Original Article

Hidden Morbidity With "Successful" Early Discharge

Division of Neonatal Medicine, Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY, USA

Correspondence to: Paula Radmacher, MS, Neonatal Nutrition Research Laboratory, 511 South Floyd Street, Room 107, University of Louisville, Louisville, KY 40292, USA

^aSupport for Mr. Massey's participation in this project was provided by the 1999 Summer Scholar Research Program at the University of Louisville School of Medicine.

Abstract

OBJECTIVE: This study was conducted to determine if early postnatal discharge (EDC; £48 hours) in well newborns had an effect on the rate of hospital readmission within the first week after hospital discharge when compared to infants who remained >48 hours after birth (later discharge, LDC).

STUDY DESIGN: This was a retrospective medical chart review. Charts of infants born between January 1994 and December 1998, discharged as "well newborns" and treated subsequently at a primary children's hospital within 7 days of neonatal discharge, were reviewed. Infants were categorized by length of neonatal hospital stay, level of medical intervention (emergency department treatment or hospital admission), and final diagnosis.

RESULTS: There was a significant increase in hospital readmission rate for LDC infants when compared to EDC infants. When considering jaundice alone as an admitting diagnosis, EDC infants were admitted at a higher rate than LDC infants and with higher serum bilirubin concentrations. Readmitted, jaundiced infants had been almost always breast-fed.

CONCLUSION: Overall, EDC of well newborns appears to be a safe and reasonable practice. However, the risk for severe jaundice is an unresolved issue that requires a discharge strategy and early follow-up to prevent serious morbidity. Journal of Perinatology (2002) 22, 15-20 DOI: 10.1038/sj/jp/7210586

INTRODUCTION

Over the past several years, as postnatal hospital stays have decreased in length for most births, and as reports of complications related to jaundice and dehydration have appeared in the medical and lay press,^1,2,3,4,5 the safety of early discharge (EDC) continues to be questioned. Healthy, breast-fed, full-term infants may be at risk for morbidities of severe hyperbilirubinemia (kernicterus) and/or dehydration. The American Academy of Pediatrics Committee on the Fetus and Newborn⁶ issued a statement in 1995, which acknowledged that within certain guidelines, postpartum stays of less than 48 hours could be safely implemented. However, the committee cautioned that this decision should be consensual between patient and physician. This decision should take into consideration the uniqueness of each mother-infant pair, the health and self-confidence of the mother, the stability of the infant, adequacy of support systems, and access to appropriate follow-up care within 48 hours of discharge. The guidelines suggest that unless these components are in place, discharge should be deferred until appropriate arrangements for follow-up are made.⁶

The Newborns' and Mothers' Health Protection Act of 1996, which became effective in 1998, insured that American women have access to a minimum of 48 hours of in-hospital care following uncomplicated vaginal deliveries or 96 hours following cesarean births. Women and their medical care providers retain the option to shorten the hospital stay if they agree to do so. While this legislation deals with issues of eligibility and the appropriate conduct of health insurers, it does not address follow-up services.

This study reports our 5-year experience of EDC from a hospital with a high-volume obstetric service linked to a free-standing children's hospital in Louisville, KY.

METHODS

We conducted a retrospective record review of infants born between January 1, 1994 and December 31, 1998 at Norton Hospital (Norton HealthCare). Medical charts of infants, discharged as normal newborns, and subsequently treated in the emergency department (ED) or admitted to Kosair Children's Hospital within 7 days of discharge were reviewed for presenting symptoms, available laboratory data, and final diagnosis. Data regarding the type of delivery, age, gravidity/parity of the mother, and length of neonatal hospital stay were documented as well as the gestational age and birth weight of the infant.

Table 1 lists our criteria for EDC (£48 hours). Table 2 describes the infants in this review, grouped by length of neonatal hospital stay, level of medical treatment (ED or readmission), and final diagnosis. In cases of multiple presenting symptoms, the primary diagnosis was used for classification purposes. The fifth category (other) was used for diagnoses which could not be readily assigned to one of the four defined groups.

Proportional differences were compared by z-test. Maternal age, infant age at treatment/admission, and length of hospitalization were compared by t-test. Statistical significance was set at p<0.05.

