Primary Care Management of Technology-Dependent Infants After NICU Discharge

Research study background

Advances in neonatal care have improved survival for preterm and critically ill infants, but many high-acuity neonatal intensive care unit (NICU) graduates go home dependent on medical technology, including oxygen support, monitoring and nasogastric (NG) tube feeding. Primary care providers (PCPs) often assume responsibility for managing these medically complex infants after discharge. Yet, outpatient care is complicated by limited evidence-based guidelines, particularly at higher altitudes, where the burden of bronchopulmonary dysplasia and oxygen requirements may be greater. Here at Children’s Hospital Colorado, 47–70% of preterm infants and 50% of term infants from our Level IV NICU in metro Denver went home on oxygen between 2021 and 2023. To better understand current practices and identify barriers, a multidisciplinary team of our neonatal and pulmonary experts surveyed PCPs across Colorado and Wyoming.

Among the 203 survey respondents, most (82%) were pediatricians practicing in urban or suburban settings. PCPs reported high comfort managing home oxygen for term and moderately preterm infants (92% and 82% respectively), but only 52% felt comfortable managing the extremely premature. Additionally, providers with at least 10 years of experience and those in suburban locations expressed greater confidence in home oxygen management. While 62% used an oxygen-weaning protocol and 81% ordered overnight pulse oximetry studies, PCP practices varied widely regarding weaning criteria, oxygen saturation targets and follow-up frequency. Respondents expressed the need for evidence-based guidelines, tailored discharge recommendations and easier access to remote or in-person subspecialty consultation. Although Children’s Colorado has an existing pulmonary guideline, only one-fourth of PCPs who reported using a protocol identified that guideline as their reference.

Regarding NG feeding, 69% of respondents accepted infants requiring NG feeds, yet only 39% felt comfortable managing them. The most common barriers to NG feeding management reported by PCPs included lack of staff training, time and reimbursement constraints and inadequate NICU-to-PCP communication during discharge. Despite this, 74% of respondents expressed interest in a structured home NG program.

Clinical implications

The findings from this study offer valuable insights from Rocky Mountain region PCPs who care for technology-dependent NICU graduates and may help inform care in other high-altitude regions facing similar challenges. Importantly, the results underscore that strong partnerships with community PCPs are essential to achieving optimal outcomes for every medically complex infant discharged from the NICU. The authors identified several opportunities to strengthen care transitions, including clearer discharge communication, evidence-based oxygen weaning protocols and improved access to subspecialists.

To address the low confidence many regional PCPs expressed in managing NG feeds, Children’s Colorado launched a multidisciplinary, telehealth-supported home NG feeding and monitoring program in 2025. Designed to enhance safety, standardization and continuity of care, the program supports earlier discharge for eligible infants, optimizing NICU capacity while helping families return home sooner. The model includes remote patient monitoring via an app integrated with Epic and Bluetooth scales, as well as coordinated telehealth visits with neonatology, registered dietitians and feeding therapy.