Acta Pædiatrica ISSN 0803-5253
REGULAR ARTICLE
Age and weight at final discharge from an early discharge programme for stable but tube-fed preterm infants AM Ahnfeldt ([email protected])1, H Stanchev2, HL Jørgensen3, G Greisen1 1.Department of Neonatology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark 2.Department of Neonatology, Naestved Hospital, Naestved, Denmark 3.Department of Clinical Biochemistry, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
Keywords Early discharge, Home visit, Neonatal nursing, Preterm infant, Tube feeding Correspondence AM Ahnfeldt, Department of Neonatology, Copenhagen University Hospital Blegdamsvej 9, 2100 Copenhagen East, Denmark. Tel: 0045 613 063 32 | Fax: 0045 35455025 | Email: [email protected] Received 18 July 2014; accepted 19 December 2014. DOI:10.1111/apa.12917
ABSTRACT Aim: Preterm birth is often associated with prolonged hospitalisation, complicating the parent–child relationship and breastfeeding rates. As a result, an early discharge programme was implemented in the department of neonatology at Rigshospitalet. The infants were stable, but required tube feeding, and during the programme, they received home visits by neonatal nurses. We evaluated the programme, focusing on the infants’ well-being, using weight gain, breastfeeding rates and total duration of hospitalisation as outcomes. Methods: Over an 11-year period, 500 infants participated in the programme and they constituted the early discharge group. They were compared with 400 infants discharged from the Naestved and Nykoebing Falster hospitals. Results: The early discharge group’s length of hospitalisation was only three days shorter than the comparison group, but they were eight days younger when they joined the programme (p < 0.0001). Total admission was 21 days longer (p < 0.0001). There was no difference in weight-for-age at discharge (p = 0.15), but infants in the early discharge group were more frequently fully or partly breastfed (88% versus 80%, p < 0.005). Conclusion: While recognising the limited comparability of the two groups, weight-for-age at discharge was similar, but the programme appeared to allow better breastfeeding success at the expense of a later final discharge.
INTRODUCTION Premature birth at under 37 weeks of gestational age is inevitably associated with prolonged hospitalisation due to the infants’ fragility and risk of morbidity during the first weeks after birth. Discharge is commonly delayed some weeks by the transition from tube feeds to full sucking feeds, due to immature sucking and swallowing reflexes in spite of the infants being clinically stable (1–4). Psychological stress often accumulates in the parents during their infants’ long hospitalisation, and this may affect breastfeeding (4–7). To address these problems, the department of neonatology at Copenhagen University Hospital, Rigshospitalet, implemented an early discharge programme in 2000. Premature infants allocated to the programme were sent home before final discharge, when they were clinically stable and still in need of tube feeding, and received home visits from a neonatal nurse until their final discharge. The early discharge programme was implemented in the department after completing a pilot project with 13 infants in 1997 and a quality control project in 2000, with 33 infants participating in the programme and 37 infants staying in the hospital until their final discharge. The results from these studies showed that the programme was well
received by the parents and suggested that it was beneficial for breastfeeding and reducing both the length of admission and staff hours (8). Other studies on the early discharge of preterm infants with or without tube feeding show contradictory results. Some have showed that it increased the duration of breastfeeding (3) and reduced the length of hospitalisation (4,5,7–9) and that the participating parents felt more prepared at the time of discharge (5–8). Other studies
Key notes
©2014 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2015 104, pp. 377–383
This study compared 500 stable preterm infants participating in an early discharge programme with 400 preterm infants hospitalised until final discharge. Programme participants required tube feeding and received home visits by neonatal nurses until they were finally discharged. Comparability was limited; however, the final discharge results showed that the programme appeared to result in similar weight-for-age and higher successful breastfeeding rates at the expense of later final discharge.
377
An early discharge programme for preterm infants
Ahnfeldt et al.
showed no increase in the rate of breastfeeding (6,7) or weight gain (4,7) at discharge. We performed a retrospective case–control study to evaluate the effects of the programme on weight gain, rate of breastfeeding at final discharge and total duration of admission. The comparison group comprised infants hospitalised in the neonatal department at Naestved Hospital including a number of infants who were transferred to its other facility at Nykoebing Falster Hospital. None of the infants were tube feeding when they were discharged.
tional age, and therefore, they were also admitted to the Naestved Hospital. When they were older than 35 weeks, clinically stable and only in need of breastfeeding establishment, infants were transferred back to Nykoebing Falster Hospital before final discharge (n = 99). The two departments shared administration and guidelines for treatment. Infants transferred to other hospitals in Denmark were excluded (n = 8), as were infants who died before discharge or had missing values during data collection (n = 37). The final number of infants in the comparison group was 400.
