Pediatric Annals

Special Issue Article 

Monitoring of Infants Discharged Home with Medical Devices

Pradeep Velumula, MD; Sanket Jani, MD; Neelakanta Kanike, MD; Sanjay Chawla, MD

Abstract

Preterm infants and term infants with complex medical conditions are often discharged home with technological support. There is a scarcity of evidence-based guidelines for post-discharge management of these infants at high risk. Common diagnoses necessitating the need for respiratory support and/or monitoring devices include apnea of prematurity and bronchopulmonary dysplasia for preterm infants, and upper airway anomalies, central nervous system disorders, and neuromuscular disorders for term infants. Some infants who are unable to receive complete oral feeds for various reasons are sometimes discharged home with nasogastric or gastrostomy tube feeds. For safe patient care at home and reduction of emergency department visits, there should be proper transition of care from hospital to primary care provider, and appropriate instruction of caregivers for care of the infant including teaching about medications, feeding, and management of medical devices. Primary care providers should be aware of these common supportive devices and their complications to provide timely intervention if needed. [Pediatr Ann. 2020;49(2):e88–e92.]

Abstract

Preterm infants and term infants with complex medical conditions are often discharged home with technological support. There is a scarcity of evidence-based guidelines for post-discharge management of these infants at high risk. Common diagnoses necessitating the need for respiratory support and/or monitoring devices include apnea of prematurity and bronchopulmonary dysplasia for preterm infants, and upper airway anomalies, central nervous system disorders, and neuromuscular disorders for term infants. Some infants who are unable to receive complete oral feeds for various reasons are sometimes discharged home with nasogastric or gastrostomy tube feeds. For safe patient care at home and reduction of emergency department visits, there should be proper transition of care from hospital to primary care provider, and appropriate instruction of caregivers for care of the infant including teaching about medications, feeding, and management of medical devices. Primary care providers should be aware of these common supportive devices and their complications to provide timely intervention if needed. [Pediatr Ann. 2020;49(2):e88–e92.]

An American Academy of Pediatrics policy statement from 2008 classifies infants at high-risk into four broad categories: “a) prematurity, b) infants with special health care needs or dependence on technology, c) at-risk infants related to family issues, d) infants with anticipated early death.”1 In this article, we review the management of infants discharged home on either monitoring or therapeutic devices. With the advancements in medical care of infants with complex disorders and survival of extremely preterm infants, many infants are being discharged home with devices, mainly for nutritional and respiratory support. Preterm infants diagnosed with apnea of prematurity (AOP), bronchopulmonary dysplasia (BPD), failure to thrive, and/or poor oro-motor skills may need multiple technological devices such as pulse oximeter, apnea monitor, nasal cannula, tracheostomy tube and ventilator, nasogastric tube (NG), and/or gastrostomy tube (G-tube) at home. Occasionally, full-term infants with upper airway anomalies (such as micrognathia, cleft palate, tracheal stenosis), central nervous system disorders (including hypoxic-ischemic encephalopathy [HIE]), and neuromuscular disorders may also need technological assistance at home after discharge from the hospital.

Discharge Preparation

Preterm infants may be discharged home when (1) they demonstrate physiological stability in respiration and maintenance of body temperature in a home environment as well as the ability to take complete oral nutrition with appropriate weight gain; (2) the family is prepared for the infant's care at home; and (3) home care arrangements and appropriate follow-up appointments to provide continued care and growth and development monitoring have been made.1 Most preterm infants attain physiological stability by 36 to 37 weeks postmenstrual age (PMA).1,2 However, some infants may take a longer time, occasionally up to 44 weeks, for sufficient maturation of respiratory control.3 A survey by Carlos et al.4 among neonatologists in the United States, Canada, and France showed that physicians from the US tend to discharge infants earlier (close to 36 weeks PMA) and discharge infants more often on supplemental oxygen and caffeine therapy. Technological devices needed at home can be divided into two main categories: respiratory and nutritional.1 Respiratory devices for monitoring include pulse oximeter and apnea/cardiac monitor, and for respiratory support include oxygen delivery devices and ventilator. Nutritional devices primarily include enteral feeding pumps used with a NG tube or G-tube.

Respiratory Support Devices

Common indications for respiratory support and monitoring include infants with AOP and BPD (Table 1).

Common Respiratory Conditions in Infants Requiring Monitoring or Therapeutic Devices at Home

Table 1.

