PEDIATRIC CLINICS

O F NORTH AMERICA

Discharge criteria for the term newborn

Michael A. Friedman, MD*, Alan R. Spitzer, MD
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Tllc biilhing process rcprescnts a 1r;lnmatic cvietion from thc warni. quiet wumb with a constant supply of tood to thc cold, bright world with nuthing to cat. Tr~.mcndous pllysiulogic strains are suddcnly placed on the newborn infant. Tn a time iranlc of a few days, the neonatc must transition successFully to extrauterine life, and thc farllily ~rluslbe prepared for the care of their newborn at horne. As defined by the Arnerican Collegc o l Obstetricians (ACOG) and thc American A~.adcmyof Pediatrics (AAP) in the joillr puhlic;lt~on "Guidelines for Pcrinatal C:are," the putpose of poslpartum care is "to idcntify nxrtemal and neonatal co~nplications,and to providc profcssiorlill ;~ssist:rrcc d u r i n ~the Lirnc whcn the mother is likcly tu need supporl and care" [I]. The length of postpartum hospitali7:1tion, huwever, has dccrcascd drarnalically ovcr thc last scvcral dec:~dcs [Z]. which ~nahesit increasingly dificult to acilicve thesc poals. This nrticlc reviews the physiologic :md soclol issucs that fi~eethe newborn and mother, discusses the specific issues created by cmly discharge, and providcs suggcstcd criteria for thc tilning of discharge of thc well term ncorlatc.

Neonatal transition to extrauterine life

Tllc pruccss of transforniing from a fetus lo a neonate is neithcr sin~plc nor quick Physiolo~ically, i t is a dynamic period ~ I Iwhich marry congenital disurders may present 2nd ir which disruption of the transition process can nrnnifcst as serious nennatnl discase. Ideally, the ncwborn shoultl 11111 hc discharged until transition is complete. Recognizing and anticrpating prohlcn~sof :cmsitiolr and tile propzr tilning of discharge can be dctcrrnincd only fivr11 all onderstandi~~g of nurnlal transitional evcntc.

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Farrsitiunol ciirldalion The hallmark of fern1 circul:~tiun is high pi~l~nonnry vascular resistance (PVR) with low pulmonary blood tlow. Thcsc circumstances prornotc rigllt-t~r left shunting through thc ductus arteriosus and the foramcn ovale, with most of the cardiac output bypassing the lungs. After- the umbilical cord is cut, the placenta no longer providcs oxygen to the neonatal blood supply. :lnd tllc PVR most fall dramatically to alloh blood flow to the infant's lt~ngs.Thc mrchanici~lact of ventilation, a fall in lhc partial pressure of carbon dioxide IPrij,). ;lnd an incrcasc in the partial pressure of oxygen (Po,) arc all impor!ant immediate postnatal stimulators for tlic normal duclinc in PVK [3-71. Kxpost~rcto light and changes in circulating vasoactivc agents also seem to mediate this proccss. The largest dccrcasc in PVR occurs during the first 12 to 24 hours of life and is related to thc production o f vasodilators, such as prostncyclin and nitric oxide [R,O]. Funllcr rcdnction in PVR occurs over days to months and involves the rcmodcl~ngof the pulmonary vascular musculature [lo]. Alterations in the norni:~l dcclinc of PVK result in the disorder known as pcrsistcnt pulmonxy hypcflcnsion of the newborn, in which postnatal elevntions in PVR result in thc continuation of ktal-typc circulation with rightto-lcll shunting and resulting cyanosis. Hypoxin, acidosis, hypercarhia. and i~iflai~lmatory medi;~rurs arc hclicved to precipitate pulmon~ryvasocunstriction and lcad to persistent ~ ~ t ~ l r n o n a hypertension ry of the ncwborn in t l ~ cprcscncc of parmci~yinallnng disease. Diseases such as mcconiuln aspirat~onsyndrome, respiratory distress syndrome, and pneumonia fall illto this catcgury [I 1-13]. Because of a diffcrcnt mccbanism, chronic intrn~~lcrinc hypoxia also can lend to persistent pulmonary hypertension of the ncwbom artcr birth, secondary to the development of an abnornial pnlrnonnry vascular bed, with thickcnzd, .~bnormalmusculariration of the pulmonary vessels [14]. In addition to abnormal rnuscularization, neonates with hypoplastic lungs, such as those with congenital diaphragmatic hernia, h;~vcan associalcd hypoplasia of the pulmonary vascul;~rhcd that is believed to contribute to thzir elevated I'VK [15].

