Neonatology

Neonatology Premature Infant Care- Columbia Asia India
NICU or Neonatal Intensive Care Unit at Columbia Asia Hospitals, specializes in the care of ill or premature newborn infants or those newborn requiring close care and monitoring. There is a step down Special Care Baby Unit (SCBU) to take care of preterm babies, who are feeding and growing rapidly but need monitoring till they are fit for discharge.

The department of Neonatology, Columbia Asia Hospitals, has neonatologists, pediatricians, pediatric surgeons and nurses trained in newborn care round the clock. The care given to the newborn is individualised and our Neonatologists practice evidence based medicine and follow internationally accepted protocols.

Treatments and Procedures
  • Provide neonatal resuscitation at every delivery
  • Evaluate and provide postnatal care to healthy newborn infants
  • Immunisation services
  • Care of babies born to “high risk” mothers
  • Care of low birth weight babies
  • Care of premature babies
  • Care of sick newborn
  • Babies requiring sustained respiratory support
  • Care and support of newborn during transport in and out of the hospital
  • Antenatal counselling when newborn problems are anticipated
  • Neonatal surgery including urological and thoracic problems
  • Post- operative care
  • Newborn screening for hearing defects
  • Newborn screening for inborn errors of metabolism
  • Parents are trained in newborn care post discharge from NICU
 
Neonatal Intensive Care Unit (NICU)

Columbia Asia Hospitals has a contemporary neonatal intensive care unit (NICU) with state-of-the-art, advanced equipment and infrastructure to manage sick and premature infants. The consultants are highly trained and are qualified from some of the best institutions in India and abroad. They follow internationally benchmarked protocols and practice evidence-based medicine. The nurses in the NICU have been specially trained to handle newborns and provide specialised care in a compassionate manner.

What is newborn care?

When the baby is in the womb; breathing, nutrition, waste elimination and protection against infections come from the mother. Immediately after birth; the lungs, heart, kidneys, digestive system and liver and immunologic systems must start functioning independently. Some babies have difficulty transitioning, more so with premature babies and those with birth defects or born by a difficult delivery. Special care that is sophisticated and coordinated is available for managing the challenges these babies face.

What is NICU?

Newborn babies needing continuous monitoring and support are admitted to the NICU where specially trained healthcare professionals are available. Sometimes, babies that need specialised nursing care and feeding support are also admitted to the NICU. Nurses with special skills are available round-the-clock in the NICU.

What facilities are available in the NICU?

The NICU is well equipped to handle any newborn needing level 3 facilities. Equipment such as phototherapy unit, radiant warmer, CPAP, ventilator, transport incubator with inbuilt ventilator is available in addition to a well equipped ambulance service.

The parents’ role

NICU encourages parents to be involved in the care plan. The healthcare providers cannot replace you. They provide the medical and nursing care, while you provide the loving touch and sound that your baby needs to have to grow out of NICU care. Parents will be encouraged to touch, talk and learn to understand the baby’s needs. As the baby progresses, you will be allowed to hold, cuddle, soothe, feed, burp, bathe, diaper and dress the little one. You will need to follow a hand wash procedure and in some cases wear a hospital gown and hospital footwear when entering the NICU. You will be asked not to touch anything except your baby.

Some risk factors that necessitate NICU admission

Maternal factors

  • Age below 16 and above 35 years
  • Associated diabetes, hypertension or heart disease
  • Multiple pregnancies
  • Bleeding during pregnancy
  • Drug or alcohol exposure
  • Sexually transmitted diseases
  • Too little or too much of amniotic fluid
  • Premature rupture of membranes

Delivery factors

  • Foetal distress / birth asphyxia
  • Abnormal presentation like breech
  • Meconium stained liquor
  • Cord around the neck
  • Forceps or caesarean delivery
  • Other birth injuries

Baby factors

  • Born before 37 weeks or after 42 weeks
  • Birth weight less than 2500 grams or over 4 kg
  • Small for gestational age
  • Resuscitation in delivery room
  • Birth defects
  • Respiratory distress (rapid breathing, grunting or apnoea)
  • Infection
  • Seizures
  • Low blood sugar
  • Need for extra oxygen or monitoring, IV or other medications
  • Need for blood transfusion
  • Neonatal jaundice needing phototherapy

Common problems encountered in NICU

Prematurity

A full-term pregnancy usually lasts 40 weeks. When a baby is born before 37 weeks of gestation, he / she is called premature or preterm. The neonatal intensive care unit is specially designed to care for premature and sick babies. When your baby is admitted to the NICU, the nurses and doctors monitor closely for changes in skin colour, breathing, heart rate, temperature, and blood chemistry values. The baby will remain in NICU until he / she can breathe and feed independently and is gaining weight. The mother should be comfortable and confident in handling the baby and there should be no medical issues prior to discharge.

