When newborns need care

Expo Magazine meets Petrina Bastrenta, neonatologist working at the Neonatal Intensive Care Unit of Vittore Buzzi Hospital, an excellence in Milan

Q: Hello Petrina, could you please introduce yourself and tell our readers what is your job an role?

My name is Petrina Bastrenta and I am a neonatologist working at the NICU (Neonatal Intensive Care Unit) of “V.Buzzi” Children’s Hospital in Milan since 2008. I work in the NICU with preterm and sick newborn infants but also, at times, in the Delivery Room (in any case of birth with vacuum extractor or cesarean section, or whenever resuscitation is foreseen), in the Nursery and in the Newborn Clinic (where healthy newborns are examined a few days after discharge from the Nursery).

 

Q: What leads you to choose this career? What are the main qualities a neonatologist must have to do this job and why?

You choose this job because you love babies. But also, you are at ease in emergency situations: in the Delivery Room and NICU it is rather common to deal with resuscitation, invasive procedures, difficult decisions or to be taken quickly. Moreover, you like “hands on” activities and fine manual work: a big part of the job consists of putting lines or tubes on very tiny babies, dealing with machines and their settings, or simply touching the baby for diagnose or comfort. Importantly, you choose this job if you are resilient. Or you become so. Night shifts or long day shifts can be very hard physically. Also, you are a good team worker when you are in team but also able of independent decisions when you are alone. Possibly, you are good at communicating with parents (and their family) who sometimes face terrible situations and you are, in turn, able to deal with these situations emotionally.

 

Q: To begin with the main focus of this interview I would like you to give us a definition of premature birth?

A premature birth occurs when the baby is born before 37 weeks of gestation. This is the upper limit. The lower limit is at the moment, in Italy, 23 weeks’ gestational age, which is when we as neonatologists proceed with resuscitation, if the newborn is considered viable, and involving the parents in the decision process; before 23 weeks’ gestation we don’t start resuscitation maneuvers. There are therefore different levels of prematurity, ranging from late preterm to extremely preterm babies.

 

Q: Which are the main causes for having premature babies?

The main causes of preterm delivery are infections, twin pregnancies, pregnancy complications (e.g. gestosis, premature rupture of the membranes, polyhydramnios, etc), intrauterine growth restriction of the fetus, chronic maternal diseases, malformations. However, sometimes no cause is identified.

 

Q: What expect parents of a baby who arrives early (32-33 weeks)?

This is the so-called moderately premature baby, who looks just like a term baby, but is thinner. Her weight is probably a bit less than 2 kilos and she will need an incubator to keep her warm and possibly, because of respiratory distress, some kind of respiratory support (e.g. NCPAP, which means continuous airway pressure delivered through cannulas in the nose). A premature baby of this gestational age will not be able to be fed with a bottle but will have a feeding tube through which he will receive milk (her mother’s if available), initially in small amounts, then, if tolerated, progressively increased. Some feeding problems are common and the process of increasing the amount of milk is quite slow, therefore an IV cannula or sometimes a central line (e.g. an umbilical line) will be necessary for the first days or weeks. Other minor problems can be jaundice and apnea of prematurity. She will be discharged from the hospital when completely independent at least with bottle feeding, and from the respiratory point of view; anyway not before 35 weeks of gestational age in my institution.

Q: What face parents that have a baby born at 28 weeks (or less)?