Fetal lu~~gflirid

Driven by lung inflation and a large incrcasc in pulmon;iry blood flow, ahsoption of fctal lung fluid occurs in the first hours :!tier birth. Lung fluid is absorbed vi:~thc pulmonary vascular bed and, to a lesser cxtcnt, lhrough the p~~lmonary lymphatic vessels. The common condilion knohn as transient tachypnea of the ncwborn is bslieved to occnr whcn the tlonnal absorption of tctal luns lluid is disn~ptcd[16]. This disorder of transition 1s most L.ommon aficr clcctivc cesarean section and m;ly be causcd by a lack of catccholan~inc surgc and abscncc of physical comprcsrion of the thorax that occurs during labor and vaginal dzliveiy [17].

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In utero, Ictal breathing is intermittent. Afier delivery, this irrcgular pattern to :\void apnea and hypovcnt~lamust bccome substantially more co~~tinuous tion. The driving forces responsible for this postnatal adaptation in the respirapattern in the first wcck tor). paticl-n arc unelsar, and d mildly irregular breathi~~g of lifc may bc considered rluimal [IS]. Pauses in breathing that are prolonged (1-20 seconds), associated with bradycardia, or accompanied by cy;lnosis should be considered pathologic and prompt invest~gationfor an underlying cnoss, such as sepsis, clccrrulytc imbalance, inrracranial bleed~ng, ~naternal dnlg use (including magnesium sulfate administration), and congenital ueurologic disorJers.

ARC>d~dively, the nconate cxperienccs cnornlous heat loss. Sornc drgrec of cold stress may bc a stimulant for the initiation of nonshivcring thennogcnesis and other transitional processes not relatcd to heat production. Upon pamrition, a ~lu~epi~~cphrinc-mediated response ensues: w h ~ c hcauses peripheral vasoco~lstrictionto conscrvc heat and 1t.e initiadon of heat production via nnnshivering thcrmogenesis in thc brown adipose tissuc [19]. The surge in thyroid hrn>non<sccn aficr hiith also may be pcrnlissive in this process [lo]. small^ for-gestational-age and prcrnature nconatcs oflcn lack brown fat and arc particulhrly vulnclable to impaired thcnnal rcgolatinn in the first days of life. Illability to maintain nonnai core temperature (36.5"-37C) also can rcprcscnt a p:ltllologic co~ldition,such as scpsis, or a central nenous system disorder and should be invcstigated when appropriate.

The fetal supply of glucosc colncs solely from the mother. and thcre is a direct rclationshjp behvcen maternal and fetal glucosc icvrls. Upon delivery, lhure is an abrupt cessation of glucose, and the newborn must maintain blood glucosc levcis indcpsndently. The catecholaminc s u y s after birth, along with an increase in glucagon levels, stimulates hepatic glycogcnolysis and gluconcogcnesis [21]. Pnnicul:~rlyin brc;~sti'cd babics, d i c ~ t ~ i ~.nrbohydrarc y inlake is low ior several days and the nconate dcpcnds on these pathuays to maintain ~iormoglyccmia.Addition:ll nlccl~anisms for clr~npcnsation in healthy infants with low glucose intakc include changes in cerebral blood flow to incrense ~ I I I cosc dclivery to ihc brain [22] and the use of ~lternative fuels, such 3s ketone bodies [23]. Kctonc hody production appears as a normal part of ad:lptation in term babies during the first 3 postnat;ll days. Thcrc is also eviclencc that brcas:fccding activatcs kctogencsis because of low cncrgy content of breast milk in tllc fir.;t days of life [21]. Onc problcrrl in determining normnglyccmia i c thc 1;lck U T u~insensusrcgord~ ing thc definition of liypoglyccmia. In 1988, Koh ct a1 1151 ruportcd signifi-

