Your baby is in the NICU, and what the machines and alarms mean

If your baby has just been taken to the NICU (neonatal intensive care unit), the room can feel frightening. Most of what you see is there to keep your baby warm, watch the heart and breathing, and help with feeding. Most alarms are not emergencies. Here are plain answers to the questions parents ask Dr Dutta most in the first few days.

What is a NICU and why has my baby been admitted?

A NICU is a ward where newborn babies who need extra help get close, round the clock care. Babies come in for many reasons: being born early, breathing trouble, infection, low blood sugar, jaundice, or simply to be watched for a day.

Admission does not always mean your baby is very sick. Some babies stay for a few hours. Others, especially those born very early, stay for weeks. Ask the doctor two simple questions on day one: "Why is my baby here?" and "What has to happen before my baby can come out?" The answers give you a map for the days ahead.

Why is my baby in an incubator or under a heater?

Small babies lose heat very fast, so the incubator or warmer keeps their body temperature steady. Staying warm saves energy for breathing and growing.

A premature baby has thin skin, little fat and a large skin surface for their size. Water leaks out through the skin and takes heat with it. A large Canadian study of babies born before 33 weeks found that problems such as brain bleeds, gut infection and death were lowest when the temperature on arrival in the NICU was between 36.5 and 37.2 degrees C.¹

• An incubator is the closed plastic box. It keeps the air warm and moist.
• A radiant warmer is an open bed with a heater above it. We use it when we need quick hands-on access.
• A small probe taped to the tummy tells the machine how warm your baby is.

Moving to an ordinary cot is a real step forward.

What do the numbers on the NICU monitor mean?

The monitor usually shows heart rate, breathing rate and oxygen level, and sometimes blood pressure. The nurse looks at these numbers together with how your baby looks.

• Heart rate comes from small sticky pads on the chest. Newborn hearts beat much faster than ours, and the rate goes up with crying or handling.
• Breathing rate also comes from the chest pads. Premature babies breathe unevenly, with short pauses that are often normal.
• Oxygen saturation (SpO2) comes from a soft light sensor on a hand or foot. It shows how much of the blood is carrying oxygen.
• Blood pressure may come from a cuff or a thin line in a blood vessel. Normal values in tiny babies are much lower than in adults.

What oxygen level is normal for a premature baby?

For a premature baby who needs extra oxygen, doctors usually aim for a saturation between 90 and 94 percent, not 100.² A reading of 92 is usually exactly what we want.

Too much oxygen can harm the growing blood vessels in the eye. Too little can be dangerous too. In a large American trial, babies kept at a lower range of 85 to 89 percent had less severe eye disease, but more of them died.³ When five trials were pooled, the lower range again meant more deaths and more serious gut infection, but fewer babies needing eye treatment.⁴ That is why units now aim for the middle band.

Why do NICU alarms keep going off?

Most NICU alarms do not mean danger. A loose sensor, a wriggling baby or a finished syringe pump all make the machines beep.

One American study counted alarms in a NICU and found an average of about 177 alarms per baby per day. When doctors checked the heart tracings behind the most urgent heart rhythm alarms, more than 99 percent turned out to be false.⁵

Nurses learn to look at the baby first and the screen second. A pink baby who is moving, with a messy wave on the screen, usually has a slipped probe. My advice is simple: watch your baby, not the numbers. If your baby looks different to you, tell the nurse straight away.

What are apnoea spells and why is my baby on caffeine?

Apnoea means a pause in breathing that lasts too long or makes the heart rate or oxygen drop. It is common in premature babies because the part of the brain that controls breathing is still immature.

Caffeine gently stimulates breathing. In a trial of more than 2000 very small babies, caffeine meant fewer babies still needed oxygen at 36 weeks, and breathing support could stop about a week earlier.⁶ WHO now strongly recommends caffeine to treat apnoea in premature babies.⁷ It is the same chemical as in tea, given in a carefully measured dose.

What is the difference between a ventilator, CPAP and high flow?

A ventilator breathes for your baby through a tube in the windpipe. CPAP and high flow only help your baby breathe on their own.

• Ventilator: for babies who are too tired, too sick or too small to breathe well enough.
• CPAP (continuous positive airway pressure): gentle air pressure through small nose prongs or a mask. It stops the tiny air sacs collapsing. WHO strongly recommends CPAP for premature babies with breathing distress.⁷
• High flow: warm, moist air through thin nose prongs, often used as babies get better.

