Breast is best, but it may not be easy.

Strike 1 - born too soon. It's tough for the mother of a preemie to get started with breastfeeding. Depending on just how early the baby is, it may be impossible to put him/her to breast for many weeks. The only stimulation she gets, unless she's tandem nursing a sibling, is from the pump. I've pumped for my full-term babies. It's not fun. It's frustrating. Sometimes it hurts. In the beginning you get little or no rewards for your efforts -- rewards being the liquid gold of breastmilk.

Strike 2 - Mom is sick. Often babies are delivered prematurely because there is a maternal problem - an infection, elevated blood pressure, placental abruption or placenta previa. Some of these complications require major surgery for delivery. The surgery and any blood loss can delay lactation. A mom who is being treated for pre-eclampsia may be unable to pump at all, much less regularly.

Strike 3 - Unrealistic expectations can lead to ineffective or infrequent pumping. Most new moms seem to think that they will have milk from the first time they pump. This just isn't realistic. Colostrum is present in small quantities from before the baby is born, but extracting it with a pump instead of a healthy newborn is sometimes an exercise in futility for the first day or 3. Our lactation consultants and the NICU staff know this and make sure that our moms know it as well. Getting them to actually hear what we're saying is a major challenge, though.

Frequent pumping, adequate hydration, and a good pump (preferably hospital grade) can all make a difference. One intervention that can help both mom and baby is skin-to-skin contact. Mom comes dressed in clothing that is easily rearranged to allow the diaper clad baby to snuggle against the skin of her chest. Even very small babies tolerate this well if their condition is otherwise moderately stable. I've seen very rapid increases in milk volume with a good pump and skin-to-skin time. Babies clearly enjoy this as well. They usually snuggle in and often go to sleep. If they don't sleep while being held, they will frequently go into a deep sleep when they are returned to their bed.

Skin-to-skin isn't just for preemies. It's one of the most effective interventions for getting term babies to focus and nurse as well.

Hold that position!

Lumbar puncture (LP, spinal tap) is a relatively common procedure in neonatal ICU's. It can be done as part of a sepsis workup - looking for infection. Less commonly it may be done as a way of treating hydrocephalus (excess fluid in the ventricles of the brain) until a shunt can be placed or until a temporary condition causing hydrocephalus resolves. The most common temporary cause of hydrocephalus is interventricular hemorrhage (IVH, Bleeding in the brain). It's been years since we've had a baby with a bleed that severe, though.

More than one physician or nurse practitioner has commented that successful lumbar punctures depend more on the skill of the person positioning the baby than on the skill of the person wielding the needle.

There's more than a little truth in that, but the person doing the tap needs to be able to tell the holder how to adjust the position for best access. The more accurate their directions, the better the position.

There are two basic positions for LP. Sitting and lying on the side. Most of the time, we position the baby on his side with the lower part of the spine curved as much as is practical given the baby's condition and equipment being used. I generally place one hand on the baby's upper back and the other on the back of the upper thighs extending onto the diaper area.

The diaper is pulled down to expose the lower spine, but not so far as to risk fecal contamination. The nurse practitioner or physician cleans the site and places a sterile drape over the lower back. The lumbar area of the spine needs to be curled in order to open the spaces between the vertebrae. This is accomplished by curling the baby's spine from the bottom, keeping the upper part of the spine as straight as possible so as not to interfere with breathing. When I position a baby this way, it is very rare for a nurse practitioner or physician to fail to get a successful tap.

The seated position can be used for less fragile babies and the principle is the same, but hand position is different. The baby needs to be leaning forward with the head supported and lower spine flexed. One hand is placed on each side. I generally have 2 fingers of each hand on the upper back, thumbs under the chin, and pinkies under the knees. My hand size limits the size of babies I can position this way. It's trickier for the holder to learn this position and to keep the baby immobilized while the LP is done.

Assume the position!

I was chatting with a nurse from another unit recently and she commented on something she'd witnessed in my NICU. She saw one of our travelers feeding a baby - baby seated on her knee and held a distance from the body. She thought this very odd in spite of the travel nurse's explanation: "This baby's a puker and I don't want to wear her formula."

Sounds very reasonable to me - and I often feed babies in a similar position, not always to avoid baby vomit.