RESULTS

During this time period, 21,628 infants were discharged as "well babies": 16,734 (77%) were EDC and 4894 (23%) were discharged later (LDC; >48 hours; Table 2). During the subsequent 7 days, 174 EDC (1.0 %) and 108 LDC (2.2%) infants were seen and discharged from the ED (p<0.001); 90 EDC (0.5%) and 43 LDC (0.9%) infants were readmitted to Kosair Children's Hospital (p<0.05). Infants were 5 or 6 days of age (p=0.004; EDC versus LDC, respectively) at the time of admission to the ED or the hospital.

No significant differences in maternal age, infant birth weight, gestational age, rates of breast-feeding, or proportions of primigravidas based on length of neonatal hospital stay (Table 3) were found. Statistically significant differences in rates of breast-feeding do exist when considering level of treatment without considering neonatal length of stay (78% vs 32%, readmissions versus ED treatment; p<0.001). There were no differences in proportions of diagnoses for infants seen in the ED regardless of the time to discharge. Diagnoses in the "other" category (Table 4) were varied and had no relation to postnatal length of stay.

LDC infants were readmitted at a rate almost twice that of EDC infants (0.9% vs 0.5%, LDC and EDC, respectively; p<0.001). However, the incidence of readmission for jaundice for the EDC population was 37/16,034 (0.22%) and 8/4894 (0.16%) for the LDC group (p<0.001). When considering jaundice separately among readmitted infants, EDC infants were more likely to be readmitted than LDC (41% vs 19%; p=0.021) and to have higher bilirubin levels than infants discharged later. Figure 1 shows that the mean admission bilirubin level for the EDC group was significantly higher than that of the LDC infants (21.6±4.6 vs 17.7±3.5 mg/dL, respectively; p=0.032). In addition, approximately one in five hospitalized, jaundiced, EDC infants had serum bilirubin levels above 25 mg/dL on admission. The maximum in this series was one EDC infant whose bilirubin was 31 mg/dL and required exchange transfusion for Coombs positive hemolytic disease. The maximum bilirubin concentration on readmission of LDC infants was 24 mg/dL. Other characteristics of the jaundiced infants were similar, including the prevalence of breast-feeding.

Of the infants readmitted, 77 EDC and 33 LCD had electrolyte reports available for review (Table 5). Serum Na values above 145 mEq/l occurred in 28 EDC (36%) and 7 LDC (21%) infants. Two EDC and one LDC infants had serum Na 160 mEq/l. The prevalence of breast-feeding in 35 infants with elevated Na was statistically significant when compared to infants with normal serum Na (86% vs 45%; p<0.001). The simultaneous occurrence of breast-feeding, jaundice, and hypernatremia was 16/77 (21%) and 2/33 (6%) in EDC and LDC infants, respectively (p=0.025).

DISCUSSION

In an effort to contain costs associated with childbirth during the past decade, EDC of healthy newborns has been instituted virtually across the country. In this system, mothers and babies go home as serum bilirubin begins to rise and, for breast-feeding dyads, before maternal milk production is established (Figure 2). In the second 24 hours after birth, women may still be requiring pain medication, be physically drained, and/or be on an uneven emotional plane. At the same time, they are bombarded with a variety of instructions about infant care: feeding, bathing, cord/circumcision care, signs of illness, normal wake/sleep patterns, car seat use, and the time and place for follow-up. The demonstration of breast-feeding or infant care techniques antenatally may not be an adequate substitute for hands-on experience once the infant has been born and is in the mother's care.

Once home, some parents lack the confidence to recognize normal infant behaviors from those that could be early signs of problems (infection, jaundice, dehydration, etc.). Our data on ED utilization indicate that significant resources are spent reassuring parents that their infants are healthy and behaving normally. These "worried parent-well child" visits point to a need for strategies to improve parental skills and to increase self-confidence for identifying and managing minor newborn issues.

