Little information, lots of ansiety

“The demand of infinite treatments” by today’s families is caused by the lackl of health informatoion. This, therefore, represents a “new need” to wich paediatricians have to reply by using techniques and means of communication in a way that they provide education and information on health effectively. To learn the needs and the interests of those who receive the message, that is parents and adolescents, the paediatricians must not examine the reality fro their point of view and on their own needs but to place themselves in the patients’ viewpoint.

The objective should be to discharge the newborns within 24 hours of delivery, as is the practice in several European states (see figure 1), in cases where the baby is born to term ,by natural childbirth, weighing over 2750 grams and having presented no problems during pregnancy, delivery or the hours following the birth.

There are many advantages to early discharge: the mother is enabled to re-establish herself in her home environment (of special importance when other children are involved), the development of the mother-child relationship is improved and the risks of intra-hospital infection are reduced.

Earlier release reduces the costs of obstetric and neo-natal units, and is also beneficial from the point of view of hospital organization.

As outlined by the Plan regarding mothers and children, the closure of birth centres where fewer than 500 births a year take place is planned. Thus a briefer period in hospital will reduce the disturbance to the family, making the amalgamation of birth centres, and inevitably a relocation of the parturient period, easier to accept.

Until today the question of early discharge has been considered mainly from an administrative perspective, and the chief concern has been the setting in place of other opportunities for mothers to receive help and guidance.

The objective, however, should be above all to enable to mother to return home with the capacity to care for the child on her own. To avoid the medicalisation of the neo-natal period – which runs the risk of disempowering the mother and slowing down the development of the mother-child relationship by delegating the parental responsibilities to other parties – the mother should be equipped with all the necessary information for her to care independently for the baby.

Released from hospital within 24 hours, she should be able to care for the baby, identify potential problems and, if necessary, know where to find assistance.

The mother, especially during the later months of pregnancy, generally acquires the greatest quantity of information on the care of newborns and on breastfeeding and seeks this type of information through purpose designed media facilities and books, rather than through ante-natal classes. Such classes are often disproportionately geared towards preparation for labour and the moment of birth itself; from the perspective of early discharge, the classes should focus more on care of newborns.

A level of collaboration should be reached with the gynaecologist, who should stipulate clearly to the mother, in the course of the routine visits made during pregnancy, that early discharge can occur only in cases where the mother (ideally in conjunction with the father) has followed preparatory classes.

During these classes, all information regarding choice of family paediatrician, location of their surgeries (particularly for residents of large cities), means of access and opening hours to the surgeries, and the presence of obstructions to disabled access should be given. Mothers should be encouraged to seek advice from friends and acquaintances with children. It is important for the parents to have a point of reference from the moment that the baby is released from hospital, to whom they can turn in case of necessity, or even just to ask questions: this can be the family paediatrician, the hospital paediatrician, in which case house calls may be arranged. The essential point is that from the moment that they leave the hospital, the parents should have a telephone number enabling them to seek medical help in the case of necessity (this is no less true in the case of ordinary discharge). Clearly, the hospital system must be organized in such a way that all the necessary screenings can be completed in the hours following the birth.

A final condition for early discharge is that the mother should have been presented with the child immediately following the birth and have practiced ‘rooming-in’.

Here follow in ten points the directions to be given to parents.

1. Necessary purchases: Before going to hospital for the birth, the mother must have equipped the house with a baby changing unit; an area in which the baby can be changed. She must have acquired a certain quantity of disposable nappies, a cot and a pram. Nothing else is needed.

2. At home: Upon arrival in the house, it is more likely for the baby to be too hot than too cold. In winter, when the temperature can be regulated, it should not surpass 20 degrees. In summer, those with air conditioning are encouraged to use it.

3. Out for a walk: The baby can be brought outside the house on the fifth day following release provided that his/her weight is over 3 kilos. Otherwise the parents should wait until this weight is attained before leaving the house. A time of day with mild and pleasant temperatures should be chosen.