European guidelines advise starting breathing support without a tube whenever possible and avoiding a ventilator if the baby can manage.² Moving down this ladder is progress, even with a few steps back on the way.

Why can my baby not cry while on a ventilator?

The breathing tube passes between the vocal cords, so no sound can come out. Your baby may still be making the face and movements of crying.

This silence upsets many parents. It does not mean your baby is in pain all the time. Nurses look for signs of discomfort and give comfort or medicine when needed. Once the tube comes out, the voice comes back, though it may be hoarse for a day or two.

What are all the tubes and lines attached to my baby?

Most lines either give fluids and medicines into a vein or give milk into the stomach. They are put in so that your baby does not need repeated needle pricks.

• Umbilical lines: thin tubes in the belly button stump in the first days. Putting them in does not hurt.
• PICC line: a long, thin line through an arm or leg vein for longer courses of drip feeding.
• Feeding tube: a soft tube through the nose or mouth into the stomach. Very premature babies cannot yet suck, swallow and breathe together, so your milk goes down this tube.
• Blue lights: phototherapy for jaundice, with soft shields over the eyes.

Who are all the people looking after my baby?

Your baby is looked after by a team led by a consultant neonatologist (a children's doctor trained in newborn intensive care). The nurses are with your baby most of the time.

• Consultant neonatologist: leads the unit and makes the big decisions.
• Resident doctors and fellows: present day and night, and usually the first to see your baby if something changes.
• NICU nurses: often notice small changes before any monitor does. Learn their names.
• Others: lactation counsellors, physiotherapists, the eye doctor for the ROP check, surgeons or heart specialists when needed.

In joint families, Dr Dutta suggests one or two people act as the main contact. Information passed through five relatives tends to change on the way.

Can I touch or hold my baby in the NICU?

Yes, in most cases you can, and you should. Many babies, including some on CPAP, can be held skin to skin on a parent's chest.

WHO advises starting kangaroo mother care (skin to skin contact) as soon as possible after birth, even before a small baby is fully stable. The exceptions are babies in shock, babies who cannot breathe on their own after resuscitation, and babies on a ventilator.⁷ In a large trial in five countries including India, starting skin to skin care straight away cut deaths in the first 28 days from 15.7 to 12.0 percent in babies weighing 1 to 1.8 kg.⁸ Ask the nurse to help you with the wires the first time.

How can I help my baby while they are in the NICU?

Your milk, your touch and your presence help more than most parents realise. You are part of the care team, not a visitor.

• Express breast milk early. In a small trial, mothers of very small babies who started expressing within one hour of birth made more milk in the first week and at three weeks than mothers who started later.⁹
• Take part in daily care: nappy changes, mouth care, temperature checks and feeds.
• Be there as much as you can. In a trial across 26 NICUs, babies whose parents stayed at least 6 hours a day and gave hands-on care gained more weight, and the parents felt less stressed and anxious.¹⁰

WHO now strongly recommends involving families in the routine care of small babies in hospital.⁷

How do I stop my baby getting an infection in the NICU?

Clean your hands every time before and after you touch your baby, and keep sick visitors away. Infection is one of the biggest risks for small babies in hospital.

• Wash hands with soap and water or use the alcohol rub at the bedside, every single time.
• Keep anyone with a cold, cough, fever, loose motions or skin boils out of the unit.
• Give your breast milk, especially the first milk (colostrum).
• Do skin to skin care. Pooled trials show that kangaroo care, compared with usual incubator care, roughly halves serious infection in low birth weight babies.¹¹

You are allowed to remind doctors and nurses to clean their hands too.

Why do I feel so guilty and anxious?

Almost every NICU parent feels this way, and it is not your fault. Early birth or illness is very rarely caused by anything a mother did.

Fear, guilt, poor sleep and tears are common in the first weeks. Spending time with your baby and taking part in care can help. In the family care trial, parents who were closely involved had lower stress and anxiety scores.¹⁰ Tell the team if you cannot sleep, cannot stop crying, or feel hopeless. Help for parents is part of good newborn care.

When should I call the nurse straight away?

Call the nurse at once if your baby looks unwell to you, even if the monitor seems fine. You know your baby, and a second look costs nothing.

• Skin looks pale, grey, blue or mottled.
• Your baby goes floppy or stops moving.
• A long pause in breathing, or breathing that suddenly looks hard work.
• A swollen, tight or shiny tummy.
• Green or bloody vomit, or blood in the stool.
• Jerking or stiffening movements.
• Your baby simply looks different from an hour ago.