Scott Webb (Host): Though parents-to-be rarely plan for their newborn to spend time in a neonatal intensive care unit, or NICU, the multidisciplinary team at the Elliot Hospital's NICU is uniquely prepared to help newborns and their families to get home as soon as possible. And I'm joined today by Dr. Lauren Priolo. She's a neonatologist with the Elliot.

 This is Your Wellness Solution, the podcast by Elliot Health System and Southern New Hampshire Health, members of SolutionHealth. I'm Scott Webb. Doctor, it's great to have you on today. We're going to get an overview of the NICU at the Elliot today, and it's nice to have you here and take us through all of this. So, let's just start there. Give us an overview of the neonatal intensive care unit, often referred to as NICU, which is just easier to say, and the different types and levels.

Dr. Lauren Priolo: Neonatal intensive care unit, or NICU, is a unit in some hospitals that is equipped to provide critical care services to newborns. Elliot Hospital has a NICU, but not every hospital that delivers infants does. There are different types of NICUs, which are often referred to as levels. All hospitals that deliver infants will have a level 1 nursery. These are well-baby nurseries, which provide routine newborn care after birth. A level 2 is often referred to as a special care nursery. These nurseries are equipped to take care of some premature infants, but are limited by gestational age of the infant. These gestational age guidelines vary; however, most will care for infants born at 32 to 33 weeks gestational age and above. Special care or level 2 nurseries can care for infants who are moderately sick, have difficulty with breathing, or maintaining blood sugar levels or body temperature. If an infant is having breathing difficulty that is not appearing to improve in a short-term time frame, or has more complex medical needs, then the infant would require a higher level of NICU care.

The Elliot Hospital has the only level 3 NICU in Southern New Hampshire and is only one of two in New Hampshire. A level 3 NICU is equipped to take care of infants born at any gestational age and birth weight. It can provide advanced breathing support to infants with different modes of ventilation or breathing machines, specialized respiratory medicines, and it has a multidisciplinary team available to care for each infant.

Subspecialty support such as pediatric surgeons, pediatric anesthesiologists, pediatric gastroenterologists, neurologists, ophthalmologists, and radiologists are also available at a level 3 NICU. They also have a neonatal follow-up program where certain infants are followed post NICU discharge by a team of nutritionists, physical and occupational therapists, and neonatologists to follow their development. The Elliot Hospital NICU also has a neonatal transport team, which is available to transport infants from community hospitals who need a higher level of service that the Elliot NICU can provide.

Lastly, a level 4 NICU is the highest level of neonatal intensive care. And this level is found in university or large academic center hospitals. In addition to the care level 3 NICU provides, a level 4 NICU can provide specialized heart surgery; heart bypass, known as ECMO; and further specialty support for more complex or critical conditions.

Host: All right. So, level 3 at the Elliot, this great multidisciplinary team. Just wondering what are some of the common conditions or reasons that newborns are admitted to the NICU?

Dr. Lauren Priolo: The most common reasons that newborns are admitted to the NICU are prematurity, breathing difficulty, low blood sugar, and concerns for infection at birth. All infants who are born at a gestational age less than 35 weeks are admitted to the NICU. When infants are born premature, they require close monitoring and, depending on the degree of prematurity, will require medications or therapies to support their body systems while they continue to grow and mature. Sometimes infants born at term or a few weeks prior to their due date might require NICU care, most commonly for delays in the transition that all infants go through at birth.

