Rational Baby Care

WELCOME LITTLE ONE.! Part 1 (Day 1)

Understand what to check in your baby before you are discharged

This blog is meant to create awareness about all the right things to be done during day 1 and 2 (unarguably the most important days in every baby’s life)

Day 0: Before the adventure:

Know how to read the monitor: The pulse oximeter is the most commonly used monitoring device on the baby after birth.

You can request the hospital staff to show you a pulse oximeter so that you are aware of what to look at when your baby comes into this world. It can contribute in reducing your stress as you are able to read the numbers. And, in case your baby needs resuscitation, you can very well absorb the inputs given by the pediatrician. It is important to know that a newborn can take up to 10 minutes to reach to a saturation level of 95%. Until then, if she is crying and moving her limbs, she is transitioning well.
Normal heart rate on CTG (fetal heart rate monitor) : Normal fetal heart rate is 120-160/ min. It is influenced by a number of factors. However, a heart rate of less than 120/min or more than 160/min if sustained, is abnormal. So, when you are waiting for the labor to progress, any such change in FHR (fetal heart rate) should be immediately addressed by your caregiver.
Request to keep delivery room temperature at 23-25 deg C: Modern day hospitals are usually fully air-conditioned. The room temperature in all labor rooms can be controlled in almost every set-up. As delivery is a tiring process, mum may perspirate. The hospital staff would be wearing drapes, which will increase their perspiration too. It applies both during normal delivery and C-section. But it is so important to remember that your baby comes out naked and wet. Therefore, a room temperature of at least 23-25 degrees is optimal for caring your baby after birth.
Make sure that a Pediatrician or Neonatologist is attending the delivery: It is critical that personnel with neonatal resuscitation skills be available for every birth.
Aside from the healthcare professional responsible for the birth (i.e., the physician or midwife), a second healthcare professional should be present whose primary responsibility is the baby and is capable of performing the initial steps of neonatal resuscitation, including effective ventilation and chest compressions. If this person cannot perform more extensive resuscitation (endotracheal intubation and administering medications), additional personnel with these skills should be available in the facility to assist immediately when called.

Day 1:
Delayed cord clamping: The world health organization (WHO) recommends late cord clamping at 1-3 minutes after birth. It should be done for all births while initiating simultaneous essential newborn care. It increases iron levels by providing extra red blood cells. This ultimately leads to 50% reduced risk of anemia at 6 months of age in your child. There is a transfer of extra stem cells and white blood cells which provide immunity.

Cried well/required help?: 10% babies require help at birth. The single most important determinant of baby’s condition is the heart rate. Any baby with a heart rate <100/min needs help. If the heart rate is <60, it is an emergency.
Color( pale/ blue): Any skin color other than pink is abnormal. The skin color is also dependent on the race and ethnicity of the baby.

APGAR: The Apgar score is a scoring system that assesses new born babies’ well-being using five different factors: heart rate, breathing, muscle tone, reflexes, and skin colour. Your new born baby will go through a number of assessments when they are first born, to make sure that they are in good health. Their first assessments, called the Apgar score, occur when they are just one minute and five minutes old.

Weight, Gender: Make sure to make a note of these important things about your baby.
Skin to skin contact: Skin-to-skin means your baby is placed belly-down, directly on your chest, right after birth. Your care provider dries your baby off, puts a hat on him or her, covers him or her with a warm blanket, and gets your baby settled on your chest. The first hours of snuggling skin-to-skin let you and your baby get to know each other. They also have important health benefits
• Calms and relaxes both mother and baby
• Regulates the baby’s heart rate and breathing, helping them to better adapt to life outside the womb
• Stimulates digestion and an interest in feeding
• Regulates temperature
• Enables colonisation of the baby’s skin with the mother’s friendly bacteria, thus providing protection against infection
• Stimulates the release of hormones to support breastfeeding.

First breast feed: Should ideally be done within 1 hour of birth. Skin to skin contact provides plenty of opportunities for the little one to breast feed.

Detailed examination: after skin to skin time
• How many arteries in Umbilical Cord? : The umbilical cord contains two umbilical arteries and one vein. Sometimes there is a single umbilical artery and recognized associations are found in 25-40% of cases with maternal and fetal implications. There is an increase in the incidence of congenital anomalies in such babies. Single umbilical artery can be diagnosed in antenatal scans, but if missed, examination at birth is the only chance to identify it.

• Vitamin K injection: prevents hemorrhagic disease of newborn
• Anal opening: The incidence of imperforate anus or anal atresia is 1 in 5000 live births. This disorder is frequently associated with other congenital anomalies such as VACTERL sequence (vertebral anomalies, anal atresia, cardiac malformations, tracheoesophageal fistula, esophageal atresia, renal anomalies and radial aplasia, and limb anomalies). An unidentified anal atresia usually results in disastrous outcomes for the baby.