Newborns, especially preemies, will generally go to sleep when held close to an adult's body. This is counterproductive when you need the baby to consume a minimum amount of expressed breast milk or formula. The solution is to hold the baby a little distance from your body so your shared warmth doesn't make him drowsy.

It takes a little time to feel comfortable holding babies this way, but it actually gives you better control over the baby's airway than traditional positioning. It also makes it easier to react to choking episodes -- or the aforementioned "puking".

The baby is seated on one of your thigh (varies with handedness of the adult, and baby's propensity to vomit) in a fairly upright position. I generally place the baby on my left thigh with my left hand behind the baby's neck. my thumb and forefinger (middle finger for big kids) are supporting the ears. Heel of hand ring and pinky fingers under the shoulders, Baby's not going anywhere, no matter how much he wiggles and my right hand is free to hold the bottle for feedings and to grab anything else I might need - burp cloth, bulb syringe, suction, etc.

Keeping the baby upright helps facilitate swallowing in sleepy babies and those who haven't entirely managed the suck-swallow-breathe maneuver. If the baby chokes or spits, it takes fractions of a second to put the bottle down and reposition the baby with his head forward and facing down over the right hand. This generally clears the airway, but if it doesn't, I can easily free a hand to grab the nearby bulb syringe or suction as needed.

When I'm burping a particularly spitty baby, I will move him to my right thigh facing away from me and leaning forward onto my right hand. This directs any vomit onto the floor instead of my clothing, making for much easier clean-up.

Another quiet night in the NICU

Telephone rings. It's labor and delivery. New patient just arrived. She's 28 weeks and she's fully dilated. We remind them to turn up the thermostat in the operating room. How high? We're not sure -- just turn it up. We'll find the policy for you later. We should all know what temperature, but "imminent delivery" can make you forget all but the essential numbers. That baby's probably coming before the temperature gets into the appropriate range anyway. Tropical. Thats what we want.

We check the admission bed, call respiratory therapy to set up the ventilator and check the resuscitation equipment in the delivery area. Must be a quiet night for them. We get 3 RTs. Not complaining. Sometimes you need 3. Tonight it's a good thing to have them all.

Over we go to the delivery area. It's already 72 and the temperature is rising rapidly. I'm not on admissions, but I'm in charge and the admitting nurse can always use an extra pair of hands with a little one. We'll be doing this in the OR to accommodate the extra people and equipment. Check equipment, draw up emergency drugs, measure and cut the endotracheal tube and the feeding tube we will use to give a dose of surfactant to help the baby breathe. Waiting for the OB team to bring in the mom.

Scrub tech has finished setting up for a C-section - just in case.

OB arrives sans mom. The news gets better. Mom had an ultrasound this week. Baby isn't 28 weeks. It's 25 weeks. Call the neonatologist to come in for backup. The nurse practitioner can handle this, but it's policy. No sleep for the neonatologist if the baby is 27 weeks or under.

Mom is FINALLY (maybe 5 or 6 minutes later) in the room and on the OR table.

"Don't push. Let me check her again"

I have my back to the action, double-checking and triple checking. I hear a wet splash and turn around to see the OB and one of the labor and delivery nurses wiping amniotic fluid from their full face masks.

The OB checks the mom again. Prolapse: the umbilical cord has slipped past the baby's head and is in danger of being compressed to the point of cutting off oxygen to the baby. The external monitor is showing a heart rate that exactly matches the mother's heart rate. We hope that the baby is just too far down in the pelvis for the monitor to pick up. There is no time to check with a sono or internal monitor.

Someone asks about fetal heart rate. A voice responds, "Three minutes ago it was 150." Three minutes is an eternity. We'd like to know what the heart rate is now, but there is no more time.

There are only a very few minutes to get that baby to the relative safety of our resuscitation warmer. The room is about 75 degrees now and much hotter for the people surrounding the warmer. Makes me glad I'm just the extra pair of hands, much as my control-freak side wants to have my hands directly involved.

