Neonatology is a team sport if there ever was one. It can be very confusing though to families as they go along their journey. The descriptions below are not meant to be exhaustive and if you are functioning in one of these roles and would like be to add something to your description please chime in! I thought it would be helpful to have a primer of who’s who in the NICU and what do they do exactly? Bear in mind that depending on where you are in the world the person caring for your baby may be different based on staffing models but here is a quick primer to the most common medical staffing positions in Canada. In Neonatology we also tend to like using abbreviations a lot so where there is a common one used I have indicated that in parentheses next to the name.
Attending Neonatologist (NEO)
This is a doctor who has done special training in newborn intensive care. Like me, they will have gone through a residency first in Pediatrics and then done anywhere from 2-3 years of extra training specific to the care of sick newborns. The Neonatologist is commonly seen leading morning rounds and will be the one typically asked to speak with parents when there is something important to share. We may not always be seen front and centre but when not on rounds we are in continual communication with the other “front line medical staff” and stay on top of what is happening with all the babies on the clinical service. You will typically see us in the hospital during day time hours but for the sickest of patients we will come in from home when on call to provide expert guidance on care. Many Neonatologists will have been certified by a national organization such as the Royal College of Physicians and Surgeons of Canada. Not all will however as there are other pathways to taking on this role.
House Medical Officer (HMO)
HMOs are members of the team will have also done a Pediatrics residency. They will have done a Neoatology fellowship as well. These individuals typically will do a mixture of day and night call. You will get to know them over time as they are on the front line and will be seen day and night in the units.
A fellow has done a Pediatric residency and is now doing specialized training in NICU. In their first year they do an abundance of clinical work as they try and learn the core knowledge of the specialty and obtain expertise in all the common procedures needed in the field. As they move into their second and optional third year they take on additional responsibilities and typically will do a “junior attending” role on a few occasions. in this capacity they act as the Neonatologist and run the NICU. The Neonatologist who is on with them continues to be appraised of the patients in the unit but will not be always on rounds during these weeks. This graduated responsibility is part of the development of the Neonatal fellow.
Residents are training to become a Pediatrician. They do a mandatory number of rotations in NICU which varies depending on the province you are in. As residents they are learning and in many cases will not yet have mastered all the procedural skills in the profession such as intubation and putting in umbilical catheters but they are on their way to obtaining those skills. These are people though who have comprehensive training in all areas of Pediatrics and will be familiar with the ability of the wards to care for your infant if they are transferred potentially to a hospital ward.
Clinical Assistant (CA)
CAs as they are also know will typically not have had a full Pediatrics Residency but in most cases have come VERY close. They function in a capacity very similar to the HMO. Do not be fooled by the lack of a complete residency in the eyes of the local College of Physicians and Surgeons. Many of these individuals are exceptional and would be impossible to distinguish in performance from an HMO.
Nurse Practitioner (NP)
NPs or Neonatal (NNPs) are nurses who have gone through a very advanced program and function as part of the medical team. If you reside in Alberta, NNPs have been the dominant form of housestaff support in Neonatal units for many years. They are meticulous care providers who by virtue of their nursing background have a very holistic approach to care of infants. Their plans always factor in impacts on nursing and in many respects their care is similar to that provided by their MD counterparts. NNPs are capable of performing all the procedural skills as their MD counterparts and it has been a real pleasure to work with them over the years both in Alberta and Manitoba.
Nurse managers are responsible for the day to day operations of the NICU. They are also the person to which all of the nurses working in the NICU report. If you have concerns about your experience in the NICU they will eventually filter there way through to this person and sometimes the medical lead for Neonatology. This person can also be of great help sometimes when you don’t feel like you are getting the answers you need as they have a great birds eye view of the unit and are well versed in policies and accepted practices.
This position is many respects is the nursing equivalent of the Neonatologist. The Charge nurse will co-lead with the Neonatologist on rounds and is involved in bed management as well. The person in this position is aware of all events that occured overnight and often serves as an advocate for the night staff who may have expressed concerns overnight that need to be dealt with on days.
