Acessibilidade / Reportar erro

Readmission of late preterm and term neonates in the neonatal period

Abstract

Objective

To determine the incidence of hospital readmissions in late preterm and term neonates, the most common reasons for readmission, and analyze the risk factors for readmission in the neonatal period.

Methods

Newborn infants admitted to a well-baby nursery ≥ 36 weeks gestation were included in this retrospective cohort study. Data for all infants born in a 3-year period and readmitted in the first 28 days of life were analyzed. Indication for readmission was one diagnosed during initial workup in the pediatric emergency room visit before readmission.

Results

The final cohort consisted of 5408 infants. The readmission rate was 4.0% (219/5408). Leading readmission causes were respiratory tract infection (29.58%), jaundice (13.70%), and urinary tract infection (9.59%). The mean ± SD age of readmitted infants was 13.3 ± 7.1 days. The mean ± SD treatment duration of treatment was 5.5 ± 3.0 days. In the multivariate regression analysis, infants that were during the initial hospitalization transferred to special care/NICU had a lower chance of readmission during the neonatal period (p = 0.04, OR = 0.23, 95% CI 0.06-0.93). Infants with mothers aged from 19-24 years had a higher risk of readmission (p = 0.005, OR = 1.62, 95% CI 1.16-2.26).

Conclusions

Finding that infants that were during the initial hospitalization transferred to special care or a NICU setting were less likely to require hospitalization in the neonatal period is an interesting one. Further research into how different approach in these settings reduce the risk of readmission is necessary.

Highlights

  • In infants gestational age ≥ 36 weeks the readmission rate is 4.0%.

  • Most common causes are respiratory infections, jaundice, and feeding problems.

  • Initial care in special care or NICU setting showed reduced readmission rates.

Introduction

Readmission of neonates in the neonatal period has in the past decades come into focus primarily due to its connection with growing trends of early discharge after birth (<48 hours in vaginally born infants). Since the 1970s, there have been increasing trends of shorter hospital stays for infants after uncomplicated vaginal birth and following C-section,11 Oddie SJ, Hammal D, Richmond S, Parker L. Early discharge and readmission to hospital in the first month of life in the Northern Region of the UK during 1998: a case cohort study. Arch Dis Child 2005;90(2):119-24. mainly due to increasing healthcare costs.22 Meara E, Kotagal UR, Atherton HD, Lieu TA. Impact of early newborn discharge legislation and early follow-up visits on infant outcomes in a state Medicaid population. Pediatrics 2004;113(6):1619-27.

A meta-analysis of 10 trials found that earlier postnatal discharge of healthy mothers and term infants do not appear to have adverse effects on breastfeeding or maternal depression when accompanied by a policy of offering women at least one nurse-midwife home visit post-discharge. Trends favoring the early discharge group were observed for all maternal and infant outcomes except for maternal and infant readmissions, which favored the standard care group.33 Jones E, Stewart F, Taylor B, Davis PG, Brown SJ. Early postnatal discharge from hospital for healthy mothers and term infants. Cochrane Database Syst Rev 2021;8(6): CD002958. 6.

Fahrat et al.44 Farhat R, Rajab M. Length of postnatal hospital stay in healthy newborns and re-hospitalization following early discharge. N Am J Med Sci 2011;3(3):146-51. reported that hospital discharge at any time ≤48 hours significantly increases the risk for readmission as well as the risk for readmission due to hyperbilirubinemia. A report from Saudi Arabia55 Habib HS. Impact of discharge timings of healthy newborns on the rates and etiology of neonatal hospital readmissions. J Coll Physicians Surg Pak 2013;23(10):715-9. found that hospital discharge of neonates within 48 hours after delivery significantly increases the risk for hospital readmission during the neonatal period with the pre-dominance of sepsis-related cases.