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The fchls livcs in an hypoxemic envirtlnmcnt with an altrnal oxygen tcnsion of approximately 35 rnln FIg. This stilnulatcs the production of c~yihropoictin and is reflected in the high red biood ccll mass in the neonate, w ~ t h ;In average hcmoglobin lcvel of ;lpproxim;dely 16.8 g/dL [35]. Depending on the position of the baby relative to the placenta and the timing of cord clamping at delive~y,thc baby may rcccive a placental transfusion [ 3 6 ] . This process further increases the lirmatocrit and enhances the potential for polycythcmia and hypcrbilirubinmmia during the transition pcriod. Other causes for polycythcmia includc twin-twin transfusion, malcrnal diabetes, intrauterine growth restriction, iniatem;~l-l'ctaltransfusion, fetal hyponia, and chsomosomal abnom~alities. The infant is usual!y plethoric and inay have sibns or symptoms of hypcr-\lscosity syndrome, such as respiratory distress, hypoglyccmia. oliguria, abnormal cr);, and evcn seizures. Any hcmatocrit of Inore than 6556, pallicolnrly in a syn~ptoniatic infant. should be repeated with a central venous or artcl-ial spccimcn. b e c ~ u s c capillan. spzcimens often givr f.ilsely high readings. Neonatal anemia also ]nay be sccn in the transition period. Causes include placental hcmonh:lge (cg. abmptio placentae, placenta previa), neonatal bleeding aftcr birth trauma (subgaleal, intracranial, inha-abdon~inal), fctal-rnatemal transfi~sion,twin-twin transfusion, and hcmolytic disease [XI. OAen the cause can be ascertained based on the presence of hypovolemia with acute blood loss, pallor wilhout Ilypovolemia with more chronic processes, and the presence of cnrly jaundicc with l~emolyticdisease. Thc cloltitig system of thc newbom is essentially intact exccpt for a delicieucy in vitan~inK-dcpcndent clntting factors. Vitamin K production dcpends on bztcterial colonizntion of the gut, which takes sevcr;il days to cstablihh in tlle neonate [37]. The risk is tile dcvelop~ncntof he~norrhayicdisease of t l ~ c newborn, which is exceedingly rare in the United Staics because of the administration of prophylactic vitamin K shortly aitcr birth. White blood cells also undergo changes in the first days of life. There is a notmal rise in the ncutrophil count in thc tirst 24 hours of life, with the ratio of imlnnturc to mature cclls remaining less than 0.2 [3R] Any typc of intrapartun stress can raise the absolutc neutrophil count and the immaturc-tomature-ccll tatio, which nlakcs the white blood cell coilnt difficult to interpret when ~ s e das n scrccning device for neorlatal infection. The picscncc of ncutinpenia is lnucl~more likely to rcprcsznt a newborn pathologic condition in this situation.

Tlic pssagc of urine in ~ltcrocontrib~ites to the amniotic fluid. The placenta. not the fetal kidncy, is icsponsible for fluid and eicctrolyte homeostasis. After hil-lh, renal bloi,d flow and glr,mcmlar lilLr;ition increase. Sondi1nli7ed tbr body surface area, this increase continues into the tliird ycnr of lifc (391.

hlosr inf:~tits (97%) pass urine in the first 2 4 hours o f life, with essentially 100'!:.i voiding in the first 4 8 hours o f lifc [40]. Thc possibility o f either renal or urin:ity tr;ict pathology should he considered with a dclay in urine passagc aftcr 2 4 hours.

In the transition from intrauterine to exlmuterine lifc, thc neonate must transition from an intn\enous continuous feeder supplied by the Inaternall placenta unit to an intennittent enteral fccdcr that depends on its own sucking. swallowing, and digestive inp;~hilities. Coordination of sucking and sw;illowilig is allnost always estahlishrd during thc first day o f life [41]. Initial feedings stimulate the release o f digestive horniones 1421 and an incrcasc in gut motility. which lcads to the passage o f stool. Ncarl) all infi~iltspass stoul in tlic first 4 8 hours o f lifc 1401. Ilelay in stool pass:lgc should prompt a n investigation for anatomic or filnctional gastrointestinal ohstmctioo.

Maternal transition

The initial day% aficr birth :~rc also a timc o f dynamic physiologic and psychosoci;il chnngs for the motlisr. Coping with these changes has a direct impact on thr ti:imcwork o f the developing mother-bnhy rclationship. Maternal mcdical i s s ~ ~ c iocluding s, postopsrativc rccovery frum a cesarean section, can dislupt this bonciing and learning period. Bcing a primigravid or first-time brcastfccding mother also makes the tr:i~isition to caregiver more difficult.

In the first days afier birth, the mothcr must transition liom providing placcntal fccding to becuming a breast milk supplier. A tremc~idousincrcase in prolactin and oxytocin nficr parturition stimulates milk production [43]. Nursing itself h ~ t h c r stimulates this proccss with a change in the composirion ol' the milk from colostnlm to maturc brcast milk by 5 days poslpaflum. Breastfccding success is enhanced with tcaching and support during [hi% critical hansitiun pcl-iud. Mc3surcs such as rooming-in, no scp3ralion nftcr birth, c:lrl) nursinf, frequent on-dcmnnd feedings, and exclusive brenstfccding nll enhance the chances for succcss [ 4 4 ] In thesc timcs o f d c c r c ~ s c dhospital staffing ond shortcr lhospitnl stays, it is increasingly iinpormnt to provide thc fa~nil)ccntcrcd cnvironmcnt nccdcd to support si~ccessfi~l brcastfccding.