Studies in the United States and Sweden in the 1970s and 1980s suggested that EDC (£48 hours) followed by at least two home visits was as effective as longer hospital stays among carefully selected populations.^7,8,9,10 With EDC as the standard of care in the US, it is not possible to make such comparisons in the current health care climate. In addition, it is unlikely that personnel-intensive, high-cost services would be offered universally to low-risk populations of mothers and infants. Lieu et al.¹¹ recently published a comparison of clinical outcomes, maternal satisfaction, and costs of home and clinic follow-up visits on postpartum days 3 or 4 in a population of low-risk mothers and newborns who were discharged within 48 hours of birth. That study showed no difference in clinical outcomes (rehospitalization, ED, or urgent care clinic visits) in the two groups. Mothers in the home visit group were more likely to rate aspects of their care as very good or excellent than those in the clinic visit group. However, the costs for in-home visitation were 26% higher than for clinic-based care. These results cannot be generalized to more socioeconomically disadvantaged (or higher-risk) populations because of a number of limitations: strict study eligibility criteria, a better-educated, higher-paid population that already had access to coordinated health than the general population.

Current reports on EDC and subsequent readmission are difficult to compare due to variations in the definition of EDC and the time frames for readmission.^12,13,14 Most series report readmission rates of 1% to 3% within the first 2 weeks after neonatal discharge with the most common diagnosis being hyperbilirubinemia. Although our overall readmission rates of 0.5% and 0.9% (EDC and LDC, respectively) within 1 week postdischarge compare favorably with these reports, we were surprised to note statistically higher rates for the LDC group.

Hyperbilirubinemia occurs universally in the early newborn period, resulting in clinical jaundice in 50% to 60% of infants.¹⁵ The peak is usually higher and the duration is often longer in breast-fed infants than those fed human milk alternatives. In our series of infants, we observed higher peak bilirubins in the EDC infants, despite fewer overall readmissions. The combination of breast-feeding and earlier discharge appeared to be associated with more extreme hyperbilirubinemia, although Maisels and Kring¹⁶ indicate that discharge <72 hours after birth is a risk factor for readmission regardless of the mode of feeding. The duration and severity of hyperbilirubinemia can be exacerbated by inadequate feeding (too little volume, too few feedings), often called breast-feeding jaundice.¹⁷ Although a rare complication, kernicterus is not extinct and there are few reliable predictors of risk for encephalopathy.¹⁸ EDC decreases the amount of time in which mothers can readily call on the expertise of nursing and lactation support staff during feedings with their babies. Despite prenatal care and classes, mothers may need to be educated and reminded about the need for frequent nursing (6 to 12 times per day) in the first days after birth to help establish their milk supply and to promote excess bilirubin excretion via the stool.^18,19 While none of our infants had a diagnosis of acute kernicterus, they will require follow-up over time for identification of neurological sequelae.

In our cohort, there was an association between breast-feeding and jaundice, which was severe enough to warrant rehospitalization. Hypernatremia existed as a co-morbidity in a number of these infants. The coupling of the time of discharge with the onset of lactogenesis and bilirubin production creates a situation which may dictate closer oversight of breast-fed infants than those fed formula. Without such monitoring by in-home or office visits, early signs of inadequate bilirubin clearance and/or insufficient milk intake can be missed, leading to potentially disastrous sequelae. In their report on breast-feeding, the Academy of Pediatrics recommends that "formal evaluation of breast-feeding performance be undertaken during the first 24 to 48 hours after delivery, and again at the early follow-up visit, which should occur 48 to 72 hours after hospital discharge".²⁰ The mild to severe hypernatremia seen in many of our breast-fed infants is an indication that some mothers may need professional lactation support during the first postdischarge days. What we do not know is how many infants may experience hyperbilirubinemia with or without dehydration, which is not recognized in the early postnatal period.

Overall, EDC of normal healthy newborns is a safe and reasonable practice, but the timing of discharge should be based on the readiness of the mother-infant dyad and not on an arbitrary time frame. Strategies are needed to identify infants at risk for severe jaundice, breast-feeding-associated difficulties, and their sequelae. The ultimate success of EDC programs is dependent on meeting established criteria prior to authorizing infant discharge and on the quality of early follow-up, which can serve to diagnose hyperbilirubinemia with or without dehydration and to reinforce optimal breast-feeding practice. Collaborative epidemiological projects, such as MAJIC (Making Advances Against Jaundice in Infant Care) from the American Academy of Pediatrics and Harvard University School of Public Health,²¹ may prove useful both as a model for broad implementation of an evidence-based practice guideline as well as a source of objective outcome data.