In most cases, newborns are readmitted due to jaundice66 Perme T, A Škafar Cerkvenik, Š Grosek. Newborn readmissions to slovenian children's hospitals in one summer month and one autumn month: a retrospective study. Pediatr Neonatol 2016;57(1):47-52. and infections.55 Habib HS. Impact of discharge timings of healthy newborns on the rates and etiology of neonatal hospital readmissions. J Coll Physicians Surg Pak 2013;23(10):715-9.,66 Perme T, A Škafar Cerkvenik, Š Grosek. Newborn readmissions to slovenian children's hospitals in one summer month and one autumn month: a retrospective study. Pediatr Neonatol 2016;57(1):47-52. Several factors have been identified to contribute to readmissions: exclusively breastfed neonates,11 Oddie SJ, Hammal D, Richmond S, Parker L. Early discharge and readmission to hospital in the first month of life in the Northern Region of the UK during 1998: a case cohort study. Arch Dis Child 2005;90(2):119-24. community nurse visit after > 72 hours,77 Escobar GJ, Greene JD, Hulac P, Kincannon E, Bischoff K, Gardner MN, et al. Rehospitalisation after birth hospitalisation: patterns among infants of all gestations. Arch Dis Child 2005;90(2):125-31. ethnic background,88 Braveman P, Egerter S, Pearl M, Marchi K, Miller C. Problems associated with early discharge of newborn infants. Early discharge of newborns and mothers: a critical review of the literature. Pediatrics 1995;96(4 Pt 1):716-26. maternal age, and a number of previous deliveries.99 Harrold J, Langevin M, Barrowman N, Sprague AE, Fell DB, Moreau KA, et al. Pediatric Emergency Research Canada Network. Parental characteristics and perspectives pertaining to neonatal visits to the emergency department: a multicentre survey. CMAJ Open 2018;6(3):E423-9.

In Croatia, there are no official recommendations for the discharge of the mother-infant dyad, but vaginally born infants are in general discharged after 48-72 hours and 5-7 days following birth by cesarean section. After discharge, every neonate is visited by a community nurse on the first working day of the week. In the studied county, primary, secondary and tertiary care for children <18 years of life is readily accessible, and all treatment for children is fully covered by national health insurance.

In this study, the authors aimed to determine the incidence of hospital readmissions in late preterm and term neonates, the most common reasons for readmission, and analyze the risk factors for readmission in the neonatal period.

Materials and methods

This retrospective cohort study was performed at a regional university hospital with a level 3 neonatal unit, special care unit, and well-baby nursery. The authors reviewed the medical charts of all live-born infants with gestational age (GA) at birth ≥ 36 weeks from January 2017 to December 2019 admitted to the well-baby nursery.

Data were analyzed for all infants readmitted after discharge from the initial hospitalization until 28 days of life that were admitted to a single university hospital. Among the data gathered for the newborns were age, sex, birth weight, length of initial hospitalization, treatment during initial hospitalization, diagnosis on admission, duration of treatment, the timing of first community nurse visit. Data for their mothers were also obtained. Among these were the age of the mother, type of delivery, number of previous deliveries, education level, and place of residence. Indication for readmission was one diagnosed during initial workup in the pediatric emergency room visit before readmission.

Ethics: The study was approved by the University Hospital Osijek Ethics committee (n° R2-13170/2020).

Statistical analysis

Data were described by using descriptive statistical methods. Differences in categorical variables were tested by the Chi-Square test. The normality of the distribution of numerical variables was tested by the Shapiro-Wilk test. Numerical data were described by the median and the limits of the Interquartile Range (IQR). Differences between numerical variables between two independent groups were tested by the Mann-Whitney U test. Logistic regression (univariate and multivariate) was used to analyze the independent factors associated with the factors influencing readmission. The level of significance was set at 0.05. Statistical analysis was performed using SPSS 17.0 (SPSS Inc., Chicago, IL, USA), and MedCalc® Statistical Software version 20 (MedCalc Software Ltd, Ostend, Belgium; https://www.medcalc.org; 2021).

Results

The initial cohort included 5454 infants with gestational age ≥36 weeks gestation, and 46 infants were immediately after birth admitted to the neonatal intensive care unit and were not included in the analysis. The final cohort consisted of 5408 infants. The overall readmission rate was 4.0% (219/5408) for infants ≤ 28 days of life and admitted for non-elective reasons. The leading cause for readmission was respiratory tract infection (29.68%), jaundice (13.70%), feeding difficulties or vomiting (10.96%), urinary tract infection (9.13%), and umbilical cord issues (6.85%). Other reasons for readmission are listed in Table 1.

