What to Expect in the NICU

1. Hypothermia/cooling treatment

2. In the neonatal intensive care unit (NICU)

3. During hypothermia treatment

4. After hypothermia treatment

5. Brain magnetic resonance imaging (MRI)

6. Frequent questions

• Because your baby may have lacked oxygen and/or blood flow around the time of birth, his/her brain is at risk of damage, and thus he/she is at risk for future developmental problems. Decreasing body temperature shortly after birth may slow down brain activity, help with brain recovery, and thereby reduce the chances of further damage occurring.
• Treatment with hypothermia has been proven in several scientific studies to reduce the risk of death and long-term developmental problems in these babies.
• Hypothermia is now the standard treatment for term and near-term babies (≥ 36 weeks of gestational age and ≥ 1800 grams at birth) who may have lacked of oxygen and/or blood flow around the time of birth (referred as birth asphyxia), and who demonstrated signs that their brain had suffered (referred as neonatal encephalopathy).

• Your baby is placed in an isolette with just a diaper on him/her, so the nurses and doctors can better watch him/her carefully. She/he is hooked up to cardiorespiratory monitoring with cables plugged in and connected to your baby’s skin through several stickers so to monitor his/her respiration (how quickly your baby breathes), saturation (how much oxygen is in her/his blood), heart rate (how fast his/her heart is beating), and blood pressure (how much force your baby’s heart is using to pump blood in her/his body). These parameters are called vital signs and will be monitored continuously, since they give your baby’s team of caregivers a great deal of information about how he/she is doing.
• Catheters are placed through your baby’s belly button into large blood vessels to allow arterial and venous access. These catheters will be used to provide the nutrition that your baby will need, and they will be plugged into the monitor to measure her/his blood pressure. Additional venous or arterial lines may also be needed, and usually will be placed on the arms, legs, or scalp.
• A machine called an electroencephalogram will monitor the electrical activity of your baby’s brain.
• At all times of the day and night, your baby is assigned to a specific nurse and a doctor (neonatologist). These caregivers will not be the same people every day or night, but be assured that they always will know your baby’s history, and you can ask to speak to them at any time if you have questions. In addition, a respiratory therapist will help with the management of the ventilator (machine for breathing support) if your baby needs this assistance.
• Every morning, the medical team will see each baby (called rounds) to discuss the evolution of the babies, and establish the plan for the day for each of them. For your baby, the medical team includes your baby’s nurse and doctor, and very often several other people: residents (doctors training to become pediatricians), fellows (usually pediatricians specializing to become neonatologists), respiratory therapists, pharmacists, dieticians, students, etc. Many parents find it intimidating, especially at first, to see all these people in front of their baby’s bed or outside their baby’s room, and to hear them discuss their baby’s condition. However, as the parent, you too are an important part of this team, and your input is always appreciated. If you have questions, or something was said that was not clear, you can always ask the nurse and/or the doctor of your baby at any time for clarification, and especially to receive an update about your baby’s progress and the daily plan. 

