Going Home From the Neonatal Unit: When Premature Babies Leave Hospital and What Helps Families Afterwards

What a large United States study, a worldwide review of home visits and two reports from one German hospital tell parents about the timing of discharge and support at home

Babies born very early are going home from hospital a few days later than they used to, and part of the reason seems to be how each hospital does things. A German hospital that taught parents early to tube-feed their babies sent many of them home about two weeks sooner, and those babies grew just as well with parents who were no more anxious or low. A worldwide review found that home visits after discharge probably help more mothers keep breastfeeding.

Why the day a baby goes home matters so much

For parents of a baby born many weeks early, the day of leaving the neonatal intensive care unit (NICU), the hospital ward for newborns who need special care, is often the day they have waited for since birth. It marks the end of long hospital stays, travel and separation, and the beginning of family life at home. But deciding when a baby is ready is not as simple as it sounds, and families are often surprised by how much the final weeks depend on feeding. The papers described here look at how that decision is made, whether it can safely happen earlier, and what support helps once a family is home.

How families and doctors have handled going home in the past

Traditionally, premature babies go home when their bodies have matured enough to breathe without help, stay warm and, especially, feed fully by mouth. Doctors describe a baby's maturity using "postmenstrual age", which counts the weeks from the start of the mother's last menstrual period and simply keeps counting after birth. A Californian study of 865 babies born at 32 weeks of pregnancy or earlier found that most of the key steps toward going home, such as breathing, keeping warm and feeding, were reached between 34 and 36 weeks of postmenstrual age, and that feeding and coming off oxygen were usually the last steps [1]. Most neonatal units still wait until a baby can take every feed by mouth [2]. Over time, babies have been going home later. Across 824 United States hospitals in a network called the Vermont Oxford Network, babies born at 24 to 29 weeks went home about 8 days older in 2018 than in 2005 [3], and a later comparison found increases in the United States, Italy and Austria [4]. Hospitals also differ widely: in Canada, between none and 12 in every 100 very premature babies went home with a feeding tube, depending on the unit [5]. The idea of sending babies home sooner with support is not new. In a United States study in the 1980s, very small babies who went home early with visits and phone support from specialist nurses left hospital about 11 days sooner and were no more likely to return to hospital, with similar growth [6]. In New Zealand, a similar approach did not reduce breastfeeding [7], and a Dutch hospital found that parents could feed through a tube at home safely, with 96 in every 100 parents saying they would do it again [8]. Even so, home tube feeding has remained unusual in many places.

The four studies and how they fit together

The first study, by Handley and colleagues, looked at 75,678 babies born between 23 and 33 weeks of pregnancy in 290 neonatal units across the United States, using anonymous electronic health records from 2017 to 2023 [9]. The second, by Durao and colleagues, is a Cochrane review, a careful summary of all the best-quality studies on a question [10]. It gathered randomised trials, the kind of study in which families are assigned by chance to one approach or another so that the comparison is fair, on home visits after discharge. The review team worked in South Africa, where the question had been flagged as a gap in local health guidance.

The last two reports come from one university hospital in Giessen, Germany [11][2]. They come from the same study at the same hospital, with largely overlapping groups of families looked at in two different ways, so they should be read as one piece of evidence rather than two separate confirmations. The hospital strengthened its "family-centred care", an approach in which parents become their baby's main caregivers while still in hospital, in stages over several years. Parents were taught early to give milk through a nasogastric tube, a thin soft tube that passes through the nose into the stomach, so that babies could go home before they were feeding fully by mouth. After discharge, families were offered a weekly home visit from a neonatal homecare service for 12 weeks.

What the researchers found

In the United States study, the typical age at going home crept later over the seven years, by about three and a half days overall and by about six days for the most premature babies, those born at 23 or 24 weeks [9]. Lung disease and the need for breathing support were the strongest predictors of a later discharge. But the particular hospital unit also mattered for babies of every degree of prematurity, which the researchers think shows that differences in hospital practice play a real part.

In the German hospital, the picture went the other way. Across six groups of babies followed over about three years, 184 babies in all, the average age at going home fell from about 37.8 weeks to 35.7 weeks, roughly two weeks earlier [11]. Before the programme, 3 of 48 babies went home with a feeding tube; in the last group, 12 of 18 did. These babies were naturally smaller when they left, because they left sooner, but their growth in weight, length and head size matched that of earlier babies when checked again around their original due date and at three months past it. No baby died after going home during the months of follow-up, and feeding tubes were usually removed within about two weeks of leaving hospital. A separate report from the same group of babies found that breastfeeding did not fall [12].

The second German report asked how parents felt. It compared 107 babies who went home with a tube and 131 who went home feeding by mouth, from 201 families [2]. Mothers and fathers filled in a widely used questionnaire about anxiety and low mood [13] just before discharge and again when their baby was three months past its original due date. Parents of tube-fed babies were no more anxious or depressed than other parents. At three months, about 10 in every 100 mothers of tube-fed babies had scores suggesting significant low mood, compared with about 24 in every 100 other mothers. The researchers are careful to say that these lower scores are preliminary, because most of the differences did not hold up once they allowed for having tested many things at once. Most families in both groups felt ready to go home.

The Cochrane review included 35 trials, of which 28 provided results on 12,021 babies [10]. When families received home visits rather than none, about 73 in every 100 babies were still being breastfed at six months, compared with about 58 in every 100 without visits. For most other things, such as development and growth, the visits made little or no measurable difference. One very large trial in Haryana, India, in which visitors supported kangaroo care (holding the baby skin to skin) for small babies at home, found fewer deaths [14]: the review estimates about 36 deaths in every 1000 babies by six months, compared with 48 [10]. That trial involved babies in the community rather than graduates of intensive care units, so its results may not apply directly to families leaving a NICU.

What this means for families

These findings do not mean every baby should go home early. In the German hospital, the earlier discharge was part of a whole package: early training, parents taking part in ward rounds and planning, support groups, psychological support, and weekly visits after discharge [11][2]. It is not possible to say which part made the difference. Parents of tube-fed babies more often accepted follow-up support after discharge, and that support may have helped them. Babies who went home with tubes were born, on average, about a week earlier, yet they went home at a similar age to babies who were feeding by mouth [2].

For parents, the encouraging message is that going home with a feeding tube, when it is well planned and supported, does not appear to harm a baby's growth or make parents more distressed. Other research has found that parents' quality of life tends to improve once their baby is home, though complex care at home can be demanding [15]. It is reasonable to ask your baby's team how they decide when a baby is ready, whether home tube feeding is an option in your unit, and what support is available after discharge. Programmes that bring parents into their baby's care in hospital have been tested in large trials; one such trial, Family Integrated Care (FICare), carried out in 26 NICUs in Canada, Australia and New Zealand, found lower parental stress and anxiety [16]. You can read more about what makes discharge teaching work and about kangaroo mother care in other In[Neo]Sight articles.

What researchers are working on next

All four research teams called for further and better research. The German results come from one hospital and a small number of babies, without families being assigned by chance, so the authors want larger studies across many hospitals, ideally with families assigned by chance. Such studies would also need to report readmissions and problems with feeding tubes, which these two reports did not include. The review team noted that no trial had counted emergency hospital visits and that none had been carried out in Africa. Together, these papers suggest that when a premature baby goes home depends partly on hospital habits, that some of the last steps can be taken at home with the right help without apparent harm to babies' growth or parents' mood, and that home visits after discharge probably help more babies keep breastfeeding.

References

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