Dear Editor,

The letters in response to our study1 raise interesting points. Dr. MacDonald suggests that breast-feeding rates at discharge may have accounted for the difference in gestational age at discharge between infants in California and the United Kingdom because of the association of lower socio-economic status and breast-feeding rates. Unfortunately, we do not have data from the United Kingdom Neonatal Staffing Study to explore this question. Data from the Moderately Premature Infant Project showed that more infants in California compared to Massachusetts received breastmilk at discharge (83 versus 63 %), suggesting that according to Dr. MacDonald’s hypothesis infants in California should have been discharged later (length of stay in California was marginally shorter than in Massachusetts). We realize that receiving breastmilk at discharge may only be a poor proxy of actual breast-feeding at discharge. The general approach to oral feeding in most study NICUs includes a combination of bottle and breast-feeding, depending on infants’ clinical status, parental desires and maternal availability. Discharge is not usually delayed for purposes of achieving full breast-feeding.

Dr. Adhvaryu describes how his NICU utilizes a specialized neonatal community team to reduce the length of stay and readmission rates to levels that are comparable to the California data. This supports the theory that health care systems that employ a more coordinated care approach experience more efficient care delivery. Dr. Adhvaryu cites the use of home nasogastric feedings as one of the components of their community program. We think that the variation of the responses in terms of the approach to feeding supports our conclusion that organization of care is an important contributor to patient outcomes beyond underlying clinical risk and socio-economic status. We accept that our study may provide more questions than answers and that examining the relationship between the approach to feeding, length of stay and future health status is worthy of future research.

Reference:

(1) Profit J, Zupancic JA, McCormick MC, Richardson DK, Escobar GJ, Tucker J et al. Moderately premature infants at Kaiser Permanente Medical Care Program in California are discharged home earlier than their peers in Massachusetts and the United Kingdom. Arch Dis Child Fetal Neonatal Ed 2006; 91(4):F245-F250.

Dear Editor,

We read with interest the findings by Profit et al demonstrating that moderately premature infants (30–34+6 weeks gestation) in California are discharged earlier (35.9 weeks) than their UK counterparts (36.3 weeks).1 The authors question the factors responsible but do not specify changes which could be implemented within a UK system to reduce length of stay.

In our level 3 unit from 2003-2005, 309 infants in this gestational age group survived to home discharge. Mean age at discharge was 35.3 weeks (SD: 2.5 weeks), one week earlier than the rate reported for the 54 UK units studied.

Like the authors we feel that earlier discharge is secondary to changes in organisational care management. In our case the provision of a specialised neonatal community team, run by neonatal and nursery nurses, allows for early discharge of infants and improves transition from hospital to home. Provision of support for nasogastric feeding of these infants at home has potentially saved 1.4 special care cots per day..

Profit et al are reassured by data from Escobar et al that earlier discharge does not seem to lead to increases in medical resource use downstream.2 Escobar et al quote an 11.2% readmission rate within their moderately premature US cohort.3 Despite comparable early discharge dates our readmission rate was lower at 9.1%.

Differences in length of stay are important given rising costs of intensive care. Although widely recognised that neonatal community services can offer significant social, economic and psychological benefits there are no national guidelines in the UK on provision of these services. The age at discharge in our centre matches the Californian cohort and our readmission rate is lower. We suggest an important factor in facilitating earlier and safer discharge of these infants is through the provision of a community neonatal service. We feel that further research in this area within a UK setting is warranted

References:

1. Profit J, Zupancic JAF, McCormick MC et al. Moderately premature infants at Kaiser Permanente Medical Care program in California are discharged home earlier than their peers in Massachusetts and the United Kingdom. Arch Dis Child Fetal Neonatal Ed 2006;91:245-250.

2. Escobar GJ, Greene JD, Hulac P, et al. Rehospitalisation after birth hopsitalisation: pattern among infants of all gestations. Arch Dis Child 2005;90:125-131.

3. Escobar GJ, McCormick MC, Zupancic JAF, et al. Unstudied infants: outcomes of moderately premature infants in the neonatal intensive care unit. Arch Dis Child Fetal Neonatal Ed 2006;91:F238-F244.

Dear Editor,

The report of Profit et al [1] demonstrated earlier discharge in the Kaiser Permanente Medical Care Program (KPMC) than from two comparator groups. In an attempt to account for this a number of demographic factors were examined.

Unfortunately there is no information provided on feeding method at discharge; yet the commonest issue that determines an infant's readiness for discharge is his/her feeding maturity. Bottle-fed preterm infants often achieve independent feeding a little earlier than their breast-fed peers. Demographic differences between the KPMC cohort and the comparator groups may be reflected in differing breast-feeding rates and time taken to achieve independent suckling. It is well recognised that increased deprivation is associated with reduced rates of breast-feeding. The KPMC cohort came from families of lower income than one of the comparator groups. The other comparator group demonstrated an association between earlier discharge and increasing deprivation. These facts support the concept that any savings from earlier dischange may be negated by reduced health benefits from breast-feeding in the longer term.

Do the authors have any information on breast-feeding rates at discharge from their three cohorts?

Reference:

1. Profit J, Zupancic JAF, McCormick MC, Richardson DK, Escobar GJ, Tucker J et al. Moderately premature infants at Kaiser Permanente Medical Care Program in California are discharged home earlier than their peers in Massachusetts and the United Kingdom. Arch. Dis. Child. Fetal Neonatal Ed. 2006; 91: F245-F250