When parents arrive at the NICU for the first time, the surroundings can be quite overwhelming for them. For most of them, the NICU is usually a strange and unfamiliar environment. Especially, the different machines, tubes, wires, sounds, and lights may be frightening. However, this special equipment helps to achieve the best possible care and development for a preterm or ill newborn baby.

Incubator and infant care bed

Incubators are a type of specialised baby beds and exist in various types. Incubators usually have the form of a closed box with several windows. They provide heated air via a fan device and the possibility to add humidity to the air inside the incubator. The regulation of body temperature is critical for minimizing stress and optimising growth of preterm born and ill newborn babies. The environmental temperature in an incubator can be regulated according to the needs of the child. The temperature inside the incubator is usually displayed on a small screen on the outside. Healthcare professionals will monitor the body temperature of the child periodically to meet the child’s needs regarding the environmental temperature. Humidity is essential for preterm born babies born before 30 weeks of gestation, in order to prevent them from losing moisture by evaporation through their immature skin.

As preterm born babies mature it is necessary to wean them from the incubator. The time for transferring the baby in an open infant care bed depends on different physical and environmental factors such as weight or thermal stability of the child. Following the transfer into an open infant care bed, the baby may not immediately be able to maintain the body temperature without any support. Radiant warmers over the bed or heated mattresses can be used to facilitate the weaning process.

Monitoring and alarms

Vital signs refer to the most important signs of a body that indicate the status of the body’s life-sustaining functions. Usually, five primary vital signs are monitored: breathing rate, heart rate, blood pressure, body temperature, and oxygen saturation.

For measuring the heart rate and the breathing rate, small pads are placed on the infant’s chest with cables running to a monitor. By looking at the monitor, healthcare professionals are able to check on the frequency and quality of the baby’s heartbeat. The monitor can also detect changes in breathing. Prolonged pauses in breathing, also called apnoea, trigger an alarm.

Another pad is usually strapped gently to the infant’s foot or hand. This device shines a red light through the skin onto a sensor to monitor the oxygen saturation of the infant’s blood. If the level of oxygen decreases an alarm will notify the healthcare team.

A blood pressure cuff is attached to the arm or leg of the child. Within regular time intervals the cuff is inflated with air and deflates again after a few seconds to measure the blood pressure. The blood pressure can also be measured continuously if a baby has a catheter (tiny tube) placed into one of the arteries. The numbers are displayed on a screen. The monitor recognises if the blood pressure is too high or too low and sets off an alarm.

The baby’s body temperature will be checked by a nurse or midwife periodically with a regular medical thermometer. The nurse or midwife can react immediately to changes in the body temperature, e.g., by regulating the temperature of the incubator.

A nurse or midwife will check all vital sign values regularly and will write these down into the clinical record of the child.  

Infusion therapy and catheters

Intravenous drip infusion and syringe pumps are used for infusion therapy of babies in the NICU. They allow healthcare professionals to accurately control the rate of fluids, medications, and nutritional components which are given to the infant. Nurses or doctors can set up speed and time for each substance introduction. Alarm systems can be implemented in the device to notify the NICU team of the completion of the medication or a fault within the system.

An intravenous (IV) line is a fine plastic tube placed in a vein near the skin surface (in the hand, lower arm, foot, lower leg, umbilical cord or scalp). An IV-line is connected to the infusion pump via an extension line. For insertion of the line, sucrose (a special type of sugar) can be given to the infant before the intervention for pain relief. Once inserted the line does not cause any pain.

A Percutaneously Inserted Central Catheter (PICC or PIC line) is used for preterm or ill newborn babies who need IV-therapy for a longer period of time or more frequently. Usually, it is inserted into a deeper vein of the arm and ends in a large vein above the heart.

An umbilical catheter is a thin tube which is inserted into one of the vessels of the umbilical cord of the baby. Through this catheter, it is possible painlessly draw blood and to administer medications, fluids, and nutrients. Additionally, a small device can be attached to continuously monitor the infant's blood pressure.

Many substances are given simultaneously via infusion pumps or drip infusion. Babies at the NICU often need intense monitoring of their fluids and electrolytes (minerals in the blood and other body fluids). This is because of increased transdermal water loss or environmental issues such as radiant warming, phototherapy, and mechanical ventilation. Medications are administered to the infants’ needs and are prescribed for a specific purpose. Parenteral nutrition (glucose, proteins, vitamins, and fat) might be necessary in the beginning.

