Sir Ganga Ram Hospital, New Delhi, India

Neonatology

Introduction

Care of newborn babies has vastly improved in India over last two decades. The department of Neonatology takes pride in undergoing this transformation. This unit came into existence in 70's.This was one of the first few level III units in northern India. With improving technological and medical expertise this unit has established as one of the best, not only in Delhi but also in India.

About the unit

We being one of the largest units have about 1200-1500 admissions per annum. This unit has 4 separate areas – consisting of two ICU’s (Intensive Care Unit) area and two step down Intermediate care units (High dependency units).Our NICU is 35 bedded level III unit, equipped with 16 ventilated beds each with wall mounted new generation multi-parameter monitors with inbuilt pulmonary graphics. Each ventilator bed is connected to a central monitoring system which allows continuous monitoring of babies. Step down areas can accommodate 19 babies; all beds are attached to multi-parameter monitor. All babies are nursed in thermo-neutral environment under radiant warmer/incubator.

Strength of the unit comes from the "State of the Art" Obstetrical and perinatal services rendered in the hospital, which attracts large number of high-risk deliveries. NICU services are covered by 7 consultant neonatologists, along with 10 post doctoral resident doctors including DNB neonatology fellows. We have a nurse: baby ratio of 1:2 for intensive care area and 1:3 nurse: baby ratio for babies not requiring intensive care. Apart from newborn care area, unit also offers a special lactation room where mothers are provided lactation counseling and can also express their milk with help of breast pumps.

Services:

  • Mechanical ventilation: Sick/preterm infants may have lung immaturity/dysfunction. These neonates may require ventilator support. The NICU takes pride in declaring that it was the first unit in private set up to start ventilation
  • High Frequency Ventilators: Babies who have severe lung disease may fail on conventional ventilators. Our Unit has one of the best high frequency ventilators named Sensor Medics for supporting such babies
  • Surfactant delivery: Premature lungs are deficient in a substance known as surfactant, leading to a stiff lung and breathing difficulty. In this situation, commercially available natural surfactant is instilled into baby’s lung through a special tube. Giving surfactant to these babies improves their lung function, helps them to come out of ventilator faster and ultimately help in improving survival and reducing lung injury.
  • Inhaled nitric oxide: Babies who have severe respiratory failure with high pulmonary artery pressure may require inhaled nitric oxide (a gas delivered into the lungs) to maintain adequate oxygen levels in blood. We are amongst the few units in India which has the experience of using nitric oxide and facilities for monitoring of such critically sick babies.
  • Parental nutrition: Because of poor swallowing capability and immature gastrointestinal functions, the small preterm and sick baby are not able to tolerate oral feeds well and requires intravenous nutrition in form of glucose, fats and proteins. This parenteral nutrition is prepared with aseptic precautions under laminar flow and is delivered via intravenous route, till the time baby is able to tolerate oral feeds. Not many units in India use laminar flow for aseptic preparation of Parenteral nutrition and drugs.
  • Phototherapy and Exchange Transfusion: Babies who develop significant jaundice require special lights called phototherapy. We have more than 10 such units including bili-blankets.Some Babies require exchange transfusion for severe jaundice. We do around 20-30 exchange transfusion per year. Most of these babies are extramural babies.
  • Bedside Echocardiography: Bed side echocardiography is very important tool in the diagnosis and management of heart problems in premature as well as term babies. We are very fortunate to have such services available round the clock which are essential for diagnosis and management of all heart problems related to neonates. All neonatal echo are done bedside by Pediatric cardiologists.
  • Neuroimaging: Premature babies are prone to have intraventricular hemorrhage (brain hemorrhage) especially in first week of life. Very preterm infants are periodically evaluated with bed side ultrasound by sonologists, who are available round the clock..Facilities of advanced imaging like MRI, Diffusion weighted MRI, MR Angiography are also available at our centre.
  • Eye Examination: Retinopathy of prematurity of prematurity (ROP) is a disease of very preterm babies, which can lead to blindness if not treated in time. To prevent ROP, a team of neonatal ophthalmologists, periodically examine retina of these preterm infants as per international guideline Babies with advanced stage of ROP are offered bedside laser therapy to halt progression of disease.
  • Universal Hearing screening: All babies in nursery are subjected to OAE (otoacoustic emission test) done to pick up babies with hearing loss. It is a simple test done in nursery at bedside. Some babies may require advanced tests like Brain stem evoked response audiometry,which is available in our unit.
  • Genetic counseling services: All babies born or admitted to institute are universally screened for certain metabolic/ genetic diseases like hypothyroidism, G6PD deficiency and congenital adrenal hyperplasia. For this a few drops of blood are collected on a filter paper. Sick neonates with congenital anomalies or suspected inborn errors of metabolism are evaluated extensively with help of geneticists.
  • Lactational Support: We are proud to be able to have a dedicated lactation counselor who takes sessions on breast-feeding and helps mother with expression of breast milk. Apart from lactation counseling she is also a qualified stress counsellor and spends valuable time helping relieving & counseling parents of sick neonates in NICU.
  • Developmental supportive Care: A team of Developmental Pediatrician and an Occupational therapist and support staff visits the nursery regularly and remains involved in the developmental support of the sick preterm babies. We try to give physical, visual and auditory stimuli once sick babies are stable for their faster recovery and rehabilitation. Mothers are also involved in the care of the baby; they are encouraged to hold the baby next to their skin (Kangaroo Mother Care), which helps in better growth and development of infants apart from helping in establishing lactation.
  • Fetal medicine: Antenatal monitoring of fetus for diagnosis and management is an essential area of Perinatology. We have Department of Fetal medicine where various antenatal procedures like amniocentesis, chorionic villous biopsy and intrauterine transfusion etc are done.

