Neonatology, one of the youngest fields in medicine, has come a long way from the early days of homemade incubators with babies on display at the 1896 World’s Fair. Up until the 1950s, the majority of babies born prematurely received little to no medical intervention and were unlikely to live. But NICU practices have changed dramatically in the last 50 years. Present-day technology and evidence-based research have drastically improved preterm infants’ chances of survival and quality of life.
Yet we still have a lot of work to do to decrease prematurity. Each year about 380,000 babies are born prematurely in the United States. This is a preterm birth rate of 10%, and it reaches as high as 15% in some cities, with large disparities between socioeconomic backgrounds and ethnicities. The preterm birth rate among black women in the United States, for example, is 50% higher than all other women. We need to do better for mothers and their babies!
Impacts of Preterm Birth
Impacts of Preterm Birth
Although infants born very prematurely now have increased survival rates, preterm birth and low birth weight still account for 17% of infant deaths, according to the CDC. Complications from preterm birth remain the number one cause of death in babies in the United States.
Premature birth not only affects infants and their families, but society as well. Its estimated societal cost is $26.2 billion annually, which includes maternal care and delivery, NICU care, early intervention, special education, and lost work and pay for people born prematurely. But the future of NICU care is promising: it will enable even very premature infants to survive with fewer long-term chronic conditions and a better quality of life, as well as decreasing the financial burden on families and society.
Advances in Neonatal Care
Advances in Neonatal Care
Fortunately, evidenced-based research has changed the way we care for our littlest patients. And over the years, medical advances have contributed greatly to increased survival rates and better outcomes in premature infants. These advances include changes to care models that allow for more family involvement, improved respiratory management and equipment, such as high-frequency ventilators, continuous positive airway pressure (CPAP), inhaled nitric oxide, and the introduction of surfactant; modernized isolettes like the Giraffe OmniBed Carestation; antenatal steroids, extracorporeal membrane oxygenation (ECMO), total body cooling, and many others.
Family-centered Care
Family-centered Care
When NICUs were first formed, there was very little family involvement in daily care. Research has since shown that optimal health outcomes are achieved when patients' families provide social, emotional, and developmental support. Family-centered care (FCC) is the concept that parents are an essential part of the infant’s team, working in partnership with healthcare providers in shared decision making. Today most NICUs encourage parents to be involved.
Inclusion in decision making and participation in rounds and care helps parents cope with the separation from their infant and the stress of the NICU. Parents are provided the opportunity for as much hands-on care as developmentally possible through healing touch, skin-to-skin, and positive oral feeding experiences. Family-centered care has been shown to shorten the length of the hospital stay, enhance breastfeeding outcomes, boost parental confidence, and decrease the risk for readmission.
Developmentally Supportive Care
Developmentally Supportive Care
Cluster care, developmentally supportive cue-based care, and small-baby protocols benefit premature babies immensely. Attention to lighting, sleep-wake cycles, noise levels, and developmental positioning and handling all help to preserve sleep and reduce stress in order to maximize positive outcomes. Today infants born as early as 22 weeks are surviving, and with fewer chronic conditions than before. Infants treated according to small-baby protocols require shorter hospital stays and are less likely to experience intraventricular hemorrhage (IVH) and bronchopulmonary dysplasia (BPD).
Better Treatment for Bronchopulmonary Dysplasia
Better Treatment for Bronchopulmonary Dysplasia
BPD continues to be a major issue in preterm infants, with estimates of 10,000–15,000 new cases per year in the United States. The National Institutes of Health Neonatal Research Network suggests that severe BPD develops in about 16% of babies born at less than 32 weeks. Infants with severe BPD have complicated clinical courses, which may include prolonged need for respiratory support (including ventilators and tracheostomy), recurrent pneumonia and respiratory exacerbations, pulmonary hypertension, and neurodevelopmental problems.
The BPD Collaborative was formed to share knowledge across hospital systems to improve care and outcomes with severe BPD. Nationwide Children’s Hospital now uses a hybrid care model that focuses on intensive therapy, including advanced ventilator settings shown to increase survival rates. Emphasis is placed on neurodevelopment by comforting babies through massage, music, speech, and physical therapies, along with FCC. Data collected by the BPD Collaborative, as well as the program at Nationwide, will help to standardize practice of care for BPD, leading to higher survival rates and lowering the risk of chronic respiratory conditions and their sequelae.
Combating Necrotizing Enterocolitis
Combating Necrotizing Enterocolitis
Necrotizing enterocolitis (NEC) has long plagued the NICU as a leading cause of infant mortality. Exciting new research is being conducted by the NEC Society Biorepository, directed by Dr. Misty Good, with participating centers throughout the United States. This biorepository includes samples of blood, urine, stool, gastric contents, DNA, breast milk, and intestine from infants with NEC. It also includes specimens from infants who did not develop NEC but had part of their intestine removed for other purposes, such as a volvulus, reanastamosis, or spontaneous intestinal perforation.
A recent comprehensive analysis of the transcriptomic and epigenetic signatures in small and large intestinal epithelial cells found that in cases of severe NEC, DNA methylation in intestinal epithelial cells significantly increased, which may eventually be used to diagnose infants with NEC. The NEC Society Biorepository’s goal is to develop a biomarker or genetic test to predict a baby’s risk of developing NEC, and to offer preventive strategies as well as effective treatment.
Benefits of Breast Milk
Benefits of Breast Milk
Increased NICU use of exclusive breast milk and human donor milk in recent years has dramatically improved the health of premature infants. Benefits include significant reduction in NEC; reduced feeding intolerance and use of total parenteral nutrition (TPN); reduced incidence of late-onset sepsis, retinopathy of prematurity, and bronchopulmonary dysplasia; improved weight gain; and decreased length of hospital stays. For each milliliter of maternal human milk provided in the first 14 days of life, it is estimated that $534 is saved from reduced morbidities like NEC.
According to the Human Milk Banking Association of North America (HMBANA), the distribution of pasteurized donor milk has increased sevenfold since 2000. Human donor milk, in absence of maternal breast milk, is now a standard of care in approximately 90% of the level 3 and 4 NICUs across the United States. Its use greatly reduces the cost of care for premature infants, at a savings of about $15,750 per day. Babies are also spending as much as 9 fewer days on TPN, and going home to their families sooner. Nurses play a vital role in educating mothers on the benefits of breastmilk for their premature infants.
Total Body Cooling
Total Body Cooling
Total body cooling for infants born with hypoxic ischemic encephalopathy (HIE) can have impressive effects on long-term outcomes, reducing death and certain disabilities by more than 10%. The baby's core temperature is lowered to 33.5 degrees Celsius for 72 hours and then slowly warmed up. Total body cooling is currently recommended for babies 35 weeks and older with moderate to severe HIE; however, research is being conducted to see whether babies with mild HIE or premature infants will also benefit from cooling.
Raising Awareness and Educating Parents
Raising Awareness and Educating Parents
November is Prematurity Awareness Month, as during this time the March of Dimes brings attention to the global crisis of premature birth. The best prevention is awareness, prenatal care, and education.
Life Events has an evidence-based, interactive patient education program for parents with a baby in the NICU. The program provides the A Little Early printed book and an app to help parents learn about the NICU environment, how they can actively participate in their baby's care, and how to care for their infant after going home from the hospital.
Every baby deserves a fair chance at starting out as a healthy full-term newborn. Urgent action is needed to end the crisis of preterm birth, not just during Prematurity Awareness Month, but every day. A special thank you to NICU nurses, who take care of premature babies and stand by their families—it takes a very special person to be a NICU nurse, and we appreciate you!
