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Newborn hospitalization: A closer look
Newborn hospitalization: A closer look W i l l i a m B. P i t t a r d III, MD, a n d Kitty M. G e d d e s , BSN From the Department of Pediatrics, Medical University of South Carolina, Charleston To assess the safety of m o d e r a t e l y early hospital discharge for normal newborn infants ( m e a n _+ SD, 31 _+ 5 hours after delivery), we c o m p a r e d the incidence of hospital readmission within 6 weeks of birth with the incidence of readmission a m o n g a similar cohort of infants with e x t e n d e d hospitalization ( m e a n _+ SD, 92 _ 44 hours) as a result of maternal illness. The hospital charts for all infants admitted to the well-baby nursery b e t w e e n January I and D e c e m b e r 31, 1985, were reviewed. Fifty-two (3.0%) of the 1714 infants who were discharged m o d e r a t e l y early and 17 (2.7%) of the 622 infants who had an e x t e n d e d hospitalization were readmitted to the hospital by a g e 6 weeks (P = NS). Maternal age, financial status, and race e a c h failed to predict infant readmission. Only four of the 52 readmission diagnoses a m o n g infants discharged moderately early could potentially have been identified (not prevented) before discharge with an e x t e n d e d newborn hospitalization. These d a t a indicate that moderately early neonatal hospital discharge does not result in an increased incidence of rehospitalization within the first 6 weeks of life. (J PEDIATR1988;112:257-61)
The American Academy of Pediatrics recommends that routine well-baby hospital discharge occur preferably 48 to 72 hours after delivery.1 Because of the need for obstetric beds, the current practice at the Medical University of South Carolina is to discharge newborn infants after 24 hours but before 48 hours after delivery. To assess neonatal well-being after this moderately early discharge, we evaluated the number of infants readmitted to the hospital within 6 weeks of birth.
cohort. The incidence of readmission within 6 weeks of birth of these two groups was compared. There were 2813 neonates admitted to the well-baby nursery during the 1-year retrospective study. Of the 2474 vaginally delivered infants, 1713 had no maternal or newborn clinical problem identified within the first 24 hours of life and were assigned to moderately early hospital 95% CI
95% confidenceinterval
METHODS All infants delivered at MUSC from January through December 1985 and admitted to the well-baby nursery were evaluated. Those with no neonatal or maternal medical reason for prolonged hospitalization were assigned to moderately early discharge and represented the experimental cohort. Those with a maternal reason for prolonged stay but having no neonatal problems were assigned to extended newborn hospitalization to facilitate motherinfant interaction; this group represented the control Submitted for publication June 10, 1987; accepted Aug. 27, 1987. Reprint requests: William B. Pittard III, MD, Medical University of South Carolina, Department of Pediatrics, 171 Ashley Ave., Charleston, SC 29425.
discharge. One neonate of the 339 delivered by cesarean section was assigned to moderately early discharge and left the hospital at age 34 hours with his adoptive parents. These neonates ( n - - 1714) remained in the hospital for 31 _+ 5 hours (mean +_ SD) after delivery. Of the remaining 761 vaginally delivered infants, 315 were assessed during the first 24 hours of life to have maternal and 446 to have neonatal reasons for extended hospitalization. Similarly, of the 338 remaining infants delivered by cesarean section, all of whom were assigned to extended hospitalization, 31 had both a neonatal reason and the maternal reason (operative delivery) for extended hospitalization. Thus there were 477 neonates (446 vaginally delivered and 31 surgically delivered) with extended
257
258
Pittard and Geddes
The Journal of Pediatrics February 1988
T a b l e I. Comparison cohort characteristics Early discharge with no n e o n a t a l or maternal problem
Prolonged hospitalization with no n e o n a t a l problem
1714 39.7 ___2.0 3228 +__462 22.5 ___5 31 +__5 864 (50) 1189 (69) 999 (58)
622 39.0 ___2.0 3273 + 506 23.8 ___6 92 + 44 325 (52) 399 (64) 321 (52)
N Gestational age (wk)* Birth weight (g)* Maternal age (yr)* Length of newborn hospitalization (hr)* Male: No. (%) Black: No. (%) Indigent: No. (%) *Mean • SD.