Allied Pediatric Sciences

  • Pediatric surgery facilities: We have excellent facilities for neonatal surgeries with 2 senior Pediatric Surgeons attached to the unit who are vastly experienced in surgical repair of anomalies such as congenital diaphragmatic hernia, trachea-esophageal fistula, intestinal atresias, imperforated anus, omphalocele to name few.
  • Pediatric Cardiac Sciences: A team of Pediatric cardiology and cardiac surgeons help us manage babies with complicated heart disease that occur by birth. Our Cardiac Surgeon hold immense experience in operating cases such as Transposition of Great Arteries/Tetralogy of Fallot/Complex Congenital Heart disease. Functional Echo and bedside PDA ligations are routinely done in our NICU by the cardiac team.
  • Others: Sir Ganga Ram Hospital is one of the largest super-specialty hospitals of the country. As such we are fortunate to have Pediatric neurosurgery, Pediatric Nephrology, Pediatric Neurology, Pediatric Endocrinology, Pediatric Gastroenterology-all under one roof .We do seek the help of these specialties if required.

Neonatal Transport Services

Transporting sick newborn babies in our country is a challenge. Our unit has two transport incubators with inbuilt breathing machines with the help of which even very sick babies can be transported. We offer transport services round the clock. In last 10 years we have transported more than 500 babies by road including 18 air transports.. We have airlifted babies from all parts of India and few even from neighboring countries. We have 24x7 helpline no-01142251167 to deal with all transport related queries. We recently transported a 26 weeks/610 gms baby from Kathmandu. Baby required surfactant and was on mechanical ventilator for 14 days. After a stormy neonatal course baby was discharged after 64 days. Baby is now doing well.

Academic Programme

The unit is first in country to be accredited with DNB neonatology program-Post MD Neonatology training equivalent to DM Neonatology. Our pass percentage in last 7 years of DNB program is more than 90% and we always attract the first two candidates selected in the common entrance test conducted by DNB. Our students have won the best DNB fellow award twice. We have also started NNF fellowship program from last year successfully. We plan to do collaboration with other institutions in the country conducting DNB and DM programs and do exchange program for better learning skill of our postgraduates.

Quality care initiatives

It is very important to have inbuilt quality care initiatives in the management of patients and we are doing number of initiatives like Hospital care associated infections audit, hand washing procedure audit, Insertion and maintenance bundles for the central lines, Surveillance information sheet, ventilator associated infection audit and human milk audit for preterm babies. The plan for the future years is to compare the various audits of our department with other departments in the country and outside. We recently sent our antibiotics usage data for international audit as part of ARPEC data base.

Research, publications and Awards

The department has been involved in a number of national (PHFI ) and international researches (NIH) and a number of publications have been there in the indexed journals. Departmental consultants have been involved as editors of the “Ganga Ram Journal” and involved in its regular publishing. Departmental research paper won NNF gold paper award in 2011. Understanding the need for strong methodological evidence based clinical practice today, our unit pushes forward research activities by our neonatal fellows and at one given time, 8 – 10 research projects are ongoing. We look forward to keep research and publications one of our top agenda and put Sir Ganga Ram Hospital on the international neonatal research map.

Organization activities

Neonatalology department is very active with academics holding National and International conferences and CMEs. The recent past saw two big international conferences “International Conference of Neonatal Nursing (2008)” and “Federation of Asia Oceania Perinatal Societies annual congress 2010” being held by the faculty of the department. Most of the faculty members have been holding important active positions in National professional bodies. We plan to hold more such conferences in future as well as plan to do neonatal skill based training CMES for tier II and II centers in the country to improve the skill of neonatal care.

Audit

The department has been collecting perinatal audit and the audit of the extramural neonates and the same is published in the hospital audit. We were part of the National Neonatal Perinatal Database also in year 2000.We plan to be the part of national and international collaborations and start sharing data with each other so as to improve neonatal care in our hospital further.

