Screening and Teaching for Discharge

1. Screening and Teaching for Discharge Patsy J. Hammonds, RN, C, MS, CNA

2. Objectives • Provide recent birth and admission statistics • Identify admission criterion for Level I, II, and III nurseries • Evaluate the knowledge level of the parents and their educational needs • Evaluate the needs of the infant prior to and following discharge. • Identify screening measures necessary for appropriate discharge • Provide information on SIDS to increase the parents awareness of how to be proactive in the care of their infant • Provide information on infant care and safety issues that are relevant to the care of an infant being discharge from the hospital • Identify home care needs and red flags

3. General Birth and Admission Statistics for 2006-2007 • 4.3 million infants born in the US • 148,403 infants born in GA • 21,007 Preterm infants born in GA • 14,209 LBW infants <2500gms in GA • 2,682 VLBW infants <1500gms in GA The data above was obtained from the Georgia Department of Human Resources, Division of Public Health http://health.state.ga.us 1

4. Statistics Continued • 10-12% of all infants (preterm and term) are admitted to Level II or Level III Nurseries • Average LOS <1500grams: 2-4 months; LOS >1500 grams: 17-30 days • Neonatal survival for 23-25 weeks gestation is 11-76% • 27% of infants <1000gms at birth who have normal Head Ultrasounds at discharge have severe to moderate CP or other severe neurodevelopmental challenges. Kelly M. Journal of Pediatric Health Care “The Medically Complex Premature Infant in Primary Care” November/ December (2006) 20 (6)367-373

5. >34 weeks, healthy Absence of prenatal care Birth trauma Murmur Hyperbilirubinemia Infant of a Diabetic Mother (IDDM) Infection risk factors (GBS, PROM, elevated temperature…(etc.) Substance abuse Temperature control issues Weight loss >8% Need for further non-oxygen observation (TTN, transition) Need for Admission into a Level I, Newborn Nursery

6. RDS (minimal-moderate O2 need) Spontaneous pnuemothorax TTN Feeding issues (cleft’s, etc.) Apnea of prematurity <34 weeks gestation or <2250 grams**(This is changing in some instances as insurance companies are refusing to pay for the low birth weight infants in the Intermediate Nurseries) Infection Narcotic withdrawal IV therapy for glucose management Perinatal challenges during birth (asphyxia, etc.) Monitoring (arrhythmias, etc.) Need for Admission into a Level II Intermediate Care Nursery

7. Respiratory distress or respiratory failure Prematurity (<1250 grams or <30 weeks gestation Cardiac deficit Diaphragmatic hernia Hematologic issues (DIC, hemolytic disorders, etc) Neurologic deficits (seizure activity, depressed skull fracture, etc) Congenital anomalies requiring supportive or diagnostic care Abdominal wall defects (i.e. gastroschisis, omphalocele) Neurologic defects (i.e. hydrocephalous, myelomeningocele) Post operative monitoring Need for Admission into a Level III NICU Nursery

8. WHEN SHOULD YOU START DISCHARGE PLANNING??? Discharge planning should start the day of delivery. Waiting until the day of discharge is too late!!!

9. Remember to plan ahead!Keep families informed. Educate them as you help them to prepare for their transition home.

10. Using a team approach is the best way to plan. • Parents • Physicians • Nurses • Patient Care Coordinator • Lactation • Respiratory Therapy • Speech-Language • Physical/Occupational Therapy • Nutrition • Pharmacists

11. Parents • Most important members of the discharge team, they are the one’s that are taking the infant home • Must learn to care for the infant • Must be prepared with the necessary items at home to care for the infant • Must be versed on special needs that the infant may have

12. Physicians and Nurses • Provide the level of care that the infant needs • Observe the infant’s and parents status day to day. • Interact with the family unit daily • Bring in other team members as needed and have periodic meetings as necessary throughout the stay, keeping the family informed as the infant makes progress, with the ultimate goal being discharge.

13. Limited financial resources/no insurance Documented substance abuse during pregnancy/positive drug screen Documented signs/symptoms of abuse/neglect/domestic violence Terminal stages of illness New diagnosis of Cancer History of postpartum depression No prenatal care/limited prenatal care Adoption/surrogate birth Teen pregnancy HIV/AIDS Patient unable to care for self or infant Extended length of stays for either vaginal or cesarean births Patient Care Coordinationchecks on many things…

14. If the infant requires home nursing or home care equipment, be sure to keep in close contact with your facility’s discharge planner or case manager. It may take several days to weeks for approval and arrangement of home care and equipment.