If you are in the NICU as you read this already you will be very familiar with this position. The bedside nurse is who you will have the most contact with. This person provides direct nursing care to your infant and is often the person you will speak most to during your day. They also wil one day help transition you to home but in the meantime you will bond with many of those you come across. With the sheer amount of time you will be exposed to each other you won’t be able to help bonding.
Registered Respiratory Therapist (RRT)
RRTs as they are known provide a great deal of support to our babies who are having difficulties with breathing. The RRT is the person who will be called when a baby is in need of CPAP or a ventilator and is also the one who takes blood for analysis to check oxygen and carbon dioxide levels amoung other things. They are experts in the airway and breathing and will often be the one seen providing breaths with a bag and mask at the head of the bed if your baby needs support getting in each breath, They also possess the skill to intubate babies so much like the residents, fellows and HMOs you may hear that if your baby needed a breathing tube they were the ones to place it.
Occupational therapist (OT)
These inividuals can perform many tasks but one of the things that has really developed into a strong role is the assessment of feeding. Many ex-preterm infants have challenges after the initial period when they were quite ill, establishing full oral feedings. Many OTs have developed exceptional skills at assessing infant sucking and swallowing. They may recommend pacing strategies to help your baby achieve full oral feedings faster than they would have otherwise.
PTs as they are often called specialize in assessing infant tone and posture. They are very helpful when it comes to helping your infant with their musculoskeletal system. They may provide devices or recommend stretching exercises to help with their limb positioning or muscle tone. Some babies can develop what are called contractures where a limb is quite flexed and they will provide recommendations to help lessen these.
You will already know what a pharmacist is but when it comes to the NICU they provide a very important role. Unlike the adult world where dosing is pretty standard for drugs, in babies the dose is typically measured out per kg of body weight. Moreover, as many studies are not done yet in babies in order to determine proper dosing, the pharmacist helps us determine what drug and at what dose is best to maximize benefit and reduce risk to your infant. Almost all drugs have side effects and by keeping track of the drugs your baby is on they remain vigilant to look for drug interactions and advise us if any are likely.
Registered Dietician (RD)
You would think that nutrition should be an easy thing to manage. Give a baby milk and they will grow. Unfortunately, while this approach works for most babies as they are born term, the preterm infant provides a lot of challenges. Considerations of calories, fat, carbohydrates and protein need to be considered and adjustments made over time. The RDs keep a very close eye on your infant and help advise us about adjustments needed in order to optimize growth and achieve the right balance for weight, length and head circumference. These people are meticulous in their monitoring of nutritional intake and the addition of them to our team has meant more babies going home with the right proportions!
NICU can be a stressful time for anyone. After you come to find the expected outcome of pregnancy has not gone as planned there is no doubt that you will experience stress. You may have other children that you are worried about or have been displaced from your home and traveling long distances to visit. In addition to the bedside nurse the social workers are here to talk to you and to help you access programs and resources that may be of help to you.
In our unit we have a person who experienced the journey through NICU firsthand. Having had a preterm baby in the NICU they are very much in tune with the needs of parents. This person may organize information sessions for families or parent groups. The veteran parent and the veteran parent volunteers that she coordinates provide direct one-on-one support to families. They also are responsible for arranging baby cuddlers as mentioned below to help ensure that your baby is not deprived of that important contact time when you can’t be there. The nurses of course help with this as much as they can but with multiple babies to care for having a dedicated person to help coordinate this.
A recent addition to the team are baby cuddlers who have volunteered their time to be with your baby when you can’t be. Parents often worry about who will be with their baby while they are gone. This service which also includes reading to the infants helps to reduce the isolation many babies would otherwise experience in particular when families are needed back home and need to take a few days to be with their family. There may be a coordinator in the unit as we have for this program who will also help families by providing information sessions and opportunities to get together and share experiences and let you know that you are not alone.
