Podcast Episode 2
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NICU Team
So you’ve suddenly found yourself in the NICU shortly after your baby was admitted. Multiple staff members have come up and introduced themselves to you. They are running through what is going on with your baby. Your head is spinning trying to understand everything they just said, let alone trying to figure out who is whom? And, just when you think you know which one is the Neonatologist and what their name is, a new one comes on service the next day!
So who are all of these people?!? In this podcast episode, we break down who the lead cast members are on your baby’s care team in the NICU, but also who holds some of the supporting roles. Not that you need to remember the names of everyone you interact with, but it is important to understand all of the different roles and how they will help you and your baby during their NICU journey.
The NICU care team is composed of many different entities that collaborate and work together to give your baby the most optimal care. Some of the care team members you will see and interact with on a daily basis, and get to know very well whereas others may work more in the background but are just as vital!
Neonatologist
To start, the Neonatologist is the physician who is caring for and overseeing the care of your baby. Neonatologists are trained to handle the most complex and high-risk situations that may occur in infants. They are thoroughly trained to treat and diagnose infants with several medical conditions including but not limited to prematurity, breathing problems, feeding issues, infections, and congenital disorders.
The Neonatologist, along with the Dietician, ensure your baby is receiving the most optimal nutrition for growth and healing. Neonatologists attend deliveries for especially high risk or preterm infants and are able to perform all of the procedures required in the NICU.
Neonatologists often collaborate with other specialties including but not limited to Pediatric surgery, pulmonology, endocrinology, neurology, infectious disease plus many more specialists to provide your infant with the best possible care.
Some NICUs have a Neonatologist who covers the unit 24 hours a day, whereas other NICUs only have NNPs that cover during the night. Each unit will also be unique in how long the Neonatologist is on service – whether it is for a week at a time, 2 weeks, or sometimes even a month.
Each unit is also different in how their care-model works in the NICU. In some units, the Neonatologist does not take on their own set of patients, they oversee every patient and the NNPs or residents care for the patients, in other models, the Neonatologist will take on their own load of some patients, as well as oversee all of the NICU patients. And finally, in some NICUs, it is only the Neonatologist who cares for the patients. Be sure to ask what kind of care model exists in the NICU where your baby is being cared for.
NNP (Neonatal Nurse Practitioner)
Neonatal Nurse Practitioners, collaborate with and work directly under the Neonatologist. Not all units have Neonatal Nurse Practitioners, but for those that do, they attend deliveries for high risk infants including premature infants, those with known congenital anomalies, or if they are at an increased risk for problems due to meconium-stained amniotic fluid, fetal distress, or due to other maternal complications.
The Neonatal Nurse Practitioners also perform procedures for infants in the NICU, including but not limited to intubation, UVC and UAC placement, PICC line placement, chest tube placement, thorancentesis or needle aspiration, reservoir tap, and arterial sticks for lab draws. NNPs typically see and round on their own set of patients but in collaboration with the attending Neonatologist. NNPs are typically present 24 hours a day to help cover deliveries and to care for the babies in the NICU.
NICU Nurse
The NICU bedside nurse is there to care for your baby around the clock. They will perform thorough assessments on your baby, start IVs, administer medications, hang IV fluids, draw labs, feed and bathe them, and most importantly, notify the Neonatologist or NNP if there is anything at all that they are concerned about.
They are there to educate you and help you throughout your baby’s NICU journey so that you can help care for your baby in the NICU and at home. The nurses will help and guide you during 2-person care, kangaroo care, or with nursing or bottle feeding your baby. They are an amazing resource for you and your family.
If you haven’t already realized this, you will become very close to some of the NICU nurses that care for your baby. You will see them day after day and they will really get to know your baby and your family, which is key! The more they know about your baby and become familiar with them and their nuances, the more they can advocate for your baby!
Respiratory Therapists
Respiratory therapists (RTs) are specially trained and dedicated members of the NICU care team who specialize in management of the therapeutic respiratory equipment. Some of the respiratory equipment they manage includes but is not limited to, High Frequency Jet Ventilator (HFJV), High Frequency Oscillator Ventilator (HFOV), standard entilators, non-invasive ventilation (nIMV), continuous positive airway pressure (CPAP), High Flow Nasal Cannula (HFNC), and Nasal Cannula. They can intubate or assist with intubations and help to administer surfactant. They perform blood gas acquisition and interpretation, and deliver nitric oxide (iNO) administration. They attend high risk deliveries and go on internal and external transports. Respiratory therapists also carefully monitor and manage the airway and assist during the transfer of the baby to the parent during Kangaroo Care or position changes.