Idcally, teaching the mothcr and far~iilytn care for rl~cirnewborn should bc mi oligoing proccss that begins heforc b i n h After a v:lginal dslivery, thc ti~iic for tc;icliing is partic~ilnrlylimited. i n additio~i10 gene131 cart is<ucs such as biltlli~~g. unibilical cord c:irc, and taking a temperi1tul.s. knu~vlcdgcuf i n h n t

s:~fetyand signs ofnco~ri~tal illness also ~nust bc taught. Providing information on safety issues, such as "back to sleep" and proper car seat use, is vital. Several dicvldcrs of thc ncrvbom, suck as jaundice, intcction, and hcart discase, may prescnt aHcr 48 hours of life, when many fernilies already havr bccn discharged, which lnakcs education o n the rzco&vition of these problems potentially lifesaving.

Early discharge

Tlic trcnd toward shorter postpartum hospitalizatinn has been an ongoing proecss since the 1960s [2]. The initial driv~ng fotce for cxly dischilrgc cvolvcd tiom the dcsirc to make tlle childbirth process less "lncdical" and more in the control of the mother :xnd family (451. As mcdicinc cntcrcd t1tc IYSOs, howcvcr, economic issues beca~ncthc stimulus for the continued downward trcnd i n lcngth of stay The introduction of managcd care al~dcapitated paylncnt cre;ired a aystcm in which hospitals could he murc protitable if they discharged patientq earlier [46]. With Lhis syrtcm, carly discharge translatcd into huge savings for hospitals, hcc;~use childhirth is the most cornrnon reason for hnspitaliration in ~IIL. U ~ ~ i t cStates. d Based on tigurcs from thc Centers for Disu;lse Control .~ndI'rcvnltion, the average lc1igth of postpaIiuln stay for a v.lginnl clclir.cr)i droppxl tiorn 3 0 days ill 1970 to 2.1 days in 1992 (Fig. 1) [?I. The downward trend continued during thz 1990s tu a puint ;it which many infants wcre discharged at or hefore 24 hours of life nRcr a vaginal dclivery Thc qllcsrion of' early dischurgc received national anentir>n-both in the lay and medical cornmui~i~-with rcpolis of'advcl-se ontcorncs and gencral dissatisfhctiun cxprcsscd hy consumers and providers [47-501. The outcry culminatcrl in the Newborns' and Mothers' Health Protcction Act. which \vent into cfi'cct on

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Fig. I .-\vcrage tenglh ofs1;ty lor i,ospital delivsrics. hy dclivrv olrlhud: Unlrsd Statci. 1'170 1497 C C ~ I ~ I'or - I I1)iseasc i,sltml Yrtnds in lcngrt~ of stay for horp1;tl dclvcnc* llnllrd Slaws. 7 1992 MMWR hlorb Moltnl Wklv Rep 190j:4411;)'i75 7 I

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.Iann;~ry 1, 1998. This legislation guaranteed payment for ;it least a 48-hour postpartuln stay after a vasinal birth and a 96-hour stny after a cesarean scction.

In light o f the negativism toward carly discharge, there are several benefits to early discharge that should not he discounted in an appropriate situation. "Demcdic:~lizing" the transitiol~pcriod after birth and placing the n ~ o t h c rand infant 111 a home environrncnt in a timely manner can promote a morc positive cxpcrience for the family. A more comforlahlc, relaxed cnviromncnt promotes breastfeeding success ;uid ongoing rnaten~:~l-infant bonding during this critical pcriod o f ch:lngc. When combined with n home nursing visit and carly medical follow-up, carly discharge may bz a more desirable arid zafe option, partictrlarly for educated families with prior cxpcriencc in child rearing. Altllougli cconomics never sho~rldbc the primary concern. *elective carly discharge in apptopriate situations has the added benefit uf reducing the cost of health carc.

The following situations can be problematic for any newborn but arc ottcn cxncerbated when bahies are discl~argcdbeforc 48 hours o f lifc.
Mi.s.verl ,~ru.bo~-n scr.wning

Mandatory newbotn screening to detect metabolic diseases was tilst introduced in hlassachusetts and Oregon in thc early li160s [Sl]. Although screening varics by state with respect to the disordcrs that are teuted, all 50 statcs have ncwbom scrrcriing programs. Some clisordcrs arc dctcctablc at birth, whereas others rcquire tile accu~nulotion o f a byproduct secclndary to the rncl;~holicdefect. The timing of t l ~ c sample is critical fix preventing false negative results. In one shrdv by hlcCabc et a1 [52], t l ~ eauthors deter~nincd that 4 8 to 72 hours was the best time to screen for pllcnylketonuria. This has led all statcs to require a repeat ncwborn scrccn as an outpatient if the newborn is dischnrgcd at less than 24 hours of lifc Clearly, this reliance on patients. health care providers, and adcqilatr follow-up may result in a tinilure to llavc a test repeated, and potentially trr;ltable diseases may be missed [53]. Even Tor i l ~ h n t snot discharged early, it is imperative f r families ~ ~ L o be cd11c;ltcd about the itnponance o f ncwhom screening. and the primary physician designated on the specimen also should bc the physiciai~w h o sccs the baby after dischargz. With ;I sipnilicant proportion 01' misscd cases caused by inzidequate follow-up c ~ fan abliorlnal screen result, strict atrelition and sound procedures to cnsurc postdiscliarge follow-up are vit;~l.

