Discharging a healthy infant from the hospital following delivery gives the family physician an important opportunity to emphasize preventive medicine and to strengthen the physician-patient relationship. However, the scope of newborn discharge instructions and recommendations is vast, making this a potentially daunting task. Although the postpartum nursing staff will cover some of this information with the parents, the family physician can ensure that key recommendations have been covered. A concise checklist can help ensure that important topics are addressed efficiently and can help new parents feel comfortable asking questions. This checklist should serve as a framework that physicians can modify based on their experiences and practice styles. It is useful to give parents written handouts emphasizing key points at the time of discharge so that they can refer to them later.
|Clinical recommendation||Evidence rating||Reference|
|Sorbitol-containing juice (e.g., prune, pear, apple) may be used to treat constipation.||C||16|
|Infants should remain in a rear-facing car seat until one year of age.||C||6|
|Infants should receive 200 IU of vitamin D per day to prevent rickets.||B||12|
|Infants should sleep on their backs in their own cribs to reduce the incidence of sudden infant death syndrome.||B||7|
|Properly feeding the infant|
Physicians should encourage breastfeeding mothers and refer them to local lactation consultants. The AAFP recommends that breastfeeding mothers be given clear verbal and written discharge instructions, including information on hunger and feeding indicators, stool and urine patterns, jaundice, proper positioning and attachment of the baby to the breast, and techniques for expressing breast milk.11 Although most prescription and over-the-counter medications are safe, physicians should inform the mother that anything she ingests potentially can be transmitted to the newborn through her breast milk. Therefore, mothers should check with their physicians before taking any prescription or over-the-counter medications. The AAP recommends that exclusively breast-fed infants and infants receiving less than 500 mL of vitamin D-fortified formula receive 200 IU of vitamin D per day to prevent vitamin D deficiency and rickets.12
Parents who choose to bottle-feed their newborn should use a formula that contains iron, and they should not change formulas without consulting their physician. Bottles and nipples do not need to be sterilized, but they should be thoroughly cleaned with hot, soapy water. Formula only needs to be heated to room temperature, although some infants may prefer warm milk. Formula may become dangerously hot if heated in a microwave, even if the bottle feels cool to the touch. Formula should be mixed thoroughly after heating and tested on the parent’s skin before it is given to the newborn. Under no circumstances should a bottle be propped up when an infant is feeding. The parents should call 9–1–1 if the child seems to be choking or turning blue during feeding, and should alert their physician if the infant is losing weight.
Bowel Movements and Urination Patterns
Breastfed infants typically have more than three bowel movements per day2 and are rarely constipated. Watery stool may be normal; however, parents should contact their physician if the infant’s stools run out of the diaper.
Formula-fed babies typically have less frequent bowel movements than breastfed babies, although a bowel movement every other day is still considered normal.
Constipation is defined as a delay or difficulty in defecation for more than two weeks.16 Parents should contact their physician if their infant has had fewer than five bowel movements per week over a two-week period.
Parents may give infants 1 oz of sorbitol-containing juice (e.g., prune, pear, apple) to treat constipation.16 Parents also may increase their infant’s fluid intake or use glycerin suppositories. If the constipation persists, the parents should contact the physician.
Breastfed infants typically have six or more wet diapers per day after they begin feeding.2 Bottle-fed infants should have a similar number of voids. However, other clinical indicators (e.g., estimated capillary refill time, skin turgor) are more accurate predictors of hydration.
Umbilical Cord Care
In the past, parents were often instructed to wipe the umbilical cord stump with isopropyl alcohol, but one study17 has demonstrated that the cord will separate sooner if it is cleansed with normal saline and allowed to dry naturally. Most cords will fall off within the first two weeks of life. If the skin around the umbilicus becomes red or if purulent discharge is present, the physician should be notified.
Neonatal skin rashes are extremely common and are often caused by maternal hormones. If the infant has a rash in the hospital, (e.g., neonatal acne, erythema toxicum neonatorum), parents should be reassured that these rashes are common and will fade, most within the first four months of life. The parents should contact their physician immediately if an infant with a rash develops a fever or becomes dehydrated, lethargic, or inconsolable.
Current data are insufficient to support routine neonatal circumcision.18 If parents choose to have their child circumcised, they should moisten the front of the diaper with petroleum jelly at each changing to prevent the penis from sticking to the diaper. The parents should continue this treatment until the skin is no longer moist (approximately five days). If the penis begins to bleed or swell, the parents should contact the physician.
Parents should gently cleanse uncircumcised genitals with warm water. The foreskin should never be forcibly retracted, because this may cause phimosis. The genitals of newborn girls should also be gently washed with warm water. Bloody vaginal discharge at this age may be a normal response to maternal hormones.19 Physicians should stress to the parents the importance of properly bathing their infants.
Physicians should give parents a clear list of warning signs that warrant a visit to their physician before the scheduled follow-up. Fever (rectal temperature of 100.5°F [38°C] or higher) is the most significant sign that parents should look for,20 because a fever may be the only sign of a serious infection. This is a good time to talk to the parents about the importance of having a rectal thermometer at home and to show them how to use it properly. Physicians should stress to parents that their child can be seriously ill and not have a fever.
Lethargy (e.g., difficulty feeding the infant) or irritability may also indicate serious infection and may warrant a visit to the physician’s office. The physician should discuss with the parents how to distinguish normal crying from an inconsolable infant.
Infants who become dehydrated should also see their physicians before the scheduled visit. Parents should look for clinical signs of dehydration such as decreased tears and dry mucous membranes.
The AAP recommends that all new parents be given written and verbal instructions regarding jaundice at the time of discharge, including an explanation of jaundice and how to monitor infants for jaundice.13 Parents should be instructed to contact their physician if their baby’s skin looks yellow, particularly on the extremities or abdomen; if the baby’s eyes turn yellow; or if these symptoms are accompanied by poor feeding, lethargy, or excessive fussiness.
Physicians should instruct parents to take their child to the nearest emergency department if they think the infant is seriously ill and they cannot reach the office.
|Infant’s age and weight|
|Birth to one year of age or weight less than 20 lbs (9 kg)|
|Type of car seat|
|Infant-only or rear-facing convertible|
|Location in the car|
|All children younger than 12 years should ride in the back seat.|
|Harness straps at or below shoulder level|
Parents should place newborns on their backs to sleep to decrease the risk of sudden infant death syndrome (SIDS). An infant’s mattress should be firm, and parents should not put pillows, comforters, or large objects in the crib with their child. In general, children should sleep in their own cribs and not with their parents or other family members.7 Breastfeeding mothers who choose to share a bed with their infants should ensure that their beds are free of soft surfaces or loose covers, and should move their beds away from the wall and other furniture to prevent entrapping their infants.
Breastfeeding mothers should avoid smoking and drinking alcohol. Children who are exposed to secondhand smoke have increased risk of upper respiratory infections, otitis media, asthma, and SIDS.7
Before discharge, physicians should provide parents with information on how to reach them during normal hours, after hours, and on weekends. Parents should be given a follow-up appointment before they leave the hospital. Infants discharged before 24 hours of life should be seen in the office within 48 hours of life.9 Those discharged between 24 and 48 hours of life should be seen within 96 hours of life, and those discharged after 48 hours of life should be seen within 120 hours of life.10
All discharge discussions should include an opportunity for parents to ask questions, and the physician should assure the parents that they can contact the office anytime with serious concerns, and that they should write down non-urgent questions to be addressed at the next office visit.