Joyce Ledwidge has helped feed about 20,000 babies in her 20 years as a dietitian in the IWK Health Centre’s neonatal intensive care unit.
She’s part of a team that cooks up an individualized menu for each of these vulnerable little humans. The nutrition can include intravenous infusions, pumped breast milk that is labelled with a bar code and refrigerated in the family's NICU room and direct breastfeeding.
Over one-third of NICU babies are there because they arrived in the world too soon. The NICU has treated premature babies born as early as 23 weeks, weighing just over a pound.
“Actually some people will refer to it as a nutritional emergency so that really just highlights how critically important nutrition is in the NICU,” Ledwidge said in a recent interview at the hospital. “When they’re born premature, they have no nutrition reserves at all. So we’re trying to help make up for that period of time when they should have stayed in utero if they could have.”
That first nutritional boost often is provided through an intravenous line. Known as parenteral nutrition, the baby receives a fluid infused with amino acids to build up protein, dextrose (because a preemie’s brain needs a sugar boost), carbohydrates, fat, minerals, electrolytes and other products.
The precise components of the parenteral mixture, and just as importantly the timing of the IV infusions, is tailored for each baby depending on their gestational age, birth weight and other factors. The medical team writes up a prescription that is sent to the IWK pharmacy.
“Certainly a very low birth weight is going to need fluid, that’s critical and part of that fluid is going to mean giving them protein,” Ledwidge said.
Then there’s the natural approach. As early as possible, depending on the baby’s ability to feed, they are given small drops of mother’s first milk, called colostrum.
Colostrum is very high in protein “but actually more importantly, it’s really high in amazing immunoglobulins … that really help boost the baby’s immune system,” Ledwidge said.
The mother is encouraged to try to manually express her colostrum as soon as possible, preferably within the first hour of birth.
Sometimes the medical team fortifies pumped breast milk with nutrients and fat. When the baby is able to feed directly, the skin-to-skin contact has been shown to be healthy for both mother and baby.
The types of conditions, and the percentage of the total, that cause babies to be in the NICU:
Prematurity (under 35 weeks) - 35%
Medical conditions (hypoglycemia and respiratory distress most common) - 30%
Infections – 20%
Surgical conditions – 15%
As for the timing of feedings, that’s been an evolving question for neonatal clinicians over the years.
“Before we might not have provided protein for even a day or two. Now we actually stay within four to six hours. . . . Within a very short time, 12 to 24 hours after, then we’re throwing in the other things to really try and optimize that nutrition.”
All of these decisions are made by a medical team on daily rounds that can include Ledwidge, Dr. Jon Dorling, the IWK’s head of neonatal-perinatal medicine, other attending doctors, a nurse practitioner, a charge nurse, a pharmacist and a respiratory therapist.
Dorling has been at the IWK for about 16 months after making a move from Nottingham in his native England, where he practised for 20 years.
He said neonatologists are constantly on the lookout for ways to improve nutrition in the NICU. For example, he and other IWK clinicians plan to start a clinical trial in January involving premature babies in the 32-week gestational age.
Some of the babies will get just breast milk and others will get milk as well as IV fluids.
“We’ll see what group does best.”
Technological advances such as automated nutrition software and monitoring apps also have helped.
In fact, a recent study involving NICUs in the United States concluded that too few have automated clinical decision support tools to calculate things such as the proper caloric intake for a baby.
The IWK doesn't have such an automated system. For one thing, it requires system-wide medical record access that the province has been working toward for years (not without controversy). But Dorling said the IWK's human-driven philosophy works well for its patients.
“We have the team approach,” he said. “We have expert people, lots of years of experience in nutrition to think about what the baby needs. . . . I think our approach is probably better than the computerized. Not to say we can’t learn from that, we do use tools as well from time to time if we need them.”
For instance, Ledwidge said she uses an app on her phone to track the exact percentile a particular baby’s growth falls into.
She and Dorling said one of the biggest advances for the IWK team has been the creation of single-family rooms as part of ongoing renovations.
The 19-room NICU North, which opened last year, features double sofa beds, optional partitions between baby and family spaces, washrooms with showers and leading-edge technology. Two rooms have been reserved for twins and one for triplets so the babies don’t have to be separated.
Work continues on another similarly designed unit consisting of 19 rooms, including three rooms for twins. It will replace the open bay NICU on the south side of the neonatal floor.
“Every day when we go into a room,” said Ledwidge, “and if the mum or the dad or the parent is there, it’s ‘tell us how your baby’s night was.’ The parent has been staying with the baby so we want to hear from them, which also then empowers them to know that they’re a really integral part of the team and we need them. . . .
“I’m humbled by these families, what they go through and their strength and their perseverance.”
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