• Swelling over scalp: The very process of birth causes accumulation of fluid and blood over various layers of scalp. The collection of fluid under the scalp skin is called as caput succedaneum and usually resolves in a week. But the collection of blood under the periosteum (the covering of scalp bones) is called as cephalhematoma and it takes 6-8 weeks to resolve. A traumatic delivery may result in a large collection of blood over scalp known as sub galeal hemorrhage; and this could lead to a low blood pressure and make your baby very sick. For both cephalhematoma and sub galeal hemorrhage, make sure to ask for a pain reducing medicine for your baby and get her bilirubin level checked before discharge.

• Molding: To facilitate delivery, baby’s head may undergo change in shape with the help of its mobile skull bones. The normal shape of head is usually restored within 48-72 hours of life.

• Bruise on face: Use of forceps during delivery can result in bruising over the area of contact. This is usually self-resolving and requires no intervention.

• Naso Gastric tube passes well? : A slender soft tube is usually passed through the baby’s nose into the stomach to ensure the patency all through. In conditions like choanal atresia wherein the baby’s internal nares fail to develop, the ng tube cannot be passed through the affected nostril. The tube may coil on itself if there is an underdeveloped food pipe- the most common defect of the esophagus in newborn. Early detection of these anomalies result in early referral for corrective procedures.

All the actions listed above is supposed to be performed by your caregiver. You can refer to this list to make sure that your baby has been thoroughly screened and manged well. I strongly believe that every baby has a right to quality health care. If unfortunately, it is not provided, being a parent you have the right to obtain it. Awareness to simple things leads to major changes in the neonatal outcome.

The part 2 of this blog will discuss about the important things which should not be missed on day 2 of life.

The Teeny Weeny bundle of Joy – A peek inside the modern day NICU

The objective of this blog is to make parents familiar with what usually happens inside the NICU. This is not meant to tell about the instruments of the NICU or the medicines, instead, it is to throw light about the daily routine and standard practices in a modern NICU.
I have subdivided this post into the following sections to facilitate easy navigation for the reader:

Even before you come to NICU
When the moment arrives
Inside-out
The critical period
Two steps forward and one step back
The long wait
The beginning

Even before you come to NICU:

For a large number of parents, NICU comes as a shocker. But a significant proportion of them will have at least a few hours in hand to be mentally prepared. Almost 1 in every 10 babies born, visit the NICU for some reason or the other.

Sometimes, due to medical reasons in the mother or identified problems in the fetus, a delivery would be a planned one. This is exactly the time when the Neonatology counselling should happen. The neonatologist should be able to tell you the expected course of events, the possible adverse outcome, probability of survival and an approximate duration of hospital stay. In general, every mother who comes under the category of a high risk pregnancy, should have a neonatal counselling done at the end of her second trimester

When the moment arrives: Irrespective of the suddenness of delivery, the hospital should be able to arrange for a neonatologist to be present at the time of delivery. Nothing can replace the clinical skill required to resuscitate a baby in the initial minutes of life. This crucial period has a direct impact on the long term outcome of the baby. Once stabilized, baby who is still sick will be taken to the NICU in a transport incubator. Your relatives may get a moment or two to look at your baby at this time.

The focus during this short period would be the manage TABC.
T: Maintain normal temperature of the baby
A: Maintain an open airway. Intubate if necessary
B: Ensure that baby is breathing. Ventilate if necessary
C: Ensure that baby has got a good blood circulation

Inside Out: This moment can be very overwhelming. But the scenario will allow you to accept the fact of NICU arrival as the nurses hand out a few forms to take your consent for admission, procedures and explain to you the rules of that particular unit. Take your time to read the forms and follow the instructions, get back to the nurse if you are not sure of what something means.

Look at the instructions for handwashing and the rules of NICU. The emphasis for a sterile environment and the attempts to reduce contamination of the unit is of vital importance and one must adhere to them for the safety of their own baby along with the others who are admitted in the same NICU. When the emergency procedures have been performed, you should be able to visit her right away..!

The NICU environment can be very stressful for first time visitors. Have a seat, breathe, relax, and look at the beautiful bundle of joy before you.

The Critical Period: The NICU journey is hard. The wires and tubes and beeps from the monitors are so overwhelming at first, but gradually you learn what they are for and how they are helping your little one.

The first 72 hours are always important for any baby inside the NICU, irrespective of its maturity or birth weight. However, the ‘critical period’ will be longer for a very preterm and a very small baby.

Ideally, the rounds start in the morning. A few units allow parents to attend the rounds of their baby. A detailed evaluation and discussion about the respiratory, circulatory, intestinal and neurological status is performed during the rounds. All the investigations are reviewed and a clear plan for the day is made. Usually an ultrasound examination of the head is performed on the completion of 24 hours of life. Reevaluations are conducted at every 2-4 hourly intervals and continuous monitoring is done inside the NICU.

Two steps forward and one step back: The one thing that an NICU experience teaches you is ‘PATIENCE’. Everyday starts with a ray of hope which stimulates you to grab your things and visit your baby. It drives you to pump milk and give it to the NICU nurse so that she can store it to feed the baby.

