointestinal obstruction, and other problems may require a longer period of observation by skilled and experienced nurses and physicians.
Furthermore, the length of stay should be based on 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. All efforts should be made to keep mothers and infants together to promote simultaneous discharge.
The AAP recommends that the following minimal criteria be met before any newborn discharge. It is unlikely that fulfillment of these criteria and conditions can be accomplished in less than 48 hours. If discharge is considered before 48 hours, it should be limited to infants who are of singleton birth between 38 and 42 weeks’ gestation, who are of birth weight appropriate for gestational age, and who meet other discharge criteria as follows:
The antepartum, intrapartum, and postpartum courses for mother and infant are uncomplicated.
Delivery is vaginal.
The infant’s vital signs are documented as being within normal ranges and stable for the last 12 hours preceding discharge, including a respiratory rate below 60 per minute, a heart rate of 100 to 160 beats per minute, and axillary temperature of 36.5°C to 37.4°C (97.7°F to 99.3°F), measured properly in an open crib with appropriate clothing.
The infant has urinated and passed at least one stool spontaneously.
The infant has completed at least two successful feedings, with documentation that the infant is able to coordinate sucking, swallowing, and breathing while feeding.
Physical examination reveals no abnormalities that require continued hospitalization.
There is no evidence of excessive bleeding at the circumcision site for at least two hours.
The clinical significance of jaundice, if present before discharge, has been determined, and appropriate management and/or follow-up plans have been put in place.
The mother’s knowledge, ability, and confidence to provide adequate care for her infant are documented by the fact that she has received training and demonstrated competency regarding the following: (1) breastfeeding or bottle feeding (the breastfeeding mother and infant should be assessed by trained staff regarding breastfeeding position, latch-on, and adequacy of swallowing); (2) appropriate urination and defecation frequency for the infant; (3) cord, skin, and genital care for the infant; (4) ability to recognize signs of illness and common infant problems, particularly jaundice; and (5) proper infant safety (e.g., proper use of a car safety seat, supine positioning for sleeping).
Family members or other support persons, including health care professionals such as the physician or his or her designees, who are familiar with newborn care and knowledgeable about lactation and the recognition of jaundice and dehydration are available to the mother and her infant after discharge.
The following maternal and infant blood test results are available and have been reviewed, including: (1) maternal syphilis and hepatitis B surface antigen status; (2) cord or infant blood-type and direct Coombs’ test results, as clinically indicated; and (3) screening tests performed in accordance with state regulations, including screening for human immunodeficiency virus infection.
Initial hepatitis B vaccine is administered as indicated by the infant’s risk status and according to the current immunization schedule.
Hearing screening has been completed per hospital protocol and state regulations.
Family, environmental, and social risk factors have been assessed. These risk factors may include but are not limited to the following: (1) untreated parental substance abuse or positive urine toxicology results in the mother or newborn; (2) history of child abuse or neglect; (3) mental illness in a parent who is in the home; (4) lack of social support, particularly for single, first-time mothers; (5) no fixed home; (6) history of untreated domestic violence, particularly during this pregnancy; and (7) adolescent mother, particularly if other conditions above apply. When these or other risk factors are identified, discharge should be delayed until they are resolved or a plan to safeguard the infant is in place.
Barriers to adequate follow-up care for the newborn such as lack of transportation to medical care services, lack of easy access to telephone communication, and non–English-speaking parents have been assessed and, wherever possible, assistance has been given the family to make suitable arrangements to address them.
A physician-directed source of continuing medical care for the mother and the infant is identified. For newborns discharged fewer than 48 hours after delivery, a definitive appointment has been made for the infant to be examined within 48 hours of discharge. It is essential that all infants having a short hospital stay be examined by experienced health care professionals. If this cannot be ensured, discharge should be deferred until a mechanism for follow-up evaluation is identified. The follow-up visit can take place in a home or clinic setting as long as the health care professionals examining the infant are competent in newborn assessment and the results of the follow-up visit are reported to the infant’s physician or his or her designees on the day of the visit.
The purpose of the follow-up visit is to:
Obtain the infant’s weight; assess the infant’s general health, hydration, and degree of jaundice; identify any new problems; review feeding pattern and technique, including observation of breastfeeding for adequacy of position, latch-on, and swallowing; and obtain historical evidence of adequate urination and defecation patterns for the infant.
Assess quality of mother-infant interaction and details of infant behavior.
Reinforce maternal or family education in infant care, particularly regarding infant feeding.
Review the outstanding results of laboratory tests performed before discharge.
Perform screening tests in accordance with state regulations and other tests that are clinically indicated, such as serum bilirubin.
Verify the plan for health care maintenance, including a method for obtaining emergency services, preventive care and immunizations, periodic evaluations and physical examinations, and necessary screenings.
The follow-up visit should be considered an independent service to be reimbursed as a separate package and not as part of a global fee for maternity-newborn labor and delivery services.