Improving NICU

Dr Prathap Chandra, Consultant Chief Neonatologist and Pediatrician, Motherhood Hospitals, gives an insight on the latest technological advances in NICU

India is projected as to be the next powerhouse of the global economy but unfortunately, the country has still a long road to cover in area of healthcare, as the figures of infant mortality are alarming to say the least.

A recent report by the UNICEF has stated that over six lakh children died within the first month of their birth in the year 2016. The neonatal mortality rate at 25.4 deaths per 1,000 births makes it the 12th worst among the 52 lower middle-income countries. However, a few states like Kerala and Goa have neonatal mortality rates of 10 per 1,000 live births, the figure for Bihar and Uttarakhand stands at 44 per 1,000 live births.

The UNICEF report states that India is currently not on track to meet the Sustainable Development Goal target for neonatal mortality of 12 by 2030. According to the report, newborn survival is closely linked to a country’s income level. Three causes including prematurity, neonatal infections and low birthweight accounted for over 80 per cent of newborn deaths. Complications during labour leading to birth asphyxia as well as infections like sepsis, meningitis and pneumonia are also major contributors.

However, this discouraging scenario should not be a disheartening factor as more number of hospitals and childbirth related medical institutions are installing the latest Neonatal intensive care unit (NICU) within their facilities. Besides, advanced NICUs have been established in teaching and non-teaching hospitals in large cities. In the smaller cities and towns there has been a rise in nurseries for newborns in small private hospitals and nursing homes. However, the biggest boost for NICU is going to come from the latest advancements in technology, which is related to software, hardware and electronics.

From a historical perspective, the progress in neonatal care was largely made with technology like the development of infant incubator, warmers and use of mechanical ventilator. However, this brought its own set of challenges in the survivors as they developed mechanical ventilation related classic bronchopulmonary dysplasia. Today, there are more sophisticated mechanical ventilators, which can be controlled through a software written algorithm, which can read the smallest of changes in the baby’s breath and give adjusted volumes for subsequent breaths.

Today, the advancements in software especially in segments like artificial intelligence, big data, and analytics can certainly boost the advancement in NICU. Technology combined with the software power can do the immediate task of regular monitoring of NICU. Take for example, if there is a centralised data repository system, which regularly monitors all the inputs, any discrepancy in the infant care can be immediately noticed and the right intervention can be availed. The high volume of data generated in an NICU can also be used for predictive monitoring.

An infant with birth complications always has high chances of mortality and their chances of survival is improved with the presence of multi-diagnostic devices. This include continuous monitoring of ECG, respiratory rate, transcutaneous carbon dioxide (Tc CO2) oxygen saturation over time, amplitude integrated EEG (aEEG), invasive arterial blood pressure and temperature of the babies. All this actually leads to early detection.

Near infrared spectroscopy (NIRS) technology is finding its clinical application in NICUs. NIRS is a spectroscopic method that uses the near-infrared region of the electromagnetic spectrum (from 780 nm to 2500 nm). Typical example of its use is in continuous accurate oxygen saturation measurement, which enables clinicians to have a better control on the prevention of hypoxemia or hyper-oxygenation. Chronic hypoxemia can lead to developmental delay and increased mortality and hyperoxemia leads to Retinopathy of prematurity and permanent blindness if not treated. Cerebral NIRS is helpful in determining changes in cerebral perfusion as well as early detection of bleeds.

Birth asphyxia or hypoxic ischaemic encephalopathy (HIE) is one of the leading causes of neonatal mortality and morbidity in survivors in India. Until a few years ago, we did not have answers to treat this condition. Thanks to some of the largest multi-centric trials in the world, we now have a therapy called ‘therapeutic hypothermia’ or ‘total body cooling’ where we lower the baby’s temperature to 33.5 deg C for three days and slowly rewarm over next 12 hours. This therapy is achieved using servo-controlled machines which maintains the temperature without fluctuations and has shown to reduce the mortality as well as gives better neuro-development outcome in the babies with moderate HIE. India has contributed a low-cost indigenously manufactured equipment using ‘phase-changing’ material, which does a similar job.

Extremely premature babies have undeveloped lungs that are too fragile to handle even the gentlest ventilation techniques. This further can hamper the adequate provision of oxygen to vital organs that they need to survive. The biggest technological advancement in NICU, which is underway, is the creation of artificial placenta where the foetus can continue to develop in a simulated environment without the physiological stress of preterm birth. The animal models are very promising but has not yet reached the clinical trails stage.

Point of care ultrasound training have gained momentum in the ICU care, which acts as an extension or adjunct to clinical examination. Have gained traction opening up new insights into brain injury and disease. The advancement of other imaging techniques including high resolution CT, MRI with diffusion and spectroscopic measurement of metabolites in the brain have added greater in sights in to the brain development, various patterns of brain injuries and provision of advanced treatment options.

The advancement in sensor technology could actually lead to a scenario where the incubator will be operated wireless without the presence of those dangling wires. This is also leading progress towards wearable and wireless devices, which creates a safer environment around NICU. Besides, devices are being created which has semiconductor chips installed in them, which can transmit information without the wires.

The game changer in NICU could be through the advent of the mobile phones, which has created a new platform called the tele medicine and tele-radiology. Today, it is not possible to have NICU centres located in remote locations with a specialist nearby. However, the technologies centering on video and internet can bring about a seamless connection.

The advances of technology in healthcare has thrown unimaginable amount of data, which can be captured, stored and analysed in the least cumbersome manner. This data actually can provide several insights for future research and development activities of neonatologists.

As these advancements are made, there is always the question of costs involved with the installation of these kind of NICU machines, which generally come at a higher price. However, it is expected that wider use of these devices could actually see them priced more reasonably. Further, there are many companies operating in India, which are working hard towards innovative devices that are more suited to Indian conditions.

Technology can become the differentiator for the healthcare industry in the country especially in the area of NICU. This would also require medical professionals to be abreast with the latest technological changes as both go hand in hand in order to create a better future for the newborn babies.