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 | Very immature infants |
| Infants with bowel problems that prevent or limit feeding through the stomach and intestines |
| Infants that require a prolonged course of intravenous antibiotics or other medications |
Side Effects and Risks
Though small, there is always a risk for infection, as with any form of IV line
Because the catheter is very soft, the catheter can rupture through the blood vessel. This can cause the IV fluid or medication to leak into body cavities or tissue
In very rare instances, erosion through a wall of the heart can occur and cause serious bleeding and poor heart function
Peripheral Arterial Catheter (PAL)
Description / Purpose
A PAL is a catheter placed in an artery in the arm or leg. The purpose of a PAL is to allow the staff to continuously monitor the baby's blood pressure and to allow for them to draw blood tests and blood gases without sticking the baby. This is especially important for babies who have breathing problems and are placed on a ventilator because they might need frequent blood gases.
Side Effects and Risks
Because it is in an artery, a PAL can interfere with blood flow to the arm, hand, leg, or foot where it is placed. The NICU nurses carefully monitor babies for any indications of this. If there is any indication that this is occurring, the PAL is usually discontinued, and there are usually no long-term side effects.
Peripheral Intravenous Catheter (PIV)
Description / Purpose
Most babies admitted to the NICU will require intraveneous (IV) access. The IV route allows the NICU staff to give babies fluids, such as sugar solutions and medications. Peripheral means it is inserted through the skin into a small vein. A PIV in a baby is much the same as in adults, only smaller. A small, thin, hollow catheter with a needle inside (called an angiocath or jelco catheter) is used to start the IV. The vein of choice for babies is usually in the hands, feet, or scalp. In these places, the veins are usually visible and easily accessible.
Side Effects and Risks
It can be quite difficult to get an IV in some babies. Babies who are extremely small and have thin, fragile veins or very large babies with veins that cannot be seen are just a few. This might then mean that the baby will have to be stuck several times before access is established. Once an IV is established, it might only last a day or two. So, a baby can have to have two or three new IV's before their medications or fluids are complete. If the catheter comes out of the vein and the fluid enters the tissue, the IV has infiltrated. This can cause the skin and tissue to get very irritated and occasionally can cause a burn of the tissues. Infection can also be a risk, as with anything that enters the skin.
Surgical Central Catheter/Cutdown
Description / Purpose
Some infants in the NICU will need TPN or IV fluids for long periods of time. To accomplish this, a PICC is usually placed. If PICC placement is unsuccessful, the neonatologist will ask a surgeon to place a central catheter, or Broviac. A Broviac catheter is a long, thin catheter that is made of a soft material, usually silicone. Broviac placement usually involves:
| placement in the NICU using sterile technique |
| tunneling |
| placement of the tip of the catheter in a large vein near the heart |
| the insertion site in the chest to be covered with a sterile dressing; the small incision in the neck to be closed with sutures |
Side Effects and Risks
The placement of a long-term catheter allows for IV access for long-term nutrition (such as is given with TPN) and IV medications (antibiotics). As with any IV access device, there is a risk for infection. If the infection does not get better by giving antibiotics through the Broviac, the catheter might have to be removed. Once the infection is gone, another catheter might be placed, if needed.
If the tip of the catheter is up against the wall of the blood vessel or against the wall of the heart, the tip could go through the vessel and cause the IV fluid to leak into the tissue or body cavity. If the Broviac tip is placed into the heart, erosion through a wall of the heart can occur and cause serious bleeding and poor heart function. Very rarely, death can result.
Simonč with a broviac
Total Parenteral Nutrition (TPN) / Intravenous Fluids
Description / Purpose
When babies are first admitted to the NICU, they are usually too sick to eat. To provide fluid and sugar, they are given fluids in their veins (IV fluids). Electrolytes and minerals can also be added to IV fluids as well. As the condition of the baby improves and they are able to tolerate feedings, the IV fluids are slowly decreased.