But, more than often, these tiny little babies tend to refuse feed or not tolerate it. Baby might throw up or have abdominal upset. A new infection may start at anytime or she may fail to gain adequate weight. These issues may weaken your morale, but it is a part of preterm birth. There are days of joy and amazement and other days of sadness, anger and guilt. Therefore, it is important to remember that although you were pushed one step backward, the progress chart is definitely moving forward.

The long wait: Depending on the maturity of the baby, the duration of stay in the NICU may vary. If baby has no acute concerns, is tolerating her feeds and started gaining weight, she can be shifted to a step down care unit. The journey towards discharge may have a few visits to the NICU.

Sometimes, medicines have to be continued through the intravenous route long after the baby is shifted out of NICU. This is the ideal time to make a list of all the questions you would like to ask the Neonatologist. When you are with the baby all the time, you will actually start having a lot of doubts in mind.

The beginning:

Finally the day of discharge arrives and your challenges will only rise. It is important to be trained in Basic Life Support and to know how to get help at home if baby becomes sick. Have a look at my previous blog about the things to be kept ready at home when you have a preterm baby.

The brave little kid fought through it when life’s first moments were the hardest. She is indeed a NICU MIRACLE.

There is no such thing as getting over the trauma of giving birth to a child prematurely. It permanently changes the world around you. Each new life, no matter how fragile or brief, forever changes the world.

NICU is a place for both miracles and tragedies, for both love and loss.

The Gut Feeling – Part 3

In brief about the anomalies which need surgical treatment in neonates

This is the last part in the series of blogs which discussed exclusively about the alimentary tract related issues in neonates.

The alimentary tract starts from the mouth and includes the esophagus, stomach, small intestine and the large intestine upto the anal opening. During embryogenesis, under development of any of these parts can lead to serious problems in a baby after birth. The complex process of organogenesis frequently fails to follow the usual developmental chronology and results in a variety of congenital defects and anomalies.

This blog will discuss briefly about the more frequently encountered conditions.

Tongue tie: Ankyloglossia or tongue tie is a condition where a short, tight lingual frenulum prevents the range of movements of the tongue. It may interfere with breastfeeding and can affect speech and pronunciation in the child. But it remains asymptomatic in many. A problem causing tongue tie is diagnosed if there is difficulty in lifting the tongue to the upper row of teeth, difficulty in side to side movements or if there is trouble in sticking out the tongue past the lower front teeth. If the tongue appears notched or heart shaped when protruded out, the tongue tie needs treatment.

Cleft lip and palate: This anomaly occurs when tissues in the baby’s face and mouth do not fuse as expected. They are among the most common birth defects and are almost always identifiable at birth. Occasionally a cleft occurs only in the muscles of the soft palate, which might go unnoticed at birth (submucous cleft palate)

All types of cleft palates lead to difficulty in feeding, nasal regurgitation of feed, nasal speaking voice and chronic ear infections.

Having a baby born with a cleft can be a huge shock for the family. But cleft lip and palate can be corrected by a series of surgeries to achieve a near normal appearance. A multidisciplinary approach helps in achieving normal speech, hearing and dentition.

Esophageal Atresia: A congenitally interrupted esophagus (food pipe) with or without an abnormal connection (fistula) with the trachea ( wind pipe) typically presents with frothing and bubbling at the mouth and nose. The inability to pass an orogastric tube in a newborn and the appearance of coiling of the tube on a chest x-ray is suggestive of Esophageal Atresia. Majority of children grow up to lead normal lives but complications are challenging especially in the first 5 years of life.

Congenital Hypertrophic Pyloric Stenosis: This condition occurs due to the thickening of the muscle in apart of the stomach called pylorus. It usually presents between 2-6 weeks of life. Boys are more commonly affected than girls. Symptoms include forceful vomiting, persistent hunger, visible wave like movements across baby’s abdomen, dehydration and poor weight gain. The surgical procedure to treat pyloric stenosis is called as pyloromyotomy in which the outer layer of thickened pylorus muscle is cut; allowing the inner lining to bulge out. This allows food to pass through to the duodenum.

Congenital Diaphragmatic Hernia: CDH occurs when there is hole in the diaphragm ,which is the thin sheet of muscle separating the chest from the abdomen. The presence of abdominal organs in the chest, limits the complete development of the lungs as a result of which baby develops severe respiratory distress after birth. CDH is one of the conditions where treatment is possible even before delivery, using fetoscopic techniques.

Intestinal Obstruction: More than 90% of intestinal atresia or stenosis occurs in the small intestine. Abnormal intestinal rotation during fetal development results in Malrotation which can inturn lead to Volvulus. Classic symptoms of Obstruction are vomiting, abdominal distention and obstipation ( inability to even pass flatus). The pictures below are self explanatory.

Meconium Ileus: This type of intestinal obstruction occurs when the meconium in baby’s intestines becomes very thick. Most of the babies with meconium ileus have Cystic Fibrosis. The obstruction can be so severe that the baby’s gut may perforate even before delivery and lead to meconium peritonitis. This may develop into a mucus cyst and result in multiple adhesions within the abdomen.

