The NICU Translated Podcast

Mary Farrelly (00:00)
Premies are tiny, but they are mighty. And they often surprise people in the ways they grow, develop, and thrive. But there are also lot of misconceptions and unknowns about premature babies, even among experienced parents and professionals. So today, I'm sharing the top five things I think everyone should know about premies. Whether you're a parent in the NICU, a doula supporting a family, or just curious about what makes these babies so

Hi everyone, welcome to this week's episode of the NICU Translated Podcast. This week we're talking all things preemies. One of the most common myths that I hear about the NICU from people, whether they're doulas, other professionals, families, anyone who's never been in the NICU themselves, is that the NICU is just for preemies. it is the only reason why someone would be in the NICU is because they're premature or born early. They have this common misconception in their head.

Likely from you know shows like Grey's Anatomy where they see all the little boxes lined up and tiny babies in there and lots of beeps and wires and tubes and all the things and there is truth to that. Premies are about roughly half of NICU patients are premature but that leaves a solid 50-ish percent of babies that are full-term that need NICU care and we're gonna have plenty of episodes coming up down the road all about things that

might bring a term baby to need a NICU stay, but today we're gonna talk a little bit about preemies and what makes them unique. Because another myth that I hear time and time again is this idea that preemies are really just tiny babies. They're just tiny full term babies that happen to be a little smaller, but they're actually quite unique and they come with their own kind of challenges and unique needs that is helpful to know about.

especially when

alongside families or if you find yourself the parent of a preemie yourself. So let's list the top five things that I think everybody should know about preemies. Number one, the first thing to note is that breathing takes practice. One of the more common things that can happen with preemies in the NICU is respiratory distress. And a baby has a hard time maintaining their own oxygen levels

without additional oxygen or pressure. And we're gonna have future episodes all about respiratory distress syndrome and CPAP and different modalities that help babies breathe. But another thing that can happen in the NICU is that babies simply forget to breathe. The part of their brain stem that tells them that they need to take a deep breath when they've held their breath for a long time is just a little bit immature. So.

You know, if you and I are swimming along in a pool and we go underwater and we take a deep breath, we go under, we hold our breath, there's a part of our brain that says, as our carbon dioxide levels rise in our bloodstream, alert, alert, alert, you need to pop back up and take a deep breath. And that little mechanism works sometimes in preemies, but sometimes it just doesn't quite fire as it's supposed to. So you might see babies in the NICU do breath-holding spells, which is called apnea.

Apnea is when a baby pauses in their regular breathing for about 20 seconds or longer. And sometimes when they pause their breathing for that long, you'll see them drop their oxygen levels, which is called a desat. And sometimes they may even drop their heart rate, which is called a bradycardia, or you might hear it referred to in the NICU as a brady. So these little breath holding moments have lots of different names depending on where you are in the NICU. might hear it called a spell or an event.

or a Brady-Dsat or ABDs, which it stands for apnea brady-dsat. There's lots of different alphabet soup around this. And we can go in a little bit more of this detailed in a future episode. But this is a very common part of a baby learning how to breathe. In the NICU, if a baby stops breathing and the alarms are beeping off, which is one of the more scary sounds that you can hear as a parent in the NICU, know that your team is very prepared and this is a very normal part of preemie development.

Most of the time babies will come out of this all by themselves. I like to think of the episode of finding Nemo, if you've ever seen it, where there's this part where the turtle is in the Gulf Stream and they're kind of cruising along and the little baby turtle pops out and Merlin, the Nemo's dad, is freaking out. like, my gosh, what are you gonna do? Go get him, go save him. And Merlin is like, in his little surfer dude accent, like, let us see what the little dude will do.

And that's really how we treat a lot of these events in the NICU. We step up to the baby's bedside and observe. And most of the time, the baby will bring themselves back out of their little breath holding spell, their little apnea Brady episode. And if they don't, if it seems like it's longer than 20 seconds or so, and they're really just kind of stuck in whatever.

little moment of time that they're in, you'll likely see your nurse or other provider kind of give the baby a little bit of stim. So a little bit of gentle stimulation, sometimes some foot taps, sometimes sitting up. A little jiggle is usually enough for a baby to take that first little breath and kind of bop themselves right back out of it and go on. They're usually looking at you like, what, what's the big deal? I'm fine. And we're all like, okay, thank you. Please keep breathing next time. And sometimes if that doesn't work, they might need a little bit of extra support.

with a little bit of extra oxygen or pressure, but that's why the NICU team has all the equipment at the bedside ready to go. So breathing takes time. Babies do grow out of this. This is all related to immaturity and babies that are preemies are born early. So the parts of their brain and body and all the organs still need time to develop. So one of the biggest things is the hurdle in breathing, but it takes time, practice and a whole lot of patience as babies are learning this super important life skill.

Life skill of breathing. Number two, temperature control is critical. All newborn babies have a harder time staying warm. There's a lot of reasons for this. Their bodies, have big old heads, so a lot of heat kind of escapes from the top of their head. Their skin, it tends to be thinner, so it's easier for them to lose heat that way. They don't really have a great ability to maintain their own heat through shivering, which is something that a larger child or adult does when they're cold. You know you'll shiver, which kind of generates heat.