15. Lactation • Preterm baby • Infants with a dysfunctional suck • Multiple gestation • Baby in NICU or Intermediate Nursery • H/O breast reduction/augmentation • Flat or inverted nipples • Baby weight loss greater than 10% • Patient’s request • Lactation will see all families, including bottle feeding infants to help with feeding difficulties

16. Respiratory Therapy • Collaborate with the physician and the nursing staff to treat infants with any breathing problems • Participate with the group as the infant and the family is prepared for discharge

17. Speech and Language Therapy • Baby with poor coordination with feeds (i.e. suck, swallow, breath and initiation) • Baby with any oral motor abnormality • Baby greater than 34 weeks with feeding problems

18. Physical/Occupational Therapy • Baby with hypersensitivity and/or compromised neurological status • Baby with poor tone or abnormal resistance to movement and greater than 34 weeks

19. Pharmacists • Reviewing discharge medications • Helping secure special medications for the preterm infant being discharged home

20. Newborn metabolic screening* Hearing screening* Eye exams* Hepatitis B vaccine* Car seat test* Synagis* Safety* Feeding and elimination* Baby care* Red Flags* Discharge Packet, Information and Teaching

21. Home phototherapy CPR instruction Lactation instruction and support Discharge summary Babies Can’t Wait or other developmental assistance programs Home health arrangements if necessary (O2, feeding, equipment, apnea monitor, phototherapy, etc.) Follow-up with Pediatrician, and Specialist visits as needed. Discharge Packet, Information and Teaching

22. Georgia Newborn Screening Program • Effective January 1, 2007 • The Georgia Newborn Screening Panel has expanded its screening tool from 13-29 tests. • There will be a $40.00 fee for specimens. • Georgia Newborn Screening website for updates: http://health.state.ga.us/programs/nsmscd/ Georgia Department of Human Resources, Division of Public Health, Newborn Screening Program http://health.state.ga.us/programs/nsmscd/

23. Why do we do Newborn Screening? • Newborn screening can identify potentially fatal diseases or ones that may cause extensive brain damage within the first few days of life. • All are treatable with diet and/or medications and it is important to get treatment early. • It is a test required by Georgia Law.

24. Phenylketonuria Congenital Hypothyroidism Maple Syrup Urine Disease Galactocemia Tyrosinemia Homocustinuria Congenital Adrenal Hypoplasia Biotinidase Deficiency Medium Chain Acyl-CoA Dehydrogenase Deficiency (MCADD) Sickle Cell Anemia (3 types) Isovaleric acidemia Glutaric acidemia type I 3OH-3-CH3 glutaric aciduria Multiple carboxylase deficiency Methylmalonic acidemias (2 types) 3 Methylcrotonyl-CoA carboxylase deficiency (3MCC) Propionic acidemia Beta- ketothiolase deficiency Very long-chain acyl-CoA dehyrogenase deficiency (VLCAD) Long-chain L-3-OH acyl CoA dehydrogenase deficiency (LCHAD) Trifunctional protein deficiency Carnitine uptake defect Citrulinemia Argininosuccinic acidemia Cystic fibrosis Newborn Screening as of January 1, 2007

27. Newborn Hearing Screening • Can be done within a few hours after birth (results can be affected by debris and fluid in the ear canals) • Allows for early treatment if hearing loss is found • Early treatment can improve the baby’s language and brain development • May be delayed if currently on or recently on antibiotic therapy • Hearing screening and follow-up are tracked by the State just like the Metabolic Screening

30. Infant Eye Exams Eye exams when applicable: • Infant birth weight less than 1300 grams (gestational age < 30 weeks) • Perform initial eye exam at 4-6 weeks of age • Continue Q1-2 week follow-up until satisfactory development • Infant birth weight less than 1800 grams (gestational age <36 weeks) and received Supplemental Oxygen • Perform initial eye exam at 5-7 weeks of age • Continue Q1-2 week follow-up until satisfactory development • Infants with prolonged Supplemental Oxygen exposure see above guidelines

31. Hepatitis B Vaccine All infants should get their first Hepatitis B vaccine prior to discharge from the hospital and should complete the series by 6-18 months of age.