ihlto-hilir.tibiiie~~tio llypcrbilimhincmia is a nomlal pat o f transition. xvith approzlmately halt' o f all bnhirs demonstrating clinical jaundice [54]. Biliri~bin-inducednrumlr~gic

dysfunction, particulnrly kenicterus. is seen morc ofien w l ~ c ~ ~ , j a u n is d ~caused ce with by hcrnolytic disease, scvcre illncss, or hepatic dysktnction [55]. Coincidir~g thu decrease in postpartllrn stay, thcrc has bcen an incrcasc in kcrnictcn~sin apparently healthy newborns [56]. Proper suneillancc and managanent of jaundice during the postpartum hospitaliz:ltion and in the days aficr i l i b ~ . l ~ : ~ ~ g c cssentinlly should eradicate kemictcrus in this group of he:tlthy tcrm habics With must babies discharged from the hospital at appruxlrnotely 36 hr,~lrsof age, thcir peak bilin~bin level occurs at home. Predicting which infants will dcvelop significant hyprrbilirubinemia remains a challenge that is cxacerbatcd by carlicr discharge. Currcr~tgl~idcllnesrely on rtsual asscsstncnt to i!ctcrn~inc which iufants retql~ircmcasuremcnt of a total senrm bilirubin. Estiin.ltin:r the total scmnl bilirubin lcvel based on visual inspection is lilnitcd and often in:lccur:rte, particularly in osr multicthnic society with its wide range o f skin pig~rientatlon L54,57,581. Discharge of a jaundiced ncwhom with reliance on outpatient follow-up and parental observation potentially leads lo rnisscd opportur~itiusto prcrcnt b i l i n ~ b ~ n - ~ n d u cneurologic cd dysfunction, bccause appointmcnls ~rlay he missed ur tltc scverity ofjaundicc may be misjudged by fainilies and health calc p~ofcssiunals. It has bccn suggested that universal hilinlbin scrccning hcfore discharge can identi& accurately infants at risk for significant hypcrbiliruhincrnia ~ ~ f t discl~:i~gc cr and inhnrs in nccd o f closer follow-up [59]. The Af\P is currently examining tlic potenlial bcnefits o f adopting this approach. Rli~ltani ct a1 [51] dcmonstratcd thc plcdictivc villue of an hour-specific total scrum bilirubin perfortncd at the timc of routine metabolic screenitig. Based on preilisch;~rgeand postdischargc total scnun bilirubin luvcls, they develupcd a (lornogram tllnt cl:!ssifies infarts as high risk, intcrmediate risk, or low risk for ultitnetely <lcveloping significant hyperbilimbincmjn ( 2 1 7 ing!dL) (Fig. 2). The noriiogranl was most predictive for totnl scrum bilinthin icvels in rhc low-risk zone (less than foniclh percentile), with none of thcsc n c w b o n ~ s lumping to the high-risk zone (more that1 nincty-fifth perczntile) and no subsequcnttneasurable risk for significant hyperhilinlhinrmia, Infants in the intermediate-risk ronc had a small but clinically significant cl~anccto jump to the high-risk zone, with 6.4% chtlnging zoncs. Universal hilin~hinscreening could be a simplc tool for p r o ~ i d i n g more ntionol and tttrgcted follow-up. Tlic usc of transcutaneous bilimbin rncasuremcnts may make universal scrccning more feasihle. l i k c n together witti :m nssessmcnt of the dcrilug~apliic risk factors of each infttnt, the hour-specific total serum bilirubin lcvel can provide the physician with a lnorc concrete asscssment of risk and subsequent need for furthcr follow-up, i:iclodtrig tlie implerncntation of AAP recommendations for lreatmrnt. Br~~as~/i!rdiirg iryr~e.~ nl-ci~sifcrdingis bcnefieiol for the molhcr and infant. Breast Inilk is imi1li1nogcnic, aod it offcrs the nursing hahy protection ti0111 diseuse [GO-631. 11 i s morc cilsily digcsled than cou,'s rnilk, and iuhlnts ar: never allergic to their niotljer's milk [64j. For thc motlicr, brcastfcediog stimul~tcsoxyrocit~relcase :m<l prvmotcs u t c r i ~ ~ involution. c less postpnrnmm blzcd~ng[65],and 11 taiter re^

of term and nc3rtmil well i ~ c w t ~ o r n based i on llicii hutlr~spccilic acnun Fig 2 Risk drs~gl~:ltinn billn~hilli l u c i . (i,iosi nhulmi \'K. lr,hurun L, Sivlcli EM Prcdiclivc .\hn!ir) t,f.c p r ~ d i s c l r ~ ~ hu gu cr ~ rl~cclIicscmn> blllrubin for suhicqllcrtr s i g ~ i t i c a i l hypcrbllintbinem~nin 1hs;illhy lcnn .>nd near-rcrm inewl~oms Pciiialr~cs 1999;103(1) 6 14, ivith pennisslon.)