They don't have a lot of brown fat stores which you can burn to maintain heat. And so term babies don't have the easiest time staying warm on their own anyways, which is why you'll see them, you know, skin to skin or bundled and really thoughtful in what we dress babies in. Premies have even less capacity for maintaining their own body temperature. So oftentimes premies will need to be in an isolette or incubator. They're the same thing. They're just two words that are kind of used interchangeably depending where in the world you are.

And so a lot of times babies are gonna need this little temperature controlled environment for a long period of time until again, the part of their body, the brain stem that helps them regulate their temperature and just their physical size, strength and capacity for maintaining heat needs to get to that point in their growth and development. So temperature is super important. One other way that is really critical for babies to stay warm is skin to skin. So oftentimes, especially if you have

a smaller preemie baby or early preemie will likely not be able to be held bundled or even wear clothes for the first days, weeks, sometimes months. So if they're going to get out to be able to be held, then they're going to likely need to be held skin to skin because the heat of the family's body will be able to provide that extra layer of temperature support for the baby even outside of the isolette.

We're gonna have a whole episode about the magic of skin to skin coming up. But temperature control is something that again, changes with time. As the babies get older, bigger, develop and become stronger, they are able to maintain their own temperature and are able to graduate from those plastic boxes, those isolates and incubators and into a regular bassinet or crib. Number three.

feeding is the final frontier. Learning to feed by breast or bottle and usually with the support of a feeding tube for a period of time is often that last milestone for discharge. And we mentioned in the discharge video or discharge episodes, if you haven't listened to that, go back and listen to the episode before this, where we talk about the things that babies need to do prior to discharge. One of the things that is really a barrier to many babies or their last final step is learning how to eat.

And it is a process. So babies, again, that are preemies especially, might not be developmentally ready to do all the things that are required to eat. Eating is the biggest exercise that a baby can do. It is really where they're burning a lot of their calories and using a lot of their focus. And it's pretty incredible to think about all the things they have to do to safely eat. But the three major things the baby has to coordinate in order to eat successfully is sucking, swallowing, and breathing.

So you might hear this called as the suck, swallow, breathe reflex. And a lot of times, this can be tricky sometimes for families or other non-medical professionals to kind of really fully kind of, I guess, see in practice because they might see their baby sucking really, really well on a pacifier. So they can suck, they've got that. Babies come out really early on having a strong sucking reflex. Even the teeny tiny newborns or micro-premies.

likely can and want to suck as a way to self-soothe. But that doesn't necessarily mean that they can suck and swallow and breathe all at the same time. They might be able to do one of each. They may be able to suck in a passie. They may be able to breathe on their own. They might be able to swallow their own secretions. Or if you put like, you know, a little bit of drop of oral care of milk on like a Q-tip or a swab, they might be able to handle that. But doing it all together, when the milk comes out of a breast or bottle or some type of nipple,

That's a lot, and usually that doesn't start to develop into a baby's capacity for doing suck-swallow-breathing It doesn't even start to show up until around 32, 33, 34 weeks, and it's not fully developed until their term. So feeding is a journey, and it takes a lot of patience, but every step forward is another lesson learned. I mentioned in the last episode that if there was a manual for teaching babies how to feed, and we could just have them watch a video, and they could do it, that would be great.

but it is a one step at a time journey and every little experience counts. And the more positive experience they have around feeding, the better long-term outcomes they're going to have related to their feeding experiences. Because feeding, the feeding journey does not end a discharge. That's another thing that sometimes can kind of sneak up on families is thinking, you know, my baby is clear to eat at discharge. Why is it still so hard at home or stressful or confusing?

So having the support of somebody who really understands the nuances of preemie feeding, like a NICU doula or a pediatrician who is specialized in preemie support or other people who really get those differences because it is different than a non-NICU baby or especially a term baby who is really born with more of those innate rooting, sucking, swallowing reflexes. It's a little bit more of a journey.

So it can be helpful to have somebody walking alongside you who understands and can help support you and guide you through those ⁓ kind of the roller coaster that is feeding. But progress can be slow, but every step counts towards safe feeding and every step is a win. Number four is every ounce of energy counts. Premies are doing so much on the inside. It can look a little bit deceiving on the outside, you know, a lot of.

preemies are quite sleepy and they oftentimes are awake for a little bursts of time, but a lot of the times they're kind of hanging out and sleeping. And you're like, okay, what are we doing? Their bodies are doing so much. All of the things that they would be doing developmentally and growing in utero is still happening. their muscles are still getting stronger. Their bones are getting extra mineralization and getting stronger and more capable.

Brains are growing and developing and forming all sorts of different neuron pathways and connections. Their GI system is developing, their heart is growing. All those things that would normally be happening in utero are happening at the same time. But also preemies that are born, those systems are turned on. So in utero, a baby that's developing, they have a heart and it's beating, but it's not maintaining its blood pressure. They have a set of lungs and they're there and they're doing little practice breaths, but they're not exchanging oxygen.