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Since the dawn of my time in Neonatology there has been cibophobia! What is this you ask? It is the fear of food and with some flexibility in the definition I would apply this to large volumes of milk rather than the fear of food itself. Most units in the world seem to use a volume range of about 135 – 165 mL/kg/d as a range considered to mean “at full feeds”. As I was discussing this on rounds today I was quick to point out though that babies with neonatal opioid withdrawal syndrome (NOWS) frequently take in excess of 200 mL/kg/d and we don’t worry about it. The counter argument though is that these infants are “bigger” and should be able to tolerate a larger volume. As readers of this blog know I truly enjoy coming across papers that suggest a change to something considered dogma. Today is one of those days as I am choosing to explore in more depth an abstract that I posted to Twitter and Facebook last month.
On the day of this blog release I also took a poll on Twitter and found some interesting results that make this post all the more important to share. Take a look!
Are Bigger Volumes Better?
Travers CP et al chose to challenge this long held practice in their recent paper Higher or Usual Volume Feedings in Very Preterm Infants: A Randomized Clinical Trial. It was a simple yet wonderful trial that asked the question of whether for infants < 32 weeks GA at birth with BW from 1000-2500g would higher volume feedings of 180-200 vs 140-160 ml/kg/d help increase growth velocity. Randomization occurred after infants had reached 120 mL/kg/d of oral feedings. In both arms advancements from this point were the same and fortification occurrred as per usual practrice but in each arm strategies targeted individual fortification to weight gain.
The authors were seeking a 3 g/kg/d difference in growth and needed 224 infants to demonstrate this difference. They enrolled the same at a mean GA of 30.5 weeks and a BW of 1445 grams. Birth characteristics including gestational age, weight, sex, race/ethnicity, Apgar scores, head circumference, length, and proportion of infants with a weight <10th percentile at birth did not differ between groups.
The outcomes showed differences as shown below.
Looking at the results
All in all I would say the results are a smashing success. Growth velocity was improved and not just in weight but in head circumference and length. What I find interesting is that if fortification of milk was targeted regardless of the volume used I am a bit baffled as to why the growth rate would still be better but it was. The difference in caloric intake received between groups was approximately 9 kcal/kg/day at day 7 after study entry (126 kcal/kg/day versus 117 kcal/kg/day) and 16 kcal/kg/day from day 14 after study entry onwards (139 kcal/kg/day versus 123 kcal/kg/day).
Blinding here would have been a challenge as nurses and other health care providers would have been able to calculate the expected volumes at different fluid administration levels. Nonetheless there was a difference.
The question though that many would ask is whether this better growth came at the expense of greater morbidity. Let’s be clear here that the study was not powered to look at adverse outcomes and the numbers in the above table are small but no difference was seen nonetheless. To appease the most cautious of Neonatologists I suspect a larger study powered to look at adverse outcomes will be needed. What this study does though is raise the question of whether we can and should try larger volumes. As the title suggests I wonder about getting bigger faster so one can go home. With this more rapid rate of growth can we expect a faster maturation as well? I doubt it but it is something to certainly question in a larger study!
I have reviewed many articles on this site in the last few years. My favourite pieces are ones in which I know the authors and I have to say my ultimate favourite is when I know the authors as colleagues. Such is the case this time around and it pertains to a topic that is not without controversy. Nasal High Frequency Oscillatory Ventilation or NHFOV for short is a form of non-invasive ventilation that claims to be able to prevent reintubation whether used prophylactically (extubation directly to NHFOV) or as a rescue (failing CPAP so use NHFOV instead of intubation). I have written about the topic before in the piece Can Nasal High Frequency Ventilation Prevent Reintubations? but this time around the publication we are looking at is from my own centre!
One of our former fellows who then worked with us for a period of time Dr. Yaser Ali decided to review our experience with NHFOV in the paper Noninvasive High-Frequency Oscillatory Ventilation: A Retrospective Chart Review. Not only is one of our fellows behind this paper but an additional former fellow and current employee Dr. Ebtihal Ali and two of my wonderful colleagues Dr. Molly Seshia and Dr. Ruben Alvaro who both taught be a few things about this chosen career of mine.
