Understanding Preterm Infant Medical Care and What to Expect in the NICU | Dr. Amna Husain

In this video, Dr. Husain helps parents in understanding preterm infant medical care and what to expect in the NICU if your baby arrives early or unexpectedly requires neonatal intensive care unit support. 0:00- Intro 1:38- Preterm infant medical care in the NICU 1:53- Message to parents of preterm infants 2:40- What does "preterm" baby? 2:55- Care of the 22-23 week preterm baby 3:41- Survival rate of a preterm infant 4:25- Prenatal consultation for parents of preterm infant 5:30- Who is a neonatologist? 6:15- Resuscitation of the preterm baby 6:44- APGAR scores and what they mean for the preterm infant 7:45- Temperature control and importance of glucose regulation 8:53- Benefits of breast milk for the preterm infant 10:00 - Neonatal lung development 11:40- Retinopathy of prematurity 12:20- Apnea of prematurity 13:00- Neonatal heart conditions 13:48- Risk of infection in the NICU infant 14:20- Intraventricular hemorrhage 15:14- Developmental outcomes of the preterm infant For further reading and resources: -Antenatal Counseling Regarding Resuscitation and Intensive Care Before 25 Weeks of Gestation; PEDIATRICS Volume 136, number 3, September 2015 -Approach to Infants Born at 22 to 24 Weeks’ Gestation: Relationship to Outcomes of More-Mature Infants; PEDIATRICS Volume 129, Number 6, June 2012 -Care of the Very Low-birthweight Infant; Pediatrics in Review Vol.30 No.1 January 2009 -Prenatal Consultation at the Limits of Viability; NeoReviews Vol.4 No.6 June 2003 -Survival and Impairment of Extremely Premature Infants: A Meta-analysis; PEDIATRICS Volume 143, number 2, February 2019 To see my other content, follow me- Instagram: https://www.instagram.com/dr.amnahusain/ Tiktok: https://www.tiktok.com/@dr.amnahusain?lang=en ***The information in this video is intended to serve as educational information and can not be construed as a substitute for professional medical advice, diagnosis, or treatment of you or your child. Content within this video is for information purposes only and does not replace a consultation with your own doctor or your child's doctor.

TRANSCRIPTION

Dr. Amna Husain: Hey, everybody. Just a quick little disclaimer for you guys. That if you hear any yelling, screaming, shouting, obnoxious crying, or laughing in this video, it's my toddler in the background. As a parent, I'm sure you guys can all relate. Sometimes, kids do not stay quiet when you need them to. I've done my best to try and tone down that background kid noise. But hopefully, you can still make good sense of what I'm saying and don't mind any of the screaming.

Hey everyone. Welcome back. My name is Dr. Amna Husain, board certified pediatrician, board certified lactation consultant, and mom. If you've tuned into the last few episodes, or follow me on social media, you'll also know that I'm expecting my second little one. Today's episode is very special. We're going to be talking about what to expect if you do deliver your baby early, or preterm, and what to anticipate when thinking about their medical care.

As part of pediatric residency, or the training to become a pediatrician. I've spent a number of months in the neonatal intensive care unit, or the NICU. Being part of the care team that takes care of these neonates. In this video, you might hear me reference weeks gestational age. And particular, 24 weeks gestational age, which is when we know babies begin to have a higher chance of viability outside the womb. I myself, posted on social media recently, how passing that 24 week milestone was a bit of a sigh of relief for me. Being a pediatrician, knowing what I know. So today, this episode is going to focus on trying to educate and empower parents on what they can expect if they do have a preterm baby.

We'll also hit on prenatal consultations, or who will review and discuss with you, your baby's prognosis if you do deliver early, and what that care could look like. Also talk about the common medical issues we see and address in neonate babies. So, let's get started. First of all, I want to make something incredibly clear, preterm birth happens, and it is incredibly distressing, traumatic, and overwhelming for parents. This is not something you expected. You thought your baby was going to be due on their due date, and they're coming early for whatever reason. This is not your fault. And we, as part of the care team, understand that completely. Fortunately, technological and therapeutic advances have improved vastly in the last 20 years, improving the chances of survival amongst even the smallest and most immature infants. Some even as young as 22 to 23 weeks gestational age. Typically, babies are considered viable at 24 weeks gestational age, where they have over 50% chance of survival outside the womb.

Before we go any further, let's talk about what the term pre-term actually means. So, preterm is any baby who's born before 37 weeks gestational age. In some institutions across the country and across the world, babies may be offered care as early as 22 to 23 weeks gestational age. Suscitation This early on is a relatively new phenomenon. And we have limited data on their chances of survival, and survival without significant impairments. Reported survival rates can vary pretty significantly in this age group, the 22 to 23 weeks gestational age, among multiple high-income countries. In fact, life-saving treatment might be offered to a 22 week-er in Sweden, some parts of Japan, Germany, even the U.S. But, medical care may not be offered to a 23 week infant in even France or the Netherlands. Survival rates can be very low, and for this reason, medical interventions may not be indicated. So, let's talk about the survival rates. Infants born alive, the survival rate increased from 74% and 25 weeks gestational age, to over 90% at 27 weeks gestational age. At 28 weeks gestational age, the survival rate is 80 to 90%.

