The majority of babies in this nation are born in good health. Expectant moms and dads may be a little nervous, but they anticipate a safe delivery and a healthy infant. When a problem does occur, it can be devastating. Can a baby delivered at 24 weeks gestation, weighing one pound, survive?
The answer is often yes, but it takes a highly skilled medical team and specialized technology to care for very low birth weight, premature or seriously ill babies. New Hampshire has three regional centers for newborn intensive care: Dartmouth-Hitchcock Medical Center in Lebanon, Elliot Hospital in Manchester and Southern New Hampshire Medical Center in Nashua.
The Elliot Hospital Newborn Intensive Care Unit (NICU) opened in 1989. In March 2005, the service moved into a new 23-bed unit, designed for a new concept in providing critical care for newborns.
The most advanced technology is in use. Most of the infants are in incubators and require mechanical assistance to breathe. Vital signs are monitored electronically and a steady stream of information is transferred to the nurses’ desks. There are alarms at the doors of each room and monitors in the hallways.
But there is no nursery, no row of cribs or incubators behind a glass wall. Each infant is in a room with his or her mother. Lighting is subdued. Window shades adjust for more or less light. Sound is monitored electronically. When it reaches 50 decibels, an orange light glows as a reminder.
For most of these fragile infants, each day includes two or three hours on mother’s or father’s chest, skin to skin. Tubes and wires are attached, as they must be. Yet to the degree possible, the warm, serene environment of the womb is replicated. The mother of a premature infant can remain with her baby, at no extra cost, up to the due date.
Elizabeth (Liz) Castrogiovanni, director of the unit, says that this approach, in place in perhaps two dozen hospitals in the nation, has reduced both average length of stay and number of days on a respirator. She notes that respiratory difficulty is common, and dangerous. Reduced respirator time is predictive of a successful outcome.
Castrogiovanni, who has worked in neonatal intensive care for 20 years, explains what it takes to care for the babies. The unit staff includes neonatal nurse practitioners, neonatal assistants, neonatologists and respiratory therapists, available 24 hours a day, seven days a week.
Physical therapists, nutritionists, pharmacists, laboratory technicians, radiologists and developmental specialists also have important roles. Each infant will be discharged with a plan that will likely involve an early childhood specialist, a social worker and a case manager. Beyond these critical roles are many technical specialists who design the miniature tubing, sampling tools and other adapted equipment.
The unit includes a family room, with television, computer, kitchen, couches and tables. Siblings are welcome. Two discharge rooms, with double beds and private baths, provide parents with a “trial run” before discharge. They experience being in charge, but with a nurse nearby.
For the exceptional need that the unit cannot meet — newborn cardiac surgery, for example — delivery and care will be transferred to Dartmouth-Hitchcock Medical Center in Lebanon or to a Boston hospital. A transport unit is always ready.
“But neonatal care is not just for those who require intensive care,” says Dr. Drew Breen, chief of Pediatrics at Portsmouth Regional Hospital. “Good neonatal care is a necessity for all babies. The first four weeks are critical.”
Most babies come into the world healthy, he says. But for about one fourth, there is a condition that needs to be stabilized. Usually this is known before delivery and the obstetrician will request that a pediatrician be present at delivery.
Often that condition is pneumonia. There may be particulate matter or fluid; airways must be quickly cleared. Pediatric staff is also present at birth for unexpected C-section delivery or if the mother is diabetic.
If there is a need for intermediate care, the pediatrician will consult with specialists (such as neurologists and cardiologists) and develop a care plan. In most situations, the infant will not need to be transferred. “Mothers remain with their babies,” Breen says. “We never send one home without the other.”
In typical circumstances, a pediatrician will see a newborn within a few hours of delivery and daily during the hospital stay. The infant will have a bilirubin level taken to determine the presence of jaundice, a condition common among newborns that is usually self-correcting, but can have serious consequences. Breen notes that New Hampshire recently increased the number of required metabolic screening tests for newborns from six to 12. These tests identify potentially damaging conditions — hypothyroidism, for one — that should be treated immediately. A universal hearing evaluation determines if the hearing mechanism is intact.
Mary Anne Steere, a pediatric nurse at Portsmouth Regional Hospital, says that these tests lead to better outcomes. Pre-delivery screening of the mother is also important. The presence of certain streptococcus bacteria in the vagina, though causing no symptoms in the mother, can lead to rapid infection in a newborn. Women are screened for the bacteria and may receive an antibiotic during delivery, resulting in a significant decline in infection.
Improved maternal health is making a difference as well. “We rarely see a woman who has had no prenatal care,” Steere says. “Most pay attention to their health and nutritional needs. We do see some moms who smoke, and an occasional newborn who has to go through drug withdrawal.”
“This is an exciting time to be involved in neonatal care,” says Breen. “We are getting better at identifying concerns ahead of time,” he says. “Improved ultrasound is on the horizon. We will soon be even better prepared to give every newborn the care that is needed.” NH