Some infants require breathing help or breathing support. Others require IV fluids to help keep their blood sugar within a normal range. And some infants require help with maintaining their body temperature. Some infants might need help with learning how to eat, or eat by bottle, or breastfeed. And one of the biggest aspects of NICU care is providing breathing support. Some infants might need minimal support, or what is called a nasal cannula, which are prongs that go in the nose and provide oxygen. One of the most common therapies is called CPAP. This supplies oxygen and some pressure through a small mask or prongs in the nose to help open up and keep the lungs open. Infants are still breathing on their own, but CPAP helps support their effort. If an infant needs more help, then they might require intubation, which is placing a tube from their mouth to their lungs and then connecting that tube to a ventilator or breathing machine. The ventilator then provides support directly to the infant's lungs in addition to the infant being able to breathe on their own. It is common for preterm infants and some infants born at term or a few weeks early to need a breathing medication called surfactant. This medication is administered through the breathing tube directly into the infant's lungs and helps the lungs stay open. This medication helps the infant to recover and for the breathing to improve as quickly as possible. The Elliot NICU also has a very specialized medication called inhaled nitric oxide, which is administered to the lungs of infants who need the most help with oxygen support.

Host: Wondering what are some of the most challenging aspects of caring for premature or critically ill newborns in the NICU?

Dr. Lauren Priolo: Some of the most challenging aspects are monitoring everything about the infant, such as blood work, physical exam, vital signs, x-ray or imaging studies, and continuously assessing how the infant is doing, what the next steps are and planning for what could happen if something changed. Sometimes, despite optimized care and vigilant monitoring of infants, unexpected changes can happen, which require creating a new care plan for the infant.

Host: Yeah. And can you walk us through the typical team members? We talked earlier and you kind of went through the whole list of this, really awesome multidisciplinary team that's available, but can you walk us through the typical team members and their roles in the NICU?

Dr. Lauren Priolo: There is a large multidisciplinary team working together to care for infants in the Elliot Hospital NICU. Neonatologists are the specialized physicians overseeing all aspects of care and management of each infant, and they work with the team to create the care plan, for each infant. Neonatal nurse practitioners and physician assistants are specialized providers that work closely with neonatologists and the entire team provide care to infants in the NICU and when infants are being delivered if needed. Neonatal nurses provide bedside care to infants, assess infants routinely throughout the day, and provide families with one on one education while their infants are in the NICU.

In addition, respiratory therapists are trained to assess how an infant is breathing and implement and monitor specialized breathing machines and equipment. Physical therapists and occupational therapists provide developmental care and support to infants and provide techniques such as infant massage to help infants grow and develop comfortably. Speech therapists are the feeding specialists in the NICU and work together with nurses to assess and help support those infants that have difficulty with taking feeds by bottle. Lactation consultants support mothers in breastfeeding and pumping. Social workers are available for all families when an infant is admitted to the NICU. They provide support and assist in areas such as financial and insurance and as emotional support for families.

Behind the scenes are pharmacists who are available to ensure that correct medication and dosing is always prescribed; nutritionists who assess the needs of each infant and work to optimize nutritional intake; and pediatric radiologists who are available to interpret the imaging studies such as x-rays, ultrasounds, and MRIs that some infants might require. Elliot Hospital also has the support of pediatric surgeons and anesthesiologists for those infants who might require surgical care. Pediatric gastroenterologists, pediatric neurologists, ophthalmologists, and pulmonologists.

Host: And you mentioned earlier that the Elliot has the only level 3 NICU in the area, but what else makes the Elliot's NICU so special?

Dr. Lauren Priolo: I think what makes the Elliot NICU so special is the team of specialists providing care here. The multidisciplinary team is committed to providing the highest quality of care to all infants and to provide it close to home in southern New Hampshire. We care for over 600 babies each year.

Host: That's amazing. Six hundred, wow. Just wondering, give parents a sense, if their newborn or infant ends up being in the NICU, what can they expect?

Dr. Lauren Priolo: So for most families, an admission to the NICU is not part of their birth plans, and we all understand that. The equipment, the sounds of the monitors, and multiple different faces of the team of care providers can all seem very overwhelming. When an infant is first admitted to the NICU, a lot of different things are happening at once to provide needed care. The providers are always available and will teach parents what everything is and why things are being done. The priority of the NICU team is to provide exceptional care to each infant, in addition to making sure parents are aware and understanding of the care plan for their infant.