One commonly special type of IV fluid is called total parenteral nutrition (TPN). TPN is usually given to very small, premature infants or those who will not be able to eat for a long time. TPN contains sugars, protein, vitamins and minerals that your baby will need to begin growing. You can tell the difference between TPN and regular IV fluids because TPN is usually bright yellow. Fats (Intralipids) might be given, as well. Intralipids are given at a much slower rate than TPN and are milky white in color. Some infants will receive TPN only a week or two, and some might need it for weeks.
Side Effects and Risks
Although TPN offers balanced nutrition, your baby will not grow as well on TPN as he would on feedings. Infants who are on TPN for an extended period of time are prone to cholestasis , a liver problem that affects the elimination of bilirubin. For this reason, infants on TPN for a long time will have blood tests every 1-2 weeks to monitor liver and kidney function, as well as other aspects of growth. If an infant will need TPN for longer than a week, they might require the placement of a percutaneously inserted central catheter (PICC) or a Broviac.
Tracheotomy(Tracheostomy)
Description / Purpose
Infants who are born very early may stay on the ventilator for many weeks. Some infants are not able to stay off the ventilator, or breathe on their own when off the ventilator. As these infants approach the time to go home, they might require the placement of a tracheotomy tube (trach) to replace the endotracheal tube.
The tracheotomy tube is a short plastic tube, attached to wings that fit into a surgically placed ‘hole' in the neck. The tube goes through the hole and into the trachea, just below the vocal cords (voice box). The ventilator tubing is attached to the trach at the neck. The wings are attached to velcro or other materials that wraps loosely around the infant's neck. These ties help to keep the trach secure and in place. The tracheostomy tube is a stable airway that is less difficult for the parents to care for at home.
Trach care usually consists of:
| Cleaning the hole with a peroxide and water mixture |
| Placing a clean gauze under the trach so it does not rub the skin |
| Changing the trach ties every day or as needed |
| Sometimes, if the skin around the trach becomes reddened, a thin coat of antibiotic ointment can be applied to the skin before the gauze is put in place. |
Side Effects and Risks
The trach can become displaced. If this happens, it needs to be reinserted quickly. Trach sites also require careful attention so that the skin around them stays healthy.
Umbilical Catheters
Description / Purpose
Most babies admitted to the NICU are sick. They might need a ventilator due to breathing problems and they might need IV fluids because they are too sick to eat. Babies who have breathing problems that require a ventilator will also need blood gases.
In the umbilical cord, there are three blood vessels; two are arteries and one is a vein. A very small, flexible tube (or catheter) can be placed in these umbilical vessels and advanced into the baby. If the catheter is placed in an artery, it is advanced into the aorta, the main artery coming off the heart. This is called an umbilical arterial catheter or UAC. This allows the NICU staff to draw blood tests and blood gases without sticking your baby with a needle. A UACalso allows for constant monitoring of the baby's blood pressure. This is especially important if the baby is on blood pressure medications.
If the catheter is placed in the umbilical vein, it is advanced into the inferior vena cava, the main vein going from the lower body to the heart. This type of catheter is called an umbilical venous catheter or UVC. It allows the NICU staff to give the baby IV fluids, TPN, medications, and even blood products without needing another peripheral IV.
Side Effects and Risks
These catheters are placed using sterile techniques and tip placement is checked with an x-ray. UACs and UVCs are usually not difficult to place and are the staff's first choice for venous or arterial access. But, they cannot stay in place indefinitely. The usual length of time a UAC or UVC is 7-14 days. At that point, there is an increased risk for the baby to develop an infection related to these lines. So, before they are discontinued, the neonatologist or nurse practitioner might place a PICC line or a peripheral arterial line (PAL). The placement of these alternative lines will allow your baby's monitoring and therapy to continue without interruption.
There are times when a UAC has to come out sooner. Because it is in an artery, it can interfere with blood flow to the legs and feet. The NICU nurses carefully monitor babies for any indications of this. If the baby's blood pressure begins to elevate, this can indicate that the UAC is interfering with blood flow to the kidneys. Again, with constant blood pressure monitoring, this is identified quickly. Because the UAC and UVC are placed in the cord, there is the possibility that they might come out if the baby is placed on his stomach. This chance is minimized by securely anchoring the lines to the abdomen and cord.
