NEONATAL CARE

AND DISCHARGE CRITERIA

N.B. Staff should be discouraged from printing this document.

This is to avoid the risk of out-of-date printed versions of the document.
The Intranet should be referred to for the current version of the document.
 NEONATAL CARE ADMISSION AND DISCHARGE CRITERIA
1. PURPOSE:
• To provide a unified and consistent format that will be followed for admission and discharge to neonatal intensive care unit
• To ensure that each newborn infant is delivered and cared for in a facility appropriate for his or her health care needs and to facilitate the
achievement of optimal outcomes.

2. INTRODUCTION:
• The guidelines set out the standards required of the hospital to ensure that a high standard of neonatal care at all levels continues to be
provided in its Neonatal Intensive Care Units (NICU).
• Neonates are a specialized cohort of patients requiring an individualized approach in nursing care.
• Goals of care include minimizing stress, conserving energy, enhancing recovery, promotion of growth and well being and protecting sleep pattern.
• All healthy inborn more than 35 weeks of gestation and appropriate for gestational age should be rooming in with their mothers.
• For neonates who require a lengthy birth hospitalization, shortening the duration of neonatal hospitalization as much as possible is beneficial
because it decreases the risk of hospital-acquired neonatal morbidity, shortens the period of separation of the parents from the infant, and lowers
medical costs.

3. Healthy baby units:

the unit for accommodating otherwise healthy babies with no medical problem staying in the hospital because of maternal (post C/S for short period
according to mother condition, Mother in the ICU, etc.) or social reason. (refer to MOH guidelines)
4. ADMISSION CRITERIA &LEVELS OF NEONATAL CARE:
Capabilities Admission criteria Health Care Provider Types
• Provide neonatal resuscitation at every delivery. • Infant with mild respiratory distress does not require
Level I • Evaluate and provide postnatal care to stable oxygen supplementation can be watches for 1-2 hours as
term newborn infants. per a Senior doctor’s order. Pediatricians,
• Stabilize and provide care for infants born 35- family physicians,
37 weeks GA who remain physiologically stable. • Requiring support with feeding nurse practitioners,
• Stabilize newborn infants who are ill and those and other advanced practice
born at <35 wks. gestation until transfer to a • Minor anomalies that may need further investigations but registered nurses.
higher level of care. don’t compromise the infant’s health in the neonatal period
such as unilateral hydronephrosis, features of Down
Syndrome

• Large for Gestational Age (LGA) with birth weight > 4 kg.

• Infant of Diabetic Mother (IDM) to monitor blood sugar as

per hypoglycemia algorithm
• Term > 37 week with PROM >18 hours who is
asymptomatic and without history of chorioamnionitis
(Refer to GBS Guideline)

