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.
Spiritual Health Services recognizes and celebrates diversity. WE provide care to all whether you identify as spiritual, atheist, religious or agnostic. We are available to journey with you and support the values and belief that are important to you. Spiritual Health Practitioners are professional members of the health care team, specifically trained to provide support for your emotional and spiritual well being especially during times of difficulty and crisis. We also arrange for ceremonies, smudge, sacraments and rituals.
If you have a baby in the NICU there is a pretty good chance there will be at least one piece of plastic inserted into your child at some point. We have all sorts of “lines” and tubes that may be present depending on the conditions your baby develops. What follows is a primer on what they are all for.
I thought I would start with the easiest one since when you gave birth the team delivering you put one in you as well. The IV in the neonate is typically put in a hand or foot rather than the crease at the elbow as we like to save the bigger veins for something that we will talk about later on. Typically the IV provides sugar water (D10 most typically which is 10% sugar in water) to provide your baby with enough sugar to satisfy their metabolic needs. If a baby is older at birth but has difficulty breathing, having this type of access allows us to give them sugar and energy while not feeding them and letting their breathing settle. Putting food in the belly may sound like a necessity but they will be fine for awhile on dextrose which will allow their breathing to settle without having a full stomach pushing up on their diaphragm.
These come in two forms; the umbilical venous and arterial catheters. The easiest way to think of these are as long IVs like the one you may have had in your hand during delivery. These are long and on the venous side allow us to provide nutrition to your child either with sugar water (dextrose) or total parenteral nutrition (TPN). We can also give medications which can be tough on small veins in the hand or feet such as those to help with boosting blood pressure. The arterial catheter on the other hand allows us to monitor your baby’s blood pressure continuously. It also gives us a way of drawing blood when we need to test a number of things such as how your baby is breathing (an art gas) or checking their biochemistry such as when you hear us order “lytes” which checks salt and water balances in the body. By the way, putting these lines in does not hurt as there are no nerve endings in the umbilical cord.
These plastic tubes go from the nose (or mouth if it is an orogastric tube) into the stomach. When your baby is too preterm to know how to suck, swallow and breathe without inhaling their food it is safest to provide their milk through one of these tubes. They are very common!
When your baby is unable to breathe on their own they may need to be put on a ventilator. The ventilator attaches to an endotracheal tube and helps your baby get oxygen in and carbon dioxide out. These tubes can also be used very briefly to administer surfactant which makes it easier for your baby’s lungs to open and take air in. You may hear the medical team refer to the INSURE approach when using the tube in this way which stands for Intubate, Surfactant, Extubate.
Thankfully these tubes are not needed as much as they used to be. When air gets in between the lung and the chest wall we call that a pneumothorax.
This air can build up and make it very difficult for the underlying lung to open and fill with air. When that happens your baby’s oxygen levels drop and the carbon dioxide rises. These tubes will be put in to drain the air and relieve the pressure. Once they stop “bubbling” the tube will be clamped and then pulled out if no air reaccumulates. You may also see these tubes placed when a baby develops fluid in the same space called a pleural effusion. In that case you are trying to get rid of the fluid rather than air that has found its way in between the lung and the chest wall.
If you are reading this and have a baby in the NICU with respiratory distress syndrome (RDS) otherwise known as hyaline membrane disease you might be surprised to know that it is because of the same condition that modern NICUs exist. The newspaper clipping from above sparked a multibillion dollar expansion of research to find a cure for the condition that took the life of President Kennedy’s preterm infant Patrick Bouvier Kennedy. He died of complications of RDS as there was nothing other than oxygen to treat him with. After his death the President committeed dollars to research to find a treatment and from that came surfactant and modern ventilators to support these little ones.
What is surfactant and what is it’s relationship to RDS?
When you take a breath (all of us including you reading this) oxygen travels down your windpipe (trachea) down into your lung and goes left and right down what are called your mainstem bronchi and then travels to the deep parts of the lung eventually finding its way to your tiny air sacs called alveoli (there are millions of them). Each alveolus has a substance in it called surfactant which helps to reduce the surface tension in the sac allowing it to open to receive oxygen and then shrink to get rid of carbon dioxide that the blood stream brings to these sacs to eliminate. Preterm infants don’t have enough surfactant and therefore the tension is high and the sacs are hard to open and easily collapse. Think of surface tension like blowing up those latex balloons as a child. Very hard to get them started but once those little balloons open a little it is much easier! The x-ray above shows you what the lungs of a newborn with RDS look like. They are described as having a “ground glass” appearance which if you recall is the white glass that you write on using a grease pencil when you are using a microscope slide. Remember that?
