Bright and early

When Gail Adler got her first job out of nursing school in 1978, neonatal intensive care units—which care for ill and premature newborns—had only recently been established at many hospitals.

“Neonatal Units—we called them intensive care nurseries back then—were just coming into being,” she said.

Adler has spent her entire career working in neonatal care for Renown Health, formerly Washoe Medical Center. Today, Renown Regional Medical Center's NICU is equipped with advanced technology and capable of providing care for 39 infants at any given time.

Adler said the advancements in technology during her nearly 40-year career have been astounding. She cited the incubators in which babies in the NICU are kept, calling them “Cadillac versions” of the models used in years past—with humidity control, radiant heat, special UV lamps for treating jaundice, and more. But even four decades ago, the hospital's NICU was on the forefront of neonatal care.

When Adler started, a local pediatrician named Dr. Donald E. Pickering was in charge of the hospital's NICU and had developed a mobile life-support unit for transporting ill and premature infants from outlying areas to the hospital. In 1979, the Reno Evening Gazette ran a story about a baby who had, a few years earlier, been saved by Pickering and “his ‘miracle machine' … a portable Infant Life Support Module (ILSM) … that can be tucked in a small airplane or van for quick transport of a tiny infant to an intensive care facility.”

The ILSM was compact, with a ventilated carrier for babies and equipment to monitor their vital signs, including the heart rate, electrocardiogram pattern, respiratory rate and pattern, body temperature and blood pressure. For years, Pickering would drive or fly his own small plane to pick up infants, taking along the ILSM and nurses from the NICU to assist him. Adler was among those who joined him and recalled the sometimes tricky conditions under which it had to be done.

“We used to fly to Lovelock, and they didn't have any landing lights,” she said. “We'd call the fire department, and they'd call the firemen in, and they'd all put their headlights on the runway, so we could land.”

The early models of the ILSM, Adler explained, could also present difficulties.

“The transport unit—you couldn't really secure it very well,” she said. “You had to take the wheels off. You had to hold onto it when you went around corners.”

But it was a revolutionary technology, nonetheless, said Adler. She's now Renown's neonatal transport unit coordinator and in charge of training the medical professionals who use it. The unit in use today is an evolution of the first ILSM created by Pickering, who sold the patent to a company called International Biomedical. According to Adler, the latest iteration—called an AirBorn Transport Incubator—is a mainstay at many hospitals. In Reno, Saint Mary's Regional Medical Center also has one, and the two hospitals take turns being on call to the surrounding communities—switching off on a weekly basis.

Adler explained that advancements in the NICU often result from improvements made to existing technologies and treatment methods. And—as was the case with Pickering in the '70s—advancements in local NICUs are often driven by the medical professionals who work in them. This is true at both Saint Mary's and Renown, where the respective NICUs rely on many of the same technologies and techniques but also branched out with new ones.

Mothers' milk

In the NICU at Saint Mary's, there's a team of medical professionals who call themselves the “NEC team.” Their goal, according to NICU clinical dietician Margaret Olander, is to prevent babies from developing necrotizing enterocolitis—a condition where a portion of the bowel dies. And a key to preventing it, she said, lies in breast milk.

In 2012, the American Academy of Pediatrics released a policy statement that recommended feeding premature babies human milk, based on findings suggesting it can have “significant short- and long-term beneficial effects,” including reducing the rate of NEC by a factor of at least two.

But nurse Erna Cordeiro, Saint Mary's NICU manager, explained that mothers of premature babies often don't produce enough breast milk. Sometimes, she said, a mother might produce only 20 calories worth at a time. There are, of course, other ways to get breast milk to newborns. Donor breast milk programs have been popular for years, but according to Olander, they're not all created equally, and some can pose risks for premature babies.

To be safe, Olander explained, donor milk needs to be tested for blood borne pathogens and adulteration, and that's why Saint Mary's NICU began working with a company called Prolacta Bioscience. Its product, Prolacta Plus, is a 100 percent human milk-based liquid human milk fortifier.

“So the reason we use it in the NICU is that it's so highly tested,” Olander said. “We know that the likelihood of there being anything in the milk that could harm our babies is extremely, extremely low. There's no HIV. There's no hepatitis. There's no cow's milk. We know exactly what we're getting.”

And the product is only available to hospitals and NICUs, she said. At Saint Mary's, Prolacta Plus has been in use for three years now. And, in the meantime, Olander and the NEC team have been exploring additional ways to supplement premature babies' nutritional needs. Recently, they began adding probiotics to the diets of their NICU patients.