They have a stomach and a baby is kind of swallowing some amniotic fluid and there's some meconium in there, but it's not really digesting or providing any type of calorie support. All of that work is done from the mother through the placenta and the umbilical cord. But when a baby is born, all their systems have to turn on and go. And so a preemie is still developing these systems, but their systems are also working at the same time. Now their heart has to maintain.

their blood pressure, now their stomach has to digest food, now their brain has to grow and develop and coordinate their breathing and thermal regulation and all those things. So sometimes it is really important to be thoughtful about allowing babies to conserve their energy and calories in order to be able to continue to grow and develop and do all these incredible things that their bodies are doing. So one of the things you might see in the NICU is a concept called clustering cares or care times.

and there's a lot to unpack about care times and we'll talk about those in another future episode. But one of the things to think about is that the importance of clustering care, which means that you're doing all those kind of hands-on ⁓ tasks that are going to likely wake up the baby or maybe disturb their sleep, it's helpful to think about them clustering together at one time. So then those babies can really have those uninterrupted deep restful periods of sleep recovery

and growth because sleep is growing in the NICU and beyond. This is when their bodies are really integrating and using all those calories. So it's really important to understand this. So if you're a parent, you know, and you're going into the NICU and you arrive at nine o'clock and the family, the nurse says, her care times were at eight. Yes, there is certainly times to think about what is best for this baby. it, it, you know, this family's only here for a few hours. We really need to be able to facilitate bonding.

But sometimes it might be helpful to think, okay, my babies' cares are eight. They're gonna be again, maybe at 11. Let's let them rest for those hour and a half, two hours so they could really get those growing and developing skills down so then when they're a bit able to be awake again at 11, they have more energy and they have more stamina and they're ready to really go at that time. So that is the why behind clustering cares and something to think about that babies are really, they're always working, even if it looks like they're taking the snooze.

their little inner bodies are doing so much, which is why even, know, if you take a picture of a baby on a Monday, they're going to look totally different than that same baby on a Friday. They're growing and developing at such an incredibly rapid rate. And sometimes we need to help facilitate those moments so babies can conserve energy for growth and also for healing. Number five is bonding is medicine too. There's so much medical care that the NICU does incredibly well.

We are so good at meeting the complex physiological and medical needs of these really fragile and pretty complicated babies. So sometimes families can feel left out or like there's nothing that they directly are doing to impact their baby's outcomes and wellbeing in the same way that the medical team can, but that is so not true. The...

gift and the medicine and the healing that a family's presence and touch and care provides to babies is not maybe as flashy and shiny as a lot of the medical research is, but we know that the babies in the NICU, they're humans and humans are wired for connection and babies that are not getting those natural positive touch points in the NICU are really missing out because a lot of the care that we give in the NICU

is uncomfortable or it is annoying or sometimes it's truly painful. A lot of times babies in the NICU do have to go through difficult and more painful and more uncomfortable procedures to be able to allow them to continue to grow and thrive and live. But the magic and the medicine of the family is those positive moments of connection and touch. And this is within the capacity that you have as a parent in that moment. This doesn't mean that you need to be in the NICU

holding your baby 24 seven skin to skin, even if you just had an emergency C-section and you're still in massive pain and you haven't slept in 48 hours and you haven't had a snack and you haven't peed and all the things. No, everybody's human needs are equally as important, but it means that you also are an equal, if not even more important, I would say more important, part of the medical care team from the unique medicine that you can provide as a family.

And this can look like so many different things. We're gonna go deep on these in future episodes, but this can look like kangaroo care, which is another word for skin to skin, those really moments of bonding and connection and the human touch with your baby. It can look like gentle reading, talking out loud. Babies know your voice, they know your smell. So oftentimes in the NICU you might see scent hearts being used, which are little simple hearts that you can share, one that smells like the baby and one that smells like the family.

and even just your presence. The overall presence of a family can set the tone for the room. It can keep energy calm and cool and collected. And it really helps to support the baby's heart rate, breathing, brain development. So even if there are days that you cannot hold your baby, which there are a lot more logistics sometimes to holding a NICU baby.

Holding and touch are super important, but they're not the only ways that you can provide your unique parental medicine. And there are so many moments and small little points of connection that really add up and are what makes a NICU stay feel more joyful and less overwhelming. So even if you can't hold your baby yet, your voice and touch matter, and you are just as important part of your care team

as any doctor, nurse or other professional.

If you want more tips like these, I have a free guide called Five Things Every Doula Needs to Know About NICU Babies and Their Families. Even if you're not a doula, it's still packed with easy to understand info and ideas to help you feel more confident in supporting preemies and their families. And

if you're not a doula you'll still find so much information in that resource that can help you deepen your understanding and care of NICU babies and their families. So preemies may have a different start, but they're no less strong, capable, or full of potential. The more we understand about their unique needs, the better we can support their journey because the NICU is only the beginning and every baby deserves to thrive. NICU love. Love, Mary.