Newborn Screening, Preventive Care, and Discharge Planning

Several screening tests are recommended before infants are discharged from the hospital to ensure adequate safety prior to follow-up with their primary pediatrician. Prior to discharge, newborns should undergo a newborn state screen as well as screening for bilirubin, critical congenital heart disease, and hearing, and car seat tests (for high-risk infants). In addition, all infants should ideally receive the first hepatitis B vaccine. Preterm infants who have reached the age of 2 months prior to discharge should also be given the standard 2-month vaccines, although live virus rotavirus vaccine is sometimes not administered in the NICU setting and is deferred to the outpatient pediatric office.

See Prevention and Screening and Anticipatory Guidance and Safety in the Preventative/Well Child Care rotation guide for an overview of prevention and screening practices in pediatrics. For more information on Newborn Screening, see Newborn Screening in the Pediatric Genetic/Metabolic Disorders rotation guide.

Prenatal Screening

Pregnant persons are being offered carrier screening to better assess their risk for autosomal recessive and X-linked conditions. Providers in the NICU should be aware of these results and the reproductive partner’s results to determine if additional management or screening is needed for the infant.

Additional screening that is performed in the prenatal space is cell-free fetal DNA (also referred to as noninvasive prenatal testing [NIPT]). This test is performed on maternal blood to screen for aneuploidies in the fetus. It is only a screen, and a normal result does not completely eliminate the possibility of trisomy 13, 18, or 21 in the fetus. Furthermore, fetuses that screen positive do require testing through amniocentesis, cord blood, or on the infant’s blood after delivery.

Newborn State Screening

All newborns are screened for diseases for which early intervention may positively impact outcomes.The Routine Uniform Screening Panel (RUSP) lists 35 core conditions and 26 secondary conditions for which every baby should be screened. The exact conditions vary slightly by state (see Conditions Screened by State). Blood spot collection must be performed after 24 hours of life and ideally once enteral feeding has begun. Some states and institutions offer supplemental newborn screening for other conditions such as Duchenne muscular dystrophy that are not covered in the RUSP.

As these are screening tests, results often are not diagnostic. Given the rarity of the conditions, many positive screens are false positives. Positive screens for individual conditions require follow-up testing to confirm a diagnosis. If an infant screen is negative, the infant is unlikely to have the condition, although false-negative results can occur. State protocols may require repeat screening for preterm and/or low birthweight infants at specific age intervals.

Hearing Screening

All infants should undergo hearing screening prior to discharge. The most common screening methods used in the nursery are auditory brainstem response (ABR) and otoacoustic emissions (OAE). Infants who fail a hearing screen should be referred for follow-up testing with an audiologist. Cytomegalovirus (CMV) testing should also be considered. All infants admitted to the NICU for longer than 5 days or those with prolonged antibiotic courses are at high risk for hearing loss and should undergo repeat hearing screening at 8 months of age. Hearing screening for older infants and children is covered in the Prevention and Screening section of the Prevention Well Child Care rotation guide.

Car Seat Testing

The American Academy of Pediatrics (AAP) recommends monitoring of preterm infants in a car seat before discharge home to ensure the infant is not at risk for hypoventilation or obstruction of the airway. Infants <37 weeks' gestation and infants with airway anomalies, hypotonia, or cardiac surgery should also be considered for a car seat test. The test involves placing the infant in the car seat for a period of observation from 90 to 120 minutes or the duration of travel, whichever is longer. Per the AAP guideline, failure criteria are determined by the physician. Most hospitals have protocols that define failure criteria for that institution. If an infant fails the car seat test, a car bed is recommended for travel, and the physician can consider a car bed test.

Safe Sleep

The incidence of sudden infant death syndrome (SIDS) has declined since the National Back to Sleep Campaign. Safe sleep positioning should be discussed with all families of newborns. The AAP recommends supine positioning; use of a firm, non-inclined sleep surface; room sharing without bed sharing; and avoidance of soft bedding and overheating. It is recommended that infants should sleep in a supine position until 1 year of age and preterm infants should be placed supine as soon as possible. Infants should be placed on a firm non-inclined sleep surface with a tightly fitted sheet and no other bedding or soft objects. Other devices besides a crib or approved sleeping surface should not be used for routine sleep. Infants should be placed back in their own crib or bassinet once feeding or comforting is complete. Bed sharing increases risk of SIDS or unintentional injury and should be avoided.