Host: Yeah. And as you say, most parents don't plan for their newborn to be in the NICU, but it happens, of course. And wondering what advice you give them to these expected parents who may be anxious about the possibility of their newborn needing NICU care.

Dr. Lauren Priolo: Fear of the unknown and lack of control of the situation is common for parents in the NICU to feel. I would like parents to feel assured that the NICU team is always doing everything possible to help their infant. and that most infants go home from the NICU as healthy, happy infants and do quite well.

The NICU stay might be longer than anticipated by parents, and there is an understandable desire of parents to have their infants at home. The NICU team is always working to get infants home as soon as the infant is safely ready to. The NICU team's goal is to partner with parents and involve parents in the care of their newborn. We are always here to answer questions and to hear any concerns parents might have.

Host: Yeah, right. The goal, obviously, is to get them home as soon as possible, happy, healthy, all that good stuff. Wondering if you could share any memorable success stories or cases from your experiences in the NICU.

Dr. Lauren Priolo: There are many success stories in the almost seven years since I've been part of the team here at the Elliot NICU. When we see infants in the NICU follow-up clinic after discharge, we are able to see how they were doing at six months, 12 months, and up to two years old. It is wonderful to see how these former preterm infants, those infants who had difficulty at birth, and those infants who were critically ill for a period after birth are doing. It's a wonderful celebration since the majority of our former NICU infants are doing amazingly well. It is particularly nice to see how well infants who underwent a treatment called therapeutic hypothermia at birth are doing in NICU followup clinic.

Sometimes, after an infant is born, there is concern that the infant had decreased blood flow or oxygen delivery to their body surrounding the time of birth. We have concern that this might have occurred based on the physical exam of the infant in addition to blood work results. When this occurs, there's a specialized treatment called therapeutic hypothermia, or cooling, which is used to help protect the infant's brain development. The infant's body temperature is lowered for a period of three days, and this has been shown to protect the brain and give those infants the best developmental outcome in terms of meeting their milestones as they grow.

The Elliot NICU transport team can initiate this treatment at community hospitals when we are called to transport an infant to the Elliot hospital. This cooling therapy is also readily available in the Elliot NICU for any infant born at the Elliot who needs it. When we see how well these infants who needed that cooling therapy are doing months later when they come to the NICU follow up clinic, it is a wonderful celebration.

Host: Yeah, that brought a big smile to my face. The celebrations, I can sort of picture them in my head. This has been really fun and educational today. Just want to wrap up, give you a chance here to dispel any myths, if you will, or misconceptions about NICU care, that you would want to emphasize to folks.

Dr. Lauren Priolo: I think sometimes the most challenging admissions to the NICU are the ones that weren't expected. An infant might be delivered at term or a few weeks early after a completely normal pregnancy and those infants still might need NICU admission. Some infants might need help with their breathing after birth and that can't be known prior to delivery or an infant could show signs of infection or have blood sugar issues after birth. So, parents might view this as a surprise, understandably have a hard time understanding the need for the infant to be separated from them. Our goal in the NICU is always to keep infants with their parents, and we take separating infants from their parents to admit to the NICU seriously. So if an infant is admitted to the NICU, a thorough assessment of medical needs and what is in the infant's best interest is always done.

Host: Yeah, as you say that often the trips to the NICU, the stay in the NICU is unplanned, can cause some anxiety in parents, some concerns and questions. And, you know, I just know that feeling of being able to hold my babies like right after they were born, how, special and precious that was. And so, I can certainly understand how parents would feel not being able to do that. And as you said here, the goal is of course, to get them home as quickly as possible, safe, happy, healthy, all that good stuff. So, thank you so much for your time today. You stay well.

Dr. Lauren Priolo: Thank you. Take care.

Host: And for more information, go to theElliothospital.org/nicu.

And if you enjoyed this podcast, please be sure to tell a friend and share on social media. This is Your Wellness Solution, the podcast by Elliot Health System and Southern New Hampshire Health, members of SolutionHealth. I'm Scott Webb. Stay well, and we'll talk again next time.