What happens in the NICU?

The Neonatal Intensive Care Unit (NICU), in contrast to the newborn nursery, is a highly specialized unit with skilled staff prepared to handle the most dangerous postnatal complications of sick or premature infants. Babies can be found in incubators known as isolettes, which control their temperatures. The  average gestational age (GA) at birth is between 38 and 42 weeks, and an infant delivered before 37 weeks is considered to be "premature". The last trimester (12 weeks) in the womb is an important time for the baby's growth, and underdeveloped organs are vulnerable. The NICU staff, led by a neonatologist, monitors around the clock to identify and manage any problems. Here are a few of the most common:

Apnea: when a baby, typically less than 35 weeks GA, stops breathing momentarily for OVER 20 seconds. This can be central (the brain needs help reminding the baby to breathe, which is treated with caffeine) or obstructive (managed with suctioning and repositioning).

Bronchopulmonary Dysplasia (BPD): when the baby's lungs do not have a change to fully develop, they will need help to breathe until their lungs mature. This may include supplemental oxygen using either a nasal cannula, CPAP, or mechanical ventilation. Typically, OB/GYN doctors help prevent this by giving steroids (betamethasone) to mothers within 24 hours of their delivery if between 24-34 weeks GA. After delivery of a preterm infant, the neonatologist may provide further protection by coating the newborn's lungs in a material called surfactant. BPD is diagnosed if any newborn requires 28 or more days of oxygen support, and is further classified as mild, moderate, or severe depending on how much oxygen he or she is on at 36 weeks GA.

Polycythemia or Anemia: when the baby's hematocrit (ratio of red cells in the blood) is greater than 65% or below 30%, respectively. Anemia of prematurity occurs in the second month of life.

Patent Ductus Arteriosis: persistence of a connection between the right sided chamber of the heart and the aorta, which normally closes at birth. Characterized by tachypnea (fast breathing), cardiac murmur, and a low mean arterial pressure (MAP). Diagnosed with an echocardiogram.

Retinopathy of Prematurity: poor formation of the blood vessels of the eyes, occurs in most infants less than 28 weeks GA, screened for by an ophthalmologist if the baby is <30 weeks GA.

Necrotizing Enterocolitis: when the baby's bowel becomes overwhelmed with bacteria, leading to air in the walls of the intestines and can lead to perforation. Usually occurs in very preterm infants and is characterized by poor feeding, abdominal distension, and bloody stools.

Intraventricular Hemorrhage: when there is bleeding into spaces within the baby's brain known as the ventricles. Usually occurring within the first 3 days of birth and in very premature infants (<1500 grams) who have not fully developed their brains yet.


Problems in full term newborns (>37 weeks) that may require a NICU stay include hypoglycemia, poor feeding, poor tone, meconium aspiration syndrome, transient tachypnea of the newborn, infection, hyperbilirubinemia, and anatomical/chromosomal abnormalities.

The Newborn Foot Examination

One of the most common questions asked by new parents concerns their newborn's feet. "Is this normal?" is an appropriate question to ask when a body part on your child doesn't quite look right. 

Though changes in the angles of the feet are typically normal, it is imperative that the pediatrician rules out conditions that require closer observation and management. Here is the "differential diagnosis" for oddly shaped baby feet:

Metatarsus Adductus

The "forefoot" or front part of the foot is turned in (adducted) toward the center, while the middle and hint foot portions are normal. Typically caused by "intrauterine molding", or the way the baby was positioned in the womb. The physician will perform a quick test to be sure the forefoot can be moved to midline without resistance. If the feet are too rigid, a referral to a pediatric orthopedist is warranted. There, the feet may be placed in special "reverselast" shoes and reevaluated in 6 weeks. If this does not fix the problem, serial lower leg casting may be required. The last step would be surgery, which isn't done until 4 years of age. 

Talipes Equinovarus (clubfoot)

The whole foot is adducted. As with above, a quick test for rigidity is performed. If correctable, it is referred to as "positional clubfoot" and is simply observed over time. The more serious diagnosis is congenital clubfoot, which occurs in 1 out of every 1,000 births. Congenital clubfoot requires x-ray imaging, referral to pediatric orthopedics and treatment with special casting referred to as the "Ponseti method". Surgery may be required between ages 3-12 months. 

 

Pes Planus (flat foot)

The lack of an identifiable arch in the foot. This is quite common, seen in approximately 1 in every 4 children. This condition is simply observed over time, since arches typically develop by age 10. If the child complains of pain in the feet as they get older, they may require stretching exercises or special shoes. 

Congenital Vertical Talus (rocker bottom foot)

Rocker bottom feet are characterized by elevated, dislocated, midfeet. The condition is typically associated with genetic syndromes or single gene deletions. Referral is made to pediatric orthopedics. 

Newborn Nursery

​ 

Thinking about having a baby?

Ever wonder what happens in the newborn nursery?

Multiple factors affect the care of a newborn in the first 48 hours. Here are just a small number of scenarios encountered and managed by pediatricians in the nursery:

 

 Small for gestational age (SGA):  <10^th percentile for weight. If no apparent reason for the small weight (maternal hypertension or tobacco use), the urine is tested for infection (cytomegalovirus) and drugs. If the infant is below 2500 grams (5.5 pounds), a car seat evaluation is performed (to ensure infant can breathe well while in the car seat) and breastfeeding may be supplemented with a high-calorie formula. A blood test is performed to check hemoglobin levels.

Large for gestational age (LGA): >90^th percentile for weight. The biggest concern is polycythemia (or too much blood), so a blood test is performed to check the hematocrit. 

Preterm: Very premature infants go to the NICU for intensive care. The babies just under 37 weeks, however, can stay in the nursery. There, as with SGA , a car seat evaluation may be  performed  and breastfeeding may be supplemented with a high-calorie formula. A blood test is performed to check hemoglobin levels.

Meconium-stained amniotic fluid: The infant’s first stool is accidently passed into the amniotic fluid before delivery. The consistency ranges from thin to thick. This can be dangerous if the infant inhales the material during his or her first breath, resulting in respiratory distress known as meconium aspiration syndrome. A resuscitation team will be present in case this happens and will perform deep suctioning to remove it.

Chorioamnionitis: Infection of the amniotic fluid that the fetus lives in. A maternal infection, defined as fever of 100.4 degrees or greater along with other signs, could cause this fluid to get infected, which is potentially deadly for the infant. Blood tests are drawn to check for signs of infection in the baby. Antibiotics are started prophylactically. The tests are repeated at 36 hours of life.​ 

Breastfeeding is always encouraged in infants. Most babies turn out just fine, but it's good to always be prepared.