Table II. Reasons for prolonged newborn hospitalization (n = 1099)
Maternal morbidity Cesarean delivery Increased total serum bilirubin, positive Coombs test, or both Sepsis evaluation Respiratory distress Low birth weight (>2000 g but <2500 g) Congenital anomalies Feeding difficulty Serum glucose instability Birth injury Cardiac concerns (murmurs, etc.) History of sibling with sudden infant death syndrome Observation for drug withdrawal
315 307 162 127 60 28 27 26 17 12 8 7 3
hospitalization because of neonatal problems. These neonates remained hospitalized for 90 • 62 hours (mean • SD) and were not included in either the experimental or the control study cohort. Finally, the 622 remaining infants (315 delivered vaginaUy and 307 delivered surgically) had no neonatal problem identified during the first 24 hours of life and were assigned to an extended newborn hospitalization solely as a result of maternal concerns. These neonates remained hospitalized for 92 • 44 hours (mean • SD). Their incidence of readmission by age 6 weeks was compared with the incidence of readmission of the 1714 infants discharged moderately early. The gestational age, birth weight, maternal age, length of newborn hospitalization, percent male, percent black, and percent indigent in these two cohorts are shown in Table I. Information recorded for each infant was collected by individual chart review and included length (hours) of newborn hospitalization, clinical factors that prolonged
hospitalization, mother's age at delivery, mode of delivery (vaginal vs cesarean section), race, and occurrence of readmission within 6 weeks of birth. If readmission did occur, the age (weeks) of the infant on readmission and the readmission diagnosis were recorded. Readmission criteria were the same for all neonates and were those which have been used at MUSC for several years. The infant's source of financial support was also recorded: private (insurance support), Medicaid (government support), indigent (no third-party financial support) and self-payment (responsible for payment without third-party support). With the use of data computed by the South Carolina Department of Health and Environmental Control, as well as the individual chart review, the incidence of death in the two study groups during the first 6 weeks after delivery was documented. If death occurred, the age of the infant at the time of death and the cause were recorded. Although neither the serum bilirubin concentration at follow-up visits nor the number of determinations after discharge was recorded, clinical icterus was monitored closely in the nursery. When any question of an elevated serum bilirubin concentration was present, follow-up within 24 hours of discharge was assured by the parents or discharge was postponed. If the infant had any clinical icterus noted, moderately early discharge was not allowed. To assess indirectly the serum bilirubin rise among infants assigned to moderately early discharge, we monitored the increase among the neonates maintained in the hospital for maternal reasons only (control cohort). The number of neonates in this extended hospitalization cohort who developed a serum bilirubin concentration >10 mg/ dL, the maximum bilirubin concentration recorded, and the age of the neonate when this concentration was reached were noted. Finally, the parents of all infants with a history of a previous sibling death from sudden infant death syndrome were routinely given the option of having their infant
Volume 112 Number 2
Newborn hospitalization: A closer look
259
Table III. Reasons for hospital readmission within 6 weeks of birth Extended hospitalization (n = 17)
Moderately early discharge (n = 52) Reason
Rule out sepsis Hyperbilirubinemia Gastroesophageal reflux Pyloric stenosis Apnea Laryngomalacia Interrupted aortic arch Failure to thrive Child abuse
n
%
36 68 4 8 3 6 2 4 2 4 2 4 1 2 1 2 1 2
receive a series of respiratory tests, which, if accepted, prolonged hospitalization. A suspicion of infection, respiratory distress, or minor congenital anomaly also extended hospitalization. A "sepsis evaluation" involved obtaining blood studies and appropriate cultures and initiating either antibiotic therapy or observation. The term "respiratory distress" referred to any difficulty in breathing; the predominant clinical observation was transient tachypnea. Finally, congenital anomalies in this population were abnormalities representing minor dysmorphic features commensurate with a well-baby nursery admission. Data were analyzed using the chi-square and unpaired Student t test techniques. RESULTS No newborn infant was discharged directly from the labor and delivery area, and none was lost to follow-up within 6 weeks of birth. The most commonly observed neonatal problem that prevented moderately early discharge was a total serum bilirubin concentration of >5 m g / d L within the first 24 hours of life. A summation of all such problems and their incidence are shown in Table II. Of the 1714 babies discharged moderately early, 52 (3.0%) were readmitted within 6 weeks of birth. Of the 622 control cohort infants, 17 (2.7%) were readmitted by 6 weeks of age. These readmission rates did not differ significantly. Of the total study population (N -- 2336), 43 of the 1320 indigent babies (3.3%; 95% CI 4.2% to 2.4%), 20 of the 643 Medicaid babies (3.1%; 95% CI 4.4% to 1.8%), and five of the 328 private service babies (1.5%; 95% CI 2.8% to 0.2%) were readmitted within 6 weeks of birth. These readmission rates did not differ significantly. Eight (2.7%) of the 307 infants delivered by cesarean section were readmitted by age 6 weeks. This readmission incidence did not differ significantly from the readmission
Reason
Rule out sepsis Hyperbilirubinemia Gastroesophageal reflux Child abuse
n
%
14 82 1 6 1 6 1 6
incidence of either the remaining control infants or the experimental infant group. Of the infants discharged moderately early, 31 (2.6%) of 1189 black infants and 21 (4.0%) of 525 white infants were readmitted within 6 weeks of birth. These readmission rates did not differ significantly from each other, nor did they differ significantly from the readmission rates among black infants and white infants in the extended hospitalization group. Similarly, 37 (3.7%) of 999 indigent infants in the group discharged early, in comparison with six (1.9%) of 321 indigent infants in the control group were readmitted by age 6 weeks, and these rates did not differ significantly. The mean age (+_SD) for mothers of all study infants (N = 2336) was 22.8 + 5 years and did not differ significantly from the age (22 + 4 years) of the mothers of the 52 readmitted infants who had been discharged moderately early. Five infants were readmitted for jaundice in the first week after discharge. None of these infants required an exchange transfusion, and the serum bilirubin concentrations declined with phototherapy in each case. One neonate of this group had an extended newborn hospitalization. This infant was breast-fed and was readmitted at age 7 days with a serum bilirubin concentration of 22 mg/dL. The remaining four infants (all discharged moderately early) each had serum bilirubin concentrations of 18 m g / d L or less on admission that potentially could have been detected with an extended hospitalization. Thirty-six babies in the control cohort (n -- 622) developed a total serum bilirubin concentration as great as 10 m g / d L in the hospital. Only one of these neonates developed a serum level > 15 mg/dL. This neonate developed a serum concentration of 18 m g / d L on day 3 of life and was treated with phototherapy. None of these infants required exhange transfusion. Four infants, three from the group discharged moderately early and one from the control cohort, died by age 6
260
Pittard and Geddes
weeks. One child was readmitted at age 12 days and died the following day (age 13 days) with disseminated herpes simplex infection. A second infant died in the emergency room at age 23 days and subsequently had an autopsy diagnosis of sudden infant death syndrome. The third and fourth infants (the single infant death in the control cohort group) were readmitted at 34 and 24 days, respectively, and died in the hospital, both with a diagnosis o f child abuse. Of the 69 total readmissions, 50 (72%) resulted from suspected infectious disease. Six infants had sepsis, with blood or spinal fluid cultures positive for bacterial growth. Table III summarizes the readmission diagnoses and offers a visual comparison between the study groups. DISCUSSION These data failed to show a difference in the readmission rate of babies discharged moderately early (3.0%) versus those who had a prolonged neonatal hospitalization (2.7%). The power of this statistical comparison to detect a 50% difference in the readmission rates is 65%. The data from this study support the moderately early discharge policy at MUSC. A possible explanation for these data is that infants could have been readmitted to another hospital in the community, thus making the detected readmission rate spuriously low. This is unlikely, however, because indigent infants in Charleston are usually readmitted to our facility. Further, although the Medicaid and private service infants who were born at M U S C may occasionally be admitted to other hospitals, neonates who require hospitalization for acute illness within the first 6 weeks of life tend to be admitted to the MUSC. Younger mothers of lower socioeconomic status have previously been associated with a higher incidence of hospital readmission of their infants? Further, although moderately early neonatal hospital discharge is often discouraged because of concern about potential problems with neonatal jaundice, jaundice has not been observed as a major clinical problem among neonates discharged early. 