WHAT YOU NEED TO KNOW WHEN YOUR PREEMIE IS IN THE NICU

I am a babyin the NICU

1 in 8 babies is born too soonSource: March of Dimes website.

Dear Parents, You have just experienced a wonderful miracle—the birth of your

baby. Your miracle, however, arrived earlier than you expected—

weeks or maybe even months early.

Now your baby is being cared for in a Neonatal Intensive Care Unit

(NICU). You probably feel overwhelmed right now and have a lot of

questions about your baby’s health, when he’ll get to go home and

how you’re going to cope with this unexpected situation.

Expect a lot of ups and downs, especially in the first 3 days after your

baby’s birth. We know you may feel completely helpless, but you can

rest assured knowing that he will get the best medical care available.

To help answer some of your questions and concerns—and we know

you’ll have a lot of them—I am Not Just a Baby, I am a Preemie in

the NICU was developed for you and is provided by your NICU staff

and the maker of the Enfamil® infant formulas. Ask for I am Not Just a

Baby, I am a Preemie Who is Going Home when your baby is being

discharged from the hospital.

In addition, don’t hesitate to discuss any questions you may have

with the NICU staff. Let them know if you’re feeling afraid or confused.

Helping parents deal with their fears, feelings and frustrations is an

important part of their job.

Celebrate your miracle! They don’t come along every day!

Your Friends at Mead Johnson,The Maker of Enfamil

Table of Contents

Your Feelings ................................................1

Premature Delivery ........................................4

Common Questions and Answers ...........4

The Premature Infant

Development Process ...................................8

Visiting Your Baby .......................................12

Understanding the NICU .............................14

Hospital Caregivers ................................15

Special Conditions of Prematurity ..................17

Need for Warmth ...................................17

Breathing ...............................................19

Jaundice ................................................21

Medication .............................................21

Umbilical Arterial Catheter ......................21

IV Pump/Superficial IV ...........................22

An Introduction to the

Equipment in the NICU ...............................23

Bililights/Bili Blanket ...............................23

Endotracheal Tube .................................24

Heart Monitor ........................................24

Incubator ...............................................24

Nasal Prongs .........................................24

Oxygen Hood ........................................24

Pulse Oximeter ......................................25

Respirator (Ventilator) .............................25

Suction Catheter ....................................25

Warmer .................................................25

Tests and Exams ........................................26

Weighing ...............................................26

Blood Tests ...........................................27

Imaging Studies .....................................28

Feedings ....................................................30

Types of Feedings ..................................30

Milestones in Development .........................36

Your Baby’s Stairway

to Development .....................................37

Transfers .....................................................38

Going Home ...............................................39

Before We Go Home .............................41

Discharge Questions ..................................42

Glossary .....................................................44

During this time, you may be experiencing a wide range of emotions. If you’re like

most parents of a premature baby, you may first feel shock and ask, “Why did this

happen?” “What could I have done to prevent it?”

At some point, you may also feel anger, guilt and depression. There may be times

you want to blame everyone—your spouse, the doctors, the world and ultimately,

yourself. You may feel, “If I had only done this…or hadn’t done that.” Words of

advice—try not to torture yourself. Don’t blame yourself for your baby’s prematurity.

Feelings of guilt and failure can interfere with your relationship with your baby. Talking

with your NICU doctor and nurses can help you understand some of the reasons for

your baby’s premature birth. (See the section titled “Premature Delivery: Common

Questions and Answers.”)

You might also feel disappointed. In a maternity ward, surrounded by new moms and

their babies, you may feel alone and disappointed that you missed the “perfect” birth

experience and immediate joy of motherhood that you envisioned while you were

pregnant. And, above all, you probably feel fear and anxiety. “Will my baby be okay?”

Try to remember, all of these feelings are completely normal. They may change on a

day-to-day basis, or come in waves that make you feel helpless and out of control.

They are natural reactions, but let’s look now at some things you can do to help

you stay motivated and positive.

Your Feelings

1

2

• Recognize that your

feelings may be

intensified by postpartum

depression, which may

affect new mothers.

Common postpartum feelings

are tension, anxiety and

sadness. These emotions

are thought to be caused by

sudden hormonal changes

after delivery. The fact that

your baby was premature

in no way changes this

postpartum chemistry. In fact,

the premature birth of your

baby makes you all the more

vulnerable. Be patient with

yourself and realize what

you’re experiencing is, in fact,

very normal.

• Get all the rest you possibly can and eat well. Your body has just

been through the exhausting experience of giving birth. Not getting enough

rest, or not eating properly, will make it harder to regain the strength

you will need to care for yourself and your baby. In addition, if you

are experiencing depression, physical fatigue may also compound

these feelings.

• Talk! Talk to your spouse, family, doctors, nurses and friends. Keep

communication open with each other and people who can give you

comfort and strength.

• Accept help from friends. Take friends or relatives up on their offers to

care for your other children, clean your house, drive you to the hospital or

run errands for you. Save your energy for visiting your baby.

did you know?Taking pictures of your baby will help you feel closer to your baby even when you can’t be with her.

3

• Look at your baby’s picture. Taking pictures of your baby will help you

feel closer to your baby even when you can’t be with her. Many hospitals

provide photographs for families to share with their loved ones. There may

even be an Internet website for posting pictures and information on your

baby’s progress! These methods of tracking your baby’s recovery can help

you navigate the difficult road you are on. Also, continue to take pictures

on a regular basis. You may not recognize your baby’s progress until you

actually see it in a photo.

• Join a support group. Sharing your thoughts and feelings with others

who have been, or currently are, in your situation is often a great form of

comfort and stress release. It’s also a great place to learn from and be

motivated by others who have been through it. Your NICU staff or social

worker can suggest local organizations in your community.

4

Common Questions and Answers

Even though you try not to, you may ask yourself, “Why me? Is this my fault?”

You’re not alone. Most women who deliver prematurely ask themselves the same

questions. For this reason, we developed this section to address some common

questions regarding premature delivery.

Remember, however, each woman, each baby, each pregnancy and each delivery

are completely unique. Your doctor is always the best source for answering

questions about your own unique experience.

Q: What causes premature delivery? Can this happen to me again?

A: Approximately half of all women who give birth prematurely go into premature

labor for unknown reasons. The remainder have medical conditions such as

pregnancy induced hypertension (PIH), incompetent cervix, placenta previa,

etc., which can often result in premature delivery. Statistically, a woman who

has had a premature baby runs a 25% to 50% chance of having another one.

Thankfully, for many women, the premature delivery is a one-time event in their

childbearing history.

Premature Delivery

5

Is it my fault my baby was born prematurely?

It is no one’s fault that your baby was born early, so don’t blame yourself.

There are some conditions related to the mother’s body that can cause

premature delivery. Maternal high blood pressure, for example, increases

the risk of premature delivery. Other factors involve the baby. Twins and

other multiple births are often born too early. Babies with birth defects such

as a hole in the heart or an open spine, or infants with underdeveloped or

poorly positioned placentas (the placenta grows from the fetal tissue), are

also often born prematurely. Remember, your doctor is your best source

for information about your individual delivery.

I went into labor prematurely. No one can explain why it happened. Doesn’t anyone know what causes premature labor?

Premature labor can begin painlessly and may be mistaken for the

Braxton-Hicks “practice” contractions most women experience during

pregnancy. Unlike Braxton-Hicks contractions, real labor contractions

occur at fairly regular intervals and cause the cervix to shorten (efface)

and open (dilate).

No one knows for sure what causes full-term labor to begin, so it’s

impossible to say for sure why it begins prematurely. However, researchers

are investigating the hormones of pregnancy to see whether abnormal

levels of these (hormones) may be involved.

As the chemistry of labor is better understood, tests to sample a pregnant

woman’s blood for particular hormone levels may help predict and prevent

premature delivery.

I was told I had an “incompetent cervix.” What does this

mean? Is there a way to correct this problem?

Incompetent cervix is the term used for a cervix that opens, often

painlessly, in mid-pregnancy, leading to a miscarriage or premature birth.

This condition usually results from damage to the connective tissue of

the cervix during previous births, or surgery involving the cervix. Most of

the time, however, the cause remains elusive. It can also be caused by

diethylstilbestrol (DES) exposure.

Q:

A:

Q:

A:

Q:

A:

6

An incompetent cervix can sometimes be reinforced by a procedure called

“cerclage.” During this procedure, the cervix is stitched closed after the first

trimester is completed and after the infant’s heartbeat is heard. The stitches

are removed before the baby is born. Since cerclage does carry risks—the

possibility of infection and even the stimulation of premature labor—doctors

may be hesitant to perform this procedure unless they feel absolutely sure

that the problem is actually an incompetent cervix. A reliable diagnosis may

be difficult to make, since a normal cervix can also open early as the result of

undetected premature labor.

I felt fine until my sixth month of pregnancy. Then I developed pregnancy induced hypertension (PIH). What causes it?

Pregnancy induced hypertension (PIH) is a condition suffered by 5% to

7% of all pregnant women during their first pregnancy. The first stage of

PIH is sometimes called pre-eclampsia. It is characterized by high blood

pressure, protein in the urine and rapid weight gain due to fluid retention. If

left untreated, it can develop into eclampsia. This is a severe form of PIH. Its

symptoms can include maternal seizures, brain hemorrhage and coma.

Because PIH often involves reduction in blood flow to the fetus, the

baby may be smaller than normal for the baby’s gestational age. PIH can

sometimes be managed by bed rest, nutritious diet and blood pressure

medication. When these measures fail, premature delivery is necessary to

save the mother and child.

