Can a 36-week preterm infant be discharged from the Neonatal Intensive Care Unit (NICU)?

Discharge Criteria for 36-Week Preterm Infants

A 36-week preterm infant can be discharged from the NICU when they demonstrate three essential physiologic competencies—adequate oral feeding, thermoregulation, and respiratory control maturity—regardless of weight, along with completion of required screenings and establishment of a comprehensive follow-up plan. 1

Core Physiologic Competencies Required (Must All Be Met)

The American Academy of Pediatrics emphasizes that discharge should be based on physiologic maturity rather than achieving a specific weight threshold, as randomized trials demonstrate this approach is safe and does not increase mortality or morbidity 1. The three non-negotiable competencies are:

1. Feeding Competency

• The infant must demonstrate competent feeding by breast or bottle without cardiorespiratory compromise, with feeding sufficient to support appropriate growth 1
• A sustained pattern of weight gain must be documented 2, 1
• Monitor during feeding for any signs of respiratory distress, desaturations, or bradycardia 1

2. Thermoregulation

• The infant must maintain normal body temperature (36.5°C to 37.4°C or 97.7–99.3°F) fully clothed in an open bed at normal ambient temperature (20-25°C) 1
• Temperature stability must be documented for at least 12 hours preceding discharge 1

3. Respiratory Control Maturity

• Physiologically mature and stable cardiorespiratory function must be documented for sufficient duration 2, 1
• Respiratory rate must be below 60 per minute without signs of respiratory distress 1
• Heart rate must be between 100-190 beats per minute when awake 1
• The infant should not have significant apnea, bradycardia, or desaturation episodes requiring intervention 3

Required Pre-Discharge Evaluations

Before discharge can occur, the following must be completed:

• Appropriate metabolic screening must be completed per protocol 2, 1
• Appropriate immunizations must be administered according to postnatal age 2, 1
• Hematologic status must be assessed and anemia treatment instituted if indicated 2, 1
• Hearing evaluation must be completed with electronic measurement 1
• Ophthalmologic examination must be performed for retinopathy of prematurity as indicated 1
• Car seat evaluation must be completed to ensure physiologic stability during transport 2, 1
• Neurodevelopmental assessment must be documented and demonstrated to parents 2, 1

Family and Home Readiness Assessment

The discharge decision must include comprehensive family assessment, which is critical for successful transition 4, 5:

• At least two family caregivers must be identified and assessed for their ability, availability, and commitment 2, 1
• Caregivers must receive comprehensive education about high-risk infant care using multiple formats (spoken, practical demonstrations, written materials) 2, 1
• Parents must demonstrate competence in infant care, including feeding techniques, temperature monitoring, and recognition of warning signs 2, 3
• Psychosocial assessment for parenting strengths and risks must be completed 2
• Home environmental assessment must be conducted, which may include on-site evaluation 2
• Available financial resources must be reviewed and adequate financial support identified 2
• Necessary medical equipment and medications must be available 2

Follow-Up Care Coordination (Essential to Reduce Readmission Risk)

A structured follow-up plan is essential to reduce readmission and mortality risks 1:

• A primary care physician ("medical home") must be identified well before discharge 2, 1
• Initial appointment with the primary care physician must be scheduled before discharge 2, 1
• Discharge summary must be provided to primary care physician before infant leaves hospital 2, 1
• Specific appointments must be arranged with all involved specialists 2, 1
• Enrollment in follow-up clinic specializing in neurodevelopmental assessment of high-risk infants must be arranged 2, 1
• Emergency care plan must be developed with clear transportation arrangements 2, 1

Special Considerations for 36-Week Infants

• Preterm infants should be placed supine for sleep from 32 weeks postmenstrual age onward to acclimate before discharge, reducing SIDS risk 1
• At 36 weeks, most infants have achieved sufficient maturity for discharge if the above criteria are met, but individual variation exists 3
• Technology-dependent infants must have all necessary equipment and supplies available with accessible sources 1

Critical Pitfalls to Avoid

• Discharging before physiologic stability is established increases mortality and morbidity risk, regardless of weight achieved 2, 1
• The overriding concern must always be physiologic maturity, not arbitrary weight thresholds or gestational age alone 1
• Inadequate parental education on infant care and recognition of warning signs should be avoided 2
• Failure to establish a clear follow-up plan with appropriate specialists should be avoided 2
• Lack of coordination between hospital and community providers should be avoided 2
• Insufficient assessment of home environment and family support systems should be avoided 2
• Staff discontinuity can delay discharge and should be minimized through clear communication 6