3 Only five infants were identified and readmitted in this study because of increased bilirubin concentrations, and younger, indigent mothers were not found to be more likely to have their infants readmitted than older, more affluent mothers. Of the 622 control cohort infants, none of whom had clinical icterus at 24 hours of age, one (0.1%) developed a serum bilirubin concentration of > 15 m g / d L in the hospital and a second one (0.3%) after discharge. This incidence is similar to the four (0.2%) of 1714 infants identified in the group discharged moderately early. These observations do not allow an assessment of how many neonates in the group discharged moderately early developed hyperbiliru-
The Journal of Pediatrics February 1988
binemia and went undetected, but they do indicate that neonates develop hyperbilirubinemia 24 to 36 hours after delivery. An interesting difference was noted between the data in this study and those reported by McCormick et al. 4 She observed a greater incidence of hospital readmission among indigent and government-supported infants than among those infants who had insurance coverage. In this study, no difference based on financial status of the parents was observed in the incidence of readmission. Perhaps there is no real difference in the severity of illness among these financial groups of infants. Alternatively, these data differences may indicate that the medical response (hospitalization ) to infant illness differs according to financial status in different areas of the country. The time of greatest medical risk for infants is thought to be the 4- to 6-hour transition period between intrauterine and extrauterine existence?. 6 At MUSC, this period is closely monitored by residents, nurses, and attending (faculty) physicians. Moreover, no infant is discharged until results of an examination by the receiving nursery nurse are normal and until both an admitting and a discharge examination by the resident and the attending physician show normal results. The infant must be feeding well from the mother's breast or a bottle, have a normal stool and urine pattern, and be maintaining a normal body temperature at room temperature before discharge is approved. Once an infant has met these criteria, his risk of serious illness is assumed to be greatly reduced. Previous investigators have documented that follow-up home visits by medical personnel after early neonatal hospital discharge are cost-effective, have resulted in no increase in infant morbidity, and have improved continuity of care for both full-term and high-risk infants. 3,7 This form of postdischarge maternal and neonatal support, although not available at MUSC, might well improve the neonatal readmission rate. Nevertheless, the readmission rate by 6 weeks of age in this study was below 3%. Previous reports note yearly readmission rates, rather than 6-week readmission rates, and describe a variation from 7% to 20% for normal birth weight infants?. 8.9 On the basis of these data, a closely monitored shortened length of neonatal hospitalization does not appear to increase the incidence of readmission within 6 weeks of birth. Suspected infectious disease was overwhelmingly the major cause for readmission; hyperbilirubinemia was rare. Maternal age, race, and parental financial status were not predictors of early infant readmission.
REFERENCES
1. American Academy of Pediatrics, Committee on Fetus and Newborn, American College of Obstetricians and Gynecolo-
Volume 112 Number 2
2.
3. 4.
5.
Newborn hospitalization: A closer look
gists, Committee on Obstetrics. Maternal and fetal medicine: guidelines of perinatal care. 1983:90-1. Adebonojo FO. A comparative study of the child health care of urban and suburban children. Clin Pediatr 1973;12:6448. Yanover M J, Jones D, Miller MD. Perinatal care of low-risk mothers and infants. N Engl J Med 1976;294:702-5. McCormick MC, Shapiro S, Starfield B. Rehospitalization in the first year of life for high-risk survivors. Pediatrics 1980;66:991-9. Desmond MM, Rudolph A J, Phitaksphraiwan P. The transitional care nursery: a mechanism for preventive medicine in the newborn. Pediatr Clin North Am 1966;13:651-68.
261
6. Britton HL, Britton JR. Efficacy of early newborn discharge in a middle-class population. Am J Dis Child 1984;138:10416. 7. Brooten D, Kumar S, Brown LP, et al. A randomized clinical trial of early hospital discharge and home follow-up of very low birth weight infants. N Engl J Med 1986;315:934-9. 8. Gordis L, Markowitz M. Evaluation of the effectiveness of comprehensive and continuous pediatric care. Pediatrics 1971;48:766-76. 9. Hendershot GE. Work during pregnancy and subsequent hospitalization of mothers and infants. Public Health Rep 1979;94:425-31.