Table 1
Reasons for readmission.
Table 2
Characteristics of all non - readmitted and readmitted infants.

When comparing two groups of infants (Table 3), infants that were transferred to the NICU during the initial hospitalization have a lower chance of readmission compared to infants that were discharged home (p = 0.02, RR = 0.25, 95% CI = 0.06-0.99) and infants whose mothers are up to 29 years old have a higher chance of readmission (p = 0.01, RR = 0.85, 95% CI = 0.73-0.98).

Table 3
Comparison of non - readmitted and readmitted infants.

In the univariate logistic regression analysis, no predictor was found to be significant for readmission (Table 4). The multivariate regression analysis (stepwise method) showed that infants that were during the initial hospitalization transferred to NICU had a lower chance of later readmission during the initial 28 days of life (p = 0.04, OR = 0.23, 95% CI = 0.06-0.93). Infants with mothers ages from 19-24 years had a higher risk of readmission in the first 28 days of life (p = 0.005, OR = 1.62, 95% CI = 1.16-2.26).

Table 4
Univariate logistic regression analysis of factors influencing readmission.

Discussion

The history of opinions regarding the proper timing of discharge of healthy neonates is a complicated one. Length of postnatal hospital stay has declined dramatically in the past fifty years worldwide. In the United States in the 1970s, the average hospital stay after uncomplicated vaginal birth was 4.1 days and following delivery by cesarean section 7.8 days.1010 Thilo EH, Townsend SF, Merenstein GB. The history of policy and practice related to the perinatal hospital stay. Clin Perinatol 1998;25(2):257-70. In 1992 postnatal stays were reduced to 2.1 days following vaginal birth and 4 days after cesarean section.1010 Thilo EH, Townsend SF, Merenstein GB. The history of policy and practice related to the perinatal hospital stay. Clin Perinatol 1998;25(2):257-70. Worldwide, postnatal hospital stays vary significantly after singleton vaginal delivery, ranging from just 0.5 days in Egypt in the year 2008 to 6.2 days in Ukraine in 2007.1111 Campbell OM, Cegolon L, Macleod D, Benova L. Length of stay after childbirth in 92 countries and associated factors in 30 lowand middle-income countries: compilation of reported data and a cross-sectional analysis from nationally representative surveys. PLoS Med 2016;13(3):e1001972.

Paper by Luciano emphasizes that too short a hospital stay can lead to higher readmission rates due to jaundice, feeding difficulties, hypernatraemic dehydration, infections, congenital heart defects, and gastrointestinal obstruction.1212 Luciano R. Early discharge of term neonates: we can do it safely. Ital J Pediatr 2015;41(Suppl 2):A42. Since the length of postnatal stay can significantly impact readmission rates and subsequently lead to increased neonatal mortality and morbidity1313 Datar A, Sood N. Impact of postpartum hospital-stay legislation on newborn length of stay, readmission, and mortality in California. Pediatrics 2006;118(1):63-72. rates of readmission, causes of readmission and factors influencing readmission should be understood in national, regional, and local contexts.

In the present study, the overall readmission rate for neonates ≥36 weeks gestation in the neonatal period is 4.0% (219/5454). This rate is slightly lower than in Slovenia in 2012 (6% in June 2012 and 5.9% in November 2012).66 Perme T, A Škafar Cerkvenik, Š Grosek. Newborn readmissions to slovenian children's hospitals in one summer month and one autumn month: a retrospective study. Pediatr Neonatol 2016;57(1):47-52.

Studies report readmission rates of 0.62% within the first ten days after discharge,1414 Paul IM, Lehman EB, Hollenbeak CS, Maisels MJ. Preventable newborn readmissions since passage of the Newborns' and Mothers' Health Protection Act. Pediatrics 2006;118(6):2349-58. 1.0% to 3.7% within two weeks after nursery discharge in infants of all gestation.77 Escobar GJ, Greene JD, Hulac P, Kincannon E, Bischoff K, Gardner MN, et al. Rehospitalisation after birth hospitalisation: patterns among infants of all gestations. Arch Dis Child 2005;90(2):125-31. A study by Metcalfe et al.1515 Metcalfe A, Mathai M, Liu S, Leon JA, Joseph KS. Proportion of neonatal readmission attributed to length of stay for childbirth: a population-based cohort study. BMJ Open 2016;6(9):e012007. found readmission rates of 4.6% in 2008-2010 among vaginal births and 2.4% among cesarean births in Canada (excluding Quebec).