4. Crying: the parents should always pick up the baby when he/she cries. Crying is not an expression of a state of suffering, but the baby’s way to communicate, given that speech is impossible. Crying can mean that the baby is lonely, or hungry; the baby must always be given a reassuring answer. To try and translate the baby’s crying, the parents can look at their watches: if less than an hour has passed since the baby was fed, then it is likely that the baby is feeling lonely. In this case, the parents should instantly pick the baby up, offer a pacifier, and rock the baby while speaking softly or singing a lullaby. If the baby has not quieted down within five minutes, milk should be offered. If it is not wanted, the parent should persist in rocking motion and calming sounds.

5. Feeding and growth: the baby should be fed when crying, according to the instructions relating to the previous point. The baby should not be held to the breast for more than 10 minutes at a time. Weighing the baby before feeding and after feeding should never be done. Weighing the baby once a week is sufficient. For the first ten days the baby will feed little and sleep greatly, as the body adapts. Up until 14 days, physiological weight loss may occur, which results in the baby losing weight rather than gaining it, or in the baby growing at an insufficient rate. Only after 14 days of life can the baby be expected to gain weight, at a rate of around 200 grams per week. The doctor should be consulted if the baby gains less than 100 grams per week. Above all, the mother should be aware that only 2 out of 100 women are unable to breastfeed, and so should be encouraged to take the baby to her breast in full expectation of producing milk. A breastfeeding mother can eat anything she wishes without worrying about allergies, but she should not wash the breast with soap, or use perfumes or deodorants. The paediatrician should be alerted if the baby goes for more than 18 hours without feeding.

6. Evacuation and characteristics of faeces: when the baby is breastfed, the parents should not be concerned about the quantity or characteristics of the faeces. Even when bottle-fed, the baby may evacuate after every feed, or every 4 days. The faeces of a breastfed baby are of a golden yellow colour and semi-liquid consistency. Those babies who are bottle-fed produce lighter and more solid faeces. There is no cause for concern if the faeces become green in the nappy, or even if they are green when emitted. This colour is produced because the air transforms bilirubin into biliverdin, thus creating the green colour in the faeces.

7. Breathing: there is no cause for alarm if the baby sneezes or breathes stertuously. Sneezes expel dust or other irritant materials from the nose, and respiratory noise is produced because the narrow cavities can function similarly to a musical instrument. The doctor should be consulted if the baby’s nose is closed, or emits a secretion. The best indication of a baby’s well-being is to count the number of breaths, by placing a hand on the abdomen. If the number of lifts (each one corresponding to a breath) is over 50 a minute, the doctor should be consulted. If the number is less than fifty, all is well.

8. Navel: This can be treated without worrying about tearing. The parents should inform themselves before being discharged about how to treat the navel, but all that is required is a sterilised gauze bandage, which will be used to bind and cover it, and elastic netting. The navel generally separates by the 12th day of life. If this does not occur, the paediatrician should be consulted. A doctor should also be advised if the gauze bandage comes away stained with yellow (i.e. pus), as this could indicate an infection, or with red, which could indicate bleeding. The paediatrician should also be consulted if the skin around the navel goes red. Babies can be bathed over three days after the separation of the navel.

9. Skin: the parents should be taught to recognize skin tones to identify problems: blue shades can signify problems with the heart or the breathing apparatus, yellow shades can signify jaundice. In both cases, the paediatrician should be consulted.

10. The first check-up: parents should be aware that in general the first check-up takes place around the end of the first month of life (between 20 an 40 days), and that the first vaccination takes place at the end of the second month.
    

Conclusion

Parents should pay particular attention to recognizing signs of the appearance of jaundice symptoms, as over 50% of re-admissions to hospital are caused by this phenomenon.

In order that early discharge be beneficial and safe, it is necessary to inform the parents, even those who already have children. Remembered procedures, often approximate and incomplete, are no basis for the care of newborns.

The best forum for education is ante-natal classes, but these also should be carefully planned as regards the methods of communicating their message. We must consider that parents live in a society based on communication, and are used to decoding media messages.

The information from the paediatrician, too, should be given in the form of simple statements.

In practice, it is recommended that single ASLs, and paediatric and neonatal societies are able to produce material for distribution among parents on the same level as that produced by the media. To this aim, videos, CDs and monographs may be produced.

Figure 1: Neonatal Discharge in Europe