Urinary Catheter
Description / Purpose
A urinary catheter is a small tube placed in the bladder. This is necessary in some infants who are ill and making little urine, so the urine output can be closely measured. In other babies, certain medications cause them to be temporarily unable to urinate on their own, so a catheter is placed.
Side Effects and Risks
Because they are a foreign body, catheters are at a small risk to become infected. There is also a small risk of injury to the urinary passage or the bladder.
When babies are born too early, they are not ready to eat and digest food on their own. Not only can they not eat from a bottle (nipple feed), but sometimes their intestines have difficulty digesting the food (breast milk or formula) that is given to them. There are many things to understand about feedings, such as the different ways a baby is fed and the different formulas a baby can be fed.
Ways to feed a baby
Most premature or sick infants will start feeding by gavage. Gavage feeding occurs when a small flexible tube (feeding tube) is inserted from the nose or mouth down the esophagus and into the stomach. Gavage feeds are also referred to as tube feedings. These tubes may be uncomfortable to be placed but they should not be painful.
When babies are first started on gavage feeds, they might also require IV fluids or TPN for a time. It can take 1-2 weeks before a baby is completely off IV fluids and only on feedings. This can be a slow process, all depending on how well your baby can digest the food. Babies who are receiving gavage feeding can sometimes suck on a pacifier, as well. But, they cannot bottle feed until they learn to suck, swallow, and breathe in the right order. Sucking is very important to babies. They often enjoy it and it helps to console them.
As your baby grows and matures, he or she will begin to breastfeed or bottle-feed. This usually does not occur until 34 weeks gestation, when the suck - swallow - breathe reflex is mature. Some babies might be able to successfully bottle-feed earlier, and some babies might take a little longer (do not get discouraged).
When bottle feedings (or nipple feedings) are started, babies will start with one per day and slowly advance the number of bottle-feeds given each day. Most premature babies eat every three hours, or eight times a day. Once we know that a baby can coordinate the suck-swallow-breathe reflex with a bottle, breastfeeding may also begin.
Different Formulas to Feed Babies
The best formula to feed your baby is breast milk. Breast milk is made to meet all of your baby's nutritional needs, as well as help them to fight infections. If your baby is premature, your breast milk might need to be fortified. Breast milk fortifiers help to increase the fat, protein, and mineral content of breast milk, which your baby needs to grow well.
If you planned to breast-feed your baby, you do not have to give up the idea just because the baby was born early or is in the NICU. The nurses in the NICU can help you learn how to pump your breasts to get breast milk. The NICU nurses can then give your baby the breast milk through a gavage tube or in a bottle, if you are not able to be present for a feeding.
If you are not planning to breast-feed, your baby can be given a premature-infant formula in place of breast milk. Premature-infant formulas are an excellent source of nutrition for your baby. They contain all the fat, protein, carbohydrates, and vitamins, and minerals that your baby needs to grow well. As your baby gets close to going home, they might be changed to a formula that is more like a regular formula, but has more calories, vitamins, and minerals.
Monitors - Home Apnea Monitor
A home apnea monitor is a piece of medical equipment that monitors the breathing (respirations) and heart rate (pulse). It is smaller than the hospital version your infant might have in the NICU. It is connected to the infant with leads in a soft foam belt that wraps around the chest and is secured with velcro. Sometimes, small, round, patch-type leads are applied to the skin of the chest with sticky, removable adhesive. An alarm will sound when the breathing or heart rate drops below a certain rate. Parents and other caregivers must be trained in observation of the infant, operation of the monitor, and infant CPR (cardio-pulmonary resuscitation). A home apnea monitor is rented from a medical equipment company. The company will set up an appointment to send a trained person to the hospital before discharge to provide monitor training and CPR training.