Can illness during pregnancy cause premature delivery?

A mother’s general health before and during pregnancy can affect the

outcome. Pre-existing illnesses such as diabetes, kidney disease, high

blood pressure and sickle cell anemia do increase the chance of premature

delivery.

Premature birth can also be the result of an illness in the unborn baby.

Although the membranes and placenta provide a barrier against many

infections, certain organisms are still able to cross the placenta or enter the

Q:

A:

Q:

A:

7

womb, possibly through weak spots in the membranes. An infected baby

may be born to a mother who has had only mild symptoms of illness or no

symptoms at all. Why some babies become infected while others do not is

a mystery.

Can sex during pregnancy cause prematurity?

A recent study of close to 11,000 pregnancies revealed no difference in the

incidence of premature rupture of the membranes, intrauterine infection or

prematurity among women who engaged in intercourse throughout their

pregnancy to those who did not. However, sexual activity may release

oxytocin, a hormone that stimulates uterine contractions. For a woman

already beginning labor, sexual activity might speed things along. This is why

doctors recommend that women abstain from these activities if they show

actual signs or symptoms of premature labor.

I did everything right during my pregnancy. A friend was

pregnant at the same time. She lived on diet soda, smoked

cigarettes and drank alcohol. She had a healthy, nine-pound

baby. I had a two-pound premature baby. Why me?

Statistically, women who eat well, avoid harmful substances and get good

prenatal care do have better pregnancy outcomes than those who do not.

However, there are always exceptions. Women who do all the “wrong”

things can still have healthy, full-term babies, and women who do everything

“right” can still have premature babies. Knowing in your heart that you gave

your baby your best effort prenatally will help you cope with the problems

after an early birth.

Q:

A:

Q:

A:

8

If your baby was premature and you haven’t seen her yet, you should know

that she may not look exactly like what you expected. You may be shocked

and alarmed at how tiny and fragile she seems. Premature babies are naturally

smaller than full-term babies. Many weigh less than two pounds.

A very premature baby is born with

a thick, white coating covering its

body called “vernix.” After this is

absorbed, the baby’s skin is red and

wrinkled and may appear almost “see-

through.” Tiny veins are visible below

the skin’s surface. Premature babies

of all ethnic groups have the same

dusky-red skin color when they are

born. Their natural skin color develops

over time.

During the last four weeks of

pregnancy, a full-term baby gains a

pound or so each week. The premature baby misses out on this baby fat. The

lack of fat filling out the skin folds gives a premature baby a wrinkled appearance

and makes her fingers, toes and nose appear disproportionately long. As the fat

layer develops, this look will disappear and your baby will look more filled out. In

time, your baby will have the creamy, rosy look of full-term babies.

The Premature Infant Development Process

9

During the first few days of life, your baby

will lose a few ounces. This is normal. It

happens with full-term babies too. After

that, she’ll begin to gain more steadily.

Her weight gain may fluctuate though,

losing an ounce or two some days, but

still making good progress overall. Often,

premature babies take longer to regain

their lost weight than full-term babies.

The rate at which your baby gains weight

helps the NICU staff tell how fast she’s

getting stronger.

Your baby’s facial features are well

developed, except for her outer ears,

which are still very soft and limp. They lie

flat against her head, and when they are

folded over they do not spring back. As

your baby continues to develop, her ears

will form a firm layer of tissue that makes

them look like those of a full-term baby.

Since the 20th week of gestation, your baby’s hair has been growing. By the time

of her premature birth, it may cover her head. The hair will probably be very fine.

Your baby may or may not have eyebrows and eyelashes. She may, however,

have a light cover of hair on much of her body. This fetal hair, called “lanugo,” may

be quite heavy (especially around the shoulders), or it may merely be a light peach

fuzzy-like covering. This hair usually disappears in a few days or weeks.

Even the very premature baby has fingernails and toenails, which usually reach

the ends of the fingertips or toes by 35 weeks of gestation.

A premature baby’s bones are very soft and easily molded, especially the bones

of the skull. Before a baby is born, amniotic fluid surrounds her head and exerts

equal pressure on all sides. But once she is born, her nice, rounded head

begins to flatten against the firm surfaces on which she lies. This elongation and

flattening of the skull bones are temporary, and the head begins to round out as

the baby develops.

The hair will probably be very fine. Your baby may or may not have eyebrows and eyelashes. She may, however, have a light cover of hair on much of her body.

10

Both premature boys and girls have immature genitals, which may look unusual

compared to those of a full-term baby. Your baby’s sex organs may look larger

than average. You can expect them to look more in proportion in a few weeks.

Like other babies, your baby will most likely stretch, yawn and move her

arms and legs. But because she lacks muscle tone, she is very limp and flexible.

In fact, some premature babies like to sleep with their feet tucked up next to their

heads. While this may look uncomfortable to you, it may be a position your baby

enjoyed while still in your womb. You may also see your baby stiffen suddenly

and then go limp. This is likely to happen because her nervous system isn’t fully

developed yet. Your baby may have a gripping reflex in her fingers, but is too

weak to maintain the grip when lifted by her hands. You may also see her arms

and legs flail about with lots of jerks. This, too, is normal for a premature baby. As

she matures, her movements will become smoother and more controlled.

Expect your baby to sleep most of the time—as much as 15-22 hours a day at

first. She may have a hard time being alert, but already some of her responses

are like those of a full-term baby. She cries for the same reasons all babies cry.

You’ll be able to see her cry, but you won’t be able to hear her if she’s on a

special breathing machine called a “ventilator.” This is because the tube from the

machine blocks her vocal cords.

You may wonder if your baby can see and hear. Right now, she hears better

than she sees. Don’t worry, her sight will improve in time. Her hearing is a bit

more advanced. You should talk to your baby. She’s already getting to know your

voice. It probably won’t take her long to learn to respond to it. Talking to her in a

calm, soothing voice will comfort her.

She can also sneeze, hiccup, smile and may even suck her thumb, skills

acquired before birth.

Your baby also knows the difference between pleasure and pain. She may

be calmed by your gentle touch, being held and rocked, or being swaddled

in a warm blanket. Many premature babies like to be covered or firmly wrapped

in a blanket.

Even a very premature baby can taste the difference between something sweet

and something salty. Like most children, she tends to prefer the sweet.

11

Expect your baby to sleep most of the time—as much as 15-22 hours a day at irst.

A full-term baby has a sense of smell so well developed that she can recognize

her mother by scent alone. No one knows for sure what a premature baby can

smell, but some nurseries place an article of the mother’s clothing in the baby’s

Isolette® in hopes that it will give a sense of her mother’s comforting presence.

For example, a handkerchief that you have worn inside your bra for 24 hours will

allow the baby to learn the natural scent of your skin. Avoid wearing perfumes,

which may seem harsh to the baby.

Even though your baby may be tiny and still in the NICU, she’s already a special,

unique person with her own personality. You may already notice that she looks

like her parents or siblings.

It’s just going to take some time for your baby to grow and develop. The

best things you can do right now are take care of yourself and spend time

with your baby, talking to her, touching her and giving her the love she

needs to grow strong.

12

Visiting Your BabyAs your baby is growing stronger in the NICU, there’s a special job to be done

that only you can do—give him plenty of loving attention. Your love and contact

are just as critical to your baby’s well-being as the food, warmth and oxygen he

needs to survive. The NICU staff recognizes this and invites you to visit your baby

as often as possible.

When you visit your baby for the first time, he may look different than what you

expected or remember. You may be shocked at how small and helpless he may

seem. You may feel an overwhelming need to protect him. You may even feel like

crying. It’s okay. Cry if you need to. Everyone caring for your baby understands.

They help parents just like you every day.

You may see medical staff and a lot of equipment that are unfamiliar. Though

some of the equipment may seem intimidating or frightening at first, each piece

is very important to the care of your baby. In the section of this book entitled “An

Introduction to the Equipment in the NICU,” we’ll help you get familiar with some

of the equipment you may see. In addition, on your first visit, your baby’s doctor

or nurse will explain the equipment used for your baby. Your NICU staff wants

you to be informed and feel as comfortable as possible.

Since the NICU is such a busy place, you’ll need to ask about the rules and visiting

guidelines when you visit. Your NICU staff can tell you the best times to visit your

baby. Visits with your baby may also be more enjoyable if they coincide with his

natural periods of alertness. A very tiny or sick baby may have very few periods of

alertness. The interactions you can have may be limited at first.

As your baby grows, his alert periods will lengthen and his tolerance for stimulation

will increase. You may want to target your visits during feeding times because the

baby is most likely to be alert and will begin to associate feeding time with Mom.

Remember, your premature baby, like the rest of us, may have good days and bad

days. Because of his maturing nervous system, what may soothe your baby one

day may not the next. Your baby may not be able to tolerate too much stimulation

13

During your visits,your NICU nurses may ask you to wear a gown and wash your hands in a special way to prevent germs from being spread to your baby.

at one time. He may be able to be touched, talked to or looked at, but not all of these

together. No two premature babies are alike. One may love to be rocked for hours,

while another is overwhelmed by the slightest touch. Don’t worry, your NICU staff will

be there to suggest how and when to touch or hold your baby.

During your visits, your NICU nurses may ask you to wear a gown and wash your

hands in a special way to prevent germs from being spread to your baby. They may

also ask you not to wear rings or other jewelry. Everything they do is to ensure the

best possible care for your baby.

If your baby is going to be in the NICU for a long time and you have other children at

home wanting to see their new baby, talk with your NICU staff about arranging visits.