The OB changes gloves as the anesthesiologist "crashes" the mom -- general anesthesia is much faster than other options for emergency C-sections. As soon as the anesthesiologist indicates that the mom is ready, things really go into high gear. An incredibly long few minutes later, we hear a weak cry. At 25 weeks, it's unusual to hear a cry. With a prolapsed cord, it's even more unusual, but it means we can take our time doing what we need to stabilize the baby. It also means that there is much less to do. No drugs. No chest compressions. That weak cry is a truly beautiful sound.

The OB hands the baby to the nurse practitioner who places it in our pre-warmed bed. The baby is covered in plastic from the neck down to minimize heat loss. The baby is working very hard to breathe, so one of the respiratory therapists begins bag-mask ventilation as another hands the laryngoscope and endotracheal tube to the nurse practitioner. In goes the tube and is carefully secured once placement is verified. Too far in? adjust it a little. Breath sounds are equal now and the baby is pink. Time for the surfactant which will help keep those tiny lungs expanded and decrease the risk of damage as we breathe for the baby.

The third respiratory therapist has finished setting up the ventilator on the transport incubator. We transfer the baby into it and off we go to the NICU ripping off masks and OR caps as we exit the OR. We're all hot, but it's worth it. When we get the baby into the NICU admission bed, the temperature is well within the normal range. WIN! But it's really only the beginning. If everything goes well, this baby will be with us until at least Valentine's Day.

Welcome to the NICU, let me show you around - Part II

Why do I have to wait so long to come see my baby?

Parents may be asked to wait 30 minutes to an hour - occasionally longer - as we admit the baby to the NICU. Other units may have different policies, but we find it easier to provide urgently needed care if we can explain it to the parents when we've finished, rather than during the procedures. Some of them can be frightening if you've never seen them before. If the mom arrives at the hospital several hours (or days) prior to delivery, our physicians or nurse practitioners will spend some time explaining the NICU admission procedures and what we expect for their baby. Unfortunately, we don't always have this opportunity.

A-B - Airway & Breathing. If the baby is having difficulty breathing, or maintaining an adequate oxygen level, we'll have to deal with that. Sometimes the problem is so severe that we need to place a breathing tube in the delivery room. Sometimes the baby just needs some supplemental pressure or oxygen.

If the baby just needs a little oxygen (bigger babies who are simply slow transitioning), we may use a nasal cannula -- just like the ones used for adults, but smaller. Humidified, and sometimes heated (depending on the flow) oxygen is provided. We use a device called a blender to mix it with air to provide just the right concentration for each baby.

Babies who need more help breathing may be placed on Continuous Positive Airway Pressure -- which we call CPAP (pronounced See-pap). Humidified, heated air mixed with oxygen (again, a blender) is delivered at a higher flow to a nasal mask which covers the nose or soft "prongs" that fit inside the nostrils. This is similar to the equipment used by adults with sleep apnea.

Babies in severe respiratory distress will have a breathing tube placed. The tube is called an endotracheal tube or ET tube and the procedure is called intubation. Babies who are intubated usually receive surfactant. Surfactant is the substance in your lung fluids which decrease the pressure needed to expand the lungs -- and decrease the effort needed to breathe. We use a natural (animal derived) surfactant rather than a synthetic surfactant because studies have shown better outcomes with the natural surfactants.

Once the baby's airway is stabilized - with one of the above - we'll need an xray to check the extent of lung disease and the placement of that ET tube.

C - for Circulation. If the baby requires full resuscitation at delivery, we will provide chest compressions and possibly some fluid in the delivery room. Most babies don't need that degree of resuscitation at birth, but it is far more common for babies to have abnormally low blood pressure for many reasons which can range from blood loss due to placental separation prior to birth to septic shock from infection. We may start an IV in the baby's arm or leg, but if the blood pressure is very low or if the baby requires an ET tube to breathe, we'll probably place catheters in the baby's umbilical cord.

The doctor or nurse practitioner will tie a sterile cord around the base of the cord to keep it from bleeding. Then they will place a flexible tube into the umbilical vein and one of the umbilical arteries. This gives us a place to provide needed fluid, a way to obtain blood samples without using needles, and a way to monitor the baby's blood pressure more accurately. Again, an xray will be needed to determine the placement of those catheters. On a good day, we get one xray for ET placement and line placement at the same time.