METHODS Between 1 January 2000 and 31 December 2010, 3,300 premature infants born at under 35 weeks of gestation were admitted to the department of neonatology at Rigshospitalet. A quarter lived in the hospital’s catchment area and were directly admitted from the delivery ward. The remainder were transferred from other hospitals in Denmark, Greenland or the Faroe Islands in utero or after birth in need of highly specialised treatment.
Intervention The early discharge programme During admission, parents had free access to their infant 24 h a day, where they gradually participated in all the infant’s care and breastfeeding establishment had often begun. Almost all Danish mothers intend to breastfeed, and the policy of the department has been to maximise encouragement and support. If the infants were significantly preterm, the mothers were encouraged to express their breast milk as soon as possible after birth and continue approximately eight times per day for as long as the infants needed tube feeds. Electric breast pumps were always available, and the mothers could borrow a machine during the programme. Infants were put to the breast and allowed to lick and suck as much as they wanted to. When sucking became significant, they were breastfed approximately eight to 12 times per day combined with tube feeds. After meeting the inclusion criteria for the programme, hospitalised infants were assigned to two or three nurses, who also became their home nurses when the families went home during the programme. The nurses were all qualified paediatric nurse specialists. Parents were formally trained in tube feeding, placement and replacement of the nasogastric tube and in basic life support. When the families went home to begin the programme, the infants were not formally discharged. They received one to two scheduled home visits each week, where growth was monitored and the parents were guided in infant care. Hospital visits to see a neonatologist in the unit were also scheduled, and the parents could phone the unit 24 h a day if necessary. Discharge was approved by a neonatologist when they met the ordinary discharge criteria: the infants had to be clinically healthy and show sufficient weight gain on breastfeeding and/or bottle-feeding without tube feeding. After discharge, the infants were seen by health visitors and in the general practitioner’s office according to the standard Danish child welfare procedures. If necessary, outpatient follow-up by the department of neonatology was offered.
Patients Infants were eligible for inclusion in the early discharge programme if: (i) they needed supplemental tube feeds when they were clinically stable, (ii) the parents were able to tube feed their infant and potentially insert the tube, (iii) the parents were capable of observing and nursing their infant, (iv) the infants lived in the Righospitalets catchment area, (v) at least one of the parents was able to speak and read Danish and (vi) the parents wanted to take their infant home as part of the early discharge programme. The intention to breastfeed was not a formal eligibility criterion, even though it could have been included. A total of 543 infants were allocated to the programme (Fig. 1). Infants not allocated to the programme were transferred to the children’s ward, to their local hospitals or discharged from the department of neonatology without tube feeding. The early discharge group was matched to a comparison group, which excluded 43 infants because they were ≥35 weeks of gestational age at birth (n = 40), died before discharge or had missing values in the database or hospital records (n = 3). As a result, 500 infants were included in the early discharge group. Between 1 January 2003 and 21 December 2009, 2,951 premature infants were admitted to the neonatal department at Naestved Hospital h, including 435 born at less than 35 weeks of gestational age. These 435 formed the preexclusion criteria comparison group. The infants were admitted from the delivery ward at the hospital or transferred from Nykoebing Falster Hospital or Rigshospitalet. Extremely premature infants (34+6 weeks (n = 40) Infants with missing values (n = 35) Infants with missing values (n = 3)
Infants included in the comparison group (CG) (n = 400)
Infants included in early discharge group (EDG) (n = 500)
Figure 1 Flow chart illustrating enrolment of infants in the study. Early discharge group (EDP); comparison group (CG).