They will do everything possible to involve your entire family in your baby’s care.

Many hospitals allow sibling visitation. Sometimes these are arranged for a specific

day of the week. You may also encourage your older children to color or draw a

picture for the baby to be left at the nursery. Allowing them to bring or send a gift

may help them feel more in touch with the baby until he gets to come home. Some

families bring an audio tape for the baby to listen to, and sing or tell stories so their

baby can be soothed by a familiar voice.

The time your baby is in the NICU may be a trying,

stressful time for your entire family. Just remember,

it won’t last forever. Your baby is growing stronger

every day. Visit your baby as often as possible.

Your love is the best medicine he can receive.

14

Understanding the NICUThe NICU is a special place where highly trained doctors and nurses are giving

your baby around-the-clock care. This kind of special care is too involved to

provide in a standard newborn nursery. Not all hospitals have NICUs, so your

baby may have been transferred here from the facility where she was born.

The goal of the NICU staff is the same as yours—to help your baby grow and

become healthy enough to go home with you, where she belongs.

At first the NICU may seem like a stark, bleak and very noisy place filled with

tubes, wires, dials, bright lights and alarms. Most of the equipment attached

to the babies has built-in alarm systems. Anytime the equipment’s monitoring

systems sense a change, an alarm sounds to alert the staff. These alarms do not

always mean something is wrong with a baby, and they may require a response

from the staff. Don’t let the sounds in the NICU scare you. The staff watches

these machines closely and is always prepared to take care of any problem that

may occur.

As you will see, the NICU is a very busy place. It takes nonstop monitoring and

care to help your baby and all the premature babies grow strong and healthy

enough to go home.

Sometimes babies need to stay in the NICU because of something that occurred

during birth or because some organ or system isn’t functioning the way it should.

But frequently, babies are placed in the NICU simply because they were born too

soon (prematurely).

A baby that stays in her mother’s womb for about nine months is known as

a full-term or term baby. A premature or preterm baby is born three or

more weeks early.

A premature baby is normal for her age while inside the womb but is not

completely ready to live in the outside world yet. She may not be able to

breastfeed or bottle-feed and may also need help to stay warm. Depending on

15

how early a baby is born, her

lungs may still need to mature.

The NICU staff members are

extensively trained to care for

her special needs.

To help you become familiar with the people caring for your baby, we’ve listed

titles and descriptions of your NICU staff below. Use this as a general guideline.

Your hospital may have fewer or more members on their NICU staff.

HOSPITAL CAREGIVERS

Neonatologist: A pediatrician (children’s doctor) with advanced training in the

area of intensive care newborn medicine. You may find that the neonatologist

in charge of the NICU unit will change. These doctors may work on a rotating

basis. The neonatologist in charge is called the “attending” doctor. Your baby

may have one attending doctor during the day and a different one at night.

Fellow: A fully trained and experienced pediatric (children’s) doctor who is

training to become a neonatologist.

Resident: A medical doctor who is specializing in pediatrics (children’s

medicine). The residents are actively involved in your baby’s care and are a good

resource for information.

Neonatal Nurse Practitioner: A nurse who has completed an advanced

educational program in neonatology and works under the direction of the

neonatologist.

NICU Nurses: Your baby will have one or more nurses assigned to each shift.

Shifts may vary between eight and twelve hours. The nurses try to care for the

same babies when they work.

A premature babyis normal for her age while inside the womb but is not completely ready to live in the outside world yet.

Primary Nurse: The primary nurse plans your baby’s nursing

care and is responsible for getting to know you and your baby

and any special needs you may have. The primary nurse’s name

is often written on your baby’s name card that hangs above the

crib. This nurse is the nurse most intimately acquainted with your

baby’s needs and will guide your baby’s individualized plan of

care.

Respiratory Therapists: In the NICU, respiratory therapists

are important members of the healthcare team. Respiratory

therapists are specially trained to care for patients with breathing

difficulties. They also are experts on the medical equipment

used to treat these types of problems. Respiratory therapists

are available in the NICU 24 hours a day. If your baby is having

any type of breathing difficulty, you will often see the respiratory

therapist at her bedside. They would be happy to answer your

questions regarding your baby’s lungs.

Newborn Unit Social Worker: If your hospital has a social worker, you may find

them to be a great support for your family. They can also help arrange for housing,

transportation and meals; clarify hospital policies and procedures; alert the attending

doctor or fellow of your questions and concerns; identify resources such as parent

groups, reading materials and computer resources; and assist in planning your baby’s

follow-up care at the time of discharge. Some hospitals are lucky enough to have

space to room in a parent along with the sick baby. The social worker will explain

what accommodations are available so that you can stay as physically close to your

baby as possible.

Other Caregivers: In addition, depending on your baby’s needs, she may require the

care of other specialized doctors. They will be introduced to you if necessary for your

baby’s care.

While this may seem like a lot of information to process, you’ll soon learn and become

comfortable with the NICU routine. At first, though, you may feel a bit confused. Don’t

be afraid to ask questions. The NICU staff is working for you and your baby and is

there to help you in any way it can. Remind yourself often that although staying in

the NICU isn’t what you had envisioned would happen to your baby, it is necessary.

This special place exists to help the baby you love.

16

Special Conditions of PrematurityIn a medical field as rapidly changing and improving as neonatology, there are bound

to be variations from hospital to hospital in terminology, technology and treatments.

Your doctor may use slightly different terms to describe some of the medical

conditions discussed here. New methods to treat the potential medical problems

of the premature baby are constantly evolving. The purpose of this chapter is to

introduce you to some potential medical problems of premature babies and some of

the methods involved for treating and correcting the problems. We hope that with this

basic information you will be better able to discuss the specifics of your baby’s care

with your neonatologist and NICU staff. The specific equipment involved in NICU care

will be discussed in the next section, “An Introduction to the Equipment in the NICU.”

NEED FOR WARMTH

From the time of conception,

your baby was nurtured inside

the warmth of your body. At

birth, he emerged wet into a

cold world where he suddenly

needed to regulate his own body

temperature.

A chubby, full-term baby who

gains a pound of fat a week

during the last weeks before

birth is relatively well insulated.

A premature baby, however, is

very vulnerable to chilling. A

1500-gram baby will lose much

more heat per unit of body

weight than an adult does.

17

18

A premature baby, especially a baby with

breathing problems, is poorly supplied

with calories and oxygen—the fuels he

needs to heat his body. Because of the

potential dangers, a main objective of

your NICU staff is to keep your baby

warm—but not too warm. Your baby’s

temperature must be carefully controlled

in an incubator or warmer. A tiny device

that acts as a thermometer is taped over

your baby’s belly. It constantly senses

your baby’s temperature and regulates

the temperature of the environment. It

will increase the warmth when your baby

gets too cool and decrease it when he’s

too warm. Your baby’s axillary (under

the arm) temperature will be checked

frequently as well. For more added

warmth, and also to keep him from

grabbing or kicking tubes and wires, your

baby may also be dressed in mittens,

booties and a hat.

The goal is to keep your baby’s body

temperature as close to normal as

possible—98.6°F (37.0°C). This is also

the temperature at which he conserves

the most oxygen and calories and gains

the most weight.

BREATHING

It’s very common for a premature baby to have breathing problems. The

severity of the problem may depend on how prematurely your baby was born.

A premature baby’s lungs aren’t as fully developed and ready to breathe as a

full-term baby’s. Let’s look now at some common problems associated with

breathing.

Apnea and Bradycardia

Apnea is the term used to describe the times a baby interrupts breathing. Apnea

is very common among premature babies in the early weeks of life. Apnea is

often accompanied by bradycardia—a lower-than-normal heart rate. For a tiny

baby, this means the heart is beating fewer than 100 times a minute. This is

considered slow for a baby, even though an adult heart rate is usually much

slower.

In the NICU your baby will be closely watched for signs of apnea and

bradycardia with the help of electronic monitoring. Small, adhesive monitoring

pads or sensors are placed on the baby’s skin to detect chest movements as

he breathes and to pick up the impulses of his heartbeat. Wires attached to

the pads transmit the information to a machine next to your baby’s bed. If your

baby’s vital signs become abnormal, an alarm will sound. These monitoring

machines only detect your baby’s heartbeat and breathing rates. They do not

control them in any way. In addition to the monitoring machines, your NICU

nurse will be personally observing your baby for any changes.

Most of the time, breathing can be started again by patting the baby or touching

the soles of his feet. If that doesn’t work quickly, the nurse may do something

called bagging. A mask attached to a soft plastic bag is placed on the baby’s

face, and the bag is squeezed to push air into the lungs and trigger the breathing

cycle.

Respiratory Distress Syndrome (RDS)

RDS is a breathing disorder found in premature babies. It is caused by the

baby’s inability to produce “surfactant.” This is the fatty substance that coats the

alveoli—the tiny air sacs in the lungs—and keeps them from collapsing.

An unborn baby’s lung tissue begins making small amounts of surfactant in the

early weeks of pregnancy, but most babies aren’t producing enough surfactant

for proper breathing until the 35th week of gestation. However, babies do vary

greatly in their rates of lung development. Some premature babies have enough

19

RDS

is treated by helping your baby with the breathing process. He may be given oxygen and a variety of other medical treatments to aid his breathing and circulation until he is able to produce surfactant and cure himself.

20

surfactant to breathe without difficulty;

some do not. In general, the more

premature the baby, the greater the

risk of developing RDS.