FELLOWSHIPS Available fellowships in pedia~tric subspecialties and those for general academic pediatric training are listed once a year, in May, in The Journal of Pediatrics. Each October, forms for listing such fellowships are sent to the Chairman of the Department of Pediatrics at most major hospitals in the United States and Canada. Should you desire to list fellowships, a separate application must be made each year for each position. All applications must be returned to The C. V. Mosby Company by February 15 of the listing year to ensure publication. Additional forms will be supplied on request from the Journal Editing Department, The C. V. Mosby Company, 11830 Westline Industrial Drive, St. Louis, M e 63146/314-872-8370.
The American Academy of Pediatrics recommends that routine well-baby hospital discharge occur preferably 48 to 72 hours after delivery.1 Because of the need for obstetric beds, the current practice at the Medical University of South Carolina is to discharge newborn infants after 24 hours but before 48 hours after delivery. To assess neonatal well-being after this moderately early discharge, we evaluated the number of infants readmitted to the hospital within 6 weeks of birth.
cohort. The incidence of readmission within 6 weeks of birth of these two groups was compared. There were 2813 neonates admitted to the well-baby nursery during the 1-year retrospective study. Of the 2474 vaginally delivered infants, 1713 had no maternal or newborn clinical problem identified within the first 24 hours of life and were assigned to moderately early hospital 95% CI
95% confidenceinterval
METHODS All infants delivered at MUSC from January through December 1985 and admitted to the well-baby nursery were evaluated. Those with no neonatal or maternal medical reason for prolonged hospitalization were assigned to moderately early discharge and represented the experimental cohort. Those with a maternal reason for prolonged stay but having no neonatal problems were assigned to extended newborn hospitalization to facilitate motherinfant interaction; this group represented the control Submitted for publication June 10, 1987; accepted Aug. 27, 1987. Reprint requests: William B. Pittard III, MD, Medical University of South Carolina, Department of Pediatrics, 171 Ashley Ave., Charleston, SC 29425.
discharge. One neonate of the 339 delivered by cesarean section was assigned to moderately early discharge and left the hospital at age 34 hours with his adoptive parents. These neonates ( n - - 1714) remained in the hospital for 31 _+ 5 hours (mean +_ SD) after delivery. Of the remaining 761 vaginally delivered infants, 315 were assessed during the first 24 hours of life to have maternal and 446 to have neonatal reasons for extended hospitalization. Similarly, of the 338 remaining infants delivered by cesarean section, all of whom were assigned to extended hospitalization, 31 had both a neonatal reason and the maternal reason (operative delivery) for extended hospitalization. Thus there were 477 neonates (446 vaginally delivered and 31 surgically delivered) with extended
257
258
Pittard and Geddes
The Journal of Pediatrics February 1988
T a b l e I. Comparison cohort characteristics Early discharge with no n e o n a t a l or maternal problem
Prolonged hospitalization with no n e o n a t a l problem
1714 39.7 ___2.0 3228 +__462 22.5 ___5 31 +__5 864 (50) 1189 (69) 999 (58)
622 39.0 ___2.0 3273 + 506 23.8 ___6 92 + 44 325 (52) 399 (64) 321 (52)
N Gestational age (wk)* Birth weight (g)* Maternal age (yr)* Length of newborn hospitalization (hr)* Male: No. (%) Black: No. (%) Indigent: No. (%) *Mean • SD.
