In-home nursing (IHN) care, that is, the care and follow-up of the newborn at his or her home rather than in the pre-discharge incubator at the hospital, is part of the new trends in neonatal care in developed countries1–4 such as the United States,5 countries in northern Europe6,7 and France.8 In Spain, the earliest references to it are from 1993 and 1997 in the Hospital 12 de Octubre of Madrid,9,10 which started an IHN programme in 1986.11 In Catalonia, the pioneering hospital was the Hospital Clínic (maternity unit), which started its programme in 2002.12 The available data suggest that the IHN programme improves the relationship and satisfaction of the parents, as it helps normalise the situation at home,13 promotes breastfeeding,14 and leads to increased weight gain, improved development15 and a decreased risk of infection in the newborn. It also allows for a higher degree of customisation in health education16 and a reorganisation of healthcare resources that is more satisfactory to the users. The reduction in the length of hospital stay can range from 417 to 17 days,18 and a previous study in our hospital found a reduction of 10.1 days,12 in which a newborn not receiving IHN care would have remained hospitalised inside a minimal care incubator, incurring all the associated healthcare staff costs.

In 2008 the American Academy of Paediatrics published a set of guidelines on the discharge of preterm infants based on the currently available scientific evidence.19 Some families refuse IHN care, possibly because they worry that they will not know how to properly care for their child. This refusal is more marked in families of preterm newborns with congenital malformations or severe complications,20 or preterm newborns whose care requires special techniques, such as gavage feeding or oxygen therapy. Parents are more likely to accept IHN care if they have received education and practised kangaroo care during the stay in the neonatal unit.21,22 Gavage feeding can be performed in a safe and efficacious manner during IHN care,23,24 achieving weight gains that may even exceed those considered satisfactory,23 and longer durations of breastfeeding.25 Psychosocial problems like anxiety or stress may develop in the family in the early days after discharge,26 impacting the quality of care.27 The nurse has to cooperate with the parents and guide them in the care of the child, offering not only his or her scientific knowledge and professional skills, but also a respectful approach to the feelings, attitudes, beliefs, and cultural values of the family.

The purpose of this study is to show that IHN care of the preterm newborn after early discharge fosters weight gain in the home, and is also safe, as it does not result in increased morbidity.

Previous studies have evaluated the IHN care of early-discharged preterm newborns,29–33 but our review of the literature did not uncover any case–control study with sufficient power to prove its potential benefits. Our study focused on the influence of IHN care on weight gain, which was greater in the home than at the hospital, after calculating the sample size required to obtain statistically significant conclusions (Table 5).

While IHN can be offered to term newborns, our study only included preterm newborns delivered at our hospital with a birth weight of 700g or greater, so the sample would be more homogeneous. In applying the inclusion and exclusion criteria, we selected a sample of preterm newborns that were fairly mature and with few instances of neonatal disease, which helped reach conclusions based solely on the IHN care and not on other intervening confounding variables. However, our sample is one of the most immature samples in the Spanish literature (Table 5). It is likely that the beneficial effects of IHN would extend to preterm newborns with chronic illnesses (such as bronchopulmonary dysplasia).

In making comparisons with other Spanish studies, we need to keep in mind that the weights at initiation and discontinuation of IHN care were different for each hospital (Table 5). This influenced the duration of IHN care and the estimated reduction in hospital stays. Logically, there are also differences in the corrected ages at discharge. To resolve these differences to the extent possible we calculated weight changes in g/kg/day.

Previous studies on IHN compare pre- and post-discharge weights in a single group of neonates participating in the programme, or compare the weight of 2 independent groups but without matching, and have always found greater weight gains in the IHN group. Esqué et al12 reported that the mean weight gain of a case in the IHN group for the 7 days before discharge was 21g/day, while it was 40g/day in the 7 days that followed discharge. The studies of Martín-Puerto et al9 and Gutiérrez-Benjumea et al17 only noted that in the IHN group the weight gains were 39g/day or 35g/day, respectively, providing no figures for the control group. Our study had a 1:1 case–control design, that is, there was one control for each case, matched by weight at discharge, birth weight, gestational age, age at discharge, and sex. To match the weight curves of each case with those of its control, we set day 0 of the study interval as that in which the weight of the control (who remained in the hospital) came the closest to the weight of the matched case. Thus, we made the case and control groups homogeneous and comparable. The weight gain of the IHN group was 38g/day, significantly higher than the weight gain of the control group (31g/day). Cruz et al.34 conducted a study similar to ours after 1995 in Cali, Colombia, although the weights at early discharge ranged between 1300 and 1350g.

In our study, the weights in the week prior to the beginning of the study and the weights at the beginning of the study were similar in cases and controls, a basic condition that needed to be met for the study to be valid. The weight gain at home was greater in the IHN group, perhaps because in these patients the weight gain in the last week in the hospital was lower than the weight gain in the control group. This lower gain was not due to differences in feeding, but probably due to various factors, among which are the less frequent use of gavage feeding in cases than in controls, as they were being prepared for discharge to the home by establishing full oral feeds. The fact that feeding tubes were not used in cases may have led to lower milk intakes and a greater energy expenditure in oral stimulation, which probably reduced their weight gain. Another aspect to consider that was not controlled was whether the newborn was in an incubator or a cot. In a Cochrane review, New et al.35 reported that weight gain may be reduced in preterm newborns that are transferred from an incubator to a cot due to increases in energy expenditure.

Setting our study apart from the remaining published studies, we attempted to determine which variables had a statistically significant and independent effect on the “weight gain in g/kg/day in the period under study”. Out of the 4 independent predictor variables, the most important was “being at home versus at hospital,” as it had the highest non-standardised coefficient (7.17) and standardised beta coefficient (0.609). Male sex also promoted weight gain during IHN care, a fact that is well known, as boys gain more weight than girls. The negative value of the percentage of breastfeeding in the multivariate analysis could be due to the fact that a lower intake of maternal milk is associated to a higher intake of artificial formula, which in turn leads to greater weight gains. In the case group, this effect of breastfeeding was counteracted by the beneficial effects on weight of being at home and by male sex. The one variable that resulted in decreased weight gain was the development of peri-intraventricular haemorrhage.

In short, IHN results in increased weight gain in the newborn that is at home rather than remaining hospitalised, and can be considered safe, as it is not associated with increased neonatal morbidity.

The authors have no conflicts of interest to declare.