It is now possible to give premature

babies additional surfactant, which

is administered to the lungs shortly

after birth. This medical breakthrough

has markedly increased the survival

rates of our tiniest babies and has

improved the fitness of many more.

While a certain number of infants will

still develop lung disease, the illness

is often less severe, and fewer babies

will go on to develop chronic lung

disease.

RDS is treated by helping your

baby with the breathing process. He

may be given oxygen and a variety

of other medical treatments to aid his

breathing and circulation until he is

able to produce surfactant and cure

himself. By the first three or four days,

your baby’s lungs may begin to produce enough surfactant for him to breathe

more easily.

Pulmonary Interstitial Emphysema (PIE) and

Pneumothorax (new´-moh-thor´-ax)

If it is necessary for your baby to be on a respirator (breathing machine), the

pressure may occasionally cause air to leak from his lungs. Tiny air bubbles

may be forced out of the alveoli and in between layers of lung tissue. This

condition, called pulmonary interstitial emphysema (PIE), usually subsides as

the baby’s respiratory problems improve and respirator pressure to the lungs

can be reduced.

Sometimes a tear can occur in one or more of the alveoli. This causes air to leak

into the surrounding chest spaces and can cause the lung to collapse. This is the

condition called pneumothorax. To treat this problem, a small plastic tube may

be placed in the chest to suck out the air between the lung and the chest wall.

This allows the lung to reinflate. The suction continues for days (or weeks) until

the lung heals. The chest tube is then removed by the NICU staff.

JAUNDICE

More than half of all full-term babies and more than three-fourths of all premature

babies get jaundice during the first three to seven days of life. This isn’t a reason

for concern most of the time, although it does cause the baby’s skin and whites

of the eyes to turn somewhat yellow.

Babies are born with a large number of fetal red blood cells. Normally, as red

blood cells break down, bilirubin, which is a yellowish pigment, forms. The

bilirubin is detoxified (processed) in the liver. Usually, especially with a premature

baby, the enzymes in the liver that detoxify the bilirubin aren’t working efficiently

yet. As a result, when the bilirubin level rises in the blood, some of it enters

body tissue, where it then temporarily causes a yellowing—the condition called

jaundice.

Your baby’s blood will be frequently checked for a rise in bilirubin. If the levels rise

closer to those that are considered unsafe, the baby is treated by phototherapy

(most common) or transfusion. Phototherapy is detailed in the next section.

MEDICATION

If your baby is in the NICU, chances are he will need to receive some type of

medication, nutrients or, perhaps, blood. There are two common ways medicine

is provided to your baby in the NICU. These are discussed below.

UMBILICAL ARTERIAL CATHETER

The umbilical arterial catheter is inserted through the end of a baby’s umbilical

cord (at the belly button) and is threaded through the umbilical artery into the

aorta, the main artery supplying the body with oxygenated blood. While this

sounds painful, it really isn’t. There are no nerve endings in your baby’s umbilical

cord where the catheter (tiny tube) is inserted.

A similar catheter, called an umbilical venous catheter, can be placed through the

vein in the umbilical cord.

Usually, these catheters are a convenient, painless way for the NICU staff

to draw blood frequently without having to “re-stick” your baby with a

21

needle every time. It also allows fluids, nutrients, blood and medications

to be easily given to your baby. These catheters are removed as soon they

are no longer necessary.

IV PUMP/SUPERFICIAL IV

An IV pump is a machine attached to a pole placed near your baby’s bed. IV

stands for intravenous (in´-trah-vee´-nous), which means into the veins. To start

an IV on your baby, a superficial IV is inserted into a superficial vein (one that is

close to the skin’s surface), with a very small

“butterfly” needle. It is called a butterfly needle

because of the small plastic “wings” that help

hold it in place. Another type of intravenous

placement is called a PIC (percutaneous

intravenous catheter) line. This line is placed by

threading a tiny catheter through the hub of a

needle into a vein. The needle is then withdrawn

and the small plastic tubing stays in place. This

type of line usually provides a more sturdy and

durable IV access.

If the IV is in the arm or leg, the limb may be

splinted with a tongue depressor and covered

with a piece of gauze so that the baby can’t

dislodge the needle.

Nutrients, medication and blood can be given

through the superficial IV, but blood cannot

usually be withdrawn because the superficial veins are too fragile. If your

baby needs frequent blood samplings, he may need to have two IV lines—an

umbilical arterial catheter for drawing blood and a superficial IV for feeding and

medications. Feeding your baby through an IV is discussed further in the section

of this book entitled “Feedings.”

22

An Introduction to the Equipment in the NICU Now that we’ve discussed some of the potential medical conditions your baby

may experience, let’s look at some of the equipment you may see in the NICU

that may be used to treat your baby and help her grow stronger. While there may

be additional specialized equipment used to care for your baby in the NICU, this

section is designed to give you a general understanding of some of the machines

you may see.

BILILIGHTS/BILI BLANKET

Babies with jaundice are frequently treated by a process called phototherapy.

This is done by placing your baby under special bright lights called bililights or by

placing your baby on a special bili blanket. The fluorescent lights are placed over

your baby’s incubator, whereas the blanket is placed directly under the baby’s

trunk. A mask or eye patch will be placed over your baby’s eyes to assure her

comfort and prevent any potential damage from the lights.

The blue light waves from the bililights change the molecular structure of

the bilirubin, which allows it to be excreted from your baby’s body. If your baby

is under phototherapy, she’ll be without clothing so as much skin as possible

can be exposed to the light. Don’t worry, her skin won’t burn or be damaged.

While undergoing phototherapy, your baby’s bowel movements may be frequent,

loose and maybe even greenish in color. Babies also tend to sleep a lot while

being treated for jaundice, waking only for feedings. Phototherapy will be

continued, usually for three to seven days, until the bilirubin in your baby’s blood

is reduced to an appropriate level.

23

ENDOTRACHEAL TUBE

An endotracheal tube is a very small, slender tube that

is passed through a baby’s nose or mouth, past the

vocal cords and down into the trachea (windpipe). This

process may also be referred to as intubating. The tube

is attached to a machine (a respirator or ventilator) that

pumps air into the lungs, under a controlled pressure, to

assist in breathing.

HEART MONITOR

A heart monitor is the machine used to monitor your

baby for signs of apnea and bradycardia (discussed

previously). Small, adhesive monitoring pads, referred to

as electrodes or patches, are placed on a baby’s skin to

detect chest movements as she breathes and to pick

up the impulses of her heartbeat. Wires attached to

the pads transmit this information to the heart monitor

machine next to the baby’s bed. If the baby’s vital signs

become abnormal, an alarm will sound, which alerts the

NICU staff.

INCUBATOR

An incubator is a heated, plastic box that you can see through. It provides a controlled

temperature environment that helps to keep your baby warm and her body at the correct

temperature. As your baby’s body varies in temperature, heat may be increased or

decreased appropriately.

NASAL PRONGS

Nasal prongs are used to help your baby breathe in a treatment called Continuous

Positive Airway Pressure (CPAP). Through this procedure, pressurized air is delivered

to your baby’s lungs through small tubes placed inside your baby’s nostrils. The tubes

provide a steady stream of oxygen. The oxygen may also be delivered at a steady

pressure through an endotracheal tube if necessary.

OXYGEN HOOD

An oxygen hood is used for babies who can breathe on their own but still need extra

oxygen. Oxygen can be piped directly into the baby’s incubator, but if high or precisely

measured doses of oxygen are required, a plastic box or dome, called an oxygen hood,

is placed over the baby’s head. Warm, moist, oxygenated air flows into the hood. An

oxygen analyzer, placed beside the baby’s head, double-checks the amount of oxygen

she is receiving.

24

PULSE OXIMETER

A pulse oximeter is a portable device that non-invasively monitors and

determines a baby’s arterial blood oxygen saturation and pulse. It provides

a quick and painless method of estimating oxygen delivery to your baby’s body

tissues.

RESPIRATOR (VENTILATOR)

A baby who is having frequent spells of apnea, or is too weak to breathe well on

her own, is intubated and her endotracheal tube is attached to a respirator. This

machine does her breathing for her until she can do it on her own.

The respirator performs several functions. It delivers a measured amount of

oxygen to the baby’s lungs. It provides constant pressure to keep the lungs

open. At regular intervals, the machine inhales for the baby by pushing in

additional air at a higher pressure. The oxygen content of the air, the volume

or pressure, and the number of breaths per minute the baby needs can all

be adjusted to her needs. The NICU staff can determine the baby’s needs by

observing the baby and by regularly measuring the oxygen, carbon dioxide and

acid levels in the baby’s bloodstream. A respirator may also be referred

to as a ventilator.

SUCTION CATHETER

A baby with breathing problems cannot cough up the mucus that accumulates

in her lungs. These secretions must be removed for her by processes called

percussion, vibration and suctioning. These processes include a variety of

methods to loosen the mucus.

Once the mucus has been loosened, the baby’s endotracheal tube is detached

from the respirator. A suctioning tube (or catheter) is quickly inserted into the end

of the endotracheal tube to vacuum up any secretions.

WARMER

A radiant warmer is a bed designed to try to keep your baby at the right

temperature. It is similar to an incubator in its function but is not enclosed entirely

like a box. It is more like a bed with warmth being provided to your baby from a

heat source above the bed. However, as in an incubator, your baby will have a

small device, which acts like a thermometer, taped to her body. The thermometer

signals heat to be increased or decreased as needed for your baby.