New point of view

In hospitals like Renown and Saint Mary's, highly advanced incubators—the “Cadillac versions” as Adler calls them—are pretty standard these days. Most are double-walled, to provide sound and temperature insulation. In addition to humidifiers and UV lights, they often have built-in scales for weighing their occupants. And at Renown, they recently got yet another new feature.

The NICview is a small, adjustable web camera. Clipped to an incubator, it provides a 24/7 livestreaming video that parents and families can log in to a website to view. The idea, according to NICU manager Jessica Bakke, is to provide parents and families with a little peace of mind.

“It has slowed down some of those phone calls,” Bakke said. “You know, moms wake up at two o'clock in the morning, and they can't sleep. They're panicked—because nobody wants to leave their baby here.”

Now, she said, they can log on any time and see that their child is doing fine

“They can see their baby and know that they're sleeping or resting and everything's OK,” Bakke said. “So peace of mind—and also I think it has really brought on a little bit more family bonding.”

Bakke explained that the visitation rules in the NICU are strict. During flu season, for example, no one under the age of 18 is allowed to visit. This can be hard on siblings of premature babies.

“Babies can be here for three, four months, and their siblings at home—they don't understand,” she said. “They have no idea what's going on. Now, the siblings can log on and see the baby in real-time—also, grandparents across the world, or if you have a dad that's deployed.”

Back to basics

High-end technology plays a crucial role in modern NICUs, but not all of the advancements made in NICUs are tech-based. At Saint Mary's, for example, a new treatment was introduced a few years ago to the NICU that required no additional equipment. It's called kangaroo care, and according the nurse Dawn Miller-Hanna, it's remarkably simple.

“Kangaroo care is the process of having a baby clothed only in a diaper go chest-to-chest, skin-to-skin with a caregiver,” she explained. “What that does is allow the baby to—for one—get contact with a parent, but then there are about 30 other different benefits that happen.”

According to Miller-Hanna, babies who are held in what she calls “kangaroo mode” on a mother or fathers chest receive benefits in the form of quickly stabilized vital signs.

“And it helps improve their oxygenation,” she said. “We've seen babies go into kangaroo care and be able to decrease on their oxygen while they're being held by their parents. It also decreases cortisol levels. They actually say that three consecutive hours of being in kangaroo mode equals two weeks of brain development that would happen in the incubator.”

Miller-Hanna and other Saint Mary's nurses have been helping parents engage in kangaroo care since 2015. Two-and-a-half years ago, Laurie Worthington and her husband, Robert, were among those parents. In a recent phone interview, Laurie recalled the experience.

“My pregnancy, until I went to the hospital, was perfect,” she said. “And then I went to the hospital, and they're like, ‘You're going to have your baby right now.' And I said, ‘No, I'm not—not me.' They brought someone in from the NICU. My husband went for a tour of the NICU. I wasn't able to go, because I wasn't able to get out of bed. So he went, and I was still, like, ‘No, my baby is not going in there. We're going to be fine. And when she's born, we're going to go home.' I still remember thinking, ‘We're going home. I don't know what they're talking about.'”

Laurie was only 27 weeks pregnant when she gave birth to her daughter, Alice, and the family ended up spending a total of 87 days in the NICU.

Alice weighed less than two pounds when she was born. For the first several days, the Worthingtons couldn't even hold Alice. But, when it was safe, they were taught about kangaroo care.

“They make you put them on your chest—just their little bare bodies on your chest,” she recalled. “They put warm blankets over them and hats on them.”

Laurie and Robert would take turns holding Alice in kangaroo mode—holding her against their bare chests for a minimum of an hour at a time.

“It was a pretty big thing to even hold her,” Laurie said. “It's overstimulating for them to be moved around a lot. So if we didn't have an hour to sit there, we couldn't hold her. She was on lots of stuff to help her breathing and her nutrition. So she had all kinds of cords and wires and everything. … It was just a lot to make sure all of the cords and everything didn't come off. That was a lot.”

But, according to Laurie, it also paid off. Alice—who is the healthy older sister to twin 10-and-a-half month old girls—now lives in Kentucky, where the family relocated in December.

At Saint Mary's, more and more families are being encouraged to try kangaroo care, and Miller-Hanna said the treatment is improving outcomes in the NICU.

“When we initiated our kangaroo policy in 2015, we had 33 percent of our babies going home before 38-and-a-half weeks,” she said. “After we initiated our kangaroo care policy, we now have 77 percent of our babies going home before 38-and-a-half weeks.”