They are incredibly knowledgeable in airway management and also administer any breathing treatments or nebulizers to the infants and also perform spontaneous breathing trials. They are an integral member of the care team and are often part of team daily rounds to discuss the most optimal options and management for our critical NICU patients.
The Dietician
The Dietician does a lot of their work behind the scenes, but their work is incredibly important. Appropriate nutrition is very important for your baby’s neuro-development. The dietician’s role is to optimize the nutrition of all of the babies during their stay in the NICU. Optimal nutrition provides the building blocks for growth and brain development. With proper nutrition, your baby will be more equipped to fight off and resist infections as well.
Premature infants are at an increased risk for poor growth due to their immature organ systems and decreased amounts of muscle and fat. Although the Neonatologist and NNPs calculate your baby’s daily weight gain or loss, the dietician looks more closely at your baby’s growth over time and closely monitors their growth on the growth curves. Dieticians monitor your baby’s energy, protein, mineral, and vitamin intake and expenditure.
Our dietician participates in daily rounds and assists with prescribing the daily total parenteral nutrition or TPN, they give recommendations for feeding advancement, and will help your family prior to discharge with home recommendations. Our dietician is also involved in the NICU follow-up clinic to help monitor growth once the infant has gone home.
Physical and Occupational Therapists
The American Academy of Pediatrics has defined guidelines that require a neonatal therapist (OT or PT) to be on staff in NICUs with level III or IV designation. Routine therapy services with PT and OT are not typically initiated until 30 weeks Post Menstrual Age (PMA), but occupational and physical therapists provide positioning and parent education consults prior to routine, continuous therapy services.
Pediatric physical therapists have a thorough understanding of infant’s development and behavior, especially preterm infants. Due to the vulnerability of premature infants, NICU-based therapists require advanced skills to optimize outcomes of our NICU infants. The therapists must also learn to adapt to all of the medical interventions that occur simultaneous to therapy interventions.
Physical therapists assist with positioning and handling your infant and give recommendations of ways to support their movements, sleep and wake states, and self-soothing abilities. They are proficient in monitoring your infant very closely for any stressful cues which may be displayed by a change in their breathing or skin color or with particular movements or gestures.
They work closely with parents and staff to educate and encourage developmental appropriate positioning and handling for your baby. They are often available and will assist with 2-person care as well.
Once your infant is ready to head home, a physical, occupational and/or developmental therapist will continue to evaluate and follow them as an outpatient. They will closely follow their development and ensure that they are hitting their milestones.
Speech Language Pathologist
Speech Language Pathologists (SLP) are a great asset to the NICU. Speech therapists that work in the NICU specialize in assessing term and preterm infants for feeding readiness, oral motor skills, and swallowing evaluations. For infants in the NICU, Speech Language Pathologists typically receive referrals from the medical team on a case-by-case basis, usually related to poor feeding or a potential swallowing dysfunction.
As you may know, preterm infants do not have the appropriate suck, swallow, and breathing coordination to efficiently nurse or bottle feed until they are around 33-34 weeks. But this gestational age is just the starting point, when they will begin to be evaluated. Speech language pathologists work with infants in the NICU and provide recommendations for oral stimulation exercises for infants who are not quite ready to nurse and bottle feed yet as well as feeding interventions to improve their skills along the way.
They give recommendations on the appropriate bottle and nipple flow based on your baby’s needs after they have been evaluated. They also help identify any swallowing difficulties in your baby and provide recommendations or if any thickening agent is needed to assist with better tolerance of feedings.
Speech language pathologists also help educate parents on how to identify feeding readiness cues as well as any stress cues during feedings. They will follow your child as an outpatient as well if your child is preterm or has any feeding-related issues. They follow infants closely and monitor their ability to eat and eventually babble and speak in the future.
Certified Lactation Counselors
Next in our line-up are the Certified Lactation Consultants (CLC)! Although you may not be able to nurse your baby initially as you may have planned if they were admitted to the NICU, our lactation specialists will be a great asset and support you through your baby’s NICU journey. They will help to educate you on supply and possibly eventually being able to do non-nutritive and nutritive nursing. They will help if you are concerned about any medications you may be taking and whether or not it crosses into the breastmilk, and clarify if they are safe for your baby. The lactation consultants will also closely follow your infant once they have been discharged so you can continue nurse at home.
Social Workers
The NICU Social Workers help to bridge the gap between you, the family and the medical team and help provide psychosocial support. They help families find their voice and navigate their way through the complex medical system. They will guide you through some of the processes you may be unfamiliar with, including but not limited to insurance questions, financial assistance, and can help you with accommodations, work exclusion letters, gas cards, and other resources available to you. They will often help arrange patient care conferences, transports, and will also help to arrange home medical supplies if needed.