Purpose
Your baby's doctor might prescribe a monitor for use after discharge if your baby had clinically significant apnea while hospitalized or if your baby is at high risk for sudden infant death syndrome (SIDS). While we do not know the exact cause of SIDS and there are no reliable tests to identify specific infants at risk for SIDS, the following four factors have been associated with increased risk of SIDS. These are:
| Placing a baby on the stomach (prone position) to sleep |
| Being exposed to tobacco smoke during pregnancy and after birth |
| Using soft surfaces and objects that trap air or gases, such as pillows, in a baby's sleeping area |
| Not breast-feeding a baby |
The length of time the monitor will be required depends on the condition of the baby and the occurrence of any true alarms. False alarms can occur with movement that might cause disconnection of the leads. Regular follow-up visits with your pediatrician or health care provider are essential. The average length of monitoring is three months. The following are examples of infants that often require home monitoring:
| Premature infants with symptoms of apnea of prematurity during sleep |
| Infants who suffered an acute life threatening event and is at risk for another |
| Siblings of an infant who died of SIDS |
| Infants with gastroesophageal reflux, causing bradycardia |
| Infants with central hypoventilation (a rare disorder where the brain does not signal the lungs to breathe) |
| Infants with a tracheostomy |
| Infants with chronic lung disease who is going home on oxygen or a ventilator |
Side Effects and Risks
Monitors are not detrimental to infants other than the possibility of increased stress and anxiety in the household due to its presence. Some believe the stress of monitoring is equaled or exceeded by the stress of an infant diagnosed with apnea and not monitored. A causal relationship between apnea and SIDS has not been established. The vast majority of infants with apnea are not victims of SIDS.
Monitors - Heart / Respiratory Rate Monitor
This is the most common monitor in the NICU. This is used to monitor the heartbeat and breathing. Stick-on electrodes (usually three) are attached to the infant in various places, usually the chest and abdomen. From the electrical signals picked up from these electrodes, the rate and regularity of the heartbeat and respirations are monitored. This allows the bedside NICU staff to determine if the heartbeat and respirations are too slow, too fast, or irregular.
When might it be used?
Monitors are used on most babies in the NICU, as most have issues with the respiratory or cardiovascular systems. It might be used for babies at risk of forgetting to breath (apnea of prematurity) or for babies receiving medications that would elevate the heart rate.
What are the risks?
There are few real risks with this equipment. The most common is mild irritation of the skin from the application and removal of the electrodes.
Heart monitor display unit
Monitors - Oxygen Saturation Monitor (Pulse Oximeter)
Description / Purpose
An oxygen saturation monitor or pulse oximeter is a piece of medical equipment that is used to monitor the amount of oxygen in the blood. A small cuff with a light element and a sensor is wrapped around the baby's foot, hand, toe, or finger over the pulse (heartbeat). Light passes through the tissues from one side of the cuff to the other. The light waves are altered by the amount of oxygen in the blood and the machine calculates the percentage of oxygen in the blood.
Pulse oximetry is currently the most widely used, non-invasive form of oxygen monitoring. The desirable range depends on the baby's condition, but generally 90 -100% is within normal limits. Since it is a percent, 100% is the maximum readout on the saturation display. Some pulse oximeters are built into the cardio-respiratory monitor , which also displays the heartrate, respirations, and blood pressure.
The oximeter allows your baby's nurses and physicians to monitor the amount of oxygen in the blood without having to obtain blood for laboratory testing. Blood might need to be obtained occasionally to measure other parameters, such as those contained in a blood gas.
Side Effects and Risks
Pulse oximeters are not detrimental to infants. They are user-friendly, do not require frequent rotation of sample sites, do not burn, do not require calibration, and have a rapid response. They are subject to false alarms due to movement.