and breastfeeding establishment had often begun. The policy to maximise encouragement and support with breastfeeding was also the same. If the infants were significantly preterm, the mothers were encouraged to express their breast milk as soon as possible after birth and continue approximately eight times per day for as long as the infants were in need of tube feeds. Electric breast pumps were also available. Infants were put to the breast and allowed to lick and suck as much as they wanted to. When sucking became significant, they were breastfed approximately eight to 12 times per day combined with tube feeds. Discharge was approved by a neonatologist when the infants met the ordinary discharge criteria: the infants had to clinically stable with sufficient weight gain on breastfeeding and/or bottle-feeding. All infants participated in the same standard child welfare programme. If necessary, outpatient follow-up by the neonatal department was offered. Data collection The two groups were compared from two different time periods defined by the data available in the two databases at the Rigshospitalet and Naestved Hospital. An early discharge programme project nurse managed the database at Rigshospitalet containing information on infants allocated to the programme. The database included details about hospital stay as well as notes from the home nursing care, all obtained from hospital records. Data on infants included in the comparison group were extracted from the Neobase clinical database and hospital records. The Neobase was
used for the registration and quality assurance of treatment of hospitalised infants, and the discharging neonatologist registered them. The database contained a range of perinatal and postnatal variables. Data analysis Significant differences between the early discharge group and the comparison group were tested using Student’s ttest, Mann–Whitney U-test or v2-test depending on the nature and distribution of the variables. All weights were converted to standard deviation scores (z-scores) using a foetal growth reference (10). Extra uterine growth percentages were calculated as the difference between the z-score at birth and at final discharge, and from birth to the start of the programme. All analyses were performed using SAS version 9.1 and Excel 2011.
RESULTS There were no statistically significant differences observed between the two groups with regard to the infants’ sex or incidence of twins and triplets. However, the infants in the early discharge group were more premature (Table 1). The infants in the early discharge group were discharged at 39.1 weeks of gestational age, and they were 16 days older than the infants in the comparison group who were discharged at 36.9 weeks of gestational age (p < 0.0001). The early discharge group’s length of admission was also 21 days longer than the comparison group (p < 0.0001). However, the infants in the early discharge group went
©2014 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2015 104, pp. 377–383
379
An early discharge programme for preterm infants
Ahnfeldt et al.
Table 1 Preterm infant’s characteristics of the early discharge group and the comparison group
N Boy/Girl (n) Multiples (%) At birth Gestational age (week day) Weight (g) Z-score weight-for-age Outcomes At early discharge Gestational age (week day) Postnatal age (d) Weight (g) Z-score (weight-for-age) Delta z-score (birth to early discharge) At final discharge Gestational age (week day) Postnatal age (d) Weight (g) Z-score (weight-for-age) Delta z-score (birth to discharge) Nutrition status Breast milk (%) Mix (%) Formula (%)
Early discharge group
Comparison group
p-value
500 270/230 32
400 221/179 30
NA 0.71 0.42
32.0 16 1731 481 1.12 1.25
32.7 15 1922 505 0.83 1.25
REGULAR ARTICLE
Age and weight at final discharge from an early discharge programme for stable but tube-fed preterm infants AM Ahnfeldt ([email protected])1, H Stanchev2, HL Jørgensen3, G Greisen1 1.Department of Neonatology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark 2.Department of Neonatology, Naestved Hospital, Naestved, Denmark 3.Department of Clinical Biochemistry, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
Keywords Early discharge, Home visit, Neonatal nursing, Preterm infant, Tube feeding Correspondence AM Ahnfeldt, Department of Neonatology, Copenhagen University Hospital Blegdamsvej 9, 2100 Copenhagen East, Denmark. Tel: 0045 613 063 32 | Fax: 0045 35455025 | Email: [email protected] Received 18 July 2014; accepted 19 December 2014. DOI:10.1111/apa.12917
ABSTRACT Aim: Preterm birth is often associated with prolonged hospitalisation, complicating the parent–child relationship and breastfeeding rates. As a result, an early discharge programme was implemented in the department of neonatology at Rigshospitalet. The infants were stable, but required tube feeding, and during the programme, they received home visits by neonatal nurses. We evaluated the programme, focusing on the infants’ well-being, using weight gain, breastfeeding rates and total duration of hospitalisation as outcomes. Methods: Over an 11-year period, 500 infants participated in the programme and they constituted the early discharge group. They were compared with 400 infants discharged from the Naestved and Nykoebing Falster hospitals. Results: The early discharge group’s length of hospitalisation was only three days shorter than the comparison group, but they were eight days younger when they joined the programme (p < 0.0001). Total admission was 21 days longer (p < 0.0001). There was no difference in weight-for-age at discharge (p = 0.15), but infants in the early discharge group were more frequently fully or partly breastfed (88% versus 80%, p < 0.005). Conclusion: While recognising the limited comparability of the two groups, weight-for-age at discharge was similar, but the programme appeared to allow better breastfeeding success at the expense of a later final discharge.
