What are the criteria and interventions for newborn discharge?

Newborn Discharge Criteria and Interventions

Newborn discharge should be based on specific physiologic criteria and family readiness rather than arbitrary timeframes, with all discharge decisions prioritizing the unique characteristics of each mother-infant dyad to ensure optimal health outcomes. 1

Core Discharge Criteria for Healthy Term Newborns

The American Academy of Pediatrics (AAP) recommends the following minimum criteria be met before discharging a term newborn (37-0/7 to 41-6/7 weeks gestation):

Physical and Physiologic Stability

• Normal clinical course and physical examination without abnormalities requiring continued hospitalization
• Vital signs within normal ranges and stable for 12 hours preceding discharge:
  • Axillary temperature: 36.5°C-37.4°C (97.7°F-99.3°F) in an open crib with appropriate clothing
  • Respiratory rate: <60 breaths/minute with no signs of respiratory distress
  • Awake heart rate: 100-190 beats/minute (sleeping rates as low as 70 beats/minute acceptable if no signs of circulatory compromise) 1

Feeding Competency

• At least 2 successful feedings documented
• For breastfeeding infants: observation by knowledgeable caregiver confirming proper latch, swallowing, and infant satiety
• For bottle-feeding infants: documented ability to coordinate sucking, swallowing, and breathing 1

Laboratory and Screening Requirements

• Review of maternal laboratory tests:
  • Syphilis status
  • Hepatitis B surface antigen status
  • HIV status
• Review of infant laboratory tests:
  • Blood type and direct Coombs test (if clinically indicated)
  • Metabolic/newborn screening completed or scheduled
  • Hearing screening completed
  • Pulse oximetry screening for critical congenital heart disease completed 1, 2

Preventive Care

• Hepatitis B vaccine administered
• Maternal Tdap vaccination (if not previously vaccinated)
• Car safety seat assessment 1, 2

Family Readiness Assessment

Discharge readiness should include evaluation of:

• Maternal/family ability and confidence to care for the infant
• Adequacy of support systems at home
• Access to appropriate follow-up care
• Completion of anticipatory guidance 1

Follow-up Planning

• First appointment with healthcare provider scheduled or parents know how to schedule it
• For infants discharged before 48 hours of life, follow-up examination within 3-4 days of life 1, 3
• Availability of family members or healthcare providers to address follow-up concerns

Special Considerations

High-Risk Infants

For preterm infants or those with special healthcare needs, additional criteria must be met:

• Demonstrated physiologic stability (temperature regulation, feeding competence, mature respiratory control)
• Active program of parental involvement and preparation for home care
• Arrangements for healthcare follow-up with providers experienced in high-risk infant care
• Organized tracking program to monitor growth and development 1

Late Preterm Infants (34-36 6/7 weeks)

• Higher risk of prolonged hospitalization (40% overall; 75% of 34-week infants)
• Common morbidities requiring extended stay: oxygen needs, jaundice requiring phototherapy, feeding difficulties, and temperature instability
• Parents should be counseled about the likelihood of morbidity and potential for prolonged hospitalization 4

Implementation Challenges

Despite clear AAP recommendations, studies show inconsistent adherence to all discharge criteria. A 2018 study found that all 17 AAP criteria were followed less than 5% of the time, with feeding assessment, maternal vaccination, follow-up timing for early discharges, and car safety seat assessment being the most frequently missed criteria 2.

Key Pitfalls to Avoid

1. Arbitrary discharge timing: Base discharge on physiologic stability and family readiness, not solely on hospital length-of-stay policies
2. Inadequate feeding assessment: Ensure proper documentation of successful feeding before discharge
3. Missing maternal serologies: Verify all maternal test results are available and reviewed
4. Insufficient parent education: Provide comprehensive anticipatory guidance and ensure parents demonstrate competence in newborn care
5. Lack of follow-up planning: Schedule appropriate follow-up, especially for infants discharged before 48 hours of life

By following these evidence-based criteria, healthcare providers can ensure safe and appropriate discharge of newborns while optimizing outcomes and reducing readmission risk.