Nutrition

Reflex sucking is seen before 28 weeks, but a coordinated 'suck-swallow-breathe' pattern usually does not occur until 34 to 36 weeks of gestational age. Until your baby can suck from your breast or a bottle, the baby is fed intravenously (called TPN) or mother’s milk and in the absence of it, a nutrient-rich formula by a nasogastric tube or ryle’s tube (a soft, flexible tube passed through the nose or mouth into the stomach). When premature babies reach the gestational age of about 34 to 36 weeks, most can begin feeding from the breast or bottle.

The best milk for all types of babies remains the mother’s milk. This has many advantages and is encouraged in all our neonatal units. If the baby is incapable of taking feeds directly from the breast for any reason, the mother is encouraged to express her milk which is then given via a paladai or nasogastric tube.

Warmth

Premature babies have very little body fat and thinner skin than full-term babies so they can easily become cold. Such babies are placed under a radiant warmer, which is a flat, open bed with heat lamps in the hood. This bed allows NICU staff to monitor your baby while keeping him / her warm.

In infants born before 31 weeks, the evaporative water loss is the route of heat loss and this has to be kept at a minimum. Such babies are usually cared for in another equipment to keep them warm called an incubator, which is a safe and toughened plastic enclosed bed with warmed and / or moist air or oxygen with a temperature regulator.

Respiratory distress syndrome

Respiratory distress syndrome or hyaline membrane disease (HMD) is a condition in which the baby’s immature lungs do not produce enough surfactant, a chemical needed to keep the air sacs of the lungs open during expiration (breathing out), which is required for exchange of oxygen and carbon dioxide. If this occurs, it becomes hard for your baby to breathe and he / she begins to 'grunt', and breathe faster - signs which suggest the baby is struggling to breathe effectively. Because of the lack of surfactant, the lungs are 'stiff' (difficult to expand). The baby may require additional oxygen and / or additional surfactant.

Sepsis / infection

All newborn infants, especially those who are premature, are susceptible to infection because their immune systems, which provide a natural defence against infection, are not mature at birth. Hence, it is easy for an infection to spread. An infection can come from the uterus, during delivery or afterwards. The NICU precautions such as scrubbing and gowning are essential to decreasing the risk of infection. An infection is generally treated with a group of medicines called antibiotics for a specified duration.

Effective hand washing is the single most important intervention which has shown to reduce the incidence of infection. All our units follow strict hand washing protocol and the same is expected of parents when they visit the NICU.

Apnoea, bradycardia, cyanosis (ABC)

While still inside the womb, a baby receives all his oxygen through the umbilical cord. At birth, he has to start breathing for himself. Because his brain is still maturing, he sometimes 'forgets' to breathe. If this period of not breathing is 20 seconds or longer, it is called apnoea and his heart often begins to slow down. This slow heartbeat is called bradycardia, if the baby’s heart rate drops below 100 beats per minute for any length of time associated with apnoea. Sometimes the baby’s skin takes on a bluish tinge, especially around the eyes and mouth. This is referred to as cyanosis.

Neonatal jaundice

Jaundice means yellow discolouration of the skin and eyes. There are various reasons for jaundice but nearly all newborn babies become jaundiced after 2 or 3 days of life. Your doctor will keep a watch on it by doing blood tests. If jaundice occurs too early or if it is very high, it is necessary to find the reason. Jaundice is generally treated with phototherapy, where the baby is placed under a special blue coloured light till the bilirubin levels improve.

Levels of NICU

The classifications of levels of NICU are defined according to the level of complexity of care provided.

Level I neonatal care (basic)

This is a well, newborn nursery and has the capability to:

  • Provide neonatal resuscitation at every delivery
  • Evaluate and provide postnatal care to healthy newborn infants
  • Apgar score < 6
  • Stabilise and provide care for infants born > 34 weeks gestation who remain physiologically stable
  • Stabilise and provide care for infants born > 34 weeks gestation < 2 kg
  • Stabilise and provide care for physiologically unstable full-term infants who require haemodynamic or respiratory support and birth weight < 2 kg
  • Stabilise newborn infants who are ill and those born at < 34 weeks' gestation until transferred to a facility that can provide the appropriate level of neonatal care

Level II neonatal care (speciality)

Special care nursery: Level II units are subdivided into 2 categories based on their ability to provide assisted ventilation including continuous positive airway pressure.

