NICU

Premature babies are those born before 37 weeks of pregnancy. The earlier a baby is born, the greater chance there is of developing complications associated with prematurity. In my experience, it is not only the baby that is premature. Mom and Dad become parents prematurely as well.

The experience is very difficult for all concerned. While modern medicine has substantially improved the long-term outcome of premature babies, the immediate medical concerns, trauma to the baby and to the parents, and the often-unexpected medical costs associated with a preterm birth elevates the stress for all concerned.

Just this week I was visited by one of my micro-prems (extremely low birth weight – in this case just 800g). For purposes of this article, I will call her Sarah*. She is now 16 years old and absolutely beautiful. She needed to have a copy of certain of her medical records. My staff could have assisted her, but she chose to wait to say hello to me. What a moment for me as a paediatrician!

There are some babies for whom you spend months fighting. Long hours, working day and night and micro-managing their very existence – and then the day comes when they go home. It may be that you don’t see them for follow-ups, and you wonder how they are and if the prematurity or medical treatment had any significant long-term effects.

“The role and level of involvement of the parents is of utmost importance for both the physical and psychological outcome of a premature baby.”

Having Sarah stand up and give me the biggest hug was a moment for me to treasure. Looking at her at 16 made all the struggles worthwhile. And boy, oh boy did we have struggles! This little Sarah threw the book at me in terms of complications associated with prematurity.

Bear in mind that not all premature babies will go through all of the complications and will be home with Mom and Dad not too long after birth. For others, the struggles are prolonged. Dealing with the complications is the responsibility of the medical team. Over and above this, the role and level of involvement of the parents is of utmost importance for both the physical and psychological outcome of a premature baby.

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How do we categorise premature babies?

• Late preterm, born between 34 and 36 completed weeks of pregnancy. The average weight being between 2.5kg and 2.8kg.
• Moderately preterm, born between 32 and 34 weeks of pregnancy. The average weight being between 1.8kg and 2.4kg.
• Very preterm, born at less than 32 weeks of pregnancy. The average weight being between 1.1kg and 1.4kg.
• Extremely preterm, born at or before 25 weeks of pregnancy. The average weight being 650g or less.

Most premature births occur in the late preterm stage, which makes their care much easier as they experience far fewer complications.

What kinds of complications can occur and what would the necessary medical treatment be?

There are a number of issues the paediatrician will be concerned with during an admission to Neonatal ICU. These include feeding issues, apnoea, jaundice, metabolic problems and then more serious complications. For our purposes here, I will only discuss those that are more serious and not easily understood by parents.

• Temperature control: Since premature babies have very little body fat, they struggle to maintain their body temperature and this may lead to hypothermia. A baby may experience breathing problems and low blood sugar levels as a result of hypothermia. Under these circumstances, the baby would need to be placed in an incubator or under a warmer.

• Lung problems: Respiratory distress syndrome may develop as a result of the baby lacking surfactant. Surfactant is a fluid secreted by the cells in the lungs which allow the lungs to expand. These days a paediatrician may administer surfactant to the premature baby thus substantially reducing the risk of respiratory distress syndrome. A baby with respiratory distress syndrome would usually require ventilation to help them breathe normally.

• Heart problems: Patent ductus arteriosus (PDA) occurs when there is an ongoing opening between two vessels emanating from the heart known as the aorta and pulmonary artery. This condition usually resolves on its own but treatment is required if it continues. The treatment may include a medication administered via a drip (intravenously), good nutrition and, if all else fails, the baby may require surgery. It is really important that a PDA is addressed, as it can lead to respiratory failure or heart failure. Low blood pressure is another problem for premature babies. Usually, the paediatrician would manage the blood pressure with fluids and medicines.

• Gastrointestinal problems: A condition known as necrotising enterocolitis (NEC) may develop as a result of a premature bowel. NEC is an infection which attacks and causes inflammation in part of the intestine. Typically, the baby would struggle with feeding, develop a bloated tummy and vomit. It is a life-threatening condition that requires urgent antibiotic treatment and may result in surgery to remove the damaged parts of the bowel.

• Brain bleeds: A baby’s blood vessels grow stronger in the last 10 weeks of pregnancy. This means that extremely premature babies are at risk of a brain haemorrhage simply because their blood vessels are fragile. Mild bleeds resolve on their own and cause no long-term damage, but larger bleeds may cause permanent damage. The bleed is known as an intraventricular haemorrhage. In extreme cases, the baby may require surgery.