turn to prcpregnency wcight 1661. Nursing mothers also have a decreased ~ i s k o f hrcast [67] and ovanart conccr [68]. Breastfccding is convenient eud cconomic, with the niother providing a continuous supply o f free nourishment ror her baby. Altliough difficult to measure, there arc clearly psychosocial hcnctits from the intimate interaction between mother and hahy that occur during nursing. With ;dl these benefits to the mother-baby dyad and to society as a whole, providing substantial resources toward the pmmotin:~ of brs:lstfeeding seenis prudent. After a vaginal delivery. abundant m ~ l kprocluct~on 1s n o t often prcssnt until atter discliarge. Brcastfeeding prohlcms. such as improper latching on, poor milk supply. and painrul cracked nipp!es, oftert present ;it liomc and cilrl lead lo an cnrly cessation of nursing [69]. hledical prohlclns, such as hypcrbilimhinemia [70] and hypcmot~.c~~iic dehydralion [71], are rnorc comlnon in brcastfed infilnts, and they often prcscnr after dischnrgc. Particularly in light of cnrly discharge practices, y~cdisshargc maternal education and the availability r~l'goodfi~llow-upservices are vital Tor successful and sarc hl-castfeeding. A supportive cnvironrncnl in the hospital during the initiation o f hrc:lsttceding is importitnt for succcss. particu1:~rly tirr the first-time hrcastf~cdingmother To plonlotc brcastfccding gloh;~lly, the United Nations Children's Fund 2nd

the World Health Organiratior~introducc(1 "he Baby-Friendly l~ospitalinitiativc" in I991 [72]. T l ~ c prugranl advocates early initiation of breastfeeding, no bottlcs or si~pplemcnt;~tion, rooming-in, and no pacificrs The program also promotes in-hospital education and postdischarge services and support. A cornerstone to tllc initiative is a hospital environment and policy conducive to breastfeeding and a supportive staff well trained in 1nct:ition. Once dischargcd from the hospital, carly personal contact with a healtl~care professional (cg, physicixn, nurse, or lactation consultant) can bc vital to breastfeeding success, An infdnt who was apparently brcastfeeding well in the hospital can begin !o have prnblems aftcr discharge as the milk supply incrcascs. Problcrns during this vital period C;III lead to decreased nutrition, dccl-cased rnnten~almilk production, and, ultimately, carly cessntior~of nursing [73]. With an e:lrly visit in the t i n t 2 4 to 72 lhours after discharge, many prohlcn~so f breastfccding can bc remedied and potential health problerns, such as dchydmtion and hypcrbilimhinemia, can bc avoided.
Cor,,yt~ilrrlann~nolim

Congenital rnalfomiations may not always he apparent at b ~ n h .They may prescnt at variuus times durins the tr~nsirionalperiod, with somc prcscnting aftcr dischargc. All discharge guidelines rcquire adequate fccding intake and passage o f stool and urine, identifying most rnalkmnations of the gash-ointeytinal and urogenital systems. Of particular concern, howcvcr, arc c;~rdiacanoln;iiies that may prcscnt during the tirst wccks o f life ;~ficr discharge. Thc complctc tr~insitionof the cardiovascular system aftcr hirth takes scvcral weeks. Scveml cardi;lc anomalies can present aftcr many n c w b o n ~ s arc at home, which ~ n a k e srecognition and timcly trcatmcnt n challenge [74]. Disorders th:it depcnd on ductal patency for systemic blood flow, sue11 as the hypoplastic lcli hcart syndrome and ductal-depcndcnt coarctation of the aurta, nlay not sl~ow cardiovascular collapse until ductal closurc occilrs [75.76]. In infints wit11 tetralogy of Fallot and pulmonary artery btcnosis or atrcsia, pulmonary blood flow also may be ductal-dcpendcnt. with cyanosis becurning apparcnt only after ductal closure. Whcn there is a venlrieular septa1 dcfcct, as wiih tetralogy of killot, these disorders of decreased pulmonary blood flow may take even lo~lgcr to dctcct. Babies wit11 transpostlion o f the grcat arteries often prescnt in the first 2 4 hours of life with cyanosis, but thc presencr of an a c c u m p a n y i ~ ~ venlrii:~llnr g scptal dcfcct can create :idequate mixing bchveen the hvo sides nf thc heart so that the haby'r condition may go undetected bcforc discharge. Recently, it has been suggested that pulse oxinictry measurement o f oxygen salur-ation before discbargc mlly be an et't'ectivc screening tool to detect cyanotic congenital heait discase [77]. Although this !nay be a promising, low-cost, noninv:~sive tool, its usc in scrccning a large nalnntal population rciluires iunher study. (:oreH11 obsen.;ition and examination whilc the baby is hospit:llizcd. parental education with rcspect to signs ot'illncss. and frcqwnt close follow-up of any abuor~nol findings. such as murmurs. ;Ire the best rneans for timely identification o i cardiac anomalies.