32. Immunizations American Academy of Pediatrics 2008 Guidelines.

33. Infant Car Seat Safety • 98 % of infants under the age of 1 year are restrained when riding in vehicles • 80% of child restraint devices are used incorrectly • Motor vehicle accidents remain the leading cause of death in children under 4 years of age • Infants should be in rear facing car seats that are secured in the back seat until 1 year of age AND20 pounds

34. 3-M’s of Infant Car Seat Safety Measurement Mounting Mobility **According to the AAP, infants <2500 grams or <37 weeks gestation at birth should be tested.

37. Definition of Sudden Infant Death Syndrome (SIDS) The sudden and unexpected death of an apparently healthy infant usually under one year of age which remains unexplained after a: --complete medical history --death scene investigation --postmortem examination SIDS is a diagnosis of Exclusion

38. What We Know • The cause(s) of SIDS remains unknown • SIDS cannot be predicted or prevented • No one is to blame for a SIDS death • Not parents • Not caregivers • Not emergency personnel or other health care providers

39. What Happens • Baby is usually healthy or may have had sniffles or a cold • Baby is put down for a nap or night • Found dead minutes to hours later • No sign of struggle or distress SIDS can happen in any family

40. Facts about SIDS • The leading cause of death in infants between one month and one year of age in the U.S. • Happens in about one of every 1000 live births • Happens most often between two and four months of age • Happens most often in the winter • Incidences of SIDS doubles in the African American population and triples in the Native American population

41. SIDS is NOT Caused By: • Suffocation • Vomiting or choking • Child abuse • Disease or illness • Immunizations

42. Maternal Risk Factors • Young--- less than 19 years of age • Tobacco use doubles the risk of SIDS • Substance use is associated with increased risk • Limited or late prenatal care • Short intervals between pregnancies

43. Infant Risk Factors for SIDS • Male gender • Infant age • Low birth-weight • Multiple births • Premature birth Babies can die of SIDS without having risk factors!

44. Multifactorial SIDS Theory Infant’sPhysiologicResponses SIDS Development Environment

45. Infant’s Physiologic Responses • Oxygen reduced, carbon dioxide increased • Arousal response deficit • Subtle brainstem dysfunction • Slow development

46. Development—Age Vulnerability • 2-4 months-------75% • 4-6 months-------15% • Respiratory system is unstable in all infants • May take less of an environmental stress to trigger SIDS at this age

47. Environmental Factors • Sleep positions • Smoking • Bedding • Swaddling • Season • Minor Respiratory Symptoms • Drug use • Poverty • Limited prenatal care

48. Ten Ways to Reduce the Risk of SIDS • Always place a baby on his or her BACK TO SLEEP even for naps. • Never allow smoking around a baby. • Place a baby on a firm, flat surface to sleep. • Remove all soft things such as loose bedding, pillows, and stuffed toys from the sleep area. • Never place a baby on a sofa, waterbed, soft chair, pillow or bean bag. • Take special precautions when a baby is in bed with you. (Infant should sleep alone, no co-bedding) • Make sure a baby doesn’t get too hot. • Keep baby’s face and head uncovered during sleep. • Share this information with everyone who cares for the baby • Consider using a pacifier at nap and bedtime once breastfeeding has been well established.

49. Smoking • Respiratory infections are frequent infants who are exposed to smoke from cigarettes. • Smoking is one factor associated with Sudden Infant Death Syndrome • Parents who smoke should be encouraged to quit, otherwise to smoke only outside the home as smoke is absorbed by the infant even when the smoking occurs in another room in the house. • Advise the parents not to smoke in the car or closed spaces around the infant.

50. Synagis • Synagis is given to the infant to protect them from RSV. • Respiratory syncytial virus (RSV) is the most common cause of bronchiolitis and pneumonia among infants and children under 1 year of age. • During their first RSV infection, between 25% and 40% of infants and young children have signs or symptoms of bronchiolitis or pnuemonia. • The majority of children hospitalized for RSV infection are under 6 months of age. • Indications: Siblings school age or in day care, smokers in the home, congenital heart disease, or less than 35 weeks. **Synagis is not a vaccine or an immunization.