Before your infant was born you may have received two needles in your buttocks. These needles contain steroid that helps your unborn baby make surfactant so that when they are born they have a better chance of breathing on their own.
Things we can do after birth
Even with steroids the lungs may be “sticky” after birth and difficult to open. The way this will look to you is that when your baby takes a breath since it is so difficult the skin in between the ribs may seem to suck in. That is because the lungs are working so hard to take breath in that the negative pressure is seen on the chest. If your baby is doing that we can start them on something called CPAP which is a machine that uses a mask covering the nose and blows air into the chest. This air is under pressure and helps get oxygen into the lungs and gives them the assist they need to overcome the resistance to opening.
Some babies need more than this though and will need surfactant put into the lungs. The way this is done is typically by one of two ways. One option is to put a plastic tube in between the vocal cords and then squirt in surfactant (we get it from cow’s or pigs) and then typically the tube is withdrawn (you may hear people call it the INSURE technique – INtubate, SURfactant, Extubate). For some babies who still need oxygen after the tube is put in they may need to remain on the ventilator to help them breathe for awhile. The other technique is the LISA (Less Invasive Surfactant Administration). This is a newer way of giving surfactant and typically involves putting a baby on CPAP and then looking at the vocal cords and putting a thin catheter in between them. Surfactant is then squirted into the trachea and the catheter taken out. The difference between the two methods is that in the LISA method your baby is breathing on their own throughout the procedure while receiving CPAP.
Even if no surfactant is given the good news is that while RDS typically worsens over the first 2-3 days, by day 3-4 your baby will start to make their own surfactant. When that happens they will start to feel better and breathe easier. Come to think of it you will too.
Things are tough out there. If you are pregnant you no doubt have lots of questions about living and ultimately giving birth during this difficult time. These guidelines are from Alberta and like with everything these days are subject to change. As of March 23, 2020 this is what is being recommended if you live in Alberta. There are many good things here that are universal no matter where you live. Social distance, wash your hands, avoid touching your face and stay at home if possible.
It’s not your fault. You come to the bedside often and there isn’t a lot to do while your infant is asleep. There are only so many games, news and social media posts to keep your attention and let’s face it the monitor attached to your infant is a big distraction.
Typically, babies will have their blood oxygen saturation monitored along with their heart rate and respiratory rate. Some babies will have other physiological parameters monitored such as the amount of exhaled carbon dioxide or the blood flowing through their brain (near infrared spectroscopy) but the first three are the most common.
What you need to understand about these monitors is that we set alarms for when we need to know if there is a problem. What you also need to understand is that these alarms while necessary so we know when a baby is in trouble, can also drive you crazy. Parents may become slaves to the monitor where they spend a great deal of the day staring at ever changing numbers. If your infant is a “swinger” meaning that for example their heart rate or oxygen saturation tends to fluctuate a lot this can mean a lot of noise all day long.
One of the things that influences the result on the monitor is something called the averaging time. Typically for us this is 8 seconds which means that the number at any given time being shown is not the number for that second but represents the average number over the last 8 seconds. Sometimes your infant will be referred for a special test called a sleep study to closely monitor their apneic events. Sometimes families are shocked when their infant who seemed to have one or two events a day suddenly is reported as having 30. That is likely because the sophisticated lab is using a 2 or 4 second averaging time. Your baby in this case hasn’t changed. The monitor has. Some of the things that can be asked of the team when you have a baby with frequent events are trying to rule out causes of these alarms that are not due to your child themselves. Is the nasogastric tube in the right place? Should it be changed if your infant’s problem is mostly low heart rate? Could it be that the probe being used to measure oxygen saturation is in need of being changed to a different limb or altogether a new probe used? Typically low heart rate limits are set to 100 BPM. Strictly speaking many would consider this bradycardia but another definition is having a heart rate that is >20% below a baby’s baseline. Some babies are born with a heart rate that is anywhere from 100-110 (normal is usually 120-160). Twenty percent below that could be 80 beats per minute. Should the alarm be lowered to that number from 100? If so many of these alarms will vanish.
Stop Thinking About The Day To Day
Lastly, I would encourage you to try and look at your baby’s progress every few days. The journey through the NICU has many ups and downs. It really is no different than a figure showing the stock market over the last many years. Individual days have their ups and downs but it is the trend over many days that matters. Try not to let the daily events ruin your day. Take a moment and ask your nurse to see how your baby is today compared to a few days or a week earlier. You might be reminded that a week earlier your baby was on CPAP and now is on room air. Overall if they are better try and let that balance out your thoughts and try to not stare at the monitor. It just might drive you crazy.