INTRODUCTION Premature birth at under 37 weeks of gestational age is inevitably associated with prolonged hospitalisation due to the infants’ fragility and risk of morbidity during the first weeks after birth. Discharge is commonly delayed some weeks by the transition from tube feeds to full sucking feeds, due to immature sucking and swallowing reflexes in spite of the infants being clinically stable (1–4). Psychological stress often accumulates in the parents during their infants’ long hospitalisation, and this may affect breastfeeding (4–7). To address these problems, the department of neonatology at Copenhagen University Hospital, Rigshospitalet, implemented an early discharge programme in 2000. Premature infants allocated to the programme were sent home before final discharge, when they were clinically stable and still in need of tube feeding, and received home visits from a neonatal nurse until their final discharge. The early discharge programme was implemented in the department after completing a pilot project with 13 infants in 1997 and a quality control project in 2000, with 33 infants participating in the programme and 37 infants staying in the hospital until their final discharge. The results from these studies showed that the programme was well
received by the parents and suggested that it was beneficial for breastfeeding and reducing both the length of admission and staff hours (8). Other studies on the early discharge of preterm infants with or without tube feeding show contradictory results. Some have showed that it increased the duration of breastfeeding (3) and reduced the length of hospitalisation (4,5,7–9) and that the participating parents felt more prepared at the time of discharge (5–8). Other studies
Key notes
©2014 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2015 104, pp. 377–383
This study compared 500 stable preterm infants participating in an early discharge programme with 400 preterm infants hospitalised until final discharge. Programme participants required tube feeding and received home visits by neonatal nurses until they were finally discharged. Comparability was limited; however, the final discharge results showed that the programme appeared to result in similar weight-for-age and higher successful breastfeeding rates at the expense of later final discharge.
377
An early discharge programme for preterm infants
Ahnfeldt et al.
showed no increase in the rate of breastfeeding (6,7) or weight gain (4,7) at discharge. We performed a retrospective case–control study to evaluate the effects of the programme on weight gain, rate of breastfeeding at final discharge and total duration of admission. The comparison group comprised infants hospitalised in the neonatal department at Naestved Hospital including a number of infants who were transferred to its other facility at Nykoebing Falster Hospital. None of the infants were tube feeding when they were discharged.
tional age, and therefore, they were also admitted to the Naestved Hospital. When they were older than 35 weeks, clinically stable and only in need of breastfeeding establishment, infants were transferred back to Nykoebing Falster Hospital before final discharge (n = 99). The two departments shared administration and guidelines for treatment. Infants transferred to other hospitals in Denmark were excluded (n = 8), as were infants who died before discharge or had missing values during data collection (n = 37). The final number of infants in the comparison group was 400.
METHODS Between 1 January 2000 and 31 December 2010, 3,300 premature infants born at under 35 weeks of gestation were admitted to the department of neonatology at Rigshospitalet. A quarter lived in the hospital’s catchment area and were directly admitted from the delivery ward. The remainder were transferred from other hospitals in Denmark, Greenland or the Faroe Islands in utero or after birth in need of highly specialised treatment.
Intervention The early discharge programme During admission, parents had free access to their infant 24 h a day, where they gradually participated in all the infant’s care and breastfeeding establishment had often begun. Almost all Danish mothers intend to breastfeed, and the policy of the department has been to maximise encouragement and support. If the infants were significantly preterm, the mothers were encouraged to express their breast milk as soon as possible after birth and continue approximately eight times per day for as long as the infants needed tube feeds. Electric breast pumps were always available, and the mothers could borrow a machine during the programme. Infants were put to the breast and allowed to lick and suck as much as they wanted to. When sucking became significant, they were breastfed approximately eight to 12 times per day combined with tube feeds. After meeting the inclusion criteria for the programme, hospitalised infants were assigned to two or three nurses, who also became their home nurses when the families went home during the programme. The nurses were all qualified paediatric nurse specialists. Parents were formally trained in tube feeding, placement and replacement of the nasogastric tube and in basic life support. When the families went home to begin the programme, the infants were not formally discharged. They received one to two scheduled home visits each week, where growth was monitored and the parents were guided in infant care. Hospital visits to see a neonatologist in the unit were also scheduled, and the parents could phone the unit 24 h a day if necessary. Discharge was approved by a neonatologist when they met the ordinary discharge criteria: the infants had to be clinically healthy and show sufficient weight gain on breastfeeding and/or bottle-feeding without tube feeding. After discharge, the infants were seen by health visitors and in the general practitioner’s office according to the standard Danish child welfare procedures. If necessary, outpatient follow-up by the department of neonatology was offered.
