Issue 10 – June 2020

In 2018, Vermont Oxford Network began collecting new measures for respiratory support at discharge, in addition to the existing oxygen and apnea/cardio-respiratory monitor at discharge items. We examined the new data items by gestational age and region among infants discharged home.

Of 27,579 infants born at 22-29 weeks gestational age in 2018 and discharged home from VON member centers, 5,182 (19%) were discharged home with respiratory support: 1.3% on conventional or high frequency ventilation, 0.7% on nasal CPAP or nasal IMV, 1.7% on high flow (>=1 L/min) nasal cannula, and 15% on oxygen only (at <1 L/min).

Rates of respiratory support at discharge differed by gestational age and region. Infants born at lower gestational ages had higher rates of all modes of support at discharge home (Figure). Rates of any type of support ranged from 2% in Africa to 21% in North America. Infants in Europe and North America had the highest rates of discharge on conventional and nasal ventilation, and infants in Asia had the highest rates of discharge on nasal CPAP.

There is perhaps no transition in the care of an extremely preterm infant that is more fraught with difficulty than the transition home on respiratory support. It is far from infrequent. Almost one out of every five infants born between 22 to 29 weeks’ gestation are discharged home on some respiratory support. Although over three quarters of those are on supplemental oxygen, an additional 4-5% require much more sophisticated support. In particular, surviving infants 22-23 weeks gestation are discharged on conventional ventilation, high-frequency ventilation, nasal IMV, nasal CPAP, or nasal cannula 12% of the time.

There is no skill that we have that is more important than our ability to help families through this difficult transition. These transitions transfer the burden of care from the hospital and our families to the families themselves and their community supports (1). Even in less trying circumstances, family find themselves “unprepared” to meet their babies needs prior to discharge home (2).

Clearly, different areas in the United States and the world will have different capacities to adequately support these needs. That said, it is perhaps the most important skill we can develop. We should encourage all teams to follow through with infants and families by helping them establish medical homes and effective communications with primary care providers (3), connecting families with appropriate community organizations and services (4), and conducting home visits before and after discharge (5).

1. American Academy of Pediatrics Committee on Fetus and Newborn. Hospital discharge of the high-risk neonate. Pediatrics 2008; 122:1119.
2.  Smith VC, Dukhovny D, Zupancic JA, Gates HB, Pursley DM, Neonatal intensive care unit discharge preparedness: primary care implications. Clin Pediatr (Phila). 2012 May;51(5):454-61.
3. Van Cleave J, Boudreau AA, McAllister J, Cooley WC, Maxwell A, Kuhlthau K. Care coordination over time in medical homes for children with special health care needs. Pediatrics. 2015;135(6):1018-1026. doi:10.1542/peds.2014-1067
4. Gottlieb LM, Hessler D, Long D, et al. Effects of social needs screening and in-person service navigation on child health: A randomized clinical trial. JAMA Pediatr. 2016;170(11):e162521-e162521. doi:10.1001/jamapediatrics.2016.2521
5. American Academy of Pediatrics. Follow-up care of high-risk infants. Pediatrics. 2004;114(Supplement 5):1377-1397. doi:10.1542/peds.2004-0866

This report is made possible by Vermont Oxford Network members who voluntarily contribute data in a global effort to improve the care of high-risk newborns. VON members can view center-specific data by logging on to Nightingale and benchmark against this NICU by the Numbers report.

Editor: Erika Edwards, PhD, MPH

Analyst: Lucy Greenberg, MS

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