Table II. Reasons for prolonged newborn hospitalization (n = 1099)
Maternal morbidity Cesarean delivery Increased total serum bilirubin, positive Coombs test, or both Sepsis evaluation Respiratory distress Low birth weight (>2000 g but <2500 g) Congenital anomalies Feeding difficulty Serum glucose instability Birth injury Cardiac concerns (murmurs, etc.) History of sibling with sudden infant death syndrome Observation for drug withdrawal
315 307 162 127 60 28 27 26 17 12 8 7 3
hospitalization because of neonatal problems. These neonates remained hospitalized for 90 • 62 hours (mean • SD) and were not included in either the experimental or the control study cohort. Finally, the 622 remaining infants (315 delivered vaginaUy and 307 delivered surgically) had no neonatal problem identified during the first 24 hours of life and were assigned to an extended newborn hospitalization solely as a result of maternal concerns. These neonates remained hospitalized for 92 • 44 hours (mean • SD). Their incidence of readmission by age 6 weeks was compared with the incidence of readmission of the 1714 infants discharged moderately early. The gestational age, birth weight, maternal age, length of newborn hospitalization, percent male, percent black, and percent indigent in these two cohorts are shown in Table I. Information recorded for each infant was collected by individual chart review and included length (hours) of newborn hospitalization, clinical factors that prolonged
hospitalization, mother's age at delivery, mode of delivery (vaginal vs cesarean section), race, and occurrence of readmission within 6 weeks of birth. If readmission did occur, the age (weeks) of the infant on readmission and the readmission diagnosis were recorded. Readmission criteria were the same for all neonates and were those which have been used at MUSC for several years. The infant's source of financial support was also recorded: private (insurance support), Medicaid (government support), indigent (no third-party financial support) and self-payment (responsible for payment without third-party support). With the use of data computed by the South Carolina Department of Health and Environmental Control, as well as the individual chart review, the incidence of death in the two study groups during the first 6 weeks after delivery was documented. If death occurred, the age of the infant at the time of death and the cause were recorded. Although neither the serum bilirubin concentration at follow-up visits nor the number of determinations after discharge was recorded, clinical icterus was monitored closely in the nursery. When any question of an elevated serum bilirubin concentration was present, follow-up within 24 hours of discharge was assured by the parents or discharge was postponed. If the infant had any clinical icterus noted, moderately early discharge was not allowed. To assess indirectly the serum bilirubin rise among infants assigned to moderately early discharge, we monitored the increase among the neonates maintained in the hospital for maternal reasons only (control cohort). The number of neonates in this extended hospitalization cohort who developed a serum bilirubin concentration >10 mg/ dL, the maximum bilirubin concentration recorded, and the age of the neonate when this concentration was reached were noted. Finally, the parents of all infants with a history of a previous sibling death from sudden infant death syndrome were routinely given the option of having their infant
Volume 112 Number 2
Newborn hospitalization: A closer look
259
Table III. Reasons for hospital readmission within 6 weeks of birth Extended hospitalization (n = 17)
Moderately early discharge (n = 52) Reason
Rule out sepsis Hyperbilirubinemia Gastroesophageal reflux Pyloric stenosis Apnea Laryngomalacia Interrupted aortic arch Failure to thrive Child abuse
n
%
36 68 4 8 3 6 2 4 2 4 2 4 1 2 1 2 1 2
receive a series of respiratory tests, which, if accepted, prolonged hospitalization. A suspicion of infection, respiratory distress, or minor congenital anomaly also extended hospitalization. A "sepsis evaluation" involved obtaining blood studies and appropriate cultures and initiating either antibiotic therapy or observation. The term "respiratory distress" referred to any difficulty in breathing; the predominant clinical observation was transient tachypnea. Finally, congenital anomalies in this population were abnormalities representing minor dysmorphic features commensurate with a well-baby nursery admission. Data were analyzed using the chi-square and unpaired Student t test techniques. RESULTS No newborn infant was discharged directly from the labor and delivery area, and none was lost to follow-up within 6 weeks of birth. The most commonly observed neonatal problem that prevented moderately early discharge was a total serum bilirubin concentration of >5 m g / d L within the first 24 hours of life. A summation of all such problems and their incidence are shown in Table II. Of the 1714 babies discharged moderately early, 52 (3.0%) were readmitted within 6 weeks of birth. Of the 622 control cohort infants, 17 (2.7%) were readmitted by 6 weeks of age. These readmission rates did not differ significantly. Of the total study population (N -- 2336), 43 of the 1320 indigent babies (3.3%; 95% CI 4.2% to 2.4%), 20 of the 643 Medicaid babies (3.1%; 95% CI 4.4% to 1.8%), and five of the 328 private service babies (1.5%; 95% CI 2.8% to 0.2%) were readmitted within 6 weeks of birth. These readmission rates did not differ significantly. Eight (2.7%) of the 307 infants delivered by cesarean section were readmitted by age 6 weeks. This readmission incidence did not differ significantly from the readmission
