Early discharge of premature infants. A critical analysis

Although significant advances in the medical management of acutely ill preterm infants have resulted in unprecedented rates of survival, issues surrounding the convalescent care, discharge preparation, and readiness of parents or other caregivers have been less well studied and represent the art of medicine. Recent consensus statements provide a degree of content validity; however, important areas of scientific inquiry remain. Much is left to understand about the pathophysiology, management, and outcomes of apnea, bradycardia, and oxygen desaturation episodes continuing at term. Why do the most immature infants have a delay in the maturation of respiratory control? Do breathing studies really provide information that predicts subsequent respiratory control abnormalities? If methylxanthines are used at discharge, what criteria should be adhered to regarding their discontinuation? How is nutrition best provided while transitioning to home? In infants whose mothers desire exclusive breast-feeding, should gavage feeds be used to supplement in order to avoid bottle-feedings? How long should breast milk be fortified, and when should supplemented artificial milks be used and for what period of time postdischarge should these more expensive special-discharge artificial milks be used? What other supplements, such as inositol, vitamins, or antioxidants, should be provided in order to achieve optimal growth and development? Technology-dependent infants pose even greater complexities. Some infants and families adapt to extensive use of technology in the home. In other situations, basic infant care is difficult to achieve. What are the essential components for successful early discharge, and how can the studies involving selected families be made universal? How can NICUs better prepare fathers and mothers for premature parenthood? To what extent are we overwhelming families with additional responsibilities and expectations that may compromise their competency in basic parenting? Furthermore, the degree of provider variation in evaluating and providing for discharge planning is now being more carefully studied. In some circumstances, integrated teams in the NICU have facilitated the discharge process saving days of hospitalization, whereas in others adherence to discharge planning guidelines has lengthened the stay in the NICU and resulted in higher costs. What is the ideal system for achieving coordination of care without co-opting parental choices in assuming more care responsibility than is comfortable? In the design of tertiary care facilities, more attention to space for rooming-in experiences needs to receive greater priority. Furthermore, because of intensity of care, adverse environmental stimuli, and for issues of better resource utilization, should not most previously ill infants be discharged from level II or intermediate care centers? Finally, issues of increasing decision-making responsibility placed on parents (with the reassurance and guiding hand of dedicated physicians and nurses focused on individual infants) must never be made subservient to the economic whims of insurers to decrease costs without understanding the value of the entirety of the care process for critical illness, through convalescence, to it is hoped a supportive and nurturing environment in the home. Our patients deserve no less. The questions posed present a sample of issues yet to be scientifically addressed. These and many other questions need to be answered before we fully understand the optimal process of discharge for the preterm infant.