Level I capabilities plus: • infants born ≥32 and less than 35 wks. GA and weighing Level I health care providers
Level II • Provide care for infants born ≥32 wks. GA and ≥1.5kg and less than 2 kg with problems that are expected to plus:
Special weighing ≥1500g who have physiologic resolve rapidly
care immaturity or who are moderately ill with Pediatric specialist who has an
nursery problems that are expected to resolve rapidly • Continuous Positive Airway Pressure (CPAP), either experiences in neonatology.
and are not anticipated to need subspecialty transitional or extended stable CPAP.
services on an urgent basis.
• Provide care for infants convalescing after
intensive care
Capabilities Admission criteria Health Care Provider Types
• Provide mechanical ventilation for brief • Mechanical ventilation for conditions expected to resolve within
duration (<24 h) or continuous positive 24 hours
airway pressure or both. • Growing preemie who is stable and who requiring oxygen during
• Stabilize infants born before 32 wk the feeding
gestation and weighing < 1500 grams as per • Stable neonatal from level III with a corrected over 30 weeks,
standard of care. and over 1.2 kg and does not requiring invasive ventilation,
subspecialty support, surgical support, advanced treatments
and investigations (transfers should be reviewed on a caseby-
case basis between the tertiary and receiving sites).
• Temperature instability
• Transient tachypnoea of new-born
• Transient problems requiring cardiorespiratory
monitoring/laboratory investigation
• Jaundice new-borns requiring peripheral IV fluid therapy and
closer monitoring and intensive Phototherapy.
• Septic work and administration of antibiotics
• Gastrointestinal problems
o such as feeding problems severe enough to cause
clinical concern.
o Hypoglycaemia (Refer to hypoglycaemia guideline)
• CNS problems
o Convulsion.
o mild birth asphyxia
• Malformations
Congenital anomalies that may require intervention unavailable
on level I, or an initial period of observation, eg Pierre Robin
Syndrome.
• Family history of inborn errors of metabolisms
 Capabilities Admission criteria Health Care Provider Types
level II capabilities plus: • infants - <32 wk gestation and less than 1.5kg Level II health care
• Provide sustained life support. • All gestational ages and birth weights with critical providers plus: Certified
Level III
• Provide comprehensive care for infants illness Neonatologist, Pediatric
NICU
born • Meconium aspiration syndrome requiring mechanical medical subspecialists,
<32 wks. GA and weighing <1500g and born ventilation pediatric anesthesiologists,
at all GA and birth weights with critical • Persistent pulmonary hypertension of the newborn pediatric surgeons,
illness. • Air leak syndrome require intervention Pediatric ophthalmologists
• Provide prompt and readily available • Moderate and sever Hypoxic ischemic encephalopathy and neonatal nurse
access to a full range of pediatric medical for cooling therapy practitioners.
subspecialists, and pediatric • Surgical conditions such as omphalocele,
ophthalmologists. meningomyelocele, gastroschisis, imperforate anus
• Provide a full range of respiratory support and tracheoesophageal fistula.
that may include conventional and/or high- • Invasive diagnostic test/procedures e.g. diagnostic
laryngoscopy, ventricular tap, intravitreal injections,
frequency ventilation and inhaled nitric
thoracentesis.
oxide.
• Hemodynamically instability and Cardiac arrhythmia
Perform advanced imaging, with
such as supraventricular tachycardia or congenital
interpretation on an urgent basis, including
heart block
computed tomography, MRI, and
• Hyperbilirubinemia requiring exchange transfusion.
echocardiography.
• Persistent hypoglycaemia (Refer to hypoglycaemia
guideline)
• Any other baby whose clinical condition cannot be
appropriately cared for in Level 2 (as per consultant
decision)
5. DISCHARGE CRITERIA
Discharge planning should be developed and implemented by a multidisciplinary team consisting of physicians, nurses, respiratory therapists, occupational
and/or physical therapists, and social workers. The process can begin soon after an infant is admitted to the NICU and is continued through regularly
scheduled planning sessions during hospitalization.

The following are the components of discharge planning.

1. Neonatal medical readiness
• Neurophysiologically stable
• There is no specific weight is required to discharge preterm infants. However, most infants do not fulfill these criteria before they can reach 1.6-
1.8 kg
• Maintain normal body temperature in an open crib with normal room temperature (24 to 25ºC) for at least 24 hours
• Demonstrate maturity of respiratory control without episodes of apnea and bradycardia, up to five days after the discontinuation of caffeine
therapy.
• Demonstrate mature oral feeding skills (breast or bottle) that will allow enough nutritional intake to promote appropriate growth.
• Demonstrate a consistent pattern of appropriate weight gain for 3 days
• Patient should be discharged from NICU to other facilities in the hospital if he reached 4 months of age in term babies and 6 months corrected
age in preterm babies