Common Respiratory Conditions in Infants Requiring Monitoring or Therapeutic Devices at Home

Apnea of Prematurity

AOP can be divided into central apnea, obstructive apnea, and mixed apnea. Interventions frequently used in neonatal intensive care units to manage AOP include (1) appropriate positioning of the neck to avoid extreme flexion or extension,5 (2) appropriate respiratory support, and (3) caffeine. Caffeine is generally discontinued around 32 to 34 weeks PMA after 5 to 7 apnea-free days.6

There is no consensus on the definitive criteria for discharging infant with AOP, as there is significant practice variation among clinicians and hospitals in discharging these infants.4,7 Infants who are medically stable for discharge but are unable to be weaned from caffeine are sometimes discharged home with apnea monitor/pulse oximeter. Caffeine may have certain adverse effects including but not limited to tachycardia, jitteriness, irritability, seizures, feeding intolerance, and growth failure.8,9 Occurrence of adverse effects may require adjustment or discontinuation of caffeine. Caffeine may be discontinued at 43 weeks PMA because it is rare to have significant AOP after that time.10

Bronchopulmonary Dysplasia

Infants with BPD may require oxygen (low flow oxygen) or ventilator support (via tracheostomy tube) for many weeks to months after hospital discharge. Oxygen use in these infants may prevent or reduce chronic and intermittent hypoxia, help with weight gain, decrease airway resistance, and reduce pulmonary hypertension.11–13 In a home setting, oxygen is usually delivered either in liquid oxygen tanks or oxygen concentrators. Humidification of oxygen is not necessary at low flow rates. About 18% to 43% of infants diagnosed with BPD are also affected with pulmonary hypertension,14 which may develop any time during infancy. Therefore, infants with BPD should be screened and evaluated for pulmonary hypertension with echocardiogram 2 to 3 times during the first year of life, as well as before and after weaning of supplemental oxygen.15,16 Infants with BPD are also at risk for systemic hypertension, and screening for hypertension should be performed at follow-up visits with primary care physicians.17,18 Infants with BPD are at risk for growth failure due to decreased calorie intake and increased energy expenditure so they may need a high-calorie diet. Infants with BPD are also at increased risk for aspiration pneumonia and respiratory tract infections, which can lead to respiratory failure and acute exacerbations of BPD.

Monitoring

Goal saturation limits for infants with BPD are controversial. Most infants with severe BPD require target saturations greater than 92% to prevent pulmonary hypertension.19 Patients with severe BPD with evidence of pulmonary hypertension have higher target saturations; peripheral capillary oxygen saturation (SpO2) ≥95% is needed to prevent worsening of cardiac function. For older infants with BPD beyond the risk of oxygen-induced retinopathy, the American Thoracic Society recommends target oxygen saturations of 95% or greater.20 A motion-resistant pulse oximeter provides vital information on pulse rate and oxygen saturation, and it is currently the preferred way of monitoring.21,22 Apnea monitors may not detect obstructive apnea and also have a high false-alarm rate.22 A study comparing reading from a pulse oximeter and smartphone-integrated baby monitors noted that smartphone-integrated baby monitors were inconsistent in detecting hypoxemia.23 According to the AAP Committee on Fetus and Newborn, use of home cardiorespiratory monitoring is not efficacious for prevention of sudden infant death syndrome.24

Weaning of Oxygen

For infants discharged home on low-flow oxygen therapy, weaning can be done by a primary care physician, neonatologist, or pulmonologist. Due to limited evidence on weaning strategies, there is wide practice variation in weaning of supplemental oxygen.19,21 Infants with BPD are generally observed by physicians every 2 to 4 weeks. Weaning of oxygen is based on an infants' effort of breathing, pulse oximeter readings (during feeds, sleep, and activity), growth parameters, and echocardiogram findings.17 Weaning is usually done by one-eighth of a liter per minute of flow, and patients should be monitored in the clinic for any desaturation. Spot pulse-oximetry in the clinic has limitations due to its inability to evaluate the infant during sleep, feeding, and activity. Caregivers should be counseled regarding potential desaturations at home post-weaning, especially during activity and sleep. They should be advised to adjust the oxygen flow for the infant to maintain predetermined goal saturations depending on evidence of pulmonary hypertension. If the infant is diagnosed with pulmonary hypertension, the weaning process should be done at a slower rate. Pulse oximeter and oxygen supply should be available for at least 3 months after the infant transitions to room air.17 The median time for an infant with BPD to wean to room air is 10 months.21

Traveling with Oxygen

Atmospheric pressure affects the oxygen diffusion through alveolar-capillary junction. As the altitude increases, the atmospheric pressure decreases, which may affect the patient's oxygenation and may necessitate an appropriate increase in support to maintain predetermined goal saturations depending on evidence of pulmonary hypertension.

