Of the 15 million babies born preterm globally, 1/5th are born in India. Given that prematurity is the leading cause of death in children under 5 years across the globe, there is no doubt that India has a huge need for neonatal critical care facilities.
In medical terms, what is prematurity?
Duration of a complete pregnancy is 40 weeks (280 days). During this period there are multiple events happening in the women’s womb that end in a baby that is born which is ready for independent life. When a baby is born before 37 completed weeks of pregnancy, it is considered as a preterm baby. This is the standard definition followed worldwide. In other words, a baby is considered born preterm if it is born before its complete maturation inside the mother’s womb.
What is the cost of setting up the neonatal intensive care unit (NICU)? In terms of investments, time, etc.
As per 2003 data, the cost was Rs 3.7 crore, we don’t have any newly published data. I presume it will be much more than that now.
Are all NICUs same?
In 2012 the American Academy of Paediatrics has divided neonatal care into four distinct levels. Level I facilities (well newborn nurseries) provide a basic level of care to neonates who are low risk. They have the capability to perform neonatal resuscitation at every delivery and to evaluate and provide routine postnatal care for healthy newborn babies.
Level II (specialty-level facility) is for the care of stable or moderately ill newborn babies who are born at ≥32 weeks’ gestation or who weigh ≥1500 g at birth with problems that are expected to resolve rapidly.
Level III NICUs are defined by having continuously available personnel (neonatologists, neonatal nurses, respiratory therapists) and equipment to provide life support for as long as necessary. These units have facilities for advanced respiratory support and physiologic monitoring equipment, laboratory and imaging facilities, nutrition and pharmacy support with paediatric expertise and social services.
Level IV units include the capabilities of level III with additional capabilities and considerable experience in the care of the most complex and critically ill newborn infants and should have paediatric medical and paediatric surgical specialty consultants continuously available 24 hours a day. Level IV facilities would also include the capability for surgical repair of complex conditions (eg, congenital cardiac malformations that require cardiopulmonary bypass with or without extracorporeal membrane oxygenation).
Different NICUs have different capabilities and thus the choice of NICU depends on the need of the patient as per his/her disease severity. Having said that, there are few things that need to be followed in all NICUs such as adequate space, good hand hygiene, adequate nursing, promoting baby-friendly hospital policies, ensuring breastfeeding and last but not the least tender love and care.
Does India have an adequate number of such facilities?
No, there is a big deficit in the required number of beds and what’s available. Especially in the public sector which has lots of patients but less number of beds. Hence we need to have a Private Public Partnership with NGOs, companies with CSR activity like we have done for our paediatric cardiac and paediatric oncology program.
Things are getting better with each day and there is increasing awareness about reducing neonatal deaths. Reducing child mortality is one of the Millennium Development Goals (MDGs) and neonatal deaths are a major contributor to this. Recognizing this, the government has launched many programmes such as India Newborn Action Plan and Rashtriya Bal Suraksha Karyakram. Government has set up many Speciality Newborn Care Units (SNCUs) across the country.
Do we have adequate clinical staff, doctors as well as paramedical staff for the volume of neonatal critical care facilities required in India?
There is a shortage of trained nursing staff. Indian Academy of Pediatrics (IAP) and National Neonatology Forum (NNF) have done very well to make sure we have enough trained doctors by continuously working towards the training of doctors, nurses and other health care professionals as well as providing standard protocols.
There are many NGOs and charitable trusts funding neonatal healthcare. The corporate sector as part of Corporate Social Responsibility (CSR) is also helping out. Having said this, for a country as large as ours with nearly 1/6th of the world’s population, we need continued sustained effort towards getting to the goal of single-digit neonatal mortality. There needs to be better awareness regarding neonatal health as it is for cancer or cardiac diseases. There are still many births taking place outside hospitals in unclean settings. For many, quality neonatal care is still out of reach.
What are the health issues that crop up most frequently in pre-term babies in India that neonatal critical care facilities need to be equipped to handle?