And at 32 weeks gestational age, the survival rate is 95%. And, these are numbers and statistics. And we'll talk about what affects these numbers and statistics a little further down the line in the video. That being said, it's not just about survival, but also morbidity. So, survival with significant impairments, and who should be the most qualified person to counsel parents on what those significant impairments could be? Well, the scope of the prenatal consultation depends not only in the maternal, medical, and pregnancy related conditions, but also associated fetal risks and prenatally diagnosed fetal abnormalities, as well as the urgency of the impending delivery. So, what does that all mean? Basically, mom's health before pregnancy, mom's health during pregnancy, baby's risk factors, any fetal abnormalities, and then what the delivery situation is looking like. Are we looking at mom having an infection? Are we looking at something that could be a placenta previa, preterm birth with multiples like triplets?

All of those situations are really going to impact what the scope of the prenatal consultation is going to be. So, who usually does these prenatal consultations, the woman's obstetrician, or maternal fetal medicine doctor play an integral role in caring for her, educating her, and supporting her during preterm labor. The neonatologist who can actually describe and educate on not only the immediate threat to life, but what the longterm sequelae can be for a preterm infant.

So, who is a neonatologist? Well, actually they are pediatricians. They complete a three-year pediatric residency, similar to me, a general pediatrician. After completing four years of medical school, they then go on to do specialized fellowship training. That's typically three years long in neonatology, or really the field of medicine related to neonates. They will then be the physicians who work in the neonatal intensive care unit, or the NICU. There'll be the ones who are running the show when it comes to resuscitating newborn infants. And that's very important because you want somebody who's incredibly skilled at the management of these infants, because time really matters, and skill really matters when it comes to resuscitating, stabilizing, and caring for a preterm infant.

Routine resuscitative equipment can include suction equipment. It can include things like a laryngoscope, and endotracheal tube, even things that could keep the baby warm, because temperature stability is so important. Even a catheter that feeds through their umbilical vein, which can actually help with fluids, and giving the baby nutritional support. If you're in the medical field, or if you've ever heard your doctor talk to you about your child's Apgar scores, they're actually scores that we immediately give in the newborn period, after baby's born to assess tone, reflexes, their heart rate, their color, their respiratory rate.

This can be really difficult to assign to a preterm infant, because tone and reflexes are just not the same as they would be in a term infant. Same thing with color, heart rate, and respiratory rate, especially with these preterm infants. So oftentimes, these scores that might be assigned to the delivery room are actually quite low. We usually assign them at minute one of life, minute five of life, and 10 minutes of life. Typically, you like to see a trend upward. So babies, as they become resuscitated, stabilized, they improve. Their heart rate, improves, their color improves, and their respiratory rate improves. So these are typically the signs that we use that resuscitation is going in the right direction. Other things that we focus on in resuscitation is actually temperature control. So, for example, when I was a medical student and a resident, if we were attending a preterm delivery, whether that be in the labor and delivery room, or whether that be in the OR. And that temperature was actually turned out pretty high to be what's ideal for the baby.

In fact, I even remember sometimes that the OBGYN's, while they were operating and performing a C-section would sometimes have ice packs on their chest or on their back, because it can get really uncomfortable warm. But again, we want to do what's ideal for the baby. [inaudible] instability can actually affect baby's glucose levels as well. So, we actually are able to help control their blood glucose initially by calculating what their adequate carbohydrate nutrition might be. And then, appropriately titrating that glucose infusion rate. Now, of course you might know that term newborns can lose up to 10% of their birth weight. Well, preterm babies can actually lose up to 15% of their birth weight. So, that's something that we also anticipate as part of the medical care team.

Now at this time, babies are not really able to take very much by mouth into their stomach, especially if they're very pre-term. However, we do know that early feedings into the stomach can decrease the risk of necrotizing enterocolitis, otherwise known as NEC. What you feed your baby here matters. Typically, we don't feed preterm infants formula. We feed them breast milk, that's because breast milk contains growth factors and antibodies that can be incredibly beneficial to promote intestinal growth and maturation. It can also decrease the risk of infection for these very preterm infants. And even improve neurodevelopmental outcome. As I've already mentioned, we can also decrease the risk of NEC with early breast milk feedings. Now, if you're a mom who delivered early, your milk may not quite be at the ready to flow yet. That's why we encourage mothers to pump.

Now, mom's status can really affect this, because maybe she's just not ready to pump, or maybe she's not feeling well enough to pump right now. For this reason, donor milk banks exist. Donor milk does undergo rigorous testing and pasteurization before it's given to infants, but it can be a huge lifesaver for these premature infants. Now, one system I haven't hit on yet is actually breathing. For the preterm baby lung development is still occurring. In fact, air sacs known as the alveoli, that live in the lungs don't actually form until week 28. So sometimes babies this young, might actually need a breathing tube. You might also hear other terms if your baby ends up in the NICU. Terms like BiPAP, CPAP, high flow oxygen, or nasal cannula. Again, it's not a set point that a baby 28 weeks and younger are the only ones that need respiratory support. Certainly, I've seen even older babies need respiratory support as well. Even sometimes term newborns.