Level II A: has the capabilities to:

  1. Resuscitate and stabilise preterm and / or ill infants before transfer to a facility at which newborn intensive care is provided
  2. Provide care for infants born at > 30 weeks' gestation and weighing.
    1. Apgar score 4 to 6
    2. Who have physiologic immaturity such as apnoea of prematurity, inability to maintain body temperature or inability to take oral feedings
    3. Who are moderately ill with problems that are anticipated to resolve rapidly and are not anticipated to need subspeciality services on an urgent basis
  3. Provide care for infants who are convalescing after intensive care

Level III (subspeciality) NICU:

2. Level III NICUs are subdivided into 3 categories.

  1. Level III A: has the capabilities to:
    1. Provide comprehensive care for infants born at > 28 weeks gestation and weighing > 1,000 g
    2. Apgar scores 3 and below are generally regarded as critically low
    3. Provide sustained life support limited to conventional mechanical ventilation
    4. Perform minor surgical procedures such as placement of central venous catheter or inguinal hernia repair

3. Level III B NICU has the capabilities to provide:

  1. Comprehensive care for extremely low birth weight infants (
  2. Advanced respiratory support such as high-frequency ventilation and inhaled nitric oxide for as long as required
  3. Prompt and on-site access to a full range of paediatric medical subspecialists
  4. Advanced imaging with interpretation on an urgent basis, including computed tomography, magnetic resonance imaging, and echocardiography
  5. Paediatric surgical specialists and paediatric anaesthesiologists on site or at a closely related institution to perform major surgery such as ligation of patent ductus arteriosus and repair of abdominal wall defects, necrotising enterocolitis with bowel perforation, tracheoesophageal fistula and / or oesophageal atresia, and myelomeningocele

3. Level III C NICU has the capabilities of a level III B NICU and is located within an institution that has the capability to provide extracorporeal membrane oxygenation and surgical repair of complex congenital cardiac malformations that require cardiopulmonary bypass.

Retrieval service for critically ill newborns

Transport of a neonate

  • Whatever be the reason for transporting a neonate, from one hospital to another or within the same hospital (from operating room to NICU), maintenance of body temperature, oxygenation and glucose levels are important.
  • Columbia Asia Hospital provides retrieval services from primary care hospitals, nursing homes and other medical establishments for critically ill neonates requiring ICU services.
  • Healthcare professionals from other centres who want to shift a patient to Columbia Asia Hospital can contact the hospital to facilitate early activation of the retrieval team and ensure timely transfer and prompt initiation of definitive care. The mother should preferably be shifted with the baby.
  • On receiving a call from a hospital, the NICU doctor of Columbia Asia Hospitals interacts with the treating doctors to ascertain the status of the baby. The retrieval team goes to get the baby in an ambulance with all facilities.

Conditions for which retrieval services are offered

  • Prematurity (always discuss / consider the possibility of intra uterine transfer if time permits as this significantly reduces the morbidity for babies)
  • Term babies with breathing difficulty
  • Babies with significant jaundice with possible need for exchange transfusion
  • Neonates needing surgical treatment (after discussing with a paediatric surgeon at Columbia Asia Hospital where facilities exist)
  • Primary consultant feels that the baby needs to be investigated and managed further at a higher centre (after discussing with the consultant)
  • Neonates who require sepsis workup and treatment

It is important to ascertain that the baby is not too sick (needing maximal pressure support / high oxygen / inotropic support) to ensure retrieval is safe and effective.

In-utero transfer

  • When it is anticipated prior to delivery that a baby may require intensive or high dependency care and this is not available locally, in-utero transfer should occur provided this does not jeopardise the mother’s health or risk delivery on the route.
  • The mother’s womb is the best incubator for the baby to be transported in.

Indications for in-utero transfer

Pregnancy Less than 32 weeks
Estimated foetal weight Less than 1,500 gm
Multiple pregnancy Less than 34 weeks
Severe Rhesus disease Requiring preterm delivery
Congenital defects detected on antenatal ultrasound scans likely to need immediate post natal surgery Congenital heart defects, diaphragmatic hernia, intestinal obstruction, renal tract dilatation, brain and spinal malformations, tumours

Ex-utero transfer

Indications

  • Infants needing oxygen for more than 4 hours
  • Infants needing more than 60% oxygen
  • Associated with apnoea
  • Associated with meconium aspiration
  • Congenital defects
  • Weight below 1,500 gm
  • Recurrent apnoea and convulsions
  • Severe birth asphyxia
  • Jaundice with a need for exchange transfusion
  • Bleeding neonate
  • Infant needing surgery
  • Infants with lethargy, poor feeding, cyanosis, vomiting