EARLY DISCHARGE OF THE NEWBORN INFANT
Saturday, August 16, 2008
The trend for several years has been toward shorter hospital stays for well mothers and infants, with typical stays in 1997 of 24 hours following a normal vaginal delivery and 48–72 hours following a cesarean section. Although there has been a growing backlash against early discharge, culminating in the United States in the passage of the Newborns’ and Mothers’ Health Protection Act (effective January 1, 1998), it is unlikely that the typical length of stay for the normal newborn will increase substantially. Discharge at 24–36 hours of age appears safe and appropriate for most infants if there are no contraindications (Table 1–7) and a follow-up visit at 48–72 hours after discharge is ensured. Most infants with severe cardiorespiratory disorders and infections are identified in the first 6 hours of life. The exception would be the infant treated with intrapartum antibiotic prophylaxis for maternal group B streptococcal colonization or infection. The Centers for Disease Control and American Academy of Pediatrics (AAP) have recommended that these infants be observed in hospital for 48 hours because of the possibility of “partial treatment” with delayed onset of symptoms of infection. Other problems such as jaundice and difficulties in breast feeding typically occur after 48 hours and can usually be dealt with on an outpatient basis provided good follow-up has been arranged.
The AAP recommends a follow-up visit within 48–72 hours for any newborn discharged before 48 hours of age. Infants who are small or slightly premature—especially if breast feeding—are at particular risk for inadequate intake. Suggested guidelines for the follow-up interview and physical examination are presented in Table 1–8. The optimal timing of discharge must be determined in each case based on medical, social, and financial factors.
CIRCUMCISION
Circumcision is an elective procedure to be performed only in healthy, stable infants. The procedure probably has medical benefits, including prevention of phimosis, paraphimosis, balanoposthitis, and urinary tract infection. Later benefits include decreased incidence of cancer of the penis, cervical cancer (in partners of circumcised men), and sexually transmitted diseases (including HIV). Most parents decide on circumcision for nonmedical reasons. The risks of the procedure include local infection, bleeding, removal of too much skin, and urethral injury. The combined incidence of these complications is less than 1%. Local anesthesia (dorsal penile nerve block or circumferential ring block with 1% lidocaine without epinephrine) or topical application of an anesthetic cream (eg, lidocaine-prilocaine cream) are safe and effective and should always be used. Techniques that allow visualization of the glans throughout the procedure (eg, using Plastibell and Gomco clamp) are preferred to a blind technique (eg, using Mogen clamp) because occasional amputation of the glans can occur with the latter technique. Circumcision is contraindicated in infants with genital abnormalities (eg, hypospadias). Coagulation screen should be performed prior to the procedure in infants with a family history of bleeding disorders.
HEARING SCREENING
Normal hearing is critical to normal language development. Significant bilateral hearing loss is present in 1–3 infants per 1000 in the well nursery and in 2–4 infants per 100 in the neonatal intensive care unit population. All infants should be screened for hearing loss by auditory brainstem evoked responses or evoked otoacoustic emissions as early as possible. Primary care providers and parents need to be advised of the possibility of hearing loss and offered ready referral in suspect cases.
The AAP recommends a follow-up visit within 48–72 hours for any newborn discharged before 48 hours of age. Infants who are small or slightly premature—especially if breast feeding—are at particular risk for inadequate intake. Suggested guidelines for the follow-up interview and physical examination are presented in Table 1–8. The optimal timing of discharge must be determined in each case based on medical, social, and financial factors.
CIRCUMCISION
Circumcision is an elective procedure to be performed only in healthy, stable infants. The procedure probably has medical benefits, including prevention of phimosis, paraphimosis, balanoposthitis, and urinary tract infection. Later benefits include decreased incidence of cancer of the penis, cervical cancer (in partners of circumcised men), and sexually transmitted diseases (including HIV). Most parents decide on circumcision for nonmedical reasons. The risks of the procedure include local infection, bleeding, removal of too much skin, and urethral injury. The combined incidence of these complications is less than 1%. Local anesthesia (dorsal penile nerve block or circumferential ring block with 1% lidocaine without epinephrine) or topical application of an anesthetic cream (eg, lidocaine-prilocaine cream) are safe and effective and should always be used. Techniques that allow visualization of the glans throughout the procedure (eg, using Plastibell and Gomco clamp) are preferred to a blind technique (eg, using Mogen clamp) because occasional amputation of the glans can occur with the latter technique. Circumcision is contraindicated in infants with genital abnormalities (eg, hypospadias). Coagulation screen should be performed prior to the procedure in infants with a family history of bleeding disorders.
HEARING SCREENING
Normal hearing is critical to normal language development. Significant bilateral hearing loss is present in 1–3 infants per 1000 in the well nursery and in 2–4 infants per 100 in the neonatal intensive care unit population. All infants should be screened for hearing loss by auditory brainstem evoked responses or evoked otoacoustic emissions as early as possible. Primary care providers and parents need to be advised of the possibility of hearing loss and offered ready referral in suspect cases.
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