Gastroschisis and Omphalocele: Gastroschisis is a birth defect of the abdominal wall in which the baby’s intestines extend outside the peritoneal cavity. The defect can be large enough to allow the stomach and liver to herniated. Any baby who has Gastroschisis must have surgery after birth. About 10% of babies with this condition also have a segment of atretic bowel.

Omphalocele or Exomphalos is again a birth defect of the abdominal wall. Here the defect is at the umbilicus unlike Gastroschisis where the defect is adjacent to the belly button. The organs lying outside the abdomen in Omphalocele are covered in a thin, transparent sac. Some babies with this condition have associated congenital anomalies in the heart, spine or digestive organs.

Congenital Aganglionic Megacolon: This condition occurs as a result of missing nerve cells in the muscles of the baby’s colon. Typically, a neonate’s failure to pass meconium within 48 hours after birth should alert the doctor. Surgery to bypass or remove the diseased part of the large intestine is the treatment. Untreated cases may progress to enterocolitis.

Biliary Atresia: BA occurs in 1/10000-15000 live births. The most common type of BA affecting 85% cases is, obliteration of the entire biliary tree outside the liver. Most patients are normal at birth and the process of progressive obliteration may be an immune or infection mediated process. All patients with suspected BS should undergo exploratory surgery. For patients in whom no correctable defect is found, the Kasai procedure is performed. The success rate of this procedure is highest when performed before 8 weeks of life.

Apart from the above mentioned conditions, there are many others which are encountered less commonly. Early diagnosis is the key to good outcome. It is essential to deliver in a specialized centre when the diagnosis is made during pregnancy.

With his we come to the end of “The Gut Feeling “.

The Gut Feeling – Part 2

Part 2 deals with the gut related issues in a preterm baby.

By definition, any baby who is born before the completion of 37 weeks of gestation is called as a preterm. Although, there is no definition for an extremely preterm baby, in general, a baby born before completing 28 weeks of gestation is considered to be an extreme preterm. Most of the problems discussed in this blog are about extremely preterm babies. But they are also applicable to those who are born between 28-34 weeks gestation.

The intestinal length of a baby at 26 weeks is approximately 150 centimeters compared to 300-350cm at 35 weeks and upto 6 meters in adults.

It is therefore evident that a 26 weeker cannot be fed like a term neonate. Just like any other organ, the gut is also not ready for extra uterine life. But, the gut has to digest feed so that baby can grow. Hence is the need for gradual introducing of feed in the NICU followed by periodic assessment of digestive capacity by a Neonatologist. For example, by looking at the quantity and colour of the pre-feed aspirate and the presence of good bowel sounds one can assume that milk is getting digested.

Normal intestinal function requires a set of bacteria called the ‘commensals’. A bug which acts like a ‘commensal’ and is normally present in the gut of an infant, may produce disease in an extreme preterm. In addition, other bacteria which are easily contracted by a premie can cause very severe intestinal disease. Due to this susceptibility to sepsis, feeding needs to be initiated very carefully.

The human milk is so well engineered by nature that it perfectly suits the needs of a preterm baby. There are significant differences in the milk produced by a mother who delivered prematurely compared to the one who delivered at term. However, too early introduction of milk or over enthusiastic increment in the volume of feed can be detrimental.

The most dreaded disease of the preterm gut is – Necrotising Enterocolitis, which is usually referred to as NEC. Literally it means ‘an intestinal rot caused due to inflammation’!

NEC usually affects in the 2nd or 3rd week of life. The cause of inflammation leading to NEC is under debate. But it is proven beyond doubt that prematurity is the greatest risk factor for NEC. Formula feeding is an important contributory factor. Therefore, expressed breast milk is the preferred option for feeding followed by donor breast milk. Multiple commercial breast milk banks are now available who can provide pasteurised milk to babies admitted in NICU whose mothers have lactation failure.

A baby born out of a pregnancy marked by severe hypertension and doppler abnormalities detected in antenatal scans has a higher risk of NEC.

The early signs of NEC are vomiting, brown coloured oro-gastric tube aspirate, lethargy, temperature instability, increased heart rate and respiratory rate (due to pain and increased metabolism). It can progress to abdominal distention, constipation, acid build-up in blood, low platelet count, fluctuations in blood pressure and increasing oxygen requirement. If not identified and treated early, the bowel can perforate and release gas outside the gut. Following this event, the baby’s clinical condition gets very critical.

An X ray of abdomen usually reveals good number of signs indicating NEC. An experienced Neonatologist can detect a vulnerable segment of gut before perforation. It is important to stop feeding and help the gut recover to prevent it from deteriorating. In addition, antibiotics will be essential.

There is no definitive treatment for NEC. A pediatric surgeon will also be involved in the management of a baby having NEC because, failure of conservative management warrants surgical intervention (medical management fails in 20-40%). Premies with NEC who require surgery or who had concomitant bacterial infection in the blood stream are at risk of adverse neurodevelopmental outcome.