Care of Infants with Tracheostomy

Common indications for tracheostomy in infants include BPD, HIE, neuromuscular disorders, and upper airway anomalies. Infants with tracheostomy usually receive positive pressure ventilation for many months. Discharge planning for these infants is crucial for appropriate transition of care at home. Discharge teaching of caregivers includes teaching tracheostomy care, replacement of tube in case of accidental decannulation, and device teaching and troubleshooting for common scenarios. This teaching plays an important role in the safety of the infant as well in preventing non-emergent emergency department visits. At least two caregivers at home need to be trained and be able to demonstrate these skills before the infant can be discharged home. Home health companies usually provide further education for home devices and provide regular post-discharge support. Most of these infants will be discharged home on multiple medications and will require a multidisciplinary follow-up visit. Medical care providers and patients' caregivers should be aware of the size and brand of the tracheostomy, when the tracheostomy was last changed, and any difficulties in replacing the tracheostomy tube. During the infant's visit to the pediatrician's office with sickness, pediatricians should assess for any increase in respiratory secretions, color, amount, and consistency of secretions, as well as increased need for suctioning. Common complications associated with tracheostomy include granuloma, infection, obstruction of the cannula, and unintentional decannulation.25

Nutritional Support Devices

Infants who are unable to feed by mouth (preterm infants with immature skills, infants with HIE, infants with neurological disorders, congenital oropharyngeal disorders) are sometimes discharged home on either an NG or G-tube (Table 2). It is important to determine the “medical home” of the NG or G-tube prior to discharge. The NG or G-tube medical home serves as the primary point of contact in case of caregiver questions and advances the nutrition based on weight trajectory with the help of a dietitian. Pediatricians often serve in this role.

Common Conditions in Infants Necessitating Nutritional Support at Home

Table 2.

Common Conditions in Infants Necessitating Nutritional Support at Home

Nasogastric Tube

At least two caregivers at home should be trained and be able to demonstrate the skill of passing the NG tube before discharging the infant home. Complications associated with using an NG tube include bleeding from trauma to nasal passage or gastrointestinal (GI) tract, dislodged or misplaced tube, tube clogging, perforation of the GI tract, reflux esophagitis, and pneumothorax.26

Gastrostomy Tube

An infant in whom long duration of tube feed is anticipated or in whom NG feeds are not safe (such as a child with high risk for aspiration), a G-tube should be considered. Although placement of a G-tube is a routine procedure, it may be associated with various complications including tube malfunction, stoma infection, and dislodgement.

Tube Malfunction

Tube malfunction is a common complication occurring in about 25% to 35% of neonatal patients.27 Tube malfunction can be prevented by using appropriate enteral formula and flushing the tube before and after its use.

Stoma Infection

Stoma infection is another common complication. Local infection can be treated with topical and/or oral antibiotics. For patients presenting with systemic signs, intravenous antibiotics are recommended.

Dislodgement

Dislodgement is a common reason for emergency department visits. Consultation with specialists such as a general pediatric surgeon or an interventional radiologist is advisable, especially in patients with an immature digestive tract.

Other Complications

Granulation tissue at the G-tube site is a common complication, but it can be cauterized using silver nitrate. Other rare complications associated with G-tube placement include peristomal leakage, bleeding, and colonic perforation.27

Conclusion

Respiratory and nutritional support are the most common reasons for the use of post-discharge devices. Pediatricians should be aware of these devices and its complications. Hospital physicians, nurses, social workers, parents, primary care physicians, and specialists involved should work in collaboration for safe transition and continuation of patient's care from hospital to home (Table 3).

Preparation for Transition of Care for Infants with High-Risk Factors Requiring Technological Devices

Table 3.

Preparation for Transition of Care for Infants with High-Risk Factors Requiring Technological Devices