Patients Infants were eligible for inclusion in the early discharge programme if: (i) they needed supplemental tube feeds when they were clinically stable, (ii) the parents were able to tube feed their infant and potentially insert the tube, (iii) the parents were capable of observing and nursing their infant, (iv) the infants lived in the Righospitalets catchment area, (v) at least one of the parents was able to speak and read Danish and (vi) the parents wanted to take their infant home as part of the early discharge programme. The intention to breastfeed was not a formal eligibility criterion, even though it could have been included. A total of 543 infants were allocated to the programme (Fig. 1). Infants not allocated to the programme were transferred to the children’s ward, to their local hospitals or discharged from the department of neonatology without tube feeding. The early discharge group was matched to a comparison group, which excluded 43 infants because they were ≥35 weeks of gestational age at birth (n = 40), died before discharge or had missing values in the database or hospital records (n = 3). As a result, 500 infants were included in the early discharge group. Between 1 January 2003 and 21 December 2009, 2,951 premature infants were admitted to the neonatal department at Naestved Hospital h, including 435 born at less than 35 weeks of gestational age. These 435 formed the preexclusion criteria comparison group. The infants were admitted from the delivery ward at the hospital or transferred from Nykoebing Falster Hospital or Rigshospitalet. Extremely premature infants (34+6 weeks (n = 40) Infants with missing values (n = 35) Infants with missing values (n = 3)
Infants included in the comparison group (CG) (n = 400)
Infants included in early discharge group (EDG) (n = 500)
Figure 1 Flow chart illustrating enrolment of infants in the study. Early discharge group (EDP); comparison group (CG).
and breastfeeding establishment had often begun. The policy to maximise encouragement and support with breastfeeding was also the same. If the infants were significantly preterm, the mothers were encouraged to express their breast milk as soon as possible after birth and continue approximately eight times per day for as long as the infants were in need of tube feeds. Electric breast pumps were also available. Infants were put to the breast and allowed to lick and suck as much as they wanted to. When sucking became significant, they were breastfed approximately eight to 12 times per day combined with tube feeds. Discharge was approved by a neonatologist when the infants met the ordinary discharge criteria: the infants had to clinically stable with sufficient weight gain on breastfeeding and/or bottle-feeding. All infants participated in the same standard child welfare programme. If necessary, outpatient follow-up by the neonatal department was offered. Data collection The two groups were compared from two different time periods defined by the data available in the two databases at the Rigshospitalet and Naestved Hospital. An early discharge programme project nurse managed the database at Rigshospitalet containing information on infants allocated to the programme. The database included details about hospital stay as well as notes from the home nursing care, all obtained from hospital records. Data on infants included in the comparison group were extracted from the Neobase clinical database and hospital records. The Neobase was
used for the registration and quality assurance of treatment of hospitalised infants, and the discharging neonatologist registered them. The database contained a range of perinatal and postnatal variables. Data analysis Significant differences between the early discharge group and the comparison group were tested using Student’s ttest, Mann–Whitney U-test or v2-test depending on the nature and distribution of the variables. All weights were converted to standard deviation scores (z-scores) using a foetal growth reference (10). Extra uterine growth percentages were calculated as the difference between the z-score at birth and at final discharge, and from birth to the start of the programme. All analyses were performed using SAS version 9.1 and Excel 2011.
RESULTS There were no statistically significant differences observed between the two groups with regard to the infants’ sex or incidence of twins and triplets. However, the infants in the early discharge group were more premature (Table 1). The infants in the early discharge group were discharged at 39.1 weeks of gestational age, and they were 16 days older than the infants in the comparison group who were discharged at 36.9 weeks of gestational age (p < 0.0001). The early discharge group’s length of admission was also 21 days longer than the comparison group (p < 0.0001). However, the infants in the early discharge group went
©2014 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2015 104, pp. 377–383
379
An early discharge programme for preterm infants
Ahnfeldt et al.
Table 1 Preterm infant’s characteristics of the early discharge group and the comparison group
N Boy/Girl (n) Multiples (%) At birth Gestational age (week day) Weight (g) Z-score weight-for-age Outcomes At early discharge Gestational age (week day) Postnatal age (d) Weight (g) Z-score (weight-for-age) Delta z-score (birth to early discharge) At final discharge Gestational age (week day) Postnatal age (d) Weight (g) Z-score (weight-for-age) Delta z-score (birth to discharge) Nutrition status Breast milk (%) Mix (%) Formula (%)
Early discharge group
Comparison group
p-value
500 270/230 32
400 221/179 30
NA 0.71 0.42
32.0 16 1731 481 1.12 1.25
32.7 15 1922 505 0.83 1.25