It is important for a parent to know what goes behind detecting NEC and managing it, because the outcome of NEC can be disastrous even after the best efforts of the treating team.

Part 3 of the ‘Gut Feeling’ will be about surgical conditions in neonates.

The Gut Feeling- Part 1

In this blog, I will discuss the common issues related to the intestinal health of a term baby. The part 2 of this blog will be about the abdominal issues of a preterm baby.

A newborn baby should start breastfeeding within on hour of birth irrespective of the mode of delivery ( Normal delivery/ Caesarian Section). A full term baby will posses mature sucking-swallowing reflex which allows it to feed on breast immediately after birth. The breast milk output is minimal in the first 2 days after delivery. But, that amount of milk is sufficient to satisfy the needs of the baby, provided the latching and feeding techniques are appropriate.

Exclusive breastfeeding is possible if mother is educated about feeding skills

The signs of successful breastfeeding are:

1. Baby should sleep for 2-3 hours after feeding.

2. Baby should pass urine 8-10 times per day

3. During feeding, mother should be able to hear the gulping sound made by baby while swallowing milk.

4. Baby should gain 25-30 grams of weight per day ( in the first 3 months of life).

5. Mother should feel her breast empty after completion of feed.

6. There should be overflowing of milk from the opposite breast.

“Although, breast feeding is a natural phenomenon, it requires plenty of patience and skill”.

After about 2 weeks of life, timed feeding is not necessary. A full term baby can start feeding on demand. It is important to burp the baby both midway of the feed and after completion of feed. Even then, many babies spit out some milk. This should not be worrisome if baby is otherwise active, passing urine well and has no temperature fluctuations.

Vomiting and feed regurgitation are not the same

Vomiting, on the other hand , is a cause for concern. In the first few hours, babies can vomit as a result of gastric irritation caused by swallowed maternal blood during delivery. Vomiting related to this cause usually subsides after the first few feedings. However, if the vomiting is persistent, the cause should be evaluated. Congenital obstruction of the digestive tract, inborn errors of metabolism or increased pressure in the skull can all cause incessant vomiting. Episodes of forceful vomiting at any age, needs further evaluation. Hypertrophic Pyloric Stenosis presents in the above fashion.

The neonatal intestine is a sterile area at birth, and gets quickly colonised by commensal bacteria within a matter of few days. The initial stool colour is dark green, which contains the material ingested during fetal life like cells shed from the baby’s body, hair, amniotic fluid, cells and debris from the intestinal lumen, and the dark green colour is due to the digestive juice called bile.

By the second day of life the stool colour is light green with speckles of yellow. The colour will change to golden yellow by the next 24-48 hours. An exclusively breastfed baby can pass stools 2-12 times per day or pass once in 4-5 days. As long as the baby is feeding well, is active and has no temperature fluctuations, one need not worry.

Due to a phenomenon called Gastro-Colic reflex, baby will pass stools immediately after or during a feed. This is normal and does not indicate diarrhea. Also, baby can have hiccups irrespective of its feeding status and can pass flatus multiple times throughout the day. If baby has not passed stools even after 24 hours of birth, observation or further evaluation is necessary

Hypothyroidism can also cause delayed passage of meconium

Suspected abdominal pain due to Colic is largely an over diagnosed and over treated condition. Kindly refer to my previous blog for further information regarding what a parent should do if a baby is crying continuosly.

At any point of time, an increasing size of abdomen is a red flag sign. In the same way, blood in stools or in the vomit is never normal.

In the second part of ‘ The Gut Feeling’ let us find out more about the diseases of the preterm intestine.

The ALVEOLUS

Hello there, this is my story of struggle against all the odds of being born too soon. I am a small sac like structure, at the end of a vast branch of a tree like structure called the ‘bronchial tree’. I have a good supply of pipelines which carry blood to and away from me, because of which I can supply oxygen and take away carbon dioxide. I am densely surrounded by multiple other sacs who are just like me. My name is ALVEOLUS.

I was formed after a result of multiple branching of a single bud which would be the future airway. My development will continue even after baby reaches full term and stops after around 5-7 years of age.

But when I was still very young, very immature, I had to face a big challenge. The baby in whom I was residing was less than 1 kg in weight. After all, mummy had been carrying her for just 26 weeks. That time, I was still waiting for the special chemical called Surfactant to be produced by the cells lining me. The surfactant would give me the ability to respire.

Just a few days later, mummy had a problem and the baby inside which I was residing, was delivered. I was not at all ready for independent survival and was struggling to even inflate myself to allow any air exchange. Soon my cavity was filled with a thick substance due to which I could no more contribute towards respiration. The baby was rushed to the Neonatal intensive care unit (NICU). My home, the lung was diagnosed with Respiratory Distress Syndrome (RDS).