610

.3f.4 k~icdinoi>. A.R. Spitzrr /Prdiiirr C'ii!i .VA,n 51 (1004) 599%618

Heiii11;y ,lrwbon~u l riskfor sepsis The confusion over the treatment of possible scpqis in the apparently healthy tern1 liewbom is dramatically illustrated by a grnup of 687 irifants froin the Paidos health management services' database who were treatcd for suspected sepsis [7R] All the infants wcrc in room air and on enter21 feeds withtn 1 day of birth arid h;ld negative hlood culturc results. Dam collcctcd from the Paidos database showed a wide variation in length of antibintic treatment, with 19% of newborns being trcated for 4 to 6 days, which appears too long if sepsis has becil ruled out for an infant and too short if one truly believes that an infant is infected. The managcmcnt of the apparently hcalthy tcrm r~ewbiirnwho is at lisk for scpsis remains controversial arid lacks consistency. The leading cause of wrly neonatal sepsis is group B streptococcus (GBS), which has a monality riitc of approximately 15% [79,80]. In thc mid-1990s, the ACOG, the AAP, and tllc Centers for Disease Control and Prevention issncd recommendations fbr preventing neonatal GBS disease that involved screening of mothcrs f i r GBS at 35 to 37 weeks' gestation, intraparturn antihilltic propliyli~xis(IAP) oT 1not11e~s who tested positive during labor, and subsequent lnanagctncnt of ncwboms born to GBS-positive mothers [XI]. The initial guidclines suggested the use of either a risk-based or culhtre-based screening npproach to IAP. The guidelines were revised in 2002 [82], and thcy rccommcndcd universal GUS scrccriing of all rllothcrs, abandoning thc option of thc riskbased approach. These recornmend;~tioiisun the m;jnagnnent of an infant born to a (iBS-positive mothcr directly affect the timing of discharge. Initial management guidelincs rccommendcd 48 hours of observation in tcnn ncwborns delivcrcd to a GBS-positive ~riotherw l ~ o receivcd adequatc IAP ( > 4 hours bcforc delivery). In a study of the impact that IAP had on the clinical prcscntation of scpsis, rcscarchcrs deterniined that the clil~icalonset was not dcl;~ycdand i t occr~ncdin more than 90% of intints in the first 24 hours of life. Di5ch:lrgc at 2-1 hours of life in a tenn (>38 weeks) newborn whosc GUS-pnzitivc mother receivcd adcquatc IAP is allowahlc. For infants whosc GRS-positivc rnothers rcccivcd inadequate IAP, the guidelines have not changed, and thcy suggest a limited evaluation and at lcast -18 hours of observation. Also impacting time of discharge is the recommendation ili:~t all infants hani tu mothers who arc givcn intrapamm antibiotics for suspected chosinainnioniti~~ h o u l dreceive an cvalualion for sepsis and cmpiric antibiotic therapy regardless of thc clinical condition of the baby. One last issoe that creates somc confilsion for pcrsons wlio care for newborns is tlic rcco~nrnctltlationthat GBS-positive women who undergo planncd cesarean section in Lhc absence of labor or nlptitre of tncmbrancs do tint requirc lAP and thus illis situation docs not represent inadequate IAP.
The ~lrt+-e.r/~,~.~ed ;ten,l>urn

Along with possihlc medical problems, myriad psycliosocial issucs cotnplicate the inaliagement of iiithn:~h o n ~to mothcrs with a history of substance ahuse. Medical issucs inclrt<le rect~gnitiano f neonatal abstinence sytidrolnc and propcr

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,l.rA. Friedrtion. A R Ypifzer /Pedioir. Chn ~ 3 A n Si i ~2lIO41Y Y 618

61;