Because babies grow so quickly during pregnancy, a premature baby born at 28 weeks is quite different from a baby born three or four weeks earlier. For instance, the former weighs around 1 kg, the latter around 500-700 grams. The incidence of complications of prematurity increases with the decreasing of gestational age, most babies will survive but the prognosis, in terms of survival and outcomes, depends both on the degree of prematurity and on the kind of complications the baby will have. These include respiratory distress (most of these babies need some degree of respiratory support) and cardiac problems (e.g patent ductus arteriosus, that is a persistence of a normal fetal cardiac structure that should close in the extrauterine life but does not in many very premature babies); cerebral complications (e.g. hemorrhages or lesions of the white matter that may or may not have long term consequences); infections (a very serious problem typical of intensive care units); simple feeding intolerance or serious complications involving the gut (e.g. necrotizing enterocolitis, that may need surgery in some cases); complications of the eye (e.g. retinopathy of prematurity, that may need surgery too in some severe cases); bronchopulmonary dysplasia-BPD (a long term complication of prematurity and ventilation that leads to oxygen dependency for a long time, even after discharge at home).

The baby will be immediately assisted in the Delivery Room in order to perform the “foetal-neonatal transition” , probably ventilated with a face mask or, in some cases, intubated. The baby will then be transferred to the NICU, placed in an incubator and connected to some kind of ventilator, depending on her needs. An umbilical catheter will be positioned and a probe for continuous monitoring of oxygenation and heart rate. The parents will be admitted to the NICU as soon as possible and will experience quite a scary environment in the beginning, but they will be as much as possible comforted and supported by the NICU team, made of doctors and nurses, and a psychologist. In my NICU they will be allowed to stay with the baby almost all day, not at night, and they will have grandparents in too for one hour in the afternoon. They will have to wear a gown and to wash their hands well before touching their babies, but they also will be able to hold them on their chest (the so called kangaroo care) once stable.

 

Q: Could you give us an advice for parents on dealing with having a preemie and health issues that come up?

My suggestion is to rely on the institution where the baby is hospitalized, to ask for information or for attention to the staff whenever they need it but also to be patient when this is not possible, and to have a “step by step” approach, in the sense that the “big picture” might appear as scary, so it is better to deal with it one step at a time. I also often suggest them to find the way to have the best possible attitude because the path might be long and full of obstacles. But also to be patient and confident, because babies can be capable of incredible surprises and a great resilience.

 

Q: What are some things you can do during your visits with your child to bond even though your baby is in the hospital?

The staff will help the parents showing them when to and how to touch their babies, and how to pay attention to baby’s cues, even if in the incubator. Moreover, as said before, we practice the kangaroo care, which means placing the baby on the parents’ chest, skin to skin. When all of this is not possible because of baby’s instability, the simple presence of the parents is of great help both for the babies and the parents. Another practice that helps bonding, and lets the mother feel more “useful”, is extracting breast milk that will be given to the baby as soon as possible.

 

Q: Any words for parents once they bring their babies home from the Intensive Care Unit?

The so called long-term Follow Up of the premature babies is a very important service that most of the NICUs offer after discharge at home. It is very likely that parents who take their baby home after weeks or months at the hospital will be worried, even if in the last period of stay they will have had the chance of caring for their baby with more and more independency. The chance to keep in touch with the NICU is always given (via telephone) and a schedule of short term medical examinations and instrumental exams is described in the discharge letter. The responsible of the Follow Up will evaluate the baby, organize what is necessary for her and guide the parents for a period of time, depending on the clinical picture of the baby, going from some weeks up to 6 years of age.

Q: This year Milan is welcoming one of the most important exhibition of the last decade. As you may know the topic is: ‘Feeding the Planet, Energy for life’.

My question is: did you see a link between the way of living and premature birth? Is there a consequence between the way you lead your life and having a preemie?

I do. Fertility is strictly related to the age of women, and women tend to procreate later than before. The large offer of medically assisted procreation has helped many women in the process but has also determined an impressive number of twin and complicated pregnancies. The modern treatment of maternal illnesses has permitted pregnancies that would have never occurred before, but with the burden of complications such as prematurity. Lifestyle factors such as smoking, stress, alcohol, obesity, excessive workload and poor antenatal care play a role in prematurity. Therefore, despite the huge progress in the obstetric field on one hand, and the important reduction of overall births due to economical “crisis” on the other hand, the prevalence of premature birth is still considerable.

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