Consensus Guidelines for the Care of the Growing Premature Infant: Roadmap to Discharge

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UCSF NCNC (Northern California Neonatology Consortium) 

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Table of Contents

• Introduction
• Roadmap to Discharge Overview
• Discharge Checklist
• References

 

Introduction

The goal of this guideline is to promote the optimal routine care of infants born at or corrected to at least 32 weeks of age and stable enough to be cared for at a Community Level 2 Neonatal Intensive Care Unit (NICU)/Intensive Care Nursery (ICN) or step-down unit.  This does not provide guidance on the work-up of specific symptoms.  Care of symptomatic infants should be guided by the abilities of the hospital unit and current evidence-based practice.

The NCNC endorses a family centered care approach where family members are considered vital members of the care team.  Parents should be included on rounds and in helping deliver care when appropriate. Recognition of family as primary caregivers is vitally important to parent-infant attachment and embracing the parental role.

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ROADMAP TO DISCHARGE OVERVIEW

Thermoregulation

• While inpatient, provide a neutral thermal environment (NTE): an ideal environmental temperature and humidity where the infant uses the least amount of energy to maintain temperature
• Before discharge, infants should be able to maintain a normal temperature of 36.5-37.5C while appropriately clothed for ambient temperature

Neurology

• Screening head ultrasound (HUS): for all infants born < 32 weeks GA OR birth weight less than or equal to1500g
  • 1 week of age
  • 1 month of age
  • Additional HUS as needed (i.e. if Grade 2 IVH is present, etc). If abnormalities are noted, weekly HUS should be obtained until stable.
• Brain MRI
  • Recommended, if available, at term corrected age for all infants born <28 weeks GA

Retinopathy of Prematurity (ROP) Screening

• Criteria for screening (per the 2018 AAP Policy Statement):
  • Birth weight less than or equal to 1500 grams or a GA less than or equal to 30 weeks as determined by an Attending Neonatologist
  • Selected infants with a birth weight 1500-2000g or GA > 30 Weeks with an unstable clinical course, including those requiring cardiorespiratory support and who are believed by their attending neonatologist to be at high risk for ROP

Congenital Hypothyroidism Screening

• Criteria for screening:
  • Birth weight <1500g or GA <32 weeks or any infant with congenital heart disease
• Two-step screen:
  • NBS at 12-48hrs of life, TSH and free T4 at 28-35 days of life
  • Consult pediatric endocrinology with any abnormal results
  • NCNC Reference for Congenital Hypothyroidism Screening

Respiratory Stability

• Monitor and treat for apnea of prematurity (AOP)
  • NCNC Apnea Guideline: https://medconnection.ucsfbenioffchildrens.org/apnea-guidelines

• Before discharge, infants should be stable off respiratory support (ideally off supplemental oxygen)
  • By 35 weeks GA, normal oxygen saturation should be >92%
    • Prior to 35 weeks, acceptable saturations range 88-92%

• Car Seat Challenges
  • The NCNC does not recommend routine Infant Car Seat Challenge testing before discharge for preterm infants or other infants thought to be "at risk" for abnormal oxygenation when in a car seat
  • NCNC Car Seat Challenge Statement: https://medconnection.ucsfbenioffchildrens.org/car-seat-challenge

Cardiovascular Health

• Every infant should have standard oximetry (congenital heart disease) screening prior to discharge (CCHD screening)
• Exception: infants that have already been cleared by echocardiography

Feeding and Growth

• Detailed information regarding starting feeds, supplementation, and monitoring nutrition and growth can be found here:
• NCNC Preterm Infant Feeding Reference https://medconnection.ucsfbenioffchildrens.org/news/consensus-clinical-reference-for-preterm-infant-feeding/

• NCNC Late Preterm Infant Feeding Guideline https://medconnection.ucsfbenioffchildrens.org/infant-feeding-guidelines

In general:

• Start oral cares within 12 hours and oral feeds within 12-24 hours if possible
• Use cue-based feeding method
• If parents wish to breastfeed, help support milk supply
• Monitor growth with at least daily weights and weekly head circumference and lengths
• Donor milk use per institutional policy

Prior to discharge:

• Should weigh enough to safely ride in a car seat at discharge
• Goal of establishing full oral feeds and ensuring appropriate weight gain trajectory
• Caregivers should have a clear plan regarding feedings: proper amounts, mixing of formulas or breast-milk fortification or supplementation, tube feeding training and supplies as necessary, and all needed follow-up in place

Hematology

Hyperbilirubinemia: For tracking and managing hyperbilirubinemia in infants born <35 weeks GA, please reference the Stanford Preemie Bili Recs calculator: https://pbr.stanfordchildrens.org

• Monitor for and treat anemia of prematurity
• Consensus recommendation is to provide adequate iron supplementation to promote erythropoiesis
• NCNC Reference for Neonatal Iron Supplementation and Blood Transfusion https://medconnection.ucsfbenioffchildrens.org/news/consensus-clinical-reference-for-neonatal-iron-supplementation-and-blood-transfusion

Infectious Disease

• RSV Prophylaxis
• Maternal Immunization: To prevent severe RSV disease in infancy, current CDC recommendations include RSV vaccination of pregnant people at 32-36 weeks gestation with Abrysvo (a bivalent vaccine). This immunization will pass protection to the infant.
• Monoclonal Antibody: If the mother was not immunized against RSV during pregnancy (or received it within 14 days of delivery), administration of Nirsevimab (Beyfortus) is recommended for the infant during the indicated seasonal timeframe.

• Vaccines
• Dosing based on chronologic age
• No prophylactic pre-medication such as acetaminophen should be given

• Vaccines for Caretakers

• Family members and caretakers should be up to date on immunizations, especially:
• Tdap (DTap for any children in the household)
• Seasonal flu vaccine
• Seasonal COVID-19 vaccine

Family and Home Environment

• Start skin to skin care as soon as possible and practice throughout hospital stay and beyond
  • Reduces: infant stress, pain during procedures, nosocomial infections (in some studies)
  • Improves: thermoregulation, cardiorespiratory stability, sleep, breastfeeding quality and duration, maternal milk production, parent satisfaction, bonding with the infant, parental engagement in infant care, colonization with natural flora
• Establish early caregiver involvement in routine care and educate on typical newborn feeding and sleep
• Discuss safety principles for car and home:
  • Car seat installation and use
  • Safe sleep practices
  • Purple crying education: https://dontshake.org/purple-crying
  • Hand hygiene and infection prevention, including vaccination
  • Recognizing signs of illness: fever, respiratory distress, dehydration and normal output/stools, lethargy etc.
• Social work support as needed to address social drivers of health

 

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Discharge Checklist: 

Weight and Age Considerations: caution if gestational age < 34 weeks and/or  < 1750 grams.

Recommend consultation with UCSF neonatology if considering discharge for infants below these criteria

Thermoregulation

• Stable temperature in an open crib (out of ambient heat, in appropriate clothing) for > 48 hours with adequate growth

Respiratory

• No apnea, bradycardia, or desaturations (A/B/Ds) during sleep requiring intervention for > 5 days
• Caffeine discontinued > 48 hours prior to A/B countdown

Feeding and Growth

• Tolerating goal oral feedings with appropriate weight gain for > 48 hours (generally ~20g/day on average)
• Demonstrates consistent weight gain, typically >1–2%/day over at least two consecutive days
• Parents demonstrate understanding of feeding plan
• For patients on tube feeds: all teaching completed, supplies delivered, follow up in place

Parental Teaching

• Feeding and fortification instructions
• Prescribed medication administration
• Routine preterm infant care
• Safety: car seats, safe sleep, home environment, hand hygiene
• Recognizing early signs of illness, dehydration
• CPR video watched and return demonstration completed

 Healthcare Maintenance

• Hearing screening completed, consider CMV testing if indicated
• Congenital heart defect (CCHD) screening completed
• California Newborn Screening completed
• Immunizations (including RSV prophylaxis) up-to-date
• Retinopathy of prematurity (ROP) screening (if needed)