2. Vaccination and screening and care:

• Medically stable preterm infants> 1800 gm and 28 days old should receive full immunization based upon their chronological age consistent
with the schedule and dose recommended for normal full-term infants
• Palivizumab should be given to eligible infants during respiratory syncytial virus season according to the guideline eligibility.
• All newborns require routine screening for metabolic screening, critical congenital heart disease, and hearing screening.
• Infants at risk for developing retinopathy of prematurity (ROP) should have routine ophthalmologic screening.
• Screening for intraventricular hemorrhage, imaging may be recommended prior to discharge to detect periventricular leukomalacia or white
matter injury in at-risk infants.
3. Parental readiness and education
• The parents should demonstrate consistent involvement in their infant's care, and readiness and competency to provide home care (feeding
techniques, positioning, medication administration, and respiratory treatments, training in gastrostomy and/or tracheostomy care and in the
use of cardiorespiratory monitoring equipment if needed).
• Cardiopulmonary resuscitation training is advisable to all parents
• Parents also should be counseled about the importance of supine sleeping.
• Special medical equipment and services needed at home should be arranged (oxygen, mechanical ventilation, cardiorespiratory monitoring,
or feeding pumps for transabdominal enteral nutrition).
• A social worker evaluation should be performed in order to assist with social or financial needs.

4. Follow up
• A full review of the infant's hospital course should be summarized and documented in infant’s medical record
• For healthy newborns in postnatal ward discharged less than 48 hours after delivery, three additional postnatal contacts are recommended for all
mothers and newborns follow up on day 3 (48–72 hours), one month old and at 2 month old.
• For infants with a complicated hospital course and ongoing health issues, review the results of diagnostic studies, such as cranial ultrasound
examinations and echocardiograms and Subspecialty consultants who will provide follow-up care should see the infant prior to hospital discharge.
• Follow up arrangements can be made for primary care, specialty care (e.g.pulmonology, cardiology, surgery), and neurodevelopmental follow- up.
• A plan for nutritional support and monitoring of growth also should be established.
• Neurodevelopmental follow-up in a special program should be arranged for extremely preterm and other high-risk infants. (per MOH guidelines)
• A visit should be scheduled within two to four days of discharge and arrangements made for ongoing care, including subspecialty care if needed.
• Dietitian consultation can help Infants with chronic disease, such as chronic lung disease, short bowel syndrome, cholestatic jaundice, or
osteopenia.
6. REFERENCES:

 Levels of Neonatal Care | From the American Academy of Pediatrics ...pediatrics.aappublications.org/content/130/3/587

 Level III neonatal intensive care unit (NICU) - Floyd Medical Centerwww.floyd.org/services/Pages/nicu.aspx
 NW Newborn Clinical Guideline - NICU Admissions, Discharges, and
...www.adhb.govt.nz/newborn/.../Admission/NICUAdmissionsDischargesAndTransfers...
 Neonatal admissions | Great Ormond Street Hospitalwww.gosh.nhs.uk › Health professionals › Clinical guidelines
 Selection criteria in the NICU: who should get effective critical care?https://www.ncbi.nlm.nih.gov/pubmed/19517656
 Criteria for Neonatal Transfer AND Neonatal NICU Admission Criteria ...www.tomwademd.net/criteria-for-neonatal-transfer-and-neonatal-nicu-admission criteria
 Admission to NICU CA4068v3 - www.nnuh.nhs.uk/publication/download/admission-to-nicu-ca4068v3/
 Discharge Criteria for the NICU | NICU Discharging Information
www.mercydesmoines.org/childrenshospital/variety-nicu-discharge
 Hospital Discharge of the High-Risk Neonate | FROM THE AMERICAN ...
pediatrics.aappublications.org/content/122/5/1119
 Going home: Facilitating discharge of the preterm infant - NCBI - NIH
https://www.ncbi.nlm.nih.gov › NCBI › Literature › PubMed Central (PMC)
 NICU Discharge Guidelines - Health Net
https://www.healthnet.com/static/general/unprotected/.../NICUDischargeGuidelines.pd..
 Neonatal Discharge Checklistafhsr.med.sa/cqi_web/web/cqi_docs/3.Documents/.../7540%20761%201522.pdf
 Download - Mid Essex Hospital Services NHS Trust
www.meht.nhs.uk/EasysiteWeb/getresource.axd?AssetID=6454&type=full..