25

Tests and ExamsAs soon as your baby is taken to the NICU, the staff will immediately begin a

series of tests and exams to determine what treatment is necessary. This is done

quickly so the staff can start the necessary treatments without delay. The tests

will continue throughout your baby’s stay in the NICU to monitor his progress

and react to any changes as necessary.

Your NICU staff will be communicating with you on a regular basis and advising

you of tests and procedures. No major tests, procedures or operations will

ordinarily be performed without your knowledge and approval. Except in the

case of a life-threatening emergency, the NICU staff is trained to receive your

consent in writing first. Most of the tests your baby will receive initially are routine.

They include checking his heart rate, blood pressure and temperature. In

addition, he will be weighed and have blood tests and imaging studies done.

WEIGHING

Weighing is a very simple and much-needed procedure. Weight gain is very

important and is usually a sure sign of progress for premature babies. To make

sure your baby is gaining weight as he should, the nurses will measure and

record the exact amounts of fluid and breast milk or formula that he receives.

His urine output and bowel

movements will also be

monitored and recorded.

In the NICU, babies’ weights

are measured in grams instead

of pounds. Grams are used

because very exact measures

are needed to track your

baby’s progress. Using grams

to measure weight may not

be familiar to you. To help you

translate grams into pounds

and ounces, we provided a

conversion ruler for you on the

next page.

26

BABY’S WEIGHT

(grams)

(pounds)

Here’s how it works

Let’s say your baby weighs 1250 grams. To figure his weight in pounds

and ounces:

• draw a line at 1250 grams (see picture). Each mark on the top of

the ruler equals 100 grams.

• look at the bottom side of the ruler to see where the line comes.

• in our example of 1250 grams, you can see it equals over 2 pounds. To figure

the exact ounces, count the number of marks past the 2. In this example,

there are 6 marks past the 2. Multiply each of these by 2. Each mark is equal

to 2 ounces (6 x 2 oz=12 oz).

• your baby’s total weight would be 2 pounds, 12 ounces.

BLOOD TESTS

Your baby will have blood tests while staying in the NICU. Blood tests can tell

a lot about his overall condition as well as alert the doctors to any potential or

actual problems. Sometimes babies who don’t have enough red blood cells,

or have a serious blood disease or disorder, may require a blood transfusion.

Frequent blood tests enable doctors to quickly react to any changes or problems

your baby may experience.

One test your baby may have is a blood gases check. A seriously ill baby may

have his blood gases checked several times each hour. A baby in a more stable

condition may be tested several times a day. These tests are very important.

They indicate how well the gases—oxygen and carbon dioxide—are being

exchanged between the lungs and the bloodstream. In addition, if your baby

is ill, they will show the effect the baby’s illness is having on the acid content of

his blood. These tests are repeated often because changes in a baby’s blood

27

chemistry can occur rapidly. Test results are reported to the NICU doctor

quickly so any abnormalities can be quickly corrected.

Samples of blood to be tested for oxygen, carbon dioxide and acid may

be taken from the baby’s arteries, since it is arterial blood that supplies

the body tissues with oxygen. Arterial blood can be withdrawn from the

aorta through the umbilical artery catheter, or from arteries in the baby’s

wrist, foot or scalp. If a drop or two of blood is needed, the blood may

be taken by pricking the baby’s heel. Other blood tests may be done

by “sticking” a vein, especially if several tests are being done at the

same time.

IMAGING STUDIES

Imaging simply means taking pictures of organs and other structures

inside your baby’s body. There are several common types of imaging

your baby may need while in the NICU. These procedures are necessary

to allow your doctor to track your baby’s progress and be aware of any

special conditions.

28

X-rays

An x-ray is the most common type of imaging exam. If your baby has breathing

problems, he may be x-rayed as often as several times a day. This is done to

evaluate the condition of his lungs and other organs and to check the positions

of any tubes or catheters inside his body.

When you were pregnant, you were probably warned against the dangers of

x-rays. With this in mind, the thought of your baby being x-rayed frequently may

make you feel worried or concerned about any negative effects an x-ray could

have on your baby. This is a valid concern on your part, but there’s no reason

to worry, because the x-ray machines used for babies use low doses of radiation

to minimize any harm to your baby, now or in the future.

To be extra safe, the NICU may provide lead shielding to protect your baby’s

genitals and reduce unnecessary exposure to the other babies in the NICU.

The NICU staff may also leave the area while your baby is being x-rayed. This

is a precaution they take since even small amounts of “scatter” radiation may

become significant to a person who is exposed every day for many years.

Ultrasound

An ultrasound picture is somewhat like an x-ray, except that it is made by

using sound waves aimed at organs in the body. The sound waves send

back different types of echoes that indicate the density of the tissue they

are examining. Ultrasound scans may be performed at your baby’s bedside.

They are simple, painless procedures that require no sedation for your baby.

They also contain no radiation.

CAT Scans and MRI Pictures

The term CAT scan stands for Computerized Axial Tomography scan. MRI

stands for Magnetic Resonance Imaging. These two advanced types of imaging

are performed when doctors need to know more than they can learn from x-rays

or ultrasound. They are frequently used to examine your baby’s brain. The CAT

scan works as a sort of combination of an x-ray machine and a computer.

They aim a very narrow beam of radiation at a specific layer of body tissue and

produce a horizontal or cross-sectional picture. Your baby will be taken to the

x-ray department because the machines are much too large to move. Your baby

may also need to be sedated because he must be completely still during the

scans. These scans are also painless procedures for your baby.

29

FeedingsBefore your baby was born, she received a steady flow of carefully selected,

predigested nutrients that crossed the placenta from your body into her own. In

other words, you were her perfect food source. Because she was born too early,

your baby was removed from that perfect food source before she was ready to

eat and digest food on her own. Good nutrition may never be more important to

your baby than it is right now.

Nutrition is a very complex science. Your baby’s nutritional needs are also

complex and very different than those of an adult. You may already know that

your baby needs protein, carbohydrates, vitamins and minerals, but you might

be surprised to learn about her needs for fat. Breast milk, the ideal food source

for nearly all babies, is about 50% fat. Fat provides highly concentrated energy

for growth and tissue-building material for the brain, eyes and central nervous

system.

Healthcare professionals recommend feeding babies breast milk. Even though

breast milk fills unique needs for your baby, for premature babies it usually

needs to be fortified to provide the best growth possible. If you are unable to

breastfeed, or choose not to do so, a special infant formula, such as Enfamil®

Premature formula, provides excellent nutrition for your baby. Enfamil Premature

formula provides a balance of nutrients especially designed to meet the special

nutrition needs of the premature baby.

Don’t be alarmed if your baby is too weak or too ill to breastfeed or bottle-feed

while she’s in the NICU. Premature babies may not yet have matured enough to

have the well coordinated suck-swallow-breathe pattern it takes to feed well by

mouth. There are other ways to provide her with the nutrition she needs. In this

section, we’ll discuss some of those ways, in addition to breastfeeding, bottle-

feeding, and tips for feeding your baby.

TYPES OF FEEDINGS

IV Feedings

A baby with breathing problems, or a very young premature baby, cannot be

given anything by mouth at first. Her immature digestive track must slowly and

cautiously be introduced to its new role in providing nourishment. Also, if a baby

30

is too sick or stressed, she may have poor circulation to her digestive tract. This

is because the body reacts to stress by temporarily sending blood to the most

critical organs needed to survive—the heart, brain, kidneys and lungs—instead

of those such as the stomach and intestines. Because a premature baby may

be using most of her energy just to breathe at first, it’s unlikely anything given by

mouth could be properly digested. Therefore, many premature babies receive

their first feeding intravenously—through a small needle or tube inserted into an

artery or vein. There are three main types of intravenous lines: the umbilical artery

or venous catheter, the superficial IV and the central line. The umbilical artery or

venous catheter and superficial IV were both previously discussed in the section

of this book entitled “Special Conditions of Prematurity.”

A central line is a thin intravenous tube that may be placed in one of a baby’s

larger veins, such as an arm, leg or neck. This type of IV is used when a baby

needs IV feedings for an extended period of time. The central line can be placed

in the vein through a small, hollow

needle. Once the tube is in place,

the needle is removed. The line may

also be inserted by a minor surgical

technique performed by a pediatric

surgeon. Under a local anesthesia, a

tiny incision is made over the baby’s

vein and the tube is threaded through

the vein until it reaches a position as

close to the baby’s heart as possible.

This procedure allows the IV line to

be placed in a large central vein,

which allows higher concentrations of

nutrients and medications to be given.

As your baby matures and grows stronger, this method of feeding will not be

necessary. In the meantime, it allows your baby to receive the best nourishment

possible.

Gavage (Tube) Feedings

As your baby progresses, she may be switched to gavage feedings, commonly

referred to as tube feedings. Tube-fed babies have a small flexible tube inserted

through their mouths or noses that passes down into the stomach or intestines.

Since the transition from IV to tube feedings must be made gradually and

31

carefully, there is usually an overlap period

when the baby receives both. Premature

babies who have not yet developed a gag

reflex do not seem to find the gavage tube

uncomfortable. The tube may be left in place

for intermittent or continuous feedings or

inserted and withdrawn for periodic meals.

A gavage-fed baby is able to suck and has

been doing so since the early months of

gestation inside her mother’s body. However,

she can’t learn to feed from a nipple until she

learns to suck, swallow and breathe in the right

order. Because sucking is a very important

activity for your baby, gavage-fed babies

are often given pacifiers to suck during their

tube feedings, or they may prefer to suck on

their fingers or their own tongues. Sucking

is an activity that infants enjoy and often find

consoling.

