By Dr Prathap Chandra
The birth of a baby is among life’s most wondrous experiences. It is estimated that about 12-15 per cent of babies born will need advanced medical care and admission to a Neonatal Intensive Care Unit (NICU). Most of the babies needing admissions are preterm with extremely low birth weight and full-term babies who may have fallen ill. Then there are those born with congenital malformations, who may need surgical intervention and babies who may not cry immediately after birth because of Neonatal Encephalopathy or Birth Asphyxia.
These babies are required to be treated in a NICU, which puts a lot of stress on the mother and families. Deliveries are usually fraught with tension and problems can be unpredictable; therefore, it is important for hospitals to be equipped with a good NICU facility. With scientific advances, we are ensuring that more babies survive and go home sooner than ever before. However, the level of intensive care is not uniform throughout the country and the presence of these advanced NICUs are far and few.
Each year, more than a million babies are born pre-term and it appears to be increasing. Prematurity is a global crisis with a premature baby dying every 30 seconds in the world. However, 75 per cent of fatalities are preventable, with adequate care around delivery and provision of good neonatal care. The evidence clearly indicates a better survival of premature babies depending on where they are born. For example, more than 90 per cent of extremely preterm babies (<28 weeks) born in maternal centers/ level 1 NICUs die within the first few days of life as compared to more than 80 per cent of the same population group surviving in a level 3 centre.
A well-established level 3 NICU provides a full range of neonatal services to address problems that need advanced medical and surgical care. A good centre should be well-equipped to deliver advanced care of ventilation support be it an invasive or non-invasive form of ventilation. The ventilation support of extreme preterm should be aimed at causing minimal damage to very premature lungs, but at the same time giving essential support. Nutrition is paramount in all the babies admitted to NICU and total nutrition can be safely administered using central lines. Adequate support should be given to mothers and families and breastfeeding should be encouraged.
‘Kangaroo’ mother and father care should also be encouraged (holding the baby on the mother or father’s chest, with skin to skin contact). This will enable better temperature control for babies, better weight gain, and help in developing a bond. Involving parents and empowering them will play a vital role in achieving the best outcomes in extreme cases of preterm babies.
While the incidence of birth asphyxia is about 1-2/1000 in developed countries, it is 40-60 times more in developing countries like ours. Usually, these are the babies that did not cry at birth due to various feto-maternal reasons and who suffer from lack of blood and oxygen supply to the brain and other vital organs. Babies born with this condition would need a high-level intensive care equipped to look after multi-organ dysfunction or failure. Until a few years ago, we did not have answers to treat this condition. Thanks to some of the largest multi-centric trials in the world, we now have a therapy called ‘therapeutic hypothermia’ or ‘total body cooling’ where we lower the baby’s temperature to 33.5 degree C for three days and slowly re-warm over the next 12 hours. This therapy is achieved using servo-controlled machines which maintain the temperature without fluctuations. This has shown to reduce mortality and give a better neuro-development outcome in babies with moderate HIE.
A vast majority of paediatric surgeries are undertaken in the neonatal period due to complications of prematurity and congenital malformations of various organs like intestines, heart, kidneys, liver and brain. It is, therefore, essential to have expert paediatric surgical and anesthetic teams to operate on these tiny and vulnerable babies backed up by a robust neonatal intensive care.
One of the most essential components of a well-established centre is the provision of transport and retrieval services. The transport teams should be well-equipped with a trained pediatrician along with a well-trained NICU nurse and paramedical staff. The transport of newborns from one centre to the other in India is not formalised. A well-established NICU, be it in a private or government setup, can expect half of their sick newborns to be born outside and it is essential that this service of retrieval is taken seriously as this will have a major impact on survival as well as future neuro-development morbidity in these babies.
Leadership from the management and experienced doctors is very important to maintain the highest standards of the care. Level 3 NICUs call for higher investment and, more importantly, a clear vision. The most important contributors of clinical care are the staff. The presence of an adequate number of trained nurses and paramedical staff is paramount in achieving better outcomes. There should be a constant programme of research, audit and training within the units, which should form the basis of quality improvement and standardisation of care. There should be provision for robust data collection as this is essential in improving the quality of clinical care.
It is important for the government healthcare sector to improve their NICU care with proper equipment and trained staff. The higher number of patients who visit these hospitals will be benefitted from the upgraded facilities. The networking of all the NICUs should form the basis of care delivered to these vulnerable babies in order to achieve a single digit neonatal mortality rate (NMR), which currently stands at 22 / 1000 live births (Karnataka- 2013). Well-established level 3 NICUs should form the hub of the wheel while the level 2 and level 1 units should act as the spokes feeding into these units. Involvement and establishment of private-public partnership goes a long way in improving the NMR in the state.
Government hospitals need more robust NICU facilities because of a variety of reasons. According to 2015 reports, Karnataka boasts of 36 special care newborn units (SNCUs). Only half of the deliveries happen in these hospitals and the rest of the admissions are of those born outside. Unfortunately, prematurity, birth asphyxia and congenital malformations are more common in low socioeconomic strata. According to 2015 statistics, prematurity and birth-related complications like birth asphyxia contributed to two-thirds of all the neonatal mortality. There is good evidence that majority of these deaths are preventable with the availability of well-established NICU set-ups.
(The writer is Consultant, Pediatrics & Neonatology, Motherhood Hospitals, Bangalore.)