The chemical which was missing in me, the surfactant, was therefore given through the airway. The surfactant prevented me from collapsing into an empty bag and helped me inflate into a balloon. Exchange of Oxygen with carbon dioxide was finally possible. However, that alone was not enough. The baby had to be ventilated with appropriate pressure, oxygen concentration, humidification and at a set rate of 45 breaths per minute. This ensured good oxygen supply to the whole body.

My neighbouring Alveoli were harbouring bacteria acquired during delivery and that was resulting in a pneumonia. The benefits of surfactant was almost getting nullified by bacterial invasion. As the baby was very premature, she could hardly put up a fight against the bug. Hence, intravenous antibiotics were stared. After almost 2 days of starting the antibiotics, the bacterial infection gradually started reducing and the air exchange was better.

One day the tube which was inserted into the airway started blocking one of the main branches of the bronchial tree. As a result, the entire left lung, the same in which I was residing, collapsed and the oxygen levels in the baby started dropping. The collapse of the lung was evident in the x-ray. It required a repositioning of the tube, cleaning of the lumen by suctioning and a few days of chest physiotherapy to reinflate myself and other collapsed parts of the lung.

By this time I was almost 5 days old, still requiring the help of ventilator, still very sick and vulnerable. It was then, that a new infection took hold of the baby and led to a drastic drop in the platelet number. Suddenly I was filled with blood, so much blood that it filled up the whole bronchial tree and spilled out of the baby’s mouth. The bleed was relentless and threatened the very survival of the baby. Timely transfusion of platelets and plasma along with additional support through the ventilator, resulted in control of bleeding in the next few hours. By this time, my home, the lung had suffered significant injuries and was susceptible to more damage by trivial factors, let alone another pneumonia or a collapse.

When I was only a week old, I was slowly healing myself and my elasticity returned to normal level. However as I was under the control of a machine (Ventilator), my elasticity was underestimated and the same pressure which was set earlier when I was sick was delivered to me. When the pressure received was much more than my capacity to expand, I GAVE AWAY.. Air started leaking out of me into the chest cavity, around the heart, in-between the other Alveoli and even underneath the skin. It was given various names like pneumothorax, pneumomediastinum, interstitial emphysema, subcutaneous emphysema etc. This air was compressing the lung due to which even the normal Alveoli strated to collapse bringing air exchange to a halt. Hence, the air had to be drained immediately.

The air leak almost took the baby to the brink of death…. timely drainage of the air present in the unwanted space, gave a new leash of life. The baby was finally taken off the ventilator and put on bubble CPAP support. Occasionally, baby was forgetting to breathe, and this led o drop in her oxygen saturation and heart rate. This problem is called as Apnea. A medicine by name Caffeine was given to the baby to reduce these episodes and CPAP was an ideal choice to continue air exchange even during apneea.

The breathing support was gradually reduced over the time of weeks but I was still requiring oxygen therapy. It was almost 2 months since birth…a variety of medicines had been started to help me come off oxygen dependency. The baby was otherwise doing well and was ready for discharge from the hospital. I was fitting into a disease by name Bronchopulmonary dysplasia (BPD) which meant, permanent changes in my home-the lung due to the premature birth, RDS, pneumonia, ventilation, pneumothorax etc. The baby was discharged on oxygen after almost 100 days of hospital stay.

Right now I am breathing without any oxygen support and the baby is 4 months old. The battle has been won and I look forward to a healthy life ahead.

Is your home equipped to manage a preterm?

This blog has everything about the essential steps to be taken to welcome a NICU graduate home

After all the battle fought in the NICU, your brave little one is ready for discharge. You cannot wait to take your little wonder home and experience motherhood in the comfort of familiar surroundings. Days of fear and uncertainity, weeks of anxiety and stress are finally over.

But is your house suitable to become a step down care for the tender life?

Yes, you have to be very careful and understand that it is going to be challenging. This blog will help you prepare well in advance for the arrival of your baby who is healthy but vulnerable.

The Ten ‘MUST HAVES’ :

1. Hand sanitizer: Have a stock of at least 1 litre of sanitizer. The need for strict hygiene cannot be overemphasized, as you are very well aware of the routine procedures followed in the NICU before you were even allowed to go near the baby. Hand washing with soap and water is the gold standard, however, in between the handwashes, hand sanitizer is a must. Keep it in multiple dispensers all around your house so that you can have access to it at all times. Avoid the ones with strong perfumes.

2. Medicines: (Nasal Saline Drops and Diaper rash cream): Apart from the medicines prescribed to you at the time of discharge, you will definitely need two extra medicines. The first one is Nasal Saline drops. Your little one’s tiny little nose can get blocked by mucus, milk feed or regurgitated feed. Although it sounds trivial, nasal block can cause significant trouble during sleep and feeding. Saline nasal drops contain salt and water which matches the body fluid’s osmolality. Hence it acts like a lubricant and helps baby swallow the substance blocking the nose. These drops can be administered 4-5 times a day, 1 drop in each nostril followed by slight massage of the nose. The diaper rash cream is another essential medicine which should always be there with you. It is preferable to apply coconut oil or a barrier cream before using a diaper to prevent rashes in the first place. There are many brands in the market, but my personal favourite is SEBAMED diaper rash cream.