New-born babies constitute one of the most vulnerable group even when born healthy and at term. Prematurity makes them even more susceptible to adverse health outcomes. Prematurity is the leading cause of death in children under 5 years across the globe. Worldwide 15 million babies are born preterm out of which 1/5th are born in India. In recent years, the trend from most countries which have reliable data collection shows that the rate of preterm birth is on the rise. Out of the 15 million babies born preterm, 1 million do not survive. Among those that survive, many suffer from many lifelong disabilities including hearing deficit and visual problems. In the developed world, 9 out of 10 extreme preterm babies survives; whereas in low-income countries including Sub Saharan Africa and South East Asia, only 1 out of 10 extreme preterms survives.
They have immature lungs and need medication to make them mature, many preterm babies need artificial nutrition for which a special NICU should be equipped with. They need a frequent ultrasound of their chest, heart, and brain so (NICU) unit should be equipped with the machine and a trained person should be available 24×7. Some of the equipment is expensive, so it is not possible for all NICUs to have all the equipment and that’s why there are standards, specifying what equipment is needed for each level of NICU. Also, it is not only the equipment but making sure all the doctors and staff are trained to use that equipment and the importance of maintaining them.
What are the health issues that any preterm baby needs to be monitored for?
Preterm babies need to be monitored that their oxygen level is within normal limits at all times; neither too low nor too high as both causes harm to the baby. Their heart and brain need to be looked at a few times in the first week of life. Their brain also needs to be looked at 14 days, 30 days and before discharge. Their weight needs to be checked every day to make sure they are gaining weight as per their gestational age. Head and length are monitored weekly. We have to watch like a hawk for any sign of infection and test for them as soon as needed. Infection is the biggest enemy for preterm babies. Their eyes need to be checked regularly and hearing before discharged. The neurological development needs to be checked regularly in the first two years to start an early interventional program if needed.
What is the post-discharge care required for preterm babies?
While we support the babies until they are fit enough to go home, it is also important to check for their growth and development. This includes monitoring weight, length, head size, eye check-up, hearing screening among others to make sure that the baby is on the right track. Hearing check-up and eye check-up are particularly very important because, if not done at the right time, it may be too late if realized later. These are some of the issues that are common across the globe.
We as a developing country face another important challenge which is an infection. Preterm neonates have very weak immunity and are prone to get infected. And once one child gets infected, the infection can then spread across the unit like a wildfire. Infection is a leading cause of the death of preterm babies in developing countries like India.
What can be done to tackle the problem of infection?
There are many simple things if done correctly can go a long way. A simple thing as diligently hand washing can reduce infection by as much as 50 percent. Another important aspect is the isolation of babies with an infection so that it does not spread to others that are vulnerable. Any good NICU should have a designated isolation area for babies that are infected with bed bugs. Adequate spacing between the beds and adequate personnel to handle the number of patients present is also important. International recommendations are to have at least 120 sq feet of space per NICU bed which have been revised to 165 sq feet. Indian government recommends at least 100 sq feet. Also, there should be a minimum gap of 4 feet between two beds.
What are the rules that need to be followed when designing, planning for NICU, PICU and extracorporeal life support (ECLS)? For instance, the Indian government recommends that there should be a minimum gap of 4 feet between two beds.
There are international as well as national guidelines for setting up a NICU which describes everything from floor planning, power supply, water supply, availability of personnel and equipment among other things. There are international standards right from 2008 and the latest update came in 2017 which states that minimum bed space for an ICU bed should be between 100 to 160 sq feet and for ECLS, it should be 200 – 240 sq feet. It also informs about the type of material to be used for the flooring/cycling, how much natural light and noise should be allowed in the unit, how many points you need for oxygen/air/suction/ electrical points and etc.
Dr. Amish Vora | Paediatric Critical Care and Emergency Services | SRCC Children’s Hospital, Mumbai