Again, birth can be unpredictable and preterm care can also be somewhat unpredictable. So, we try to anticipate what we can foresee and then plan for that. For example, surfactant, which is a molecule that is put out by the lungs to help decrease surface tension on those air sacs or alveoli may not actually be formed for very preterm infants. So, that's something as part of the NICU team that we can help give the infants initially during the resuscitative period to help set their lungs up for success. So, the consequences of lung immaturity can actually be compounded by some of the interventions we do. Going too hard with pressure, or too high with oxygen can actually adversely impact the long-term prognosis for these children, or can result in development of chronic lung disease for these preterm babies. Some of these infants might even go home on oxygen, then gets weaned months down the line. Avoidance of too much oxygen is actually also important to help protect the eyes and prevent retinopathy of prematurity.

So as you can see, management of the neonatal lung system can be incredibly complicated, delicate, and really crucial to their long-term prognosis. So, we've talked a lot about temperature stability, baby's ability to take in food by mouth, or inability to, and the importance of using their gut. We've also talked about their lungs, and how delicate the respiratory system is. Briefly, I do want to let you know that your baby can continue to have lapses in breathing, or what we call apneas, and that may not necessarily be related to their lungs, but more related to their immature brain. So, their brainstem really controls breathing. And at this time, if they're born too early, that center might be a little immature. That can then result in, decreased heart rates or what we call bradycardias, which then results in desaturations or, lower oxygen levels.

Commonly, in the NICU, we call these A's, B's, and D's. We do see these in preterm infants. And usually, these do improve as baby continues to get older and receive the medical care that's needed for them. Thinking of baby's heart rate. What about their heart? So in the preterm baby, there are a few common conditions we can anticipate. One of those being, something called a PDA. So, a ductus arteriosus is actually a duct that's part of normal newborn heart development. If baby is born too early, this duct can stay open. Typically, it closes after the first few days of life in a term newborn, after they take in oxygen. If it stays open, we call it a patent ductus arteriosus, or PDA. This can actually cause issues because it can shut too much blood into the baby's lungs. So what do we do about it? Typically, we can give medications that can help close the duct. And if those don't work, we can take more intensive interventions with the help of our pediatric cardiologists.

Infection is also incredibly important at this age. Neonatal sepsis, or a bloodstream infection is something preterm babies are at a very high risk for. They have a very immature immune system. That's why even simple measures like donor breast milk are trying to keep their glucose levels normal or their temp stable, are very important, because these are all subtle signs of infection. For this reason, your baby might be started on antibiotics very early on, even sometimes antivirals to help decrease the risk of infection. Another common issue we sometimes see in preterm infants is the risk of brain bleeds. The blood vessels within the brain are incredibly fragile and delicate. Sometimes in the resuscitative period, for whatever reason, baby can be subject to having brain bleeds. These can be on the term of grade 1 all the way to grade 4. With grade 4, being the most severe.

Now, we again might anticipate this, so that's why we have a way of doing things when resuscitating, and stabilizing, and caring for a preterm infant, but still we keep a very high threshold of caution and make sure we check baby's brain for this, in the first few days of life. First, when we talk about baby's brains, we're all thinking about how will baby turn out developmentally, right? All of us wonder, "Will my baby have a normal life? Will they be a normal toddler? Will they do well in school? What can I expect from a preterm baby, as they grow older?" Well, the degree of prematurity actually correlates the most strongly with developmental outcomes. These babies go home, they will often have appointments regularly with physical therapy, occupational therapy, speech therapy, and even developmental behavioral pediatricians. Periodic neurodevelopmental assessment is essential through a child's school age years to determine an individual child's functional abilities and developmental needs.

Sometimes, we won't know where baby falls developmentally, until even after the age of two. And that's when we can really assess after they've had regular therapy, which should be actually coordinated before babies even discharged from the NICU. And that was a lot of information that we covered. Even as a pediatrician who has trained in the NICU and taken care of neonatal babies. I feel as a parent receiving this information at a very distressing, traumatic time in my life would be very overwhelming. So regardless, of whether your decision is to forego or pursue resuscitation of your baby, depending on their gestational age and what their prognosis could be, I feel like it's incredibly important that parents be informed about their choices, from comfort care to aggressive resuscitation and what all of those could mean.

As someone who's worked in the NICU, and seeing parents immediately hours after delivery and the NICU, hear the alarms, see their concern, the questions written on their face, the worry, the anticipation, and all the hands on deck taking care of their baby. I want you to know that we all care about your child and it is totally okay to lean on the NICU team. There are so many supports in place. And, we consider you all warriors, not just our patients, but their families too.

The ICU can get crazy. It's okay to feel overwhelmed. It's okay to ask for help and ask for support. I hope this video was helpful for you. I hope we were able to review a lot of data. I do have many sources cited below in the show notes. So please make sure to check them out. If you have questions, please feel free to ask them below, give this video a thumbs up if you like it. Share it with somebody who you think might benefit from it. I'll see you all next week.