As gavage feedings are increased, IV feedings

are decreased and stopped altogether once

the baby is receiving enough calories by

gavage.

Your baby’s first gavage meal may be diluted

sterile glucose water. If she digests the glucose

water, she is given half-strength formula or

breast milk for a day or two. Then, if all goes

well, she is started on full-strength breast milk

or formula. Some doctors like to begin with

a formula especially designed for the needs

of low-birth-weight infants, such as Enfamil®

Premature formula. In addition, through gavage

feedings, your baby can receive breast milk that

you have pumped and taken to the NICU.

32

You may also hear a feeding tube referred to as a nasogastric tube or an

orogastric tube. The tube may also be used to remove air from your baby’s

stomach. When your baby gets stronger, she’ll be able to breastfeed or take

formula from a bottle. Let’s look now at both.

Breastfeeding

If you had planned during your pregnancy to breastfeed your baby, you don’t

have to give up the idea just because your baby is in the NICU. The milk that

comes in the first few days after you give birth is especially good for your baby.

It’s called colostrum, and it contains many disease-fighting substances.

Breastfeeding a premature baby is usually divided into two stages. During the

first stage, breast milk is pumped or expressed and fed to a baby by a gavage

tube or a bottle. During the second stage, the baby will be allowed to nurse from

the breast. Since it may be a while before your baby can nurse from the breast,

it’s very important to pump your breasts to stimulate milk production. You can

pump or express milk with a breast pump. There are several types of breast

pumps on the market. The battery and electric types of pumps are the easiest

for most mothers to use. Your hospital may even have breast pumps available for

your use while you’re in the hospital.

For a newborn baby, you should pump at least eight times a day, with one of the

pumpings being at night. Any milk that you produce can be saved and later given

to your baby. Your hospital’s staff will discuss the guidelines for pumping, storing

and transporting your breast milk with you. If you have any questions about how

to pump your breast milk, discuss them with the NICU nurses. They can get you

started or refer you to a nurse or lactation consultant who can help you.

For most small premature babies, a substance called a fortifier, such as Enfamil®

Human Milk Fortifier Acidified Liquid, is added to your breast milk to provide the

extra nutrients that your premature baby may need. Remember, even if your

breast milk is being given to your baby by bottle or tube-feeding, you are still

successfully breastfeeding. For most babies, transition to the breast is only a

matter of time.

33

did you know?If you had planned during your pregnancy to breastfeed your baby, you don’t have to give up the idea just because your baby is in the NICU.

Latching On

To feed from your breast, your baby will need to learn the right way to “latch on”

to your nipple. By latching on correctly, it will be easier for her to get enough milk,

and it will also be more comfortable for you.

To latch on properly, your baby should hold your nipple firmly between her

tongue and the roof of her mouth. To get your baby to latch on, lightly touch

the center of her lower lip with your nipple. She will open her mouth as if she’s

searching for it. This is called rooting. Place your nipple on the top of her tongue

and guide it toward the back of the roof of her mouth.

Many premature babies need to be wrapped snugly to feed well. They should be

held so the head, neck and back are in alignment and have good support. The

first feedings may only involve licking and mouthing of the nipple as the reflex

to suck may still be weak. Your baby’s feeding skills will improve as she gets

stronger and can stay awake longer.

Formula-Feeding

Experts agree on the many benefits of breast milk; however, many mothers have

questions about breastfeeding and bottle-feeding. And the answer is not always

either/or. Sometimes a combination of the two might be best. Talk to your doctor

and make an informed decision that works for you. Either way, your baby will be

healthy and happy with your decision.

In the NICU, your baby’s first formula will most likely be one that’s designed for

premature babies, such as Enfamil® Premature formula. Premature babies have

unique nutritional needs to support their rapid growth and development. For this

reason, when your baby leaves the hospital, talk to the doctor about transitioning

her to Enfamil® EnfaCare®, a milk-based, 22 Cal/fl oz formula that supports the

needs of babies born prematurely or with low birth weight.

34

35

Because we are so small, we need a special kind of formula.

Babies born prematurely have special nutritional needs

For this reason, many doctors recommend Enfamil® EnfaCare® through 9 months

of age to help with growth and development. Enfamil EnfaCare provides the extra

nutrition premature babies need.

This special formula is scientifically designed with more protein, calcium and other

important nutrients than our routine formulas to help provide better growth and

development for babies born prematurely. In fact, babies fed a program of

Enfamil® formulas* achieved growth similar to full-term, breastfed babies.

Premature babies fed Enfamil formulas* during the irst year have achieved growth† similar to that of healthy, full-term, breastfed infants.1

35

* Enfamil® Premature LIPIL, Enfamil EnfaCare LIPIL and Enfamil® with Iron.

† Weight at 18 months corrected age, length at 9 months corrected age.

1. Clandinin MT et al. J Pediatr. 2005;146:461-468.

I am a babyin the NICU

Milestones in DevelopmentDevelopment is a term that refers to the ways in which an infant matures and

learns new skills. If your baby had stayed in the womb until your due date, his

development would have continued there until he was ready to be born. But

because he arrived early, he still has some developing to do. This is the reason his

age doesn’t match the things he’s able to do. Therefore, you can’t compare your

baby to a full-term baby who was born at about the same time.

Don’t worry—in time your baby’s development will improve. Remember, also, that

no two babies are alike. One may progress faster in one area, but take longer in

others.

Some babies in the NICU may need special help with their development. Some

NICUs have staff members with special training to hold, touch and play with your

baby in special ways to help his senses develop. They may talk to him and show

him patterns and shapes. They may expose him to different sounds and give him

tests and exams to make sure his progress is right on target.

Thus, early in life, your baby’s development will progress in very small steps. Every

day he’s learning to gain control over his body in ways that full-term babies are

born knowing and doing automatically. Your baby’s nervous system controls how

well his vital organs function. Because his nervous system is still maturing and

developing, his heart rate, breathing, nerves and muscles aren’t working properly

yet. The stronger he grows, the more signs you will see that his nervous system

is gaining control. On the next page we’ve listed some milestones in development

that you will notice in your baby as he develops.

36

3737

YOUR BABY’S STAIRWAY TO DEVELOPMENT

Step 5 Baby can focus attention outside himself without loss of control.

Step 4 Baby can focus better on sights, sounds, sense of touch.

Step 3 Awake times get longer. Differences between sleeping and waking become clearer.

Step 2 Muscles work more smoothly and get stronger.

Step 1 Heartbeat, breathing, digestion and other functions become smoother and better regulated.

Heartbeat and Breathing Rate – These will become regular and grow

stronger. He will no longer need medicines to help regulate them.

Lungs – His lungs will mature and develop and he will no longer need machines,

such as a respirator, to help him breathe.

Digestive System – As your baby’s digestive system matures, he will progress

from IV feedings to tube-feedings and eventually to breast or bottle-feeding.

Muscle Control – As your baby’s nervous system develops, he’ll gain better

control of the muscles in his arms, legs and entire body. His movements will

become smoother, and he’ll be able to make his muscles do what he wants

them to.

Regular Sleeping and Waking Patterns – Since premature babies require

so much sleep, it may be hard for your baby to be wide awake and pay attention

to what’s going on around him. Soon though, his waking and sleeping patterns

will be more like those of a full-term baby. As your baby grows, you’ll be able to

better predict his waking and sleeping patterns. Soon enough he’ll be alert, able

to grab your finger or hair and give you that unforgettable first smile.

Sometimes…babies are transferred to a “stepdown” nursery, where it’s quieter and there are fewer machines.

38

TransfersSometimes, depending on your hospital, babies are transferred to a “stepdown”

nursery, where it’s quieter and there are fewer machines. If you live a long

distance from your NICU, your baby may be transferred to a hospital nursery

near your home. A hospital transfer will be discussed with you in advance and

will occur only after the neonatologist, your local doctor and you agree that the

transfer is appropriate. In most cases, a hospital transfer will take place

by ambulance.

If your baby is transferred, don’t be surprised if you experience some feelings of

anxiety. Leaving a familiar place where you are comfortable and adjusted is often

hard. Just remember, even if they do things a little differently, your baby’s new

care providers are just as concerned about her well-being as the NICU staff.

Give yourself time to get used to the new faces and surroundings.

3939

Going HomeEach NICU will have its own guidelines regarding the discharge of your

baby from the hospital. Listed below are some of the most common ones:

• you have acquired the skill and judgment necessary for her care at home.

• she is able to successfully feed by mouth and grow well on breast

milk or formula.

• your baby will be able to control her own body temperature and keep herself

warm without the help of an incubator.

• she will be able to breathe regularly except for occasional apnea.

However, some babies may go home on oxygen or a monitor.

• her medical condition is stable and all unresolved medical issues

have been addressed.

40

Although we know you’re very happy that your baby is going home, we

understand that you may be a little nervous too. This is completely normal. Don’t

worry, though, your NICU staff will not send you home unprepared. The NICU

nurses are trained to help you get ready and guide you as you practice your

baby’s daily routines before taking her home. The nurses will help you bathe your

baby and change her diapers. They’ll coach you through her

daily care and answer all your questions about feeding.

They’ll also teach you how to take your baby’s temperature

and watch for signs of illness. If your baby is going home on

oxygen or on some type of monitor, they’ll show you how to

connect and troubleshoot it. They’ll instruct you in the use of

any medications as well.