References

  1. American Academy of Pediatrics Committee on Fetus and Newborn. Hospital discharge of the high-risk neonate. Pediatrics. 2008;122(5):1119–1126. doi:10.1542/peds.2008-2174 [CrossRef] PMID:18977994
  2. 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(15):934–939. doi:10.1056/NEJM198610093151505 [CrossRef] PMID:3531852
  3. Eichenwald EC, Aina A, Stark AR. Apnea frequently persists beyond term gestation in infants delivered at 24 to 28 weeks. Pediatrics. 1997;100(3 Pt 1):354–359. doi:10.1542/peds.100.3.354 [CrossRef] PMID:9282705
  4. Carlos C, Hageman J, Pellerite M, et al. Neonatal intensive care unit discharge of infants with cardiorespiratory events: tri-country comparison of academic centers. J Neonatal Perinatal Med. 2015;8(4):307–311. doi:10.3233/NPM-15814077 [CrossRef] PMID:26836819
  5. Kurlak LO, Ruggins NR, Stephenson TJ. Effect of nursing position on incidence, type, and duration of clinically significant apnoea in preterm infants. Arch Dis Child Fetal Neonatal Ed. 1994;71(1):F16–F19. doi:10.1136/fn.71.1.F16 [CrossRef] PMID:8092863
  6. Zhao J, Gonzalez F, Mu D. Apnea of prematurity: from cause to treatment. Eur J Pediatr. 2011;170(9):1097–1105. doi:10.1007/s00431-011-1409-6 [CrossRef] PMID:21301866
  7. Darnall RA, Kattwinkel J, Nattie C, Robinson M. Margin of safety for discharge after apnea in preterm infants. Pediatrics. 1997;100(5):795–801. doi:10.1542/peds.100.5.795 [CrossRef] PMID:9346978
  8. Spitzer AR. Evidence-based methylxanthine use in the NICU. Clin Perinatol. 2012;39(1):137–148. doi:10.1016/j.clp.2011.12.011 [CrossRef] PMID:22341542
  9. Schmidt B, Roberts RS, Davis P, et al. Caffeine for Apnea of Prematurity Trial Group. Caffeine therapy for apnea of prematurity. N Engl J Med. 2006;354(20):2112–2121. doi:10.1056/NEJMoa054065 [CrossRef] PMID:16707748
  10. Eichenwald ECCommittee on Fetus and Newborn, American Academy of Pediatrics. Apnea of prematurity. Pediatrics. 2016;137(1):e20153757. doi:10.1542/peds.2015–3757 [CrossRef] PMID:26628729
  11. Tay-Uyboco JS, Kwiatkowski K, Cates DB, Kavanagh L, Rigatto H. Hypoxic airway constriction in infants of very low birth weight recovering from moderate to severe bronchopulmonary dysplasia. J Pediatr. 1989;115(3):456–459. doi:10.1016/S0022-3476(89)80855-8 [CrossRef] PMID:2769506
  12. Abman SH, Wolfe RR, Accurso FJ, Koops BL, Bowman CM, Wiggins JW Jr, . Pulmonary vascular response to oxygen in infants with severe bronchopulmonary dysplasia. Pediatrics. 1985;75(1):80–84. PMID:3838113
  13. Askie LM, Henderson-Smart DJ, Irwig L, Simpson JM. Oxygen-saturation targets and outcomes in extremely preterm infants. N Engl J Med. 2003;349(10):959–967. doi:10.1056/NEJMoa023080 [CrossRef] PMID:12954744
  14. Berkelhamer SK, Mestan KK, Steinhorn RH. Pulmonary hypertension in bronchopulmonary dysplasia. Semin Perinatol. 2013;37(2):124–131. doi:10.1053/j.semperi.2013.01.009 [CrossRef] PMID:23582967
  15. Tarazona SP, Esteban SR, Diego JA, et al. del Grupo de Trabajo de Patología Respiratoria Perinatal de la Sociedad Española de Neumología Pediátrica. Guidelines for the follow up of patients with bronchopulmonary dysplasia [in Spanish]. An Pediatr (Barc). 2016;84(1):61.e1–61.e9. doi:10.1016/j.anpede.2015.04.011 [CrossRef]
  16. del Cerro MJ, Sabaté Rotés A, Cartón A, et al. Pulmonary hypertension in bronchopulmonary dysplasia: clinical findings, cardiovascular anomalies and outcomes. Pediatr Pulmonol. 2014;49(1):49–59. doi:10.1002/ppul.22797 [CrossRef] PMID:23788443
  17. Anderson C, Hillman NH. Bronchopulmonary dysplasia: when the very preterm baby comes home. Mo Med. 2019;116(2):117–122. PMID:31040497
  18. Harer MW, Kent AL. Neonatal hypertension: an educational review. Pediatr Nephrol. 2019;34(6):1009–1018. doi:10.1007/s00467-018-3996-1 [CrossRef] PMID:29974208
  19. Abman SH, Collaco JM, Shepherd EG, et al. Interdisciplinary care of children with severe bronchopulmonary dysplasia. J Pediatr. 2017;181:12–28.e1. doi:10.1016/j.jpeds.2016.10.082 [CrossRef] PMID:27908648
  20. Allen J, Zwerdling R, Ehrenkranz R, et al. American Thoracic Society. Statement on the care of the child with chronic lung disease of infancy and childhood. Am J Respir Crit Care Med. 2003;168(3):356–396. doi:10.1164/rccm.168.3.356 [CrossRef] PMID:12888611
  21. Yeh J, McGrath-Morrow SA, Collaco JM. Oxygen weaning after hospital discharge in children with bronchopulmonary dysplasia. Pediatr Pulmonol. 2016;51(11):1206–1211. doi:10.1002/ppul.23442 [CrossRef] PMID:27093064
  22. Nassi N, Piumelli R, Lombardi E, Landini L, Donzelli G, de Martino M. Comparison between pulse oximetry and transthoracic impedance alarm traces during home monitoring. Arch Dis Child. 2008;93(2):126–132. doi:10.1136/adc.2007.118513 [CrossRef] PMID:17893118
  23. Bonafide CP, Localio AR, Ferro DF, et al. Accuracy of pulse oximetry-based home baby monitors. JAMA. 2018;320(7):717–719. doi:10.1001/jama.2018.9018 [CrossRef] PMID:30140866
  24. Committee on Fetus and Newborn. American Academy of Pediatrics. Apnea, sudden infant death syndrome, and home monitoring. Pediatrics. 2003;111(4 Pt 1):914–917. PMID:12671135
  25. Dal'Astra AP, Quirino AV, Caixêta JA, Avelino MA. Tracheostomy in childhood: review of the literature on complications and mortality over the last three decades. Braz J Otorhinolaryngol. 2017;83(2):207–214. PMID:27256033
  26. Kirby DF, Delegge MH, Fleming CR. American Gastroenterological Association technical review on tube feeding for enteral nutrition. Gastroenterology. 1995;108(4):1282–1301. doi:10.1016/0016-5085(95)90231-7 [CrossRef] PMID:7698596
  27. Sealock RJ, Munot K. Common gastrostomy feeding tube complications and troubleshooting. Clin Gastroenterol Hepatol. 2018;16(12):1864–1869. doi:10.1016/j.cgh.2018.07.037 [CrossRef] PMID:30077033