An interesting outlier in these reports is a study by Kavehmanesh et al.1616 Kavehmanesh Z, Mohammadieh NE, Zarchi AK, Amirsalari S, Matinzadeh ZK, Torkaman M. Prevalence of readmission for hyperbilirubinemia in healthy newborns. Iran J Pediatr 2008;18:130-6. with readmission rates of 12.6% just for hyperbilirubinemia in Iranian infants > 2500 g birth weight. The study reported a mean (SD) length of nursery stay was 30.2 (23.9) hours.

In the present study, the median (IQR) length of postnatal stay was 3 (3-5) days with no statistically significant difference in length of initial stay between readmitted and non-readmitted infants (p = 0.11).

Regarding the reason for readmission, the present study found interesting differences from earlier studies. In the present study, the five leading reasons for readmission were respiratory tract infection (29.68%), jaundice (13.70%), feeding difficulties or vomiting (10.96%), urinary tract infection (9.13%), and umbilical cord issues (6.85%). In contrast to the present study, the majority of reports classify jaundice as the leading cause of readmission.66 Perme T, A Škafar Cerkvenik, Š Grosek. Newborn readmissions to slovenian children's hospitals in one summer month and one autumn month: a retrospective study. Pediatr Neonatol 2016;57(1):47-52.,1414 Paul IM, Lehman EB, Hollenbeak CS, Maisels MJ. Preventable newborn readmissions since passage of the Newborns' and Mothers' Health Protection Act. Pediatrics 2006;118(6):2349-58.,1616 Kavehmanesh Z, Mohammadieh NE, Zarchi AK, Amirsalari S, Matinzadeh ZK, Torkaman M. Prevalence of readmission for hyperbilirubinemia in healthy newborns. Iran J Pediatr 2008;18:130-6. This may be due to the study's institutional rigorous clinical observance for hyperbilirubinemia during initial hospitalization.

In the present study, even though respiratory tract infections are the leading cause of readmission, the season of birth is not significantly different between readmitted and nonreadmitted infants, excluding the causal connection with seasonal viral infections and timing of birth. Also, there are no differences between the two groups of infants regarding or not the infant has an older sibling (Table 2). Regarding this finding, the authors can only hypothesize that cultural context comes into view regarding well-established local customs of immediate family visits after discharge in Croatia, but the authors did not include this data in this study. Also, the local practice could influence the admission rates for respiratory tract infections since clinicians have a low threshold for hospitalization in the neonatal period.

Feeding difficulties are among the most common reasons for readmission reported earlier.1717 Young PC, Korgenski K, Buchi KF. Early readmission of newborns in a large health care system. Pediatrics 2013;131(5):e1538-44. In the study's cohort of readmitted infants, feeding difficulties and poor weight gain presented a significant proportion of readmitted infants. Although these conditions are sometimes associated with exclusively breastfed infants, and the readmission rate for breastfeeding problems is approximately 0.3% to 2% of term or near-term infants,1818 Hall RT, Simon S, Smith MT. Readmission of breastfed infants in the first 2 weeks of life. J Perinatol 2000;20(7):432-7. the authors found no correlation between exclusivebreastfeeding rates in readmitted and non - readmitted neonates (Table 3), and exclusive breastfeeding was not found to be a risk factor for readmission (Table 4)

One specific of this study is that in the reasons examined, particular interest was placed on parental concerns as a reason for readmission. These concerns accounted for 4.57% of all readmissions. These infants were in all cases hospitalized for short workups and discharged mostly the next day. Even though these cases do not account for a large number of readmissions, they could indicate that a more methodical approach needs to be undertaken in preparation of the family for newborn discharge, similar to those proposed in the American Academy of Pediatrics recommendations from 2010.1919 American Academy of Pediatrics. Committee on fetus and newborn. Hospital stay for healthy term newborns. Pediatrics 2010;125(2):405-9. In accordance with the AAP recommendations,2020 Blumovich A, Mangel L, Yochpaz S, Mandel D, Marom R. Risk factors for readmission for phototherapy due to jaundice in healthy newborns: a retrospective, observational study. BMC Pediatr 2020;26(1):248.. 20. both cohorts of neonates were visited by a licensed health care professional. However, 83.2% were visited in the preferred 72 hours after discharge. This was not found to be a risk factor for readmission (Table 4)