3. At least 4 feeding sets: Feeding can be performed by anything which is convenient to you. Pallada, spoon katori, bottle with spoon or bottle with nipple. But all the utensils, bottles and nipple should be sterilised before each use. As feeding a premie takes a long time, you might have less time to do the cleaning work. Therefore, have multiple sets of feeding equipments ready.

4. Breast Pump: Manual or electric breast pumps are readily available in the market. Electric ones cost at least 6-8 times more than manual pump. Both are equally effective in extracting milk. The advantage of electrical pump is that, you are free to rest, read, browse, knit or even cook while pumping milk. Please remember to sterilise all the parts of the pump which comes in contact with milk, before every use. Excess milk can be stored in air tight containers or breast milk storage bags which are available both online and in pharmacies.

5. Sterilizer: It should now be clear to you that there is so much cleaning work to do. Sterilising feeding equipments by boiling method is tedious and time consuming. Moreover, one is never sure about the effectiveness. No-touch technique cannot be practiced strictly when sterilising by boiling method. Hence, a Sterilizer is a must. Sterilizer of a medium size is available for around 2.5-3000 rupees and lasts for years.

6. Portable Saturation probe: Your baby was under continuous monitoring in the NICU. Baby would have been under constant observation in the nursery and ward too. But after getting discharged, close observation by a medical personnel is not possible. Therefore, the use of a portable saturation probe which gives a reading of both the oxygen saturation and the heart rate is advisable. In addition to the various pre-existing lung conditions like BPD ( bronchopulmonary dysplasia), a preterm baby is also susceptible to lung infection, aspiration pneumonia etc. Premies are too weak to show symptoms of sickness early. An increase in heart rate or a low oxygen saturation are warning signs to take the baby to the hospital. The normal oxygen saturation level is above 98%. The normal heart rate is 130-160 beats/ min.

7. Cradle with firm mattress: It is very important not to sleep with the baby on the same bed. Use a cradle instead. Accidental suffocation by blanket, pillow, any body part of mother like hand or breast can lead to SIDS ( sudden infant death syndrome). For the same reason, a firm to hard mattress is recommended. A soft and fluffy one can easily block the nose.

8. Thermometer: Temperature maintenance is the key factor in taking care of a premie. Prevention of hypothermia helps in better weight gain and lesser infections. The no-contact thermometers are preferred. Check the temperature at least 4 times a day. Normal temperature is 36.5-37.5 deg C or 97.7-98.7 deg F. BEMPU watch is a great alternative, but it does not indicate fever. Fever in a premie is a medical emergency and in that case, you have to rush to the hospital immediately.

9. Underpads: An underpad is nothing but an absorbent sheet of cloth. You would have seen it in hospitals. When purchased online, they are available at 20 rupees per sheet. One underpad can be divided into 4 parts and used throughout the day.

Don’t want to use a diaper but still avoid the mess? Use an underpad instead

10. Electronic Appliances: (Washing machine, Water purifier) : For obvious reasons, a washing machine is unavoidable. Believe me, there will be mountains of clothes. It is advisable to use a machine which has provision for washing kids clothing at a higher temperature. Also use of disinfectant fluids like Dettol/ Savlon is recommended during washing. Another compulsory appliance is a water purifier with UV and RO system, because, you can never be sure about the safety of the water provided by the municipal corporation or the supply from a bore well. Ground water contamination and mixing with sewage water in the pipelines is a reality.

You have a huge task at hand, be both careful and confident. Best wishes.

Every cry is NOT Colic.

There are 4 important things to do when your baby cries incessantly:

1. Feed the baby: Hunger is the most common reason for crying. A baby who is fed well; sleeps well and plays well. Irrespective of the type of feeding, baby will exhibit some clues that he/she is hungry ( eg: opening mouth widely, sucking the fingers etc.. which will gradually progress to a stage of crying). Remember to burp after every feed.

2. Check the nappy: The feel of a full bladder or the pressure of bowels is itself enough to make your baby uncomfortable and result in crying. The same is true after wetting the nappies. Wearing a diaper helps keeping the bottom dry, but it doesn’t guarantee a cry free behaviour. However, if you consistently observe that baby cries during the passage of urine, then he/she could be having a urinary tract infection. Please consult the doctor.

3. Check the temperature: Babies do not like being too cold or too hot. Measuring the temperature, preferably with a forehead thermometer is useful ( measuring temperature in the mouth or armpit in a crying baby is difficult). Normal temperature is 97.7-98.7 deg F or 36.5-37.5 deg C. If the child is cold, put on cap, mittens, socks and an additional wrap and recheck the temperature after an hour. If hot, unwrap the baby, recheck after 1 hour. If the temperature is still above 99 deg F, please visit the hospital.