Reason
Rule out sepsis Hyperbilirubinemia Gastroesophageal reflux Child abuse
n
%
14 82 1 6 1 6 1 6
incidence of either the remaining control infants or the experimental infant group. Of the infants discharged moderately early, 31 (2.6%) of 1189 black infants and 21 (4.0%) of 525 white infants were readmitted within 6 weeks of birth. These readmission rates did not differ significantly from each other, nor did they differ significantly from the readmission rates among black infants and white infants in the extended hospitalization group. Similarly, 37 (3.7%) of 999 indigent infants in the group discharged early, in comparison with six (1.9%) of 321 indigent infants in the control group were readmitted by age 6 weeks, and these rates did not differ significantly. The mean age (+_SD) for mothers of all study infants (N = 2336) was 22.8 + 5 years and did not differ significantly from the age (22 + 4 years) of the mothers of the 52 readmitted infants who had been discharged moderately early. Five infants were readmitted for jaundice in the first week after discharge. None of these infants required an exchange transfusion, and the serum bilirubin concentrations declined with phototherapy in each case. One neonate of this group had an extended newborn hospitalization. This infant was breast-fed and was readmitted at age 7 days with a serum bilirubin concentration of 22 mg/dL. The remaining four infants (all discharged moderately early) each had serum bilirubin concentrations of 18 m g / d L or less on admission that potentially could have been detected with an extended hospitalization. Thirty-six babies in the control cohort (n -- 622) developed a total serum bilirubin concentration as great as 10 m g / d L in the hospital. Only one of these neonates developed a serum level > 15 mg/dL. This neonate developed a serum concentration of 18 m g / d L on day 3 of life and was treated with phototherapy. None of these infants required exhange transfusion. Four infants, three from the group discharged moderately early and one from the control cohort, died by age 6
260
Pittard and Geddes
weeks. One child was readmitted at age 12 days and died the following day (age 13 days) with disseminated herpes simplex infection. A second infant died in the emergency room at age 23 days and subsequently had an autopsy diagnosis of sudden infant death syndrome. The third and fourth infants (the single infant death in the control cohort group) were readmitted at 34 and 24 days, respectively, and died in the hospital, both with a diagnosis o f child abuse. Of the 69 total readmissions, 50 (72%) resulted from suspected infectious disease. Six infants had sepsis, with blood or spinal fluid cultures positive for bacterial growth. Table III summarizes the readmission diagnoses and offers a visual comparison between the study groups. DISCUSSION These data failed to show a difference in the readmission rate of babies discharged moderately early (3.0%) versus those who had a prolonged neonatal hospitalization (2.7%). The power of this statistical comparison to detect a 50% difference in the readmission rates is 65%. The data from this study support the moderately early discharge policy at MUSC. A possible explanation for these data is that infants could have been readmitted to another hospital in the community, thus making the detected readmission rate spuriously low. This is unlikely, however, because indigent infants in Charleston are usually readmitted to our facility. Further, although the Medicaid and private service infants who were born at M U S C may occasionally be admitted to other hospitals, neonates who require hospitalization for acute illness within the first 6 weeks of life tend to be admitted to the MUSC. Younger mothers of lower socioeconomic status have previously been associated with a higher incidence of hospital readmission of their infants? Further, although moderately early neonatal hospital discharge is often discouraged because of concern about potential problems with neonatal jaundice, jaundice has not been observed as a major clinical problem among neonates discharged early. 3 Only five infants were identified and readmitted in this study because of increased bilirubin concentrations, and younger, indigent mothers were not found to be more likely to have their infants readmitted than older, more affluent mothers. Of the 622 control cohort infants, none of whom had clinical icterus at 24 hours of age, one (0.1%) developed a serum bilirubin concentration of > 15 m g / d L in the hospital and a second one (0.3%) after discharge. This incidence is similar to the four (0.2%) of 1714 infants identified in the group discharged moderately early. These observations do not allow an assessment of how many neonates in the group discharged moderately early developed hyperbiliru-
