What are the discharge criteria for a 21-day-old infant with no fever?

Discharge Criteria for a 21-Day-Old Afebrile Infant

A 21-day-old infant without fever who is well-appearing, feeding adequately, maintaining normal body temperature, and has stable respiratory control may be safely discharged home with appropriate parental preparation, close follow-up arrangements within 24 hours, and clear return precautions. 1

Age-Specific Risk Considerations

Your 21-day-old infant falls into the neonatal period (0-28 days), which carries the highest risk for serious bacterial infection (SBI) at 13% incidence, even in well-appearing infants. 1, 2 Importantly, 58% of infants with bacteremia or bacterial meningitis appear clinically well, making clinical assessment alone insufficient for risk stratification in this age group. 1

Essential Physiologic Competencies Before Discharge

The infant must demonstrate three core physiologic competencies: 1

• Adequate oral feeding sufficient to support appropriate growth
• Normal thermoregulation in a home environment (maintaining body temperature without external support)
• Mature respiratory control without apnea or significant desaturations

These competencies are typically achieved between 36-37 weeks postmenstrual age for preterm infants, but for term infants like yours at 21 days of life, these should already be established. 1

Critical Discharge Prerequisites

Parental Readiness and Support

Before discharge, ensure: 1

• Active parental involvement with demonstrated competence in infant care
• Verbal and written instructions provided for monitoring at home
• Clear understanding of warning signs requiring immediate return
• Transportation access to return promptly if needed (consider transportation vouchers for families with insecurity) 1

Follow-Up Infrastructure

Mandatory arrangements include: 1

• Scheduled clinical reevaluation within 24 hours by a physician experienced in high-risk infant care
• Phone or telecommunication contact at appropriate intervals after discharge
• Organized tracking and surveillance program to monitor growth and development
• Clear escalation plan for changes in clinical status

Red Flag Symptoms Requiring Immediate Return

Parents must understand to return immediately for: 1, 3

• Altered consciousness or severe lethargy (difficult to arouse)
• Respiratory distress (labored or rapid breathing)
• Feeding difficulties (refusal to feed, persistent vomiting)
• Signs of dehydration (decreased urine output, dry mucous membranes)
• Fever development (rectal temperature ≥38.0°C/100.4°F)
• Petechial or purpuric rash
• Any clinical worsening

Special Considerations for Neonates

When NOT to Discharge

Do not discharge if: 1, 4

• The infant was recently evaluated for fever (even if afebrile now)
• Any diagnostic workup is pending or incomplete
• CSF analysis was not obtained or is uninterpretable during a recent evaluation
• Parents cannot reliably monitor the infant or return for follow-up 5
• The infant does not meet all three physiologic competencies
• There are unresolved medical issues requiring ongoing hospital-level care

The 29-Day Threshold

Note that at 21 days, your infant is still in the highest-risk neonatal period. Infants aged 29-60 days have lower SBI risk (9%) and may be risk-stratified using validated criteria (Rochester or Philadelphia criteria), but your 21-day-old does not yet qualify for this less intensive approach. 1, 2, 6

Common Pitfalls to Avoid

• Do not assume well appearance equals low risk in neonates—the majority of infected neonates appear well initially 1
• Do not discharge without confirmed 24-hour follow-up arrangements in place 1
• Do not rely on parental temperature monitoring alone—ensure parents have accurate thermometers and know proper technique 1
• Do not discharge if there are concerns about parental ability to recognize deterioration or access care 5

Documentation Requirements

Document clearly: 1

• All physiologic competencies are met
• Parental education provided and comprehension confirmed
• Specific follow-up appointment scheduled (date, time, location)
• Return precautions reviewed and understood
• Contact information for urgent concerns provided