The study involved our experience with using this technique (Draeger VN500 providing HFOV through first a RAM cannulae and then later with the FlexiTrunk Midline Interface (FlexiTrunk Midline Interface, Fisher & Paykel Healthcare) either using a prophylactic or rescue approach. The settings were standardized in both approaches as follows.
• Frequency of 6 to 8 Hz. • Mean airway pressure (MAP)2 cmH2Oabove the MAP of invasive ventilation (whether conventional or high-frequency ventilation). • Amplitude to achieve adequate chest oscillation while at rest.
• Frequency of 6 to 8 Hz. • MAP 1 to 2 cm H2O higher than positive end expiratory pressure (PEEP) on CPAP or biphasic CPAP. • Amplitude to achieve adequate chest oscillation while at rest.
All in all there were 32 occasions for 27 patients in which prophylaxis was used in 10 and rescue in 22. In the rescue group 77% of the time transfer onto NHFOV was done due to apneic events. The study was retrospective and lacked a control group as such so when it comes to the prophylactic approach it is impossible to know how many of these babies would have done fine with CPAP or Biphasic CPAP. Having said that, in that arm the intervention was successful in keeping babies extubated for at least 72 hours in 6/10. Since I really don’t know if those same babies would have done just as well with CPAP I will stop the discussion about them now.
The Rescue Group
These infants were on a fair bit of support though prior to going on to HFNOV with a mean SD CPAP of 7.9 cm H2O; while for the biphasic CPAP, the levels were 10.2 cm H2O and 7.7 cm H2O. In the rescue group 73% of the infants did not get intubated.
Let’s Process This For A Minute
I think most of you would agree that an infant on CPAP of +8 or NIPPV who is having repetitive apnea or significant desaturations would inevitably be intubated. In three quarters of these patients they were not but I can assure you they would have been if we had not implemented this treatment. When you look at the whole cohort including prophylactic and rescue you can see that the only real difference in the babies were that the ones who were on lower MAP before going onto NHFOV were more likely to fail.
Interestingly, looking at the effect on apnea frequency there was a very significant reduction in events with NHFOV while FiO2 trended lower (possibly due to the higher MAP that is typically used by 1-2 cm H2O) and pCO2 remained the same.
If pCO2 is no different how does this treatment work if the results are to be believed? Although high frequency ventilation is known for working well to clear CO2 I don’t think when given via this nasal interface it does much in that regard. It may be that the oscillations mostly die out in the nasopharynx. I have often wondered though if the agitation and higher mean airway pressures are responsible compared to straight CPAP or biphasic CPAP alone. There is something going on though as it is hard to argue with the results in our centre that in those who would have been otherwise intubated they avoided this outcome. You could argue I suppose since the study was not blinded that we were willing to ride it out if we believe that NHFOV is superior and will save the day but the information in Table 3 suggests that the babies on this modality truly had a reduction in apnea and I suspect had the sample size been larger we would have seen a reduction that was significant in FiO2.
My thoughts on this therefore is that while I can’t profess that a prophylactic approach after extubation would be any better than going straight to CPAP, I do wonder if NHFOV is something that we should have in our toolkits to deal with the baby who seems to need reintubation due to rising FiO2 and/or apnea frequency. What may need to be looked at prospectively though is a comparison between higher pressures using CPAP and NHFOV. If you were to use CPAP pressures of +10, +11 or +12 and reach equivalent pressures to NHFOV would these advantages disappear?
Surfactant administration is a frequent topic on this blog and as I look over the last five years there has been an evolution with its administration from InSure to LISA/MIST and even pharyngeal surfactant through an LMA. We have also discussed aerosolization of surfactant once and now a much larger trial is out that brings this technique which has to be the least invasive into the limelight. What gives me great pleasure is being able to highlight the article here Aerosolized Calfactant for Newborns With Respiratory Distress: A Randomized Trial as the lead author is our CPS Fetus and Newborn Committee American of Pediatrics liaison Dr. James Cummings. Being able to review an article by a colleague and friend I think is always something that gives me some trepidation as what happens if the article is a poor one but in this case I feel pretty safe. The study was done by a large group of investigators known as the AERO-02 group and there are lots of gems to pick apart here.