Initial hcparitis B vaccine has bccn administered or an appointnlcrir has been scheduled for its administration, and the importance of maintaining ncwbom immunization has been stressed. i\ physician-clircctcd source of continuing medical cyme for the inother :ind tilc neon:ite has hcen identified. For newborns discharged before 48 hours alter delivery, an appointment has been made for the neonate to he examined within 48 hours o f dischargc. The follow-up visit can take place in a home or clinic setting, as Ions as the personnel who examine the nconatc arc eompctcnt in newborn asscss~ne~it and the results o f the follow-up visit arc reported to the neonate's pliysician or designees on the day of the visit. Family, environmental, and social risk f~~ctol-s have been assessed. When risk factors are present, the discharge should hc dclaycd until thcy arc resolved or a plan to sal'cguard the newborn is in place. Such factors may include, hut arc not limited to: Untrwtcd parental substencc use or positive urine toxicology test results in thc mother or thc newborn. IIistory of child abuse or neglect. Mental illness in a parcnt who is in the home. Lack o f social support, particularly for single, lirst-time mothcrs. No fixed holnc. tlistory of untrc;ltcd domcstic violence. particularly during this prcgnancy. Adolcsccni noth her. particularly if othcr risk tictors arc prcscnr.

(FFOIII,lnlcrican Acedcmy oi' Pediatrics and the American C:ollegc o f 0bstctrici:lns and Gynecologists. Care of the neonate. In: Guidclincs for perinatal care. 5" edition. Elk Grove Village (IL) and Wdshington, DC.: AAPIACOG; 2002. p. 187-235, with permission.)

Thc "Guidclincs for Pcrinatal Care" also state that for infants discharged at less than 48 lio~lrsafter delivery, it is essential th:~t they hc exanlined by "expcrienccd health care providers within JX hours of discharge" [I]. If this visit cannot be assured, then thc discharge should be delayed. The purpose o f this postdischarge visit is to perfonn the following assessments: Assess the newborn's gcneral health, hydration, and degrce of jaundice nlld rdentifi any new problems. ' ICcvicw feeding plttcrn and techniqoe, including observation o f brmstfccding for adequacy o l position. I;~tcll-on,and s\\,allowing. Asscss historical c\ idcrice of adequate slool and urine patterns. Asscss quality of ma1eri:al-ncoriatc i~iteraction and delails o f ncwhorn heha\'ior.

. .

Reinforce maternal or family edncation in neonatal care, particularly regarding feeding and slcep position. Review rcsults ol'laboratory tests performed at dischargc. Pc~fonn screening tcsts in accordance with statc regulations arid other tests that arc clinically indicated. Identify a plan for hcalth carc m;~intcnancc,including a method for obtainpreventive care and imrnnnizations, periodic cvaling emergency sc~vices, uations and physieill examinations, and necessary screening.

(FTOIN A~nericanAcademy of Pediatrics and the American College of Obstetricians and Gynecologists. Care of the neonatc. In: (iuidelines for perinatal care. 5" edition. Elk Grove Village (IL) and Washington, DC: AAPIACOG; 2002. 11. 187-235, with pcm~ission.) Not all1 states require insurance companies to pay for an early follow-up visit, which further eomplicatcs carly discharges evcn in appropriate sihlations.

Guidelines in medicine never should bc mistaken for strict edicts. They should provide a framework to direct the physician in his or hcr dccision making. In determining the timing of poshiatal discharge, each mothcr-baby pnir must be evaluated in the context of the guidelines summarized in this article as proposcd by the AAP and the ACOG. In addition to thcsc guidclincs, many fi~ctorsmust be considered, including medical ]risk factors in the neonate and mother, previous experience with childbearing (including brcastfccding), psychosocial and linancial state of the family, the ability of the family to care for the infimt, and the availability of follow-up care. Only altcr a multiiactorial analysis is made can the length of stay for each neonate bc dctcr~nincd. Although costs and third-party payer considerations cannot be ignored, the timing of discharge inust be between the physician and the family and must be free of financial pressures. When done colrectly and cfticiently, the postnatal hospitalization can ensurc the immcdiatc health and well-being of the newborn during transition and prepare the family for their vital role in the future hcalth and wcll-bcing of their haby.

Arncrkim ,\cudemy of Pediarrics and the t\merlcim College olObstetriciiins and Ciynrculogisls. Curt. olthc nconatz. Ill: Gilslrap LC. 0 1 1W. rdirors. Gu~drlinsr lib uzr~nntul c a r t iCh edition Elk G m \ c V~llngc AAI'!,\COG; 2002 p. 187 2 3 1 . 121 C c n s r a Tor Discnsr Conlri>l. Trends 111 length of stay for honpikal deliuelirr: United St;tlrs, IU70 1902 MMWR M o h Mortal Wkly Reu 1945:44(17)335 7. 131 Pcrmurt S, Kilcy KL. FIrnrodyni~rnlcsof cullapsible veiscls svith lone the vissculur w:iicrT~II. I hppl Phtriol l')63:18:9?4 32

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