Discharge Planner
Now, you have spent weeks or months in the NICU with your little one and it is almost time to take them home! You are beyond excited, but terrified all at the same time, what do I do? What follow-up appointments do we have? How am I going to keep it all straight? In steps the discharge planner.
Not every NICU has an assigned discharge planner, but if they do, they help to ease your transition home with your baby. The discharge planner will help arrange all of your baby’s follow-up care once they leave the NICU. They may hold educational discharge class to prepare you for home. They may also help to arrange medical supplies and connect you with the specialized services and resources available in your own community.
Palliative Care Specialist
Some NICU units also have a dedicated Palliative Care Specialist. The palliative care team works with many of our families, not just those who are enduring end-of-life care. Palliative care is offered to any patient with chronic, life-limiting illness, which is often the case for our infants. The care focuses on the relief of the physical, psychological, and spiritual suffering from chronic illness or life-limiting illness, whether death is imminent or not. All hospice care is palliative care, but not all palliative care is hospice care.
In the NICU, we care for the most fragile and vulnerable patients. NICU patients have a 40-200 fold increased risk of neonatal death. Even the infants who survive are at an increased risk of serious long-term sequelae or residual affect of their conditions including but not limited to chronic lung disease, short gut syndrome, vision problems, impaired learning and cerebral palsy.
Palliative care can also be extended throughout the life of your baby even once they are home as an outpatient. In collaboration with the medical care team, the palliative care team, will develop unique goals of care with the baby’s family, provide support in relief of physical pain and discomfort of the infant as well as spiritual end-of-life care when appropriate. Unlike hospice care, palliative care can be provided in conjunction with ongoing curative care and continued beyond the discontinuation of curative care.
The palliative care team is often consulted for patients and families of infants born at the edge of viability (22-24 weeks), infants with chromosomal or anatomical anomalies that are known to be life-limiting, infants with significant neurological injury, and those with a G-tube or tracheostomy.
It is most ideal for palliative care to be introduced to the family early so trust is well established so the palliative care team should be consulted once a prenatal diagnosis is established or as soon as the condition is identified in the NICU. By providing early establishment of support for the family, it will improve connection and communication between the team and the parents.
The Chaplain
Last, but certainly not least is the Chaplain! The NICU chaplain is so valuable for our NICU families. As I’m sure you have quickly learned, when your baby is in the NICU, it is an incredibly difficult time for the parents and the whole family. Most often, parents find themselves in this situation and they were absolutely not prepared for it! Even if you were aware of a prenatal diagnosis that could potentially place your infant in the NICU, there really is no preparation for what is to come!
The Chaplain, from the pastoral care department, is there to offer and provide you with spiritual support. They are there to comfort NICU parents and to offer prayer for those wanting spiritual guidance. For me, the chaplain was always a familiar face and she prayed with me everyday that I was with William, which was – everyday! She would check on me, ask how I was feeling, and ask if I needed anything. Our current chaplain in our NICU (prior to the COVID pandemic) would come around to the unit to the nurses, nurse practitioners, etc with a cart full of tea and chocolate! He is always smiling and is such a great asset to our NICU families.
Summary
Well, that sums up the major key players in the NICU. There are also so many people behind the scenes that are there to ensure that your baby or babies get the best possible care as well as support you during your baby’s NICU journey.
All of the different roles mentioned above collectively provide your baby or babies with the most optimal care. Please do not hesitate to ask questions or for clarification on topics or issues that you do not fully understand. Someone will be able to help you or direct you to a resource who can. We understand that you have been introduced to a variety of staff in several different roles AND I also know that if you are a NICU parent, you are stressed and exhausted, so no one will be offended if you ask for clarification. Remember, you are the parent and a part of the care team, so it is important for you to know the different roles and what is each individual’s purpose in the NICU.
It is incredibly difficult to leave your baby in the hospital with complete strangers. We, as parents are not supposed to be separated from our children, especially right after they are born. I cried EVERY NIGHT that I had to leave William. But, one way or another, you have to find a way to trust and have faith in your baby’s care team.
You will eventually develop strong, memorable relationships with some members of the NICU team. Some of the members of William’s NICU care team are like family now. I will never forget them and the role they each had in not only saving William, but me as well.
We have put together our top tips for NICU parents. These tips will help you to be more equipped to help care for your baby in the NICU. I have also included self-care tips to help you physically and mentally as you navigate through this very unfamiliar journey so your health is at its very best. The PDF will give you the knowledge and skills you need so YOU can take care of your baby! There are also tips to help with your unique financial situations.
We have A LOT more to get into so be sure to subscribe so you do not miss an episode!
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