On to the Study
This trial involving 22 NICUs enrolled Among 457 infants born with a GA from 23 to 41 (median 33) weeks and birth weight 595 to 4802 (median 1960) grams. In total, 230 infants were randomly assigned to aerosol; 225 received 334 treatments, starting at a median of 5 hours. The study allowed for repeat dosing of aerosolized surfactant up to 3 times with each treatment providing 6 mL/kg of 35 mg/mL calfactant suspension, 210 mg phospholipids/kg body weight, through a modified Solarys nebulizer shown below. The delivery device was like an inverted nipple placed in the mouth in order to deliver surfactant while the infant was on non-invasive support (CPAP, hi-flow or NIPPV).
From prior animal studies use of this method is thought to deliver approximately (14%), the surfactant dose used in or about 29 mg/kg reaching the distal alveolar bed. By allowing up to three treatments in 72 hours (there had to be a reduction in FiO2 with each treatment to allow a further one) the total delivered would be aboout 90 mg/kg although in some likely more and others less depending on depostion amounts. The study originally was planned as two cohorts but since they enrolled all in the first the second one was not used. The first cohort were:
2. had not previously received surfactant, 3. Between 1 hour to 12 hours of age,
4. Suspected or confirmed RDS requiring therapeutic administration of nasal respiratory support by nCPAP, HFNC, or NIPPV
5. Initially, there was an entry requirement FIO2 concentration of 0.25 to 0.40. Four months into the trial, it was discovered that several sites were using higher positive airway pressures to minimize FIO2. Because of this practice change, the minimum FIO2 requirement was removed in the fifth month of the trial
The trial was a pragmatic one where the authors did not specify what criteria were needed to decide when to intubate for surfactant. While this lack of standardization might turn some people off, many trials are headed this way as it represents “real life”. In other trials where you have rigid criteria if your own centre doesn’t typically use them the results of the trial in the end might just not apply. The question then is did this style of trial design in the end find a difference in outcome for the babies randomized to aerosolization or standard care with CPAP, HFNC or NIPPV to avoid intubation?
The trial met its number of patients required in the power calculation to find a difference in outcome. Demographics, receipt of antenatal steroids and levels of respiratory support at baseline were similar between groups. In the aerosol group. 225 infants received 334 treatments at a median age of 5 hours (interquartile range [IQR]: 3–7);149 (66%) received only one aerosol treatment, 43 (19%) received 2 treatments, and 33 (15%) received 3 treatments. It is also important to note that by defining the entry point of 1-12 hours of age, those with severe RDS would not have been enrolled here. Infants with apnea, or severe distress would not have been able to wait the hour time frame for entry and moreover since the aerosolization technique takes about an hour to administer those in need of urgent treatment would not be enrolled. As such we are really talking here about babies with mild to moderate RDS.
Intubation for surfactant occurred in 113 infants (50%) in the control group and 59 infants (26%) in the aerosol group, in an intent-to-treat analysis (P , .0001); RR: 0.51 (90% CI: 0.41–0.63). The number needed to treat to prevent 1 intubation is 5.
The impact of this approach was quite significant. Interestingly you would think that as GA decreased the effectiveness of the intervention would lessen but when the authors groups GA into two week brackets as shown below the only GA bracket that showed no difference in approach was the 23/24 week group. Having said that the numbers are very small on the lower end of GA for the study but again overall the results find a 50% reduction in need for intubation using this technique with the trend (by my eye) being that as GA increases the effectiveness seems to get even better.
The study was not blinded and as such the authors also took the time to look for evidence of bias in the study and found none. The last figure to show is the effect of this intervention on total duration of respiratory support between the two randomized groups. In other words while the use of the technique reduced your likelihood of intubation by 50% it didn’t get you off of non-invasive support any faster in the 72 hours after treatment.
Looking at complication rates between groups there was no difference as well.