• After birth asphyxia, your baby may be very sick during the first days of his/her life, since her/his major body organs may have lacked oxygen and/or blood flow around the time of birth.
  • His/her lungs may have suffered injury, and your baby may have needed to be intubated (have a breathing tube placed through her/his nose or mouth into his/her airway to help him/her breathe) at birth or shortly after. He/she may need to be on a special machine called a ventilator to help him/her breathe, and she/he may need extra oxygen to ensure good oxygen delivery to all his/her body organs. In addition to oxygen, some babies may need treatment with a second gas called nitric oxide (NO) to improve the oxygen delivery to all his/her body organs.
  • Her/his heart also may have suffered because of the birth asphyxia. One or more medications may be needed to maintain adequate blood pressure and heart function. While he/she is receiving the cooling treatment, his/her heart rate may be lower than what we usually see in the babies.
  • With asphyxia, the kidneys of your baby may have suffered, so it may take some time before he/she produces urine.
  • Her/his liver may have suffered, and he/she may need transfusions because he/she is bleeding easily.
  • She/he may present with seizures because his/her brain may have suffered from the lack of oxygen and/or blood flow around the time of birth, and medications may be needed to stop the seizures or prevent further episodes.
  • Rarely, some babies who suffered from birth asphyxia may need even more intensive treatments to try and support the function of their organs, such as dialysis, if their kidneys cannot function, or more complete support with extracorporeal membrane oxygenation (ECMO, also called a heart-lung machine or life support) if their heart, lungs, and kidneys are too sick.
  • Unfortunately, even with all of the technology, knowledge, and intensive care, some babies who suffered from birth asphyxia may die of these complications if they become too severely sick.
• During hypothermia treatment, your baby will not be fed by mouth. Instead, he/she will receive all nutrients (sugars, proteins, and lipids) that she/he needs through an intravenous line. However, we encourage you to eventually breastfeed your baby when he/she is doing better. To eventually breastfeed, you should start pumping your milk as soon as possible, and do it regularly every 3 hours for a total of 6–8 times/day (with breaks no longer than 4–5 hours overnight). When you are with your baby in the NICU, we have all the equipment you will need, and your baby’s nurse or a lactation consultant can help you learn how to do this; for home, you can rent the equipment. Every drop of milk that you are producing is important for your baby. So you should collect it all, place it in containers in your fridge when you are at home, and bring them to the NICU when you come to be with your baby. Your milk will be frozen until your baby can start feeding by mouth or through a feeding tube placed in his/her nose or mouth into his/her stomach.
• Unfortunately, during the hypothermia treatment, you cannot hold your baby because your body temperature will warm her/him, making the hypothermia treatment less efficient. We know that this is very difficult for you, but keep in mind that this is temporary while the cooling is underway, and when the baby is most fragile. You will have an important role to play holding your baby as soon as it is safe to do so.

• After 72 hours, your baby will be rewarmed slowly over several hours until he/she reaches normal body temperature.
• Ventilation may be weaned progressively, and your baby may be extubated when he/she can breathe efficiently by himself/herself. Oxygen support also may be weaned progressively if the saturation remains within normal limits. Recovery of the lungs’ function occurs at different rates for different babies, depending on how severely they were initially affected. We will be monitoring this closely.
• After hypothermia, feeding by mouth or through a feeding tube placed in your baby’s nose (nasogastric, NG) or mouth (orograstric, OG) into his/her stomach will be started and progressed as tolerated by your baby. We encourage you to breastfeed once your baby demonstrates that she/he can swallow safely. Some babies progress quickly to the breast or bottle, while others may take more time.
• After the hypothermia treatment is completed, you are encouraged to hold your baby in your arms or skin to skin (called kangaroo care) if he/she is stable enough to tolerate being moved out of the isolette. If your baby is not yet stable enough to be moved, ask your baby’s nurse or doctor if modified holding techniques are an option.

• A brain imaging is performed after the hypothermia treatment is completed, usually around day 10 of life in our NICU to evaluate whether your baby is showing signs of brain damage.
• A MRI is a machine with a magnetic field that enables very detailed pictures of your baby’s brain. MRI is one of the safest techniques to do images of the body because it does not involve exposure to harmful radiation such as x-rays. Each MRI may take up to 1 hour to get all the necessary images. A nurse (and a respiratory therapist and/or physician, if needed) will accompany your baby during the transport between the NICU and the MRI scan, and will remain with him/her during the imaging.
• For the MRI, your baby will be bundled comfortably in blankets and a styrofoam pillow to decrease his/her movements during the exam. As the MRI machine makes loud banging noises during the scanning session, your baby will need to wear earmuffs and earplugs to protect him/her from the noise. All metal objects will be removed from her/his body, since MRI is a strong magnet. If your baby can eat, he/she will be fed a few minutes before the MRI scan, so she/he will sleep or remain quiet during the entire exam. If he/she should wake up and be restless during the exam, she/he will be offered some sugar water or more milk to help keep him/her still until the end of the exam. All medications and support that your baby required in the NICU will be continued during the exam. If possible, we try not to use sedation (medication to make a baby sleep) for the imaging procedure, since the bundling and feeding just before the exam is generally enough to keep a baby calm during the MRI scan. However, for some babies, a dose of sedation may be needed to ensure that she/he stays still for all the necessary pictures.
• Once your baby’s doctor receives the results of the MRI, she/he will explain them to you. In addition to the brain imaging results, the doctor will review with you your baby’s overall progress, the changes in the clinical and neurological exam, as well as any results about the electrical activity of his/her brain (electroencephalogram, EEG). All this information will be used to try and predict how your baby will do in the future.

a. When will I know how my baby will do?