4. Look for rashes: Two types of rashes are notorious to cause incessant crying. First and the most important is a painful diaper rash. The second is the rash produced at the site of insect bite. Bite by a honeybee or a wasp causes enormous pain. But it is important to know that mosquito/ ant bite can also result in equally long duration of cry in babies.

“Knowing the reason for cry is more important than stopping the cry”

My baby cries for none of the above reasons. Now what?

Baby might be crying to gain your attention. Holding baby close to the chest calms it down. Take him/her outside the room. A car ride might help. Bike ride is not advisable. Music would be soothing, also a lullaby can do wonders. Babies love moving objects and are happy watching moving vehicles, birds, toys, projecting disco lights etc. Meanwhile, remember to avoid exposure to mobile, laptop or TV screens.

When nothing works, it is possible that baby might be having a colic. Abdominal Colic is a diagnosis of exclusion. Every cry isn’t due to Colic. Therefore, one should not administer medicated drops which have no scientific evidence. Homemade cocktails like asafoetida water, jeera water, ajwain extract, garlic infused oil, various kashayaas are equally dangerous.

When should you be worried?

1. If baby is unresponsive between the crying episodes/ has abnormal body movements/ turned blue- It could be a seizure

2. If baby is not feeding well

3. If baby is unusually sleepy, less active and dull

4. If there is fever

Do not become overwhelmed by the responsibility of parenthood. Raising a child requires a mountain of patience. Keep in touch with your doctor and avoid unnecessary anxiety.

The 3 golden rules to follow when you have a newborn at home.

Becoming a parent is a huge responsibility. The survival of your baby/ babies is entirely dependent on you. Once you are ready to be discharged from the hospital after delivery, a huge task stares at you. Therefore it is essential to have a clear picture of what are the do’s and don’ts when there is a newborn baby in your house.

The 3 Golden rules are separate for parent and baby.

For the parent:

1. Hygiene– Wash your hands with soap and water after changing the baby’s nappy and use a hand sanitizer everytime you touch your baby. Sterilise all the utensils/ feeding bottles/ pacifiers after every use. Minimise the number of visitors and keep away from people who are sick. Any person who went out of house should wash hands with soap and water after entering the house.

2. Don’t be a supermom– Dedicate your entire time to your baby. Your body is just recovering from a birth and is vulnerable. In addition, you also need adequate rest and sleep. Take help for household chores and for cooking. Physical exhaustion and fatigue significantly affects breast milk output and bonding with your baby. Spend adequate time on yourself so that you are not overwhelmed by motherhood.

3. Don’t Google everything– Anxious googling will lead to scary results. This adds to the stress and you can land up in confusion. Unreliable sources of information might suggest dangerous ‘remedies’ for the presumed issues in your baby. Always consult the expert.

For the baby:

1. Warmth– Use of a cap, mittens and socks is compulsory. A single wrap would be sufficient in summer, and additional layers would be required in winter season. Make sure that the palms and soles are pink in colour and they are as warm as the baby’s tummy. Temperature should be measured by a thermometer at least twice a day. The normal temperature of a baby is 36.5-37.5 deg C/ 97.7-98.7 deg F. Depending on the environmental temperature, usage of fan/ cooler/ AC/ warmer is not harmful. If using AC, keep the temperature at 25-26 deg C. Never use a plastic lined wrap.

2. Feeding– In the first 2 weeks of life, feeding should be 2-3 hourly, both during day time and during the night. After this period, demand feeding can be practiced. The more relaxed you are, the more successful will the breastfeeding be. Stress, tiredness, poor mental health, negative thoughts will drastically reduce breast milk output. A nutritious diet will improve the quality of milk. Please burp after every feed.

3. Keep the lights on– A well lit room is a prerequisite to detect even subtle changes in baby’s skin colour/ activity. This is true even when it gets dark. Never switch off all the lights. You never know, a small piece of blanket on baby’s nose can suffocate him/her. Also, a small amount of milk regurgitated by baby can block the airway and cause choking if not identified early.

I have tried to keep things simple and have highlighted the absolutely essential things which you should remember.

What is this page about?

The branch of pediatrics deals with the health issues of babies from the moment they are born, till the age of 18yrs. Neonatology is a sub-speciality of pediatrics which deals with the health of babies below 1 month of age. As a matter of fact, Neonatology takes care of the most tender and vulnerable babies.

Every year millions of preterm babies succumb to easily preventable and treatable ailments. This is especially true in less developed countries where basic health care is sparse. Neonatal mortality is the leading contributor to under 5 mortality in India. Education and awareness of parents goes a long way in preventing neonatal mortality as they became aware of danger signs and seek timely medical attention.

It is equally true that parental awareness reduces unnecessary anxiety and panic. Empowering parents also reduces the hospital visits for trivial issues. Knowledge is contagious. Thus, in the long run I hope to reset the mindset of at least a few families.

In the vast ocean of knowledge available, common man is frequently misled by false claims. I am attempting to bridge this gap in neonatology with the help of this blog.

Almost every good doctor will have an urge to educate in his/her own style. This is my way of explaining every change occuring in baby’s body in the simplest way possible.