While your baby is still in the NICU, it is a good time to take

a course in infant cardiopulmonary resuscitation (CPR). This

life-saving course will teach you how to get your baby’s heart

and lungs working again if they should ever stop for any

reason. Chances are you won’t ever need to use CPR on

your baby, but knowing it will increase your confidence and

could save your baby’s life.

Taking your baby home is a big step, but we know you can

handle it! It will help to spend as much time with your baby

in the NICU before going home. The staff will do everything they can to make the

transition home the wonderful event you’ve been waiting for!

On the following pages we’ve provided a pre-discharge checklist to help you

remember everything you might need or want to know before going home, and

a final list of discharge questions to help make sure you have covered everything

you wanted to cover.

41

BEFORE WE GO HOME…Pre-discharge Checklist for Mom

Before the exciting journey home, take a few minutes to review the

following checklist. It’s best to use this section several days before

your baby’s discharge date so if there are things you still need to ask

about or do, such as take a CPR class, there will still be time before

going home.

I am:

comfortable giving my baby a bath

comfortable taking care of her umbilical cord

comfortable feeding my baby

comfortable giving her medicines

I:

know how long to breastfeed or how much to feed

know how to mix infant formula, in case I decide to formula-feed

know how to take an axillary (underarm) or skin temperature and

how to read the thermometer

know how to use a bulb syringe

know how to perform CPR on my baby if necessary

have a car seat I will use to take my baby home

know how to use a car seat properly and where and how to

position it in my car

have clothes for my baby to wear home

have received my Enfamil® EnfaCare® Carryall

42

• Do you know and understand what was wrong with your baby?

• Do you know and understand what problems or conditions may

continue after your baby’s discharge and how to handle them?

• Have you discussed your baby’s feeding needs and schedule with

your doctor?

• Do you know what follow-up appointments your baby needs and why

he needs them?

• Have you scheduled the appointments? If not, do you have the phone

number(s) to call and schedule them?

• Did you complete a course in infant CPR?

• Is there anything else you want to know or practice before taking your

baby home?

• Did you ask for your free Enfamil® EnfaCare® Carryall?

Discharge Questions

43

Also included is a molded ice pack, collapsible water

bottle to keep you hydrated, AAP Breastfeeding Guide,

I am a Baby in the NICU booklet and Smart Symphonies

music CD.

Be sure and ask your baby’s nurse at the hospital for your FREE NICU Parents Support Kit.

Free Gift At The Hospital!

44

Alveoli – Tiny sacs in the lungs where

oxygen and carbon dioxide are exchanged in

the blood stream.

Anemia – An abnormally low number of red

blood cells, which are the cells in the blood

that carry oxygen to the tissues. Anemia is

very common in babies in the NICU, especially

premature ones. Severe anemia is treated with

blood transfusions. Babies with anemia are

also given vitamins and iron to build up their

blood.

Antibiotics – Drugs that fight germs, kill

bacteria or interfere with their growth, and

help cure or prevent infections.

Antibodies – Proteins produced by the

body to combat specific harmful substances

like bacteria or viruses that have entered

the bloodstream.

Aorta – The artery leading from the

heart that supplies the body with oxygenated

blood.

Apnea – A temporary stop or pause

in breathing.

Areola – The dark area on the breast

surrounding the nipple.

Arterial blood gases test – A sampling

of blood from an artery for its oxygen, carbon

dioxide and acid content.

Arterial catheter – A thin plastic tube

placed in an artery to withdraw blood for

testing. Arterial catheters are most commonly

placed in the umbilical artery.

Artery – Any blood vessel that leads away

from the heart. Arteries carry oxygenated

blood to the body tissues, except for the

pulmonary artery, which carries

non-oxygenated blood from the heart

to the lungs.

Bacteria – One-celled organisms that can

cause disease.

Bagging – Squeezing a bag to pulse air

and/or oxygen into a baby’s lungs through a

mask that covers the baby’s nose and mouth.

Bili blanket – A specially lighted cover that

is placed under the baby to treat jaundice.

Bililights – Special, intense lights placed

above a baby’s bed to treat jaundice.

Bilirubin – A yellowish-red pigment

produced when red blood cells break down.

An excess of bilirubin in the bloodstream leads

to jaundice.

Blood gases – A test to determine the

oxygen, carbon dioxide and acid content of a

sample of blood.

Blood pressure – The pressure the

blood exerts against the walls of the blood

vessels. It is this pressure that causes the

blood to flow through the veins. The blood

pressure measurement is given in the form of

two numbers. The top number, the systolic

pressure, is the measurement of the pressure

exerted when the heart contracts and sends

blood to the body. The bottom number, the

diastolic pressure, is the measurement of

the pressure exerted during the relaxation

between heartbeats.

Blood transfusion – Putting blood from

a donor into a baby’s blood circulation. Blood

types are matched carefully and donor blood

is tested thoroughly.

Bonding – The process by which parents

and baby become emotionally attached.

GlossaryWhile your baby is in the NICU, you may hear many new terms that are unfamiliar to you.

Here are some of the more common ones and their meanings. You’ve already been

introduced to some of them in this book.

45

Bradycardia – A slower-than-normal

heartbeat. In infants this is below 100 beats

per minute. This usually accompanies apnea.

Bronchial tubes – The tubes that lead

from the trachea (windpipe) to the lungs.

Capillaries – Tiny blood vessels that come

into close contact with the body cells to

supply the cells with oxygen and nutrients and

to remove waste products.

Carbon dioxide – A waste product of

bodily processes that is carried by the blood

to the lungs where it is exhaled.

Cardiologist – A doctor who specializes in

the branch of medicine dealing with the heart

and circulation.

Cardiopulmonary resuscitation

(CPR) – A method of reviving a person

whose breathing and heartbeat have stopped

or slowed abnormally.

Catheter – A thin tube used to administer

fluids to the body or drain fluids from the body.

CAT scan – Computerized Axial

Tomography. Pictures that give a 3-D view of

the body’s internal organs and structures.

Central line – An intravenous line that is

threaded through the vein until it reaches a

position as close to the heart as possible.

Central nervous system – The brain and

spinal cord.

Cerclage – A procedure sometimes used to

reinforce an incompetent cervix that involves

stitching the cervix closed during pregnancy.

Cervix – The lower section of the uterus that

shortens (effaces) and opens (dilates) during

delivery.

CLD – Chronic Lung Disease. This lung

problem occurs in some premature babies

and requires treatment with oxygen or a

breathing machine for a prolonged time.

Colostrum – The breast milk produced in

the first few days after delivery. This milk is

especially rich in nutrients and antibodies.

CPAP – Continuous Positive Airway

Pressure. Pressurized air, sometimes with

additional oxygen, that is delivered to the

baby’s lungs to keep them expanded as the

baby inhales and exhales.

Digoxin (dij-ox´-in) – A heart medicine

that makes a baby’s heartbeat stronger

and more regular.

Electrodes – Devices attached to

adhesive pads that are placed on a baby’s

body to conduct the electrical impulses of

his heartbeat and breathing motions to a

monitoring machine.

Endotracheal tube – A thin plastic tube

inserted into the baby’s trachea (windpipe) to

allow the delivery of air and/or oxygen to the

lungs.

Full-term baby – A baby born between

37 and 42 weeks of gestation.

Gastroenterologist – A doctor who

specializes in disorders of the digestive

system. A pediatric gastroenterologist only

treats infants and children.

Gavage feeding – Feedings given through

a tube passed through the nose or mouth and

into the stomach.

Geneticist – A doctor who specializes in the

study and treatment of disorders or conditions

that tend to run in families.

Gestation – The length of time between the

first day of the mother’s last menstrual period

before conception and delivery of the baby.

Gestational age – Baby’s age in weeks

from the first day of the mother’s last

menstrual period before conception until the

baby reaches term (40 weeks).

Glucose – The type of sugar that circulates

in the blood and is used by the body for

energy.

46

Gram – A unit for measuring weight. One

gram equals 1/28th of an ounce; 454 grams

equal one pound.

Heel stick – The procedure of pricking

a baby’s heel to obtain small amounts of

capillary blood for testing.

Hematologist – A doctor who specializes

in the treatment of blood problems.

Human milk fortifier – A nutrient

supplement added to breast milk to

meet special needs of premature and

low-birth-weight infants.

Hyperglycemia – Abnormally high sugar

levels in the blood.

Hypoglycemia – Abnormally low sugar

levels in the blood.

Imaging studies – Tests and exams that

involve taking pictures of internal organs. X-ray

pictures are one kind of imaging. Ultrasound

exams are another. High-tech kinds of

imaging are CAT scans and MRI.

Incubator (in´-cu-ba-tor) – A small bed

enclosed in a plastic box for newborns. It

keeps the baby’s body warm and at an even

temperature.

Infant development – The mental and

physical progress of a baby.

Infectious disease specialist – A

doctor specializing in the treatment of

contagious diseases.

Infusion pump – A pump attached to an

intravenous line to deliver IV fluids to the baby

in tiny, precisely measured amounts.

Intake – Nourishment (liquids for infants)

taken in by the body. The opposite of intake

is output, which refers to fluids and solids that

leave the body. A baby’s intake can come

from IV feedings, the breast or the bottle.

IV feedings – IV stands for intravenous,

which means into a vein. Both nutrition and

medicine may be given by IV.

IVH – Intraventricular hemorrhage (in-truh-

ven-trik´-kew-ler hem-or-aj). This term means

bleeding in the brain. IVH can be very mild or

severe. It’s thought to affect about 4 in every

10 babies who weigh under 3 1/2 pounds at

birth. If doctors suspect a baby has IVH, they

do tests for proper diagnosis. Usually, these

tests don’t hurt. Treatment depends on how

severe the bleeding is and where it’s located.