Babies who aren't so sick will have a thorough physical exam and some basic lab work, possibly an IV placed in an arm or leg, and an xray. Families of those babies usually get to visit within about a half hour. If things seem to be taking an unusually long time, the nurse from the delivery room can call the NICU to find out what is holding things up -- it may be an emergency with another baby. Occasionally we admit 2 or even 3 babies at the same time -- and that's not counting the twins and triplets. Larger NICU's in hospitals with busier delivery suites are likely to be even busier.

Once the baby's condition is stabilized and the urgently needed procedures are completed, we let the nurse in the delivery suite know so the family can come visit the baby.

Hello, Baby! Goodbye.

23 weeks, male, mom had prolonged rupture of membranes and chorioamnionitis - an infection of the fetal membranes and amniotic fluid. It doesn't get much more grim than that in the NICU. This baby has about as much chance as a snowball in Death Valley in August. The perinatologist's recommendation was that we simply do nothing. The parents want us to do "everything possible" and that's what we are going to do. The parents cannot possibly understand what "everything possible" means - or why we do it reluctantly, but with all possible skill.

It's not my favorite part of the job, this fending off death for a few hours until there is simply no more to do. Even more difficult is facing the parents and trying not to destroy their hope -- but trying harder still not to offer them hope that simply does not exist. They want so much for me to say "yes" when they ask if the baby is doing better now. He's not really. He looks it, but I've seen the lab results. I know about the unofficial, but devastating head sonogram - the docs haven't shared that with them just yet, so I dance quickly away from that minefield.

I see the dark spots - the petechiae and hematomas that result from the overwhelming infection that has destroyed most of his clotting factors and platelets. We're replacing fluids, platelets, red cells, electrolytes - but not as fast as they're leaking through his gelatinous skin and being destroyed by the infection. I handle his tiny limbs as gently as possible so as not to cause any more damage, but I must turn him frequently, because lying too still causes his head to flatten. I titrate his dopamine and give more boluses of saline solution and sodium bicarbonate to sustain his blood pressure and reverse the acidosis that will surely kill him if it is not corrected, but I know that his serum sodium is rapidly rising -- approaching dangerous levels and soon there will be no more to do.

An aunt comments that this place is filled with angels. I pause a moment and realize that she is right. It is alway so when one of these little ones hovers between life and death. Perhaps it is always so and I am most aware of it at such times.

With great reluctance, I try to start an IV in veins almost smaller than the catheter, because we must give insulin now, and it's not compatible with the fluids in the existing IV lines. I call the doctor to do it, because I cannot bear to try a second time when my first attempt fails. She is as reluctant as I, but there is no one to whom she can pass this. She succeeds on the second attempt and we are able to continue our efforts to postpone the inevitable.

I leave in the morning knowing that he will not be there when I return less than 12 hours later. My husband asks how I feel about this baby dying. My answer: I'm sad for his family, but happy that he has moved on to a better place.

Delayed Cord Clamping - benefits for preemies

Delayed cord clamping (30 seconds to 2 minutes after delivery) has been around for a while, but it hasn't been standard practice - at least not at my hospital - for preterm deliveries. That's changing thanks to some recent randomized trials on the subject. There have been several. They have different study criteria and slightly different outcomes. They all have one thing in common, though. There are benefits to delaying cord clamping for 45 seconds or longer, even when the baby is less than 30 weeks gestation.

45 seconds feels like a long time while you're waiting for the OB to hand over that preemie -- if you're used to the traditional quick clamp and immediate resuscitation. It was fascinating and a little scary to watch as the OB dried the baby, bulb suctioned his mouth, waited nearly a minute before clamping the cord and - unthinkable only a few weeks ago - offered the scissors to the father to cut the cord.

8 hours later, the admission nurse was still griping about the delay and the small study in Rhode Island found that "the DCC* group were more likely to have higher initial mean blood pressures and less likely to be discharged on oxygen. DCC group infants had higher initial glucose levels (*ICC=36 mg/dl, DCC=73.1 mg/dl; p=0.02)." and a meta-analysis of 7 studies found decreased need for transfusions and decreased incidence of intraventricular hemorrhage.

Risks? Apparently nothing significant was discovered over the course of several studies and hundreds of preterm births - both vaginal and C-section.


*DCC=Delayed Cord Clamping. ICC=Immediate Cord Clamping