The amount of infusions and lines may be overwhelming and distressing for parents at the beginning. Healthcare professionals can explain more about the infusion therapy and support parents to cope with the situation.  

Ventilators

A ventilator, also called conventional mechanical ventilator (CMV) in technical language, may either support or take over the breathing of a preterm born or ill newborn infant.

If a baby needs breathing support from a conventional mechanical ventilator (CMV) a soft plastic tube, also called endotracheal tube, is passed through the baby’s mouth or nose into the trachea (windpipe). The tube is fixed with an adhesive tape or a special endotracheal tube holder. The other end of the tube is attached to a ventilator that blows a measured amount of air into the lungs at a certain rate meant to imitate normal breathing. The rate, the volume of air (pressure), and the oxygen content can be adjusted to the baby’s medical condition by the medical team. Modern ventilators can sense when a baby is about to take a breath and synchronise ventilator breaths with the spontaneous breaths of the baby. In this way, CMV can be used to support breathing rather than replace it.

As the health condition improves the baby will be weaned off the ventilator. This process can take a few hours or a few weeks. The first time that a baby is taken off the ventilator breathing may still be tiring for the child. In this case, the medical team will need to replace the ventilator and try to take it off again later. Additionally, infectious lung diseases or surgery may lead to temporary need of ventilator support.

Some babies require a different form of ventilation called High Frequency Oscillatory Ventilation (HFOV). This form of ventilation delivers very fast small breathes and is used to help overcome respiratory difficulties in preterm or ill newborn babies.

Continuous Positive Airway Pressure (CPAP)

The CPAP (Continuous Positive Airway Pressure) machine continuously blows warmed moist air into the baby’s lungs under a slight positive pressure while the baby breathes by him- or herself.  If needed, oxygen can be added. The air and oxygen can be delivered by soft plastic tubes inserted into the nose (nasal prongs) or by a mask placed over the infant’s nose. Both of them can be fixed by ties to a cap on the infant’s head. The positive pressure prevents the lungs from emptying completely. This facilitates the breathing for the infant.

CPAP can also help to limit apnoea, which is a common condition in preterm born infants. Apnoea is a short period when the infant does not breathe. Therefore, CPAP can be used to support the transition from the ventilator to breathing without any support. Babies may require a few weeks until the can be taken off the CPAP completely.

Nasal oxygen

Some infants require low levels of oxygen even when they are breathing without any support, e.g., after they have been weaned off the CPAP. Oxygen can be administered through the incubator or through thin plastic tubes placed into the nose of the baby, also called nasal cannula. The nasal cannula is connected to an oxygen supply such as a portable oxygen generator or a connection in the wall of the NICU via a flowmeter which measures the amount of oxygen. Some babies may require oxygen for a longer period of time. Sometimes oxygen supply may even be necessary after discharge. Healthcare professionals will train parents how to handle the portable generator and how to put on the nasal cannula.

Respirator bag and mask

If the baby stops breathing the medical team can help to re-start the breathing with an intervention called “bagging”. A small mask attached to a soft plastic bag is placed over the child’s mouth and nose. The bag is squeezed gently by a medical doctor, midwife, or nurse to push air into the infant’s lungs. This can stimulate the baby to start breathing again. CPAP or mechanical ventilation can support the baby’s breathing, if the stimulation is not sufficient.

Blue light therapy

Sometimes a bright blue light is placed over the infant's incubator or care bed. It is used to treat jaundice, also called neonatal hyperbilirubinemia or neonatal icterus, which is the yellowing of the skin and other tissues of a newborn infant. This condition is caused by an increase of bilirubin in the blood of the infant, which is a breakdown product of a process where aged red blood cells are renewed. In adults, bilirubin is decomposed and excreted by the liver. The liver of newborn babies is still relatively immature. Blue light therapy helps to convert bilirubin into a form that can be excreted more easily. During the therapy, babies only wear a nappy to maximise the surface of the skin exposed to the light. In this way, the therapy will be most effective. Soft shields or pads are placed on the baby’s eyes to protect them from damage. Healthcare professionals can explain more about the individual blue light therapy of an infant to the parents.

 
© 2017 EFCNI - European Foundation for the Care of Newborn Infants
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