Intubation – The insertion of a tube into the

trachea (windpipe) to allow air to reach the

lungs.

Isolette® – A trademarked brand of

incubator.

Jaundice – The yellowing of the skin and

whites of the eyes caused by excessive levels

of bilirubin in the blood.

Lab technician – A person who specializes

in the study of blood and tissue samples.

Lanugo – The fine, downy hair that covers

the fetus from about the fourth or fifth month

in the womb and disappears toward full term.

Lanugo is often still present on premature

babies.

Lasix – A drug that helps reduce swelling or

fluid accumulation by increasing urine output.

Low birth weight – A weight at birth of

less than 2500 grams (about 5 1/2 pounds).

Monitor – A machine that records vital

signs such as heartbeat, breathing and body

temperature.

MRI – Magnetic resonance imaging. MRI

machines are more complex than CAT scan

equipment.

Mucus – A sticky secretion produced by

mucus membranes.

NEC – Necrotizing Enterocolitis (nek´-ruh-

tize-ing ent-er-o-koh´-lit-is). A severe problem

with the intestines. The cause is not very well

understood. Babies with NEC are often given

medicine to treat an infection that may be

present. They also receive fluids in a vein to

47

provide their bodies with water and nutrition

until their intestines are ready to be used.

Neonatal – Near the time of birth.

Neonatal nurse – A registered nurse

who specializes in the care of sick babies

in the NICU.

Neonatal nurse practitioner –

A registered nurse who has received

specialized training in the management of

newborn infants. This nurse is qualified to

perform some procedures generally done

by physicians.

Neonatologist – A doctor who

specializes in pediatrics and has taken

further specialty training in the care of sick

newborns.

Neonatology – A specialty field in

medicine and nursing, devoted to the care

of premature and sick newborns.

Nervous system – The brain and the

nerves that connect it with all parts of the

body. The job of the nervous system is

to receive all information coming in (eg,

pain, pleasure, sights, sounds) and send

messages to organs and tissues telling

them what to do (eg, draw away from an

object causing pain, smile with pleasure).

Neurologist – A doctor who specializes

in disorders of the brain and nervous

system.

NG feedings – NG stands for

nasogastric, which means going from the

nose into the stomach. Gavage feedings

are given through a small flexible tube

inserted through the nose and down the

esophagus and into the stomach. Formula

or breast milk is dripped into the tubing at a

steady rate.

NG tube – A small, flexible tube inserted

through the nose, down the esophagus

and into the stomach. Used to gavage-feed

a baby.

NICU – Neonatal Intensive Care Unit.

Occupational therapist –

A healthcare specialist who helps babies

improve control of their small muscles

so they can develop at the normal rate.

Occupational therapists may also be a

resource for feeding problems.

OG feedings – OG stands for orogastric,

which means going from the mouth into the

stomach. OG feedings are given much the

same way as NG feedings, except that the

tube is passed through the baby’s mouth.

OR – Operating room.

Orthopedist – A doctor who specializes

in disorders of the bones and connective

tissues.

Otologist – A doctor who specializes in

disorders of the ear.

Output – Fluids and solids that leave the

body usually in the form of urine, stool or

emesis (vomiting). The opposite is intake,

which means fluids and solids taken in by

the body for nourishment.

PDA – Patent Ductus Arteriosus (pat´-ent

duck´-tus ar-teer´-ee-oh-suss). A temporary

heart condition in some newborns, which

is usually treated with drugs. If this fails,

surgery may be considered.

Perinatal – Describing the period from

20-28 weeks gestation to one week

following delivery.

Perinatologist – An obstetrician who

specializes in complicated pregnancies and

deliveries.

Periodic breathing – Breathing

interrupted by pauses as long as 10 to 20

seconds. Common in premature babies.

Phototherapy – Treatment of infants

with jaundice by exposing them to light

therapy using a bili blanket or bililights.

Physical therapist – A healthcare

specialist who helps babies improve control

of their large muscles so they develop at

the normal rate.

48

Placenta previa – A condition in which

the placenta is abnormally positioned over the

cervix; can result in bleeding during middle

or late pregnancy. Cesarean delivery is often

necessary.

Pneumonia (new-moan´-yah) –

An infection of the lungs that causes

fluid to collect, making breathing hard.

An antibiotic (an´-tie-bye-ah´-tik) is

given to treat the infection. The baby

may also be given oxygen or put on

a breathing machine.

Postpartum – After delivery.

Pregnancy Induced Hypertension

(PIH) – A complication of pregnancy in which

the mother has protein in the urine, high blood

pressure, rapid weight gain and swelling from

fluid retention. This previously was called pre-

eclampsia or toxemia.

Premature formulas – Special formulas

designed to meet the needs of premature

infants.

Premature infant – A baby born before

being in the womb at least 37 weeks. The

word “premature” refers to something that

happens before it’s supposed to.

Prenatal – Before birth.

Pulmonary interstitial emphysema

(PIE) – A condition in which air bubbles are

forced out of the alveoli and in between the

layers of lung tissues.

Radiologist – A doctor who has

completed special training in the use

of x-rays and other imaging studies

for diagnosis and treatment.

RDS – Respiratory Distress Syndrome. This

previously was called hyaline (high´-ah-lin)

membrane disease. Babies with RDS have

trouble breathing. This condition is a common

problem in premature babies because their

lungs haven’t developed enough to work on

their own.

Red blood cells – Cells in the blood that

carry oxygen and carbon dioxide to and from

body tissues.

Respiratory therapist – A healthcare

professional who is trained to help people with

breathing difficulties.

Retinopathy (ret-in-ah´-path-ee) of

Prematurity (ROP) – An eye problem that

babies born very early may have. The back

of the eye (the retina) may be injured, and

special treatment may be needed. Whether

the baby’s sight is affected depends on how

severe the problem is and how well treatment

works.

Rooting – Head and mouth movements

made by a baby searching for a nipple to suck

on. A mature rooting reflex (usually seen at 37

weeks gestation and beyond) consists of the

infant simultaneously turning his head toward

the nipple, opening his mouth and extending

his tongue to enclose the nipple.

Scalp IV – An IV placed in a vein in the

baby’s head.

Seizures – A short-circuiting of the brain’s

electrical impulses. The baby may tense

up or may have repetitive jerking. The baby

may lose consciousness for a few moments.

Seizures are common in NICU babies and are

frequently treated with medicines.

Sepsis – An infection that gets into the

blood that can affect the baby’s whole body.

Sepsis is treated with antibiotics. If the sepsis

is very bad, blood transfusions may be

needed.

Social worker – A specialist who helps

families cope with emotional stress and

makes practical arrangements for care. Social

workers can also help patients and their

families cope with financial stress and strain.

49

Surfactant – A substance formed in the

lungs that helps keep the small air sacs,

or alveoli, from collapsing and sticking

together. Many premature infants are now

given surfactant at birth to help prevent or

minimize breathing problems.

Stepdown nursery – A nursery that

babies may go to after the NICU but before

they are moved to a standard nursery. The

care in a stepdown nursery is less intensive

than a NICU but still more specialized than

in a standard nursery.

Tachycardia – An abnormally fast heart

rate. In an infant, a rate above 160-180

beats per minute.

Trachea – Windpipe; the tube that

extends from the throat to the bronchial

tubes.

Tracheotomy – A surgical opening in

the trachea, below the larynx (voice box),

made to allow air to enter the lungs when

the throat becomes obstructed or the baby

needs to be on the ventilator for a longer

time.

Ultrasound – A technique in which

echoes of high frequency sound waves

produce a picture of the body’s tissues.

Umbilical artery catheter – A small,

flexible, plastic tube inserted through an

artery in the infant’s umbilical cord. It can be

used to obtain blood samples and monitor

blood pressure.

Vein – A blood vessel leading to the heart.

Veins carry non-oxygenated blood from the

body to the heart, except for the pulmonary

veins which carry oxygenated blood from

the lungs to the heart.

Vital signs – Temperature, pulse rate,

rate of respiration and blood pressure.

Warmer – An unenclosed bed that helps

keep your baby at the right temperature

with radiant heat.

Let Enfamil® help you nourish milestones with up to

$250 in FREE gifts.

focusing

begin todaymilestones

tomorrow’s

Our privacy policy is available at the phone number or website below. Offer limited to one per household and subject to change without notice. Enfamil Family Beginnings beneits may vary.

FREE samples and discounts, up to $60 in savings on any Enfamil formula

FREE goodiesFREE informative articles, booklets and emails

0-3 months

they’re nourished over time.

milestonesdon’t happen overnight.

For online registration: enfamil.com/4baby105 or call 1-800-4BABY42 ext 105.

for newborns, infants and toddlers.

The maker of Enfamil® has a line of formulas designed to meet your patient’s changing nutritional needs.

for babies with feeding issues.If feeding issues arise anytime in the first year,

rest assured there is an Enfamil formula to help.

Fussiness & Gas Frequent Spit-Up Soy Cow’s Milk Allergy

nourishing development at every stage.

Newborn Infant Toddler

2011064 LF64 REV 3/13 ©2013 Mead Johnson & Company, LLC

The maker of Enfamil® wishes to express appreciation to

Pamela Lemons, MS, CNNP at James Whitcomb Riley Hospital for Children,

for her guidance in preparing this booklet.

Our commitment to you and your baby

We are committed to making the highest-quality formulas

with nutritional benefits proven in independent clinical studies.