3 NICU Milestones That Must Be Met Before Discharge

Female doctor examining newborn baby in incubator
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Discharge from the neonatal intensive care unit (NICU) is based on milestones. A premature baby must typically meet the following criteria before they are ready to go home.

1. Open Crib 

Your baby will progress from the incubator or radiant warmer to an open crib based on their gestational age, weight, and ability to regulate their body temperature. The transition is usually gradual. Your baby may be returned to the warmer environment at the first sign of inability to maintain temperature.

Maintaining body temperature involves calories and oxygen. The more energy your baby uses to keep warm, the less they will have for growing and healing. It’s important to keep a close eye on your baby’s temperature during this transition period.

When your baby is in an open crib, it is important to begin safe sleep practices. For Sudden Infant Death Syndrome (SIDS) prevention, your baby should always sleep on their back. Your baby’s crib should be flat and free from toys, pillows, bumpers, and loose or rolled blankets.

2. Hearing Screen

Before you bring your baby home from the NICU, your baby will need to have a hearing screen. The newborn hearing test is a non-invasive test that screens for possible hearing problems in newborn babies.

Premature babies and term babies who require NICU care are at a greater risk for hearing loss for several reasons including prematurity, low birth weight, jaundice, intraventricular hemorrhage, certain medications, and infections.

There are two screening tests that may be used:

  • Otoacoustic Emissions (OAE): This test measures sound waves produced in the inner ear. A tiny probe is placed just inside the baby's ear canal. It measures the response (echo) when clicks or tones are played into the baby's ears.
  • Automated Auditory Brainstem Response (AABR): This test measures how the hearing nerve responds to sound. Three sensors with self-adhesive tabs are placed on the infant: one on the upper forehead, one on the nape of the neck, and one on the back of the right shoulder. Soft plastic earmuffs are placed over the baby's ears. During the test, clicks are transmitted through the earmuffs. The sensors on the baby's skin detect the baby’s brainwave response to the clicks.

Your baby’s hearing screen may be performed when your baby is:

  • Getting close to discharge
  • In an open crib
  • 34 weeks gestation (adjusted or actual) or older
  • Receiving no central nervous system stimulants (such as caffeine)
  • Sleeping or in a relaxed state

3. Car Seat Study/Test

The American Academy of Pediatrics (AAP) recommends a car seat test, or car seat challenge, for all babies born before 37 weeks gestation prior to discharge from the hospital. The car seat challenge is used as a way to determine your baby’s readiness for travel in a car seat and to monitor for possible apnea, bradycardia or oxygen desaturation while sitting in their seat for an extended period of time.

All infants who meet one of the following criteria at the time of discharge should undergo a car seat challenge:

  • Gestational age less than 37 weeks
  • Requiring oxygen supplementation
  • Being sent home on an apnea monitor
  • Having a medical condition which places the infant at high risk for apnea, bradycardia or oxygen desaturation

During the test, your baby will be placed or remain on a cardiopulmonary monitor with pulse oximetry to continuously observe for signs of distress. The car seat should be reclined at a 45-degree angle. Your baby will remain in the car seat for a total of 90 minutes, with the harness clip positioned at chest level. The car seat challenge should be performed one to seven days prior to going home.

Research indicates that some infants, particularly those born at less than 37 weeks gestation, may be subject to transient episodes of bradycardia, apnea, and oxygen desaturation when traveling in a standard car safety seat.

If your baby does not pass the test, it will be repeated usually 24 hours later. If your baby fails the car seat challenge three times, testing in a car bed should be performed.

Other NICU Discharge Milestones

Before discharge, your baby will also need to be:

  • Able to eat all of their food by mouth while taking in an adequate number of calories
  • Gaining adequate weight
  • Breathing on their own. Most babies are off oxygen when discharged from the NICU, but some infants may need supplemental oxygen for a longer period of time and may be sent home with this therapy.
  • Free from any episodes of apnea (pauses in breathing), bradycardia (slow heart rate), or change in color. You may be able to take your baby home on a monitor if they have short, self-resolving episodes that do not require any intervention.

A Word From Verywell

Since every baby is different, and every NICU journey will vary, it is difficult to say when your baby will hit all these milestones and be ready for discharge. It may be helpful to keep track of your baby’s progress by starting a journal or checklist, and to celebrate these important milestones as they happen.

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Article Sources
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  1. KidsHealth from Nemours. Taking your preemie home. Updated March 2015.

  2. Centers for Disease Control and Prevention.  Sudden unexpected infant death and sudden infant death syndrome. Updated December 2019.

  3. American Academy of Pediatrics. Newborn hearing screening FAQs. Updated December 2018.

  4. Stanford Children’s Health. Prematurity.

  5. Davis NL, Zenchenko Y, Lever A, Rhein L. Car seat safety for preterm neonates: implementation and testing parameters of the infant car seat challenge. Acad Pediatr. 2013;(13)3:272-7.  doi:10.1016/j.acap.2013.01.009