Follow-up Care

• Primary Care Physician (PMD):
• Appointment scheduled within 1 week of discharge (typically < 72 hours)
• Discharge summary and important documentation (including growth chart) sent from NICU to PMD office, including all follow-up plans and referrals
• High-Risk Infant Follow-up Clinic:
• Check eligibility: GA<32 weeks or BW less than or equal to 1500g, OR the infant meets criteria based on conditions diagnosed while in the NICU (check current CA DHS criteria)
• Subspecialty Care:
• Ophthalmology (if needed)
• Other specialties (if needed)
• Note: Ensure parents are aware of previously arranged subspecialty care follow-up from UCSF or the referring hospital. Document these follow-up care arrangements in the discharge summary

• Support Services

• Verify referrals for support services:
• Regional Center
• California Children’s Services (CCS)

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References

Fierson WM, AAP AMERICAN ACADEMY OF PEDIATRICS Section on Ophthalmology, AAP AMERICAN ACADEMY OF OPHTHALMOLOGY, AAP AMERICAN ASSOCIATION FOR PEDIATRIC OPHTHALMOLOGY AND STRABISMUS, AAP AMERICAN ASSOCIATION OF CERTIFIED ORTHOPTISTS. Screening Examination of Premature Infants for Retinopathy of Prematurity. Pediatrics. 2018;142(6):e20183061

LaFranchi SH. Screening preterm infants for congenital hypothyroidism: better the second time around. J Pediatr. 2014 Jun;164(6):1259-61. doi: 10.1016/j.jpeds.2014.02.031. Epub 2014 Mar 20. PMID:24657124. https://pubmed.ncbi.nlm.nih.gov/24657124/

Rose, S. R., Wassner, A. J., Wintergerst, K. A., Yayah-Jones, N.-H., Hopkin, R. J., Chuang, J., Smith, J. R., Abell, K., LaFranchi, S. H., Wintergerst, K. A., Bethin, K. E., Bruggeman, B., Brodsky, J. L., Jelley, D. H., Marshall, B. A., Mastrandrea, L. D., Lynch, J. L., Burke, L. W., Geleske, T. A., … Spire, P. (2022). Congenital hypothyroidism: Screening and management. Pediatrics, 151(1). https://doi.org/10.1542/peds.2022-060419. https://pubmed.ncbi.nlm.nih.gov/36827523/

Woo HC, Lizarda A, Tucker R, Mitchell ML, Vohr B, Oh W, Phornphutkul C. Congenital hypothyroidism with a delayed thyroid-stimulating hormone elevation in very premature infants: incidence and growth and developmental outcomes. J Pediatr. 2011 Apr;158(4):538-42. doi: 10.1016/j.jpeds.2010.10.018. Epub 2011 Jan 13. PMID: 21232766. https://pubmed.ncbi.nlm.nih.gov/21232766/

German K,  Vu P, et al.. Zinc Protoporphyrin-to-Heme Ratio and Ferritin as Measures of Iron Sufficiency in the Neonatal Intensive Care Unit. J Pediatr 2018;194:47-53

https://doi.org/10.1016/j.jpeds.2017.10.041.

Kalpashri Kesavan, Joanna Parga; Apnea of Prematurity: Current Practices and Future Directions. Neoreviews March 2017; 18 (3): e149–e160. https://doi.org/10.1542/neo.18-3-e149

Karlsson V, Blomqvist YT, Ågren J. Nursing care of infants born extremely preterm. Semin Fetal Neonatal Med. 2022 Jun;27(3):101369. doi: 10.1016/j.siny.2022.101369. Epub 2022 Jun 18. PMID: 35739009.

Lubbe W. Clinicians guide for cue-based transition to oral feeding in preterm infants: An easy-to-use clinical guide. J Eval Clin Pract. 2018; 24: 80–88. https://doi.org/10.1111/jep.12721

Wight N, Kim J, Rhine W, Mayer O, Morris M, Sey R, Nisbet C. 2018. Nutritional Support of the Very Low Birth Weight (VLBW) Infant: A Quality Improvement Toolkit. Stanford, CA: California Perinatal Quality Care Collaborative

National Center on Shaken Baby Syndrome - PURPLE Crying. Accessed September 8, 2025. https://dontshake.org/purple-crying

 

Northern California Neonatal Consortium. Originated 9/2025.

Approved by UCSF Pharmacy and Therapeutics Committee: 12/2025