I think what has been shown here is that aerosolized surfactant in a real world research model is safe and effective for mild to moderate RDS in reducing the need for intubation. For those infants with more significant RDS or severe apnea they will not be able to make it long enough to get these treatments. For others this does seem like something worth exploring as for those that you were going to commit to a non-invasive approach is there really any harm? There will be those that will fail but overall this data suggests that you could expect a 50% reduction in this occurrence for all your patients with mild to moderate RDS. The one fly in the ointment I see that could influence the effectiveness of this intervention is the level of support you are accustomed to using in your centre. It could be in those centres that are a bit “peepaphobic” and use a maximum of +5 or +6 on CPAP this intervention could be quite effective but in those that are willing to use +7or +8 the rate of intubation or surfactant might well be less. Regardless the intervention appears to be safe, well tolerated and can make a difference. If a delivery device could be prepared that increased deposition rates to even higher levels imagine how effective it just might be.
This topic has been making its rounds for awhile now. Periodically whether on Twitter or via email I get asked this exact question. Anecdotally, the numbers of babies in the NICUs across many units in Canada seem to be lower as estimated by various Neonatologists. The question is whether this is real or not and without national data it is tough to say for sure. This week though a research letter came out of the UK entitled Change in the Incidence of Stillbirth and Preterm Delivery During the COVID-19 Pandemic. The authors compared two time periods at a single centre ; St George’s University Hospital, London in 2 epochs: from October 1, 2019, to January 31, 2020 (preceding the first reported UK cases of COVID-19), and from February 1, 2020, to June 14, 2020. Specifically they wanted to look at the rate of stillbirths and preterm births during these two time periods.
What did they find?
There were 1681 births in the prepandemic period and 1718 births during the pandemic. There were no differences in maternal characteristics before and after so presumably if there is a difference in rates of stillbirth and preterm birth it might be the influence of the pandemic. As it is an observational study though it certainly is possible that unmeasured factors are different in the groups but let’s give them the benefit of the doubt.
The rate of stillbirth was up and by a significant margin but the rate of preterm birth was not. There certainly was a trend though towards an increase in preterm delivery prior to 34 weeks. While I don’t know what the cause of all this is for sure it sure is fun to speculate.
Possible reasons for higher rates of stillbirth
It has been documented that rates of perforated appendicitis in our own centre increased during the pandemic. As the population became frightened of leaving the home, more and more people waited longer to go to the hospital to seek care. I can’t help but wonder if the same thing may have happened here. Might the pattern of seeking care by women for decreased fetal movement shifted ever so slightly? What about the frequency of prenatal visits? In Manitoba a COVID modified approach was done with fewer visits than normal. It certainly is possible that women by having fewer visits could have in some cases missed clinical findings that might have alerted a midwife or obstetrician to a reason to deliver early.
Possible reasons for a decline in preterm birth
The authors here did not find a difference but in fairness out of the number of pregnancies the number of preterm births would have been about 10% so difficult to really find a difference. Given that under 34 weeks showed a trend to a lower number let’s assume that there might be a difference (or not).
At least in terms of the perception of lower rates, this might be a case of confirmation bias. One of my colleagues who initally sent me an email from another institution two weeks later sent another that said “I thought we were seeing lower rates and now we are packed to the rafters”. It could well be that we are all noticing when the census is low and not paying attention to the times when it rises. Every time the numbers drop it seems to confirm our suspicions.
It wasn’t from people choosing to delay family planning as it was too early to see a change in birth rate. I do worry though that we may see declining admissions in the latter part of the year and then a “boom” when a vaccine is produced as families once again choose to conceive. This happened similarly during the Zika epidemic in Brazil.
It could also be that the finding is real. During the pandemic essentially all pregnant women went on extended rest. Instead of dealing with stressful daily tasks like battling traffic, being late for work and working altogether they were told to stay at home. Financial stress could have then been a factor but at least in Canada the government provided $2000 a month to offset the job losses. It is quite possible at least in my mind that an extended period of rest could have truly led to less preterm birth.
The next step I imagine will be for larger organizations such as the Public Health Agency of Canada to publish their data on this and see what happened across Canada during this period. When we are able to look at tens of thousands of pregnancies we will have enough numbers to drill down whether there has been a change for our smallest infants or not.