When comparing both groups of infants, readmitted infants were more commonly born to mothers ≤ 29 years of age (p = 0.01, OR = 0.85, 95% CI = 0.73-0.98), and non - readmitted infants were more often hospitalized in special care or NICU setting (p = 0.02, OR = 0.25, 95% CI = 0.06-0.99). However, in the univariate analysis (Table 4), no single factor was identified to significantly contribute to readmission.

In the multivariate analysis, if the initial hospitalization continued with transfer to special care or NICU setting with subsequent discharge, these infants were less likely to be readmitted later on (p = 0.04, OR = 0.23, 95% CI = 0.06-0.93). This finding can be analyzed from several points of view. At first view, this finding is consistent with previous findings that a longer length of stay reduces the readmission rates.2020 Blumovich A, Mangel L, Yochpaz S, Mandel D, Marom R. Risk factors for readmission for phototherapy due to jaundice in healthy newborns: a retrospective, observational study. BMC Pediatr 2020;26(1):248.. 20. However, the duration of initial hospitalization did not significantly vary between readmitted and non-readmitted infants (Table 2).

In the study's institution, when an infant is transferred to special care or NICU setting, infants are hospitalized with their mothers, with a larger number of nursing staff and presumably more support regarding infant care. This all can contribute to alleviating common readmission issues and parental concerns (i.e., feeding difficulties, umbilical cord care) and could reduce the risk for readmission.

The only factor that was found to lead to a higher risk for readmission was maternal age from 19-24 years (p = 0.005, OR = 1.62, 95% CI = 1.16-2.26). Interestingly, maternal age ≤ 18 years was not found to be a significant risk factor as previously reported.2121 Martens PJ, Derksen S, Gupta S. Predictors of hospital readmission of Manitoba newborns within six weeks postbirth discharge: a population-based study. Pediatrics 2004;114(3):708-13. The authors of the present study hypothesize that this is due to the perception that these young mothers will require more help, and the nursing staff and family support system after discharge is sensitized to help after the initial discharge.

The findings of this study have to be seen in the light of some limitations. This is a,single-center, retrospective study, and therefore its conclusions could be affected by local practices. Also, there may be a small number of infants readmitted to nearby county hospitals more adjacent to the parents’ place of residence; however, empirically, the authors found that parents are more inclined to present newborn infants to the hospital of birth in thec region the authors focused on.

In conclusion, readmission rates in the neonatal period for infants born at ≥36 weeks gestation and admitted to a well-baby nursery in the studied cohort is 4.0% and is similar to those reported earlier. In contrast to other studies, respiratory tract infections are the leading cause of readmission, followed by jaundice. The present study's data suggest that length of initial hospitalization should not be the main focus of discussion in the prevention of readmission in the neonatal period, but more emphasis needs to be placed on providing expert staff support to the family of the infant. In this light, the authors’ finding that infants transferred to special care or a NICU setting during the initial hospitalization were less likely to require hospitalization in the neonatal period is an interesting one. Further research into how different approaches in these two settings reduce the risk of readmission is needed.