References

1 Cooper WO, Atherton HD, Kahana M, Kotagal UR. Increased incidence of severe breast-feeding malnutrition and hypernatremia in a metropolitan area. Pediatrics 1995; 96: 957-60. MEDLINE

2 Catz C, Hanson JW, Simpson L, Uaffe SJ. Summary of workshop: early discharge and neonatal hyperbilirubinemia. Pediatrics 1995; 96: 743-5. MEDLINE

3 Helliker K. Dying for milk: some mothers, trying in vain to breast-feed, starve their infants. Wall St J 1994; 224: 1-4.

4 Kasindorf JR. Home too soon. Good Housekeeping 1995; 221: 115-7.

5 Davis R, Appleby J. Porous safety net allows lethal medical mistakes. USA Today 2000; 1-2.

6 The Academy of Pediatrics Committee on the Fetus and Newborn, 1994-1995. Hospital stay for healthy term newborns (RE9539). Pediatrics 1995; 96: 788-90.

7 Yanover JM, Jones DJ, Miller MD. Perinatal care of low-risk mothers and infants: early discharge with home care. N Engl J Med 1976; 294: 702-5. MEDLINE

8 Waldenstrom U. Early and late discharge after hospital birth. Health of mother and infant in the postpartum period. Uppsala J Med Sci 1987; 92: 301-14.

9 Waldenstrom U. Early discharge with domiciliary visits and hospital care: parent's experiences of two modes of post-partum care. Scand J Caring Sci 1987; 1: 57-8.

10 Carty EM, Bradley CF. A randomized, controlled evaluation of early postpartum hospital discharge. Birth 1990; 17: 199-204. MEDLINE

11 Lieu TA, Braveman PA, Escobar GJ et al. A randomized comparison of home and clinic follow-up visits after early postpartum hospital discharge. Pediatrics 2000; 105: 1058-65. MEDLINE

12 Lee KS, Perlman M, Mallantyne M et al. Association between duration of neonatal hospital stay and readmission rate. J Pediatr 1995; 127: 758-66. MEDLINE

13 Britton JR, Britton HL, Beebe SA. Early discharge of the term newborn: a continued dilemma. Pediatrics 1994; 94: 291. MEDLINE

14 Braveman P, Egerter S, Peral M et al. Early discharge of newborns and mothers. A critical review of the literature. Pediatrics 1995; 96: 716. MEDLINE

15 Maisels MJ, Clifford K. Normal serum bilirubin levels in the newborn and the effect of breast-feeding. Pediatrics 1986; 78: 837-43. MEDLINE

16 Maisels MJ, Kring E. Length of stay, jaundice, and hospital readmission. Pediatrics 1998; 101: 995-8. MEDLINE

17 DeCarvalho M, Klaus MH, Herkatz MB. Frequency of breast-feeding and serum bilirubin concentrations. Am J Dis Child 1982; 136: 737-8. MEDLINE

18 Turkel SB, Guttenberg ME, Moynes DR, Hodgman JE. Lack of identifiable risk factors for kernicterus. Pediatrics 1980; 66: 502-6. MEDLINE

19 Gartner LM. Neonatal jaundice. Pediatr Rev 1994; 15: 422-32. MEDLINE

20 American Academy of Pediatrics, Work Group on Breast-feeding. Breast-feeding and the use of human milk. Pediatrics 1997; 100: 1035.

21 American Academy of Pediatrics, Committee on Quality Improvement. Making advances against jaundice in infant care (MAJIC) http://www.aap.org/visit/majic.htm

Figures

Figure 1 Initial serum bilirubin (mg/dl) in infants readmitted for jaundice (mean±SD).

Figure 2 Changes in serum bilirubin during lactogenesis in the first postpartum week. Adapted and reproduced with permission from Gartner [Gartner LM. Pediatr Rev 1994;15:423; Figure 1] and Neville et al. [Neville MC, Allen JC, Archer PL, et al. [Am J Clin Nutr 1991;54:83; Figure 2].

Tables

Table 1 Criteria for EDC

Table 2 Distribution of Infants by Length of Neonatal Stay and Level of Treatment

Table 3 Characteristics of Mothers and Their Infants Based on Length of Neonatal Stay or Level of Medical Treatment

Table 4 "Other" Causes for Treatment in the First Postdischarge Week

Table 5 Jaundice and Hypernatremia Among Readmitted Infants

January 2002, Volume 22, Number 1, Pages 15-20

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