Respiratory Support - Continuous Positive Airway Pressure (CPAP, NPCPAP)
Description / Purpose
Many babies with respiratory conditions require extra oxygen. Some require a ventilator because they cannot breathe well enough on their own. There are also babies that breathe well enough to not need the ventilator, but need a combination of extra oxygen and pressure to help keep their lungs well inflated. CPAP can provide this last group with what they need. To deliver CPAP a tube (or tubes) is placed in the nose and air or extra oxygen is delivered through this tube to the back of the nose. This flow of air produces pressure that goes into the lung to keep the lung better inflated. Since the pressure from the CPAP is delivered to the back of the nose (or nasopharynx), it is also called NPCPAP. NPCPAP might be used in conditions such as, Respiratory Distress Syndrome (RDS) when the baby needs more than extra oxygen, to try and prevent the need for a ventilator. Some babies, after they are taken off the ventilator, might be given NPCPAP to keep their lungs inflated. Also NPCPAP might be used on babies who have apnea such as Apnea of Prematurity to decrease the frequency or severity of the apnea.
The main benefit of NPCPAP is the ability of delivering both extra oxygen and pressure without the need for the more invasive endotracheal tube and ventilator.
Oxygen Blender
Side Effects and Risks
The main risks of this therapy are nasal irritation (from the tube) and abdominal distention (from pressure in the back of the nose that goes into the stomach instead of the lung). However, just like with the ventilator, babies on NPCPAP might be at risk for pneumothorax.
Respiratory Support - Conventional Mechanical Ventilator
Description / Purpose
Babies who are too small or sick to breath on their own might be intubated with an endotracheal tube and placed on a conventional mechanical ventilator. Another word for ventilator is respirator. The ventilator delivers oxygen to the baby with each breath. It also gives pressure at regular, timed intervals to act as breaths for the baby. Another setting on the ventilator is the constant pressure to keep the lungs open. These settings on the ventilator are increased or decreased (weaned) based on blood gases. Sometimes the support of a conventional ventilator is not enough for some babies. These babies might need to be placed on a high-frequency ventilator.
Side Effects and Risks
One of the risks to babies on ventilators is a collapsed lung, or pneumothorax. When a lung collapses, the air around it inside the chest needs to be removed in order for the lung to expand. This is done with a chest tube. Babies who are very premature when they are born might need the support of a ventilator for some time. The longer the babies require this support, the higher risk they have for scarring /damage in the developing lungs, called bronchopulmonary dysplasia.
Duvan connected to the ventilator
Respiratory
Support - Extra-Corporeal Membrane Oxygenation
Description / Purpose
The use of ECMO peaked in 1992 when over 1,500 infants in the United States were treated. Due to many improvements in care, currently fewer than 500 infants each year require treatment with ECMO. The most common conditions resulting in the need for ECMO are:
| Congenital Diaphragmatic Hernia (CDH) |
| Meconium Aspiration Syndrome (MAS) |
| Severe Pulmonary Hypertension |
| Cardiac Malformations |
| Severe Air Leak problems |
The purpose of ECMO is to provide oxygen to the body when the lungs and/or heart are too sick to do the job.
ECMO allows us to "rest" the lung and/or heart
Recovery of the lung and/or heart function usually occurs in 3–7 days, but might require 2–4 weeks
Side Effects and Risks
ECMO is the highest risk therapy used in the NICU. Due to this risk there are certain conditions that might prevent the use of ECMO.
| Significant bleeding that has occurred in the brain (intracranial hemorrhage) |
| Prematurity with estimated gestation less than 34 weeks |
| Congenital malformations that are known to produce death, regardless of support |
| Severe pulmonary disease that has persisted for more than 14 days |
| Several important risks that can occur with ECMO include: |
| Rupture of the ECMO circuit tubing |
| Formation of blood clots (thrombosis/clots) in the tubing and the baby |
| Due to the use of "blood thinners", bleeding can occur in any part of the body |
| ECMO requires the use of many blood transfusions; reactions and risks are possible |
| Infection is always a risk factor with ECMO |
| Death can occur due to the underlying lung/heart problems or from complications of ECMO; infants who require treatment with ECMO are at risk for long-term lung, neurologic, and developmental problems |
Respiratory Support - High-Frequency Ventilator
Description / Purpose
Babies who are too small or sick to breath on their own are intubated with an endotracheal tube and placed either on a conventional mechanical ventilator or a high-frequency ventilator. All ventilators deliver pressurized breaths with oxygen to the baby at regular timed intervals. A high-frequency ventilator is a special ventilator that uses very high rates (often 480 to 840 breaths/minute) and very small opening pressures for each breath. These ventilators are especially useful for very tiny babies or babies with air leak.
