If there is one question that is asked more than any other it is this one. As I have told countless parents, few really expect to have a stay in the NICU so when it happens you are caught off guard. The normal period of bonding after birth is disrupted and as many families will say, they just can’t wait to go home. When a baby is born preterm though they have to get through many obstacles such as dealing with respiratory distress syndrome, need for CPAP and perhaps problems related to the pesky patent ductus arteriosus. For sure these apply to the babies who are quite preterm but even those who are born later such as between 32-36 weeks or others who are born at term but quite small (we call those intrauterine growth restricted or IUGR infants) have a few milestones to achieve before they can go home. Knowing these are needed may help you on your journey and are summarized here. Please note this applies to my practice and although I suspect will be close to others, there may be some differences depending on where you are.
The “Big Four”
Feedings by mouth
We sometimes confuse families I think when we say on rounds that their infant is on full feeds. What we mean by this is that there is no longer a requirement for any intravenous fluid supplementation. In order to go home though in almost all cases your infant will need to be free of a plastic tube that is either passing from the nose or mouth to the stomach (NG or OG tubes). There are some instances where families may be trained to provide these “gavage” feeds at home but this is the exception rather than the rule. To enable full oral feeding there may be some different nipple and bottle options tried as well as strategies for different frequency of feeding. Typically, babies will be given feeds every 2 or 3 hours (q2 or 3H) and then with time given more flexibility (semi-demand or cue based feeds). When you hear “ad lib demand feeding” that means that they can feed as much as they want and as often as they want to and that means home is close.
When a baby leaves the NICU they will need to travel in a car seat for safety. In order to properly fit in a car seat you need to be about 4 lbs or 1800g. For this reason most centers keep infants until they are about this size. If you have a baby born at 1200g and they need to gain 600g they usually will lose weight for a few days and regain to birth weight by a week or two. Average weight gain for preterm infants is about 15-20g/kg/day which means that after the first couple weeks it would take on average about 30 days to reach the 1800g mark.
Small babies don’t have a lot of fat to keep them warm. As such your small infant starts off life in an isolette or what others call an incubator. Infants are all different but you can expect to begin seeing babies trialed out of isolettes as small as about 1500g. There are many babies who can’t successfully get out into an open crib even up to 4-5 lbs. Don’t be frustrated by this. It will happen but until they can maintain their body temperature outside of an isolette between about 36.3 – 37.4 degrees they will not be able to go home.
As discussed in another post, irregular breathing from apnea of prematurity can last for some time. Units across the globe vary in their approach to dealing with such “events”. On the short end there are units that like to see three days without an event at rest before stopping monitors while others use a five day period and others even longer at 7 or 8 days apnea free. These dips in oxygen saturation and/or heart rate can be VERY frustrating to families. Events that occur with feedings are less worrisome but still usually require a day or two of monitoring before your doctor will let you go. Sometimes they can last for weeks even when feeding seems to have gotten on track. The good news is that they will end eventually.
Of course there are other specific reasons why infants will need to remain in hospital but if you keep track of these “big four” it will give you a rough idea of when home might be around the corner.
Thank you for this 🙂
However it is very different in Sweden… Temperature stability is needed – 36,8-37,2 for st least one day. We ask parents to control temperature several times a day the first days at home ad keep the baby skin to skin a lot. Full oral feeds is not needed since we have a system for home care. The parents are guided to feed their Nas nts in the tube from day one. They do not put new tubes in, but know all the tricks for checking correct position. Mother and baby practice breastfeeding and a nurse comes home twice a week to check the weight, observe breastfeeding and general appearance. If needed nurses take blood samples at home. When ready for discharge (and is needed before that) they come to the clinic for a doctor’s appointment. Most of our families go home when the infant is as boyt corrected age w34. The youngest I sent home was 33+5… The smallest baby I sent home was between 1600 and 1700 grams… Nurses go by car and cover an area with approximately a one hour drive from the hospital. This is so recommended!
Wow! That is amazing!