The Journal of Pediatrics February 1988
binemia and went undetected, but they do indicate that neonates develop hyperbilirubinemia 24 to 36 hours after delivery. An interesting difference was noted between the data in this study and those reported by McCormick et al. 4 She observed a greater incidence of hospital readmission among indigent and government-supported infants than among those infants who had insurance coverage. In this study, no difference based on financial status of the parents was observed in the incidence of readmission. Perhaps there is no real difference in the severity of illness among these financial groups of infants. Alternatively, these data differences may indicate that the medical response (hospitalization ) to infant illness differs according to financial status in different areas of the country. The time of greatest medical risk for infants is thought to be the 4- to 6-hour transition period between intrauterine and extrauterine existence?. 6 At MUSC, this period is closely monitored by residents, nurses, and attending (faculty) physicians. Moreover, no infant is discharged until results of an examination by the receiving nursery nurse are normal and until both an admitting and a discharge examination by the resident and the attending physician show normal results. The infant must be feeding well from the mother's breast or a bottle, have a normal stool and urine pattern, and be maintaining a normal body temperature at room temperature before discharge is approved. Once an infant has met these criteria, his risk of serious illness is assumed to be greatly reduced. Previous investigators have documented that follow-up home visits by medical personnel after early neonatal hospital discharge are cost-effective, have resulted in no increase in infant morbidity, and have improved continuity of care for both full-term and high-risk infants. 3,7 This form of postdischarge maternal and neonatal support, although not available at MUSC, might well improve the neonatal readmission rate. Nevertheless, the readmission rate by 6 weeks of age in this study was below 3%. Previous reports note yearly readmission rates, rather than 6-week readmission rates, and describe a variation from 7% to 20% for normal birth weight infants?. 8.9 On the basis of these data, a closely monitored shortened length of neonatal hospitalization does not appear to increase the incidence of readmission within 6 weeks of birth. Suspected infectious disease was overwhelmingly the major cause for readmission; hyperbilirubinemia was rare. Maternal age, race, and parental financial status were not predictors of early infant readmission.
REFERENCES
1. American Academy of Pediatrics, Committee on Fetus and Newborn, American College of Obstetricians and Gynecolo-
Volume 112 Number 2
2.
3. 4.
5.
Newborn hospitalization: A closer look
gists, Committee on Obstetrics. Maternal and fetal medicine: guidelines of perinatal care. 1983:90-1. Adebonojo FO. A comparative study of the child health care of urban and suburban children. Clin Pediatr 1973;12:6448. Yanover M J, Jones D, Miller MD. Perinatal care of low-risk mothers and infants. N Engl J Med 1976;294:702-5. McCormick MC, Shapiro S, Starfield B. Rehospitalization in the first year of life for high-risk survivors. Pediatrics 1980;66:991-9. Desmond MM, Rudolph A J, Phitaksphraiwan P. The transitional care nursery: a mechanism for preventive medicine in the newborn. Pediatr Clin North Am 1966;13:651-68.
261
6. Britton HL, Britton JR. Efficacy of early newborn discharge in a middle-class population. Am J Dis Child 1984;138:10416. 7. Brooten D, Kumar S, Brown LP, et al. A randomized clinical trial of early hospital discharge and home follow-up of very low birth weight infants. N Engl J Med 1986;315:934-9. 8. Gordis L, Markowitz M. Evaluation of the effectiveness of comprehensive and continuous pediatric care. Pediatrics 1971;48:766-76. 9. Hendershot GE. Work during pregnancy and subsequent hospitalization of mothers and infants. Public Health Rep 1979;94:425-31.
FELLOWSHIPS Available fellowships in pedia~tric subspecialties and those for general academic pediatric training are listed once a year, in May, in The Journal of Pediatrics. Each October, forms for listing such fellowships are sent to the Chairman of the Department of Pediatrics at most major hospitals in the United States and Canada. Should you desire to list fellowships, a separate application must be made each year for each position. All applications must be returned to The C. V. Mosby Company by February 15 of the listing year to ensure publication. Additional forms will be supplied on request from the Journal Editing Department, The C. V. Mosby Company, 11830 Westline Industrial Drive, St. Louis, M e 63146/314-872-8370.