Background
Increasing survival rates of small and immature infants are the result of high technological advances and quality professional care. Nevertheless, continuing efforts are necessary to improve healthcare services, within a framework that is more family centred.
Reducing hospitalization length is suggested to be beneficial for both infants and parents in terms of promoting family processes and progressing parental role performance. In coherence with this hypothesis, early discharge of stable preterm babies who still need gavage feeding would be an appropriate intervention, if contextualized in a support programme to guide transition to full sucking feeds.
Objective
The main objective of this study1 is to determine the effects of early hospital discharge programmes for stable preterm infants with domiciliary home support of gavage feeding versus prolonged hospitalization until infants have reached full sucking feeds.
Intervention/methods
The criteria for the inclusion of primary studies in the review were as follows:
1. Controlled clinical trials (CCTs) including randomized controlled trials or quasi-randomized studies.
2. CCTs considering infants born at less than 37 weeks' gestation and requiring no intravenous supplementation at the time of discharge.
3. CCTs comparing an early discharge home intervention including home support for infants with gavage feeds versus later discharge home when full sucking feeds are accomplished.
4. CCTs measuring clinical, satisfaction and economic variables as follows: number of days to reach full sucking feeds, breast-feeding prevalence, weight gain, days of hospitalization, neurodevelopmental outcome at 12 months, rehospitalization during the period of home gavage feeding, rehospitalization in the first year after discharge, adverse events (milk aspiration, infection during period of gavage feeding, death within the first year after discharge), parental satisfaction, intervention cost and healthcare service use.
A search was conducted of Cochrane CENTRAL, CINAHL, EMBASE and MEDLINE databases with no language restriction until March 2015.
Study quality was assessed taking as reference standard methods of the Cochrane Neonatal Review Group and the Cochrane 'Risk of bias' tool.
Results
A total of 12 CCTs were identified. Of these identified CCTs, only one met the inclusion criteria of the review. The included study is a quasi-randomized controlled trial including 88 infants [mean gestational age at birth of 31.4 weeks (SD = 2.8) in the experimental group and 32 weeks (SD = 2.3) in the control group] from 75 families (45 infants/40 families in the experimental group and 43 infants/35 families in the control one).
The intervention consisted of early discharge with nurse home visits for infants who required special care, mainly gavage feeds (80%), compared with hospitalization until clinically stable (gaining weight) and no nursing care needed (full sucking feeds).
The results at the end of the intervention (discharge from the home gavage programme for the experimental group and discharge from hospital for the control group) were as follows:
1. No statistically significant differences between groups in the proportion of infants who had stopped any breast-feeding.
2. No significant difference in weight gain [mean difference (MD) 1.10 g/day, 95% confidence interval (CI) 3.94-1.74].
3. Shorter hospital stay (MD -9.30 days, 95% CI -18.49 to -0.11) for infants in the home gavage programme.
4. 17% of the infants in the experimental group were readmitted to the hospital during the intervention.
5. No significant differences between groups in re-admissions cases during 1-year post-intervention period [risk ratio (RR) 1.09, 95% CI 0.54-2.18].
6. Lower risk of infection during the home gavage period compared with time in hospital (RR 0.35, 95% CI 0.17-0.69).
7. No significant difference in mortality between groups (RR 0.32, 95% CI 0.01-7.62).
8. No significant differences in confidence score of mothers (MD 0.40 g/day, 95% CI -0.66 to 1.46) or fathers (MD 0.60 g/day, 95% CI -0.45 to 1.65) related to handling their baby at the time of discharge from the home or from hospital.
9. Higher but not statistically significant feeling of being prepared to take responsibility of infant's care in experimental group mothers (MD 0.90 g/day, 95% CI -0.01 to 1.81).
10. No significant differences in maternal (MD -2.30 g/day, 95% CI -5.49 to 0.89) or paternal (MD -1.80 g/day, 95% CI -4.60 to 1.00) state anxiety.
11. No significant differences in healthcare service use (non-elective visits) in the year post intervention.
Conclusion
Early hospital discharge programmes reduce the risk of infection for stable preterm infants.
There are no cost comparisons, but early discharge is more cost effective than supporting in-patient hospital care.
Implications for practice
Evidence on early discharge with home support of gavage feeding for stable preterm infants, compared with traditional care, is circumscribed to only one study, so recommendations for practice must be considered with caution.
Further studies (randomized controlled trials) with adequate sample size, complete follow-up evaluation and intervention cost comparison are needed.
Acknowledgements
Teresa Gonzalez-Gil is a member of the Cochrane Nursing Care Field (CNCF).
Reference