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Role of the mother in the care of her premature baby

I have treated enough premature babies to know that mothers often carry huge guilt around having a premature baby. It is traumatic and far from the ideal picture painted in the media and dreamt about by new parents.

The clinical interference by medical staff to attend to your premature baby may leave you feeling robbed of normal interaction with your baby and useless in the situation. The truth is that your role is vital to the overall well-being of your baby and there are certainly things that you can do for your baby during the NICU stay.

• Breast milk: A premature baby may not be strong enough to suck from the breast, but breast milk is still of utmost importance. The colostrum that is produced in the first few days helps to seal the baby’s gut and lowers the risk of infection. Breast milk itself contains all that is required for your baby’s health and plays a huge role in preventing NEC.

The nursing staff and your husband can certainly help in ensuring the colostrum gets to your baby as soon as possible even if you are unable to do so. Breast pumps are available for you to use to extract the milk, which will then be given to your baby via a nasogastric tube until such time as your baby is able to feed from the breast.

• Kangaroo care: This is the practice of holding your baby skin-to-skin against your bare chest. This form of care helps to regulate the baby physiologically. A baby cared for this way shows more stability in blood pressure and temperature regulation, breathing and heart rate. In addition, kangaroo care stimulates and increases breastmilk and bonding for the mother and immunity, sleep, cognitive development and motor development in the baby.

• Talk to your baby: A fascinating study was done to test the effects of a mother talking to the baby in a NICU setting. The findings were published in the American Journal of Paediatrics. Not only were the babies able to settle easier after painful procedures, but the talking also encouraged the baby to make eye contact and to vocalise its own sounds. Beyond this, the study showed that the cognitive and language ability of babies spoken to by their parents while in NICU was substantially increased when tested at 18 months of age.

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Role of the father in the care of his premature baby

Fathers often report feeling isolated and excluded from the care of their premature baby. This may be particularly so if the baby is rushed from the delivery room and straight to a NICU. Anger and frustration are common emotions.

Traditionally, men want to care for and protect their families but the emergency, unforeseen occurrences associated with a premature birth certainly overrule this natural instinct of a father, unless he gets involved immediately.

There is a huge role for fathers to play. Mothers, in a premature birth situation, are often ill or at risk themselves. The onus is placed on the father to take the reins in the parental role and the studies show that the outcome for the family as a whole is extremely positive.

• Breastfeeding: We have established that breastfeeding is vital to the well-being of a baby. Breast milk plays a role in preventing NEC in the premature baby and there is a significant association between the quantity of human milk received during a hospital stay and the neuro-behavioural development at 18 months and at 30 months.

Mothers included in a study on the success of breastfeeding were unanimous in their opinion that the attitude of their partner to the breastfeeding far outweighed the importance of medical staff. This very interesting study, published in the British Medical Journal for Paediatrics, concluded that the chances of successful breastfeeding and the duration of breastfeeding was highly linked to the involvement of the father.

Since breast milk is usually expressed and given via a nasogastric tube in very premature babies, fathers are able to take the role of giving the feeds to the baby. Fathers also often get involved in monitoring the amount and frequency of feeds.

• Kangaroo care: Fathers play a vital role in the Kangaroo care (skin to skin) of their baby. The positive effects on the baby are the same as for when mothers hold their baby. Kangaroo care increases the father’s ability to bond with his baby and this cannot be ignored. Since the mother may not be in a position to care for her preterm baby, fathers often take up this role and I would certainly encourage it. Kangaroo care is generally encouraged for about an hour a day.

• Talking to the baby: Again, the aforementioned benefits for mothers speaking to their babies apply equally to the father.

• Emotional support of the family: Mothers of preterm babies are more likely to develop postpartum depression. This interferes with the mother’s ability to respond to her baby’s subtle needs. Under these circumstances, the studies show that fathers often take over this role. Furthermore, studies have shown that the likelihood of postpartum depression is lessened when the father is intricately involved in the care of a preterm baby.

It is not always possible to predict if a baby will be born prematurely. There are factors which increase the risks such as previous premature births, smoking, infection or multiple births. Often the cause of a premature birth is not clear. Regardless, the risks and trauma of such a birth are not something one is easily prepared for.

Being in a hospital with a good NICU is vital to the positive outcome of the infant. Equally important is the role of both the mother and father. With the correct support and care, your premature baby is likely to grow up beautifully and to achieve all the milestones necessary for a fully functional life.

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