Common Respiratory Conditions in Infants Requiring Monitoring or Therapeutic Devices at Home

Etiology Device or Medication Pearls for the Primary Care Provider
Apnea of prematurity Pulse oximeter Apnea monitor Caffeine Rare to have apnea of prematurity after 43 weeks postmenstrual age Half-life of caffeine is high (5–7 days) Monitor for side effects of caffeine High rate of false alarms with apnea monitor Apnea monitor may not detect obstructive apnea
Bronchopulmonary dysplasia Low flow oxygen Pulse oximeter Tracheostomy tube Ventilator Needs multidisciplinary care including but not limited to primary care physician, pulmonologist, cardiologist, nutritionist, occupational therapist Follow up every 2–4 weeks Low flow can be weaned by one-eighth of a liter per minute Age-appropriate immunization of infant including influenza and respiratory syncytial virus prophylaxis Monitor electrolytes if taking diuretics Optimize nutritional support Caregiver should receive appropriate vaccinations, including pertussis and Influenza Be aware of worsening of pulmonary hypertension and/or increased oxygen requirement with viral infection

Common Conditions in Infants Necessitating Nutritional Support at Home

Etiology Devices Common Complications
Immature oro-motor skills due to prematurity Structural central nervous system disorders Neuromuscular disorders Congenital oropharyngeal anomalies Encephalopathy   Metabolic   Genetic   Hypoxic ischemic   Infectious Nasogastric tube Gastrostomy tube Trauma Dislodged or misplaced tube Clogging of tube Pneumothorax Aspiration Tube malfunction Stoma infection Dislodgement

Preparation for Transition of Care for Infants with High-Risk Factors Requiring Technological Devices

Safe Discharge Practice Measures
Appropriate screening Audiology evaluation Evaluation for retinopathy Cyanotic congenital heart disease screening
Caregiver preparation Encourage to get involved in infant care while in hospital Appropriate caregiver teaching about:   Medication   Device   Cardiopulmonary resuscitation
Home setup Adequate equipment availability Emergency plan in place
Outpatient Home nursing services as appropriate Medications and support devices are set up Medical home is identified Follow-up appointments are scheduled
Authors

Pradeep Velumula, MD, is a Fellow, Neonatal-Perinatal Medicine. Sanket Jani, MD, is an Assistant Professor, Department of Pediatrics. Neelakanta Kanike, MD, is an Assistant Professor, Department of Pediatrics. Sanjay Chawla, MD, is an Associate Professor, Department of Pediatrics. All authors are affiliated with the Children's Hospital of Michigan, Hutzel Women's Hospital, Wayne State University.

Address correspondence to Pradeep Velumula, MD, Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI 48201; email: pvelumul@dmc.org.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/19382359-20200121-01

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