Side Effects and Risks
One of the risks to babies on ventilators is a collapsed lung, or pneumothorax. When a lung collapses, the air around it inside the chest needs to be removed in order for the lung to expand; this is done with a chest tube. Babies who are very premature when they are born might need the support of a ventilator for some time. Unfortunately, this support might also damage the developing lungs, resulting in scarring known as bronchopulmonary dysplasia.
Respiratory
Support - Oxygen Therapy
Description / Purpose
Babies with breathing problem are usually admitted to the NICU. Most times, these breathing problems will require oxygen therapy. Normal air that we breathe is 22% oxygen. When oxygen is given to babies, it is measured in percentages, from 22% up to 100%. There are several different ways to administer oxygen to babies. The first is an oxygen hood (halo). This is used for babies who can breathe on their own but still need extra oxygen. A hood is a plastic dome or box with warmed and humidified oxygen inside. The baby's head is placed under the hood. Oxygen tents are the same set up as hoods, except that they are made of a soft, flexible plastic.
Michelle under the Oxygen Hood/Head Box
Another way to give oxygen is via nasal cannula (NC). This is made of soft, thin, plastic tubing through which oxygen flows. There are soft prongs that fit into the baby's nose so they can breathe the oxygen. This type of oxygen therapy is usually reserved for babies who are going to need oxygen for some period of time. Some infants will even go home on oxygen with a nasal cannula.
Side Effects and Risks
Prolonged oxygen therapy can be related to retinopathy of prematurity (ROP). This is why oxygen is weaned (decreased) as soon as possible. Sometimes, infants under hoods or tents can get chilled if the temperature of the humidified oxygen is not warm enough. Infants on nasal cannula oxygen can get dry or irritated noses from the cannula prongs.
Phototherapy is a way to treat neonatal jaundice by exposing an infant's skin to ultraviolet light. Jaundice (yellow color of the skin) is caused by increased levels of circulating bilirubin in the blood. Bilirubin is a by-product of red blood cell breakdown. Bilirubin levels can increase from a variety of causes, including bruising, liver dysfunction, blood incompatibility (baby's blood type not matching mother's blood type), or inherited blood disorders.
When bilirubin is exposed to certain types of light, a process occurs called "photo-oxidation", and the bilirubin is converted so that it can be excreted in the urine and stool.
Closed incubator with Phototherapy light
When do we use phototherapy?
Phototherapy is started before the bilirubin level gets close to the point where it can cause harm in the infant. These levels will depend on the infant's gestational age, how old they are (day of life), and birth weight. Sometimes, phototherapy might be started to prevent jaundice in infants who are very premature or who are badly bruised.
What is the technique of phototherapy?
Special "light banks" are used. These light banks have bulbs that give off light in the blue spectrum. It is this blue spectrum of light that helps to change the bilirubin in the skin so the baby can excrete it.
The more skin that is exposed to the light, the more effective phototherapy is, so infants are usually in isolettes or on warmers and wearing only a diaper. This allows most of their skin to be open to the light. Babies will also be wearing eye shields that look somewhat like sunglasses. This protects the baby's eyes from the light.
Some larger infants who are in cribs can use a "bili-blanket". This is a flexible blanket of light that does the same thing as a bank of phototherapy. The bili-blanket allows the infant to be swaddled and held while still exposing the skin to light.
Mignon being treated with the bili-lights
What are the side-effects of phototherapy?
The greatest problem of phototherapy is the risk for dehydration. The baby can lose fluid through their skin by evaporation from the light. This can be prevented by increasing the amount of fluid a baby is receiving. Placing an infant in an isolette can help, as well.
Other side effects, while infrequent, may include:
| Diarrhea |
| Low blood calcium levels |
| Eye and vision damage if eyes are not shielded properly |
| Delayed bonding between mothers and babies |
Resource: Pediatrix Medical Group
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