Survival as per birth weight Survivals

The survivals of premature babies have improved in the last decade with advances in neonatology. Almost 80% of babies

Parent’s Information Guide

We encourage parents to get involved in the care of their babies as we feel that there can be nothing better than the “Human Touch” for the stimulation and recovery of sick babies. So parents form a very important cogwheel in the management of babies admitted in the NICU.The department has come out with a “Parent Information Booklet” which is given to all parents on admission of their baby to the Nursery. This booklet introduces the parents to the Neonatal intensive care and serves as a reference during the baby stay in the nursery – it contains simple information about various gadgets and monitoring devices in the nursery and also touches upon common neonatal diseases and their management. The highlight of this booklet is the liberal use of excellent photographs for better demonstration of the text.

Frequently Asked Questions

I have delivered today I don't have milk's?

The milk produced in the first 2-3 days (colostrums) is less in quantity but it is sufficient and very essential for the baby. The more the baby suckles the more milk will be produced. After first 2-3 days, enough milk is usually produced.

When should the baby be first put to the breast?

New born must be put to the breast within half to one hour of the delivery. Starting to breast-feed immediately after birth stimulates the production of hormones that help milk production. Early skin to skin contact even if the baby does not suckle stimulates milk production. It also helps in improving the mother child bonding.

Elders in the family want to give honey to the baby before I start breast-feeding Is it alright?

Prelacteal (any fluids given in the initial 2-3 days after birth) feeds should not be given as they replace the essential colostrums and the baby’s earliest feeds. Babies given prelacteal feeds are more likely to develop infections and allergies. Prelacteal feeds also interfere with sucking.

How often should I breast feed?

Babies should be fed on demand. (as and when they want to feed)

Advantages of demand feeding:

  • Breast milk “comes in" sooner
  • Baby gains weight faster
  • Fewer breast problems such as engorgement
  • Breast feeding more easily established

Feed at least 10 times in 24 Hours more if he/she is willing. You should let him suckle whenever he seems interested. The baby should also be breastfed during the night.

What should be the duration of one feed. Should I feed from both breast at one feed?
The baby should be allowed to feed from one breast till he/she is satisfied. Foremilk is the milk that is produced early in a feed. Hind milk is the milk that is produced later in a feed, this milk contains more fat with provides energy and satiety so it is important not to take the baby off the first breast till he had enough hind milk-otherwise he will not be satisfied after the feed. Let the baby suckle from only one breast at each feed. But if he wants more milk shift to the other part. 

Should I give water to my baby, as it is very hot?

Babies do not need other drink (of water) before they are 6 months old, even in hot climate. Babies get a large amount of water from foremilk, this is all that the baby needs.

 

I have had a caesarian section so I am in pain. How do I breast feed?

You can breast fed in whatever position you and the baby are comfortable

Till when should exclusively breast feed?

Breastfeed exclusively for 6 months, Break milk is adequate for the baby till the age of 6 months if the baby is growing well.

I have flat / inverted nipples can I breast feed successfully?

Tell the mother after delivery before you start breastfeeding you should try to make the nipples stand out by using finger thumb/ pump / syringe. If the nipples cannot be made to stand out even after manipulation and the baby is unable to suckle give the baby expressed milk. 

Is it necessary for me to breast fed at night? What difference will one bottle feed (at night) make? 

Breastfeeding at night gives the baby extra time for suckling. More Prolactin (which is a hormone that helps in milk production) is secreted at night than during the day. So it is always better if you breast feed the baby during the day and night. This helps to keep up the milk supply. Moreover even one bottle feed at night may cause infection. The easiest way to do so is to let the baby sleep with you so that he can breast feed without disturbing you.

How do I know that my baby is getting enough milk?

An exclusively breast fed baby who is getting enough milk usually passes dilute urine 6-8 times in 24 hours. Also for the first 6 months babies will again 125 grams (500 grams / month) if adequately breast-fed. If the baby is gaining enough weight and passing urine 6-8 times a day he / she adequately breast-fed. 

My baby is passing watery stools is it because I am breast feeding him?

 

Breast milk is safe. Some exclusively breast fed babies pass frequent watery stools at times green or with mucus but they are normal, active and pass urine frequently. This is physiological and breast feeding should be continued. Similarly some normally thriving breastfed babies pass a motion once every 3-5 days this too is normal.

 

Healthy tips for Newborn care

  • Baby should be given only breast milk for first six months of life.
  • Exclusive breast feeding means nothing except breast-feeds not even water, ghuttis, gripe water, tonics or any form of milk.
  • Babies need proper clothes, which covers them properly especially head, hands and feet. They should not be over clothed as well.
  • Babies pass watery stools after first 3-4 days of life especially after feeding which is normal for them.
  • A baby, who is feeding well, will be passing urine at least 8-10 times a day.
  • Babies don't need any Kajal, Surma, Talcum powder or daily bath. Bathing should be postponed for first few days after birth. A good rule to follow is delay bath till umbilical cord falls.
  • Vaccination is the most cost-effective way of health for children