Although this is an extremely important question, your baby’s doctor and nurse will not be able to predict how your baby will do as soon as he/she arrives in the NICU. Generally, it will take several days as the medical team closely follows his/her daily progress and does a variety of tests to begin to have a clearer idea about how she/he is doing. In addition, they will need to review his/her brain imaging to see if he/she showed signs of brain damage. The doctor will then sit down with you and review your baby’s progress and all the tests he/she had so to give you their best prediction on how your baby will do in the future. However, since each baby is unique, it will be important that she/he continues to be followed by our team of specialists, to continue to monitor her/his progress and provide help and extra services if necessary.

b. When will I know if my baby has brain damage?

A brain imaging is performed after the hypothermia treatment is completed, usually around day 10 of life in our NICU, to evaluate whether your baby is showing signs of brain damage. Your baby’s doctor should explain to you the results of this brain imaging. Once the doctor receives the results the MRI, she/he will explain them to you.

In some hospitals where research about birth asphyxia is ongoing, brain imaging already may be offered during the hypothermia treatment as part of the research protocols. If you are interested in learning more about this, ask your baby’s doctor if this type of research is occurring at your hospital.

c. How long will my baby stay in the NICU?

Babies treated with hypothermia usually stay in the NICU for around 10 days. This stay may be shorter (around 6–7 days) or it may be longer (sometimes several weeks). It all depends on how your baby is recovering.

d. When can I hold my baby?

Unfortunately, during the hypothermia treatment, you cannot hold your baby because your body temperature will warm her/him, making the hypothermia treatment less efficient. We know that this is very difficult for you, but keep in mind that this is temporary while the cooling is underway, and when the baby is most fragile. You will have an important role to play holding your baby as soon as it is safe to do so.

After the hypothermia treatment is completed, you are encouraged to hold your baby in your arms or skin to skin (called kangaroo care) if he/she is stable enough to tolerate being moved out of the isolette. If your baby is not yet stable enough to be moved, ask your baby’s nurse or doctor if modified holding techniques are an option.

e. When can I feed my baby?

During hypothermia treatment, your baby will not be feed by mouth. Instead, he/she will receive all nutrients (sugars, proteins, and lipids) that he/she needs through an intravenous line. However, we encourage you to eventually breastfeed your baby when he/she is doing better. To eventually breastfeed, you should start pumping your milk as soon as possible, and do it regularly every 3 hours for a total of 6–8 times/day (with breaks no longer than 4–5 hours overnight). When you are with your baby in the NICU, we have all the equipment you will need, and your baby’s nurse or a lactation consultant can help you learn how to do this; for home, you can rent the equipment. Every drop of milk that you are producing is important for your baby. So you should collect it all, place it in containers in your fridge when you are at home, and bring them to the NICU when you come to be with your baby. Your milk will be frozen until your baby can start feeding by mouth or through a feeding tube placed in his/her nose or mouth into his/her stomach.

After hypothermia, your baby will be fed by mouth or through a feeding tube placed in his/her nose (nasogastric, NG) or mouth (orogastric, OG) and into his/her stomach. This feeding will be started and progressed as tolerated by your baby. We encourage you to breastfeed once your baby demonstrates that he/she can swallow safely. Some babies progress quickly to the breast or bottle, while others may take more time.

f. Are there treatments in addition to hypothermia that can help my baby’s brain to recover?

For now, hypothermia treatment is the only proven effective treatment for babies who have suffered from birth asphyxia. A baby’s brain presents a certain degree of ability to create new connections around an area that was damaged from asphyxia (called plasticity). The extent to which this occurs is unique in each baby, and cannot necessarily be predicted early in a baby’s life. If brain damage occurs, the standard treatment to optimize the long-term outcome of these children is a close follow-up by specialists who will monitor this plasticity, with the addition of supportive rehabilitation therapies, such as occupational therapy and physical therapy if needed.

In some hospitals where research about birth asphyxia is ongoing, other treatments may be offered as part of research protocols. If you are interested in learning more about them, ask your baby’s doctor if this type of research is occurring at your hospital.