References

  • 1
    Oddie SJ, Hammal D, Richmond S, Parker L. Early discharge and readmission to hospital in the first month of life in the Northern Region of the UK during 1998: a case cohort study. Arch Dis Child 2005;90(2):119-24.
  • 2
    Meara E, Kotagal UR, Atherton HD, Lieu TA. Impact of early newborn discharge legislation and early follow-up visits on infant outcomes in a state Medicaid population. Pediatrics 2004;113(6):1619-27.
  • 3
    Jones E, Stewart F, Taylor B, Davis PG, Brown SJ. Early postnatal discharge from hospital for healthy mothers and term infants. Cochrane Database Syst Rev 2021;8(6): CD002958. 6.
  • 4
    Farhat R, Rajab M. Length of postnatal hospital stay in healthy newborns and re-hospitalization following early discharge. N Am J Med Sci 2011;3(3):146-51.
  • 5
    Habib HS. Impact of discharge timings of healthy newborns on the rates and etiology of neonatal hospital readmissions. J Coll Physicians Surg Pak 2013;23(10):715-9.
  • 6
    Perme T, A Škafar Cerkvenik, Š Grosek. Newborn readmissions to slovenian children's hospitals in one summer month and one autumn month: a retrospective study. Pediatr Neonatol 2016;57(1):47-52.
  • 7
    Escobar GJ, Greene JD, Hulac P, Kincannon E, Bischoff K, Gardner MN, et al. Rehospitalisation after birth hospitalisation: patterns among infants of all gestations. Arch Dis Child 2005;90(2):125-31.
  • 8
    Braveman P, Egerter S, Pearl M, Marchi K, Miller C. Problems associated with early discharge of newborn infants. Early discharge of newborns and mothers: a critical review of the literature. Pediatrics 1995;96(4 Pt 1):716-26.
  • 9
    Harrold J, Langevin M, Barrowman N, Sprague AE, Fell DB, Moreau KA, et al. Pediatric Emergency Research Canada Network. Parental characteristics and perspectives pertaining to neonatal visits to the emergency department: a multicentre survey. CMAJ Open 2018;6(3):E423-9.
  • 10
    Thilo EH, Townsend SF, Merenstein GB. The history of policy and practice related to the perinatal hospital stay. Clin Perinatol 1998;25(2):257-70.
  • 11
    Campbell OM, Cegolon L, Macleod D, Benova L. Length of stay after childbirth in 92 countries and associated factors in 30 lowand middle-income countries: compilation of reported data and a cross-sectional analysis from nationally representative surveys. PLoS Med 2016;13(3):e1001972.
  • 12
    Luciano R. Early discharge of term neonates: we can do it safely. Ital J Pediatr 2015;41(Suppl 2):A42.
  • 13
    Datar A, Sood N. Impact of postpartum hospital-stay legislation on newborn length of stay, readmission, and mortality in California. Pediatrics 2006;118(1):63-72.
  • 14
    Paul IM, Lehman EB, Hollenbeak CS, Maisels MJ. Preventable newborn readmissions since passage of the Newborns' and Mothers' Health Protection Act. Pediatrics 2006;118(6):2349-58.
  • 15
    Metcalfe A, Mathai M, Liu S, Leon JA, Joseph KS. Proportion of neonatal readmission attributed to length of stay for childbirth: a population-based cohort study. BMJ Open 2016;6(9):e012007.
  • 16
    Kavehmanesh Z, Mohammadieh NE, Zarchi AK, Amirsalari S, Matinzadeh ZK, Torkaman M. Prevalence of readmission for hyperbilirubinemia in healthy newborns. Iran J Pediatr 2008;18:130-6.
  • 17
    Young PC, Korgenski K, Buchi KF. Early readmission of newborns in a large health care system. Pediatrics 2013;131(5):e1538-44.
  • 18
    Hall RT, Simon S, Smith MT. Readmission of breastfed infants in the first 2 weeks of life. J Perinatol 2000;20(7):432-7.
  • 19
    American Academy of Pediatrics. Committee on fetus and newborn. Hospital stay for healthy term newborns. Pediatrics 2010;125(2):405-9.
  • 20
    Blumovich A, Mangel L, Yochpaz S, Mandel D, Marom R. Risk factors for readmission for phototherapy due to jaundice in healthy newborns: a retrospective, observational study. BMC Pediatr 2020;26(1):248.. 20.
  • 21
    Martens PJ, Derksen S, Gupta S. Predictors of hospital readmission of Manitoba newborns within six weeks postbirth discharge: a population-based study. Pediatrics 2004;114(3):708-13.

Publication Dates

  • Publication in this collection
    16 Mar 2022
  • Date of issue
    2022

History

  • Received
    22 July 2021
  • Accepted
    30 Nov 2021
Faculdade de Medicina / USP Rua Dr Ovídio Pires de Campos, 225 - 6 and., 05403-010 São Paulo SP - Brazil, Tel.: (55 11) 2661-6235 - São Paulo - SP - Brazil
E-mail: clinics@hc.fm.usp.br