NEONATAL INTENSIVE CARE NURSERY

The overall goal and objective of the rotations for the pediatric residents in the Neonatal Intensive Care Nursery is to gain extensive experience in the recognition and care of the high-risk, low-birth-weight, premature (in our institution, this includes babies <2100gm or <35wks) and term neonate who requires intensive or intermediate care, surgery, or evaluation by other pediatric specialists. During the course of the three-year pediatric residency the first year residents will rotate through the Neonatal Intensive Care Nursery for two months on average and one month during the second year.

A. First Year Pediatric Residents

The following goals have been established for the first year pediatric residents rotating through the Neonatal Intensive Care Unit. These are primarily aimed at gaining experience in the intermediate care area (i.e., less acute) during the first rotation and with the sicker neonate in the second rotation.

• To understand the importance of obtaining a thorough family and maternal history, which includes pertinent information regarding prior pregnancies, the current pregnancy and events related to labor and delivery.
  
  
• To understand the differences in the examination of the premature, term and sick neonate of all ages, how this differs from older infants and children, and how to assess the clinical estimate of gestational age using the Ballard examination.
  
  
• To understand the basic needs of the premature and sick neonate, which includes temperature regulation, fluid and electrolyte therapy, metabolic requirements, and nutritional needs, including the use of parenteral nutrition, oral alimentation, and special formula needs. In addition, the resident will learn how to maintain and utilize growth curves in order to recognize problems of inappropriate nutrition and growth.
  
  
• To familiarize themselves with appropriate chart documentation, including admission notes, daily notes, and notes regarding major events during the course of the day.
  
  
• To gain experience with common procedures used in the care and stabilization of the sick neonate, which include spinal taps, suprapubic bladder aspiration, umbilical venous and arterial catheter placement, neonatal intubation and stabilization, the placement of chest tubes versus the use of thoracentesis for treatment of pneumothorax, and to understand the indications for each procedure.
  
  
• To thoroughly understand common medical conditions seen in the premature and sick term neonate, including:
  respiratory distress syndrome
  transient tachypnea of the newborn
  apnea and bradycardia of prematurity
  neonatal sepsis and pneumonia
  congenital infections
  patent ductus arteriosus
  chronic lung disease
  cyanotic congenital heart disease
  hyperbilirubinemia
  hemolytic anemia of the newborn
  stabilization and care of the infant of the diabetic mother
  hypoglycemia
  fetal growth restriction
  necrotizing enterocolitis
  intracranial hemorrhage
  ischemic encephalopathy
  retinopathy of prematurity
  recognition of common neonatal surgical problems
  
  
• To understand and appreciate the problems that parents of the low-birth-weight, premature and sick neonate experience, including the need for social service intervention, the use of child protective agencies, and counseling for parents with an infant that is likely to die. Also, to learn how to deal with these parents on a daily basis as part of patient care.

B. Second Year Pediatric Resident

While the rotation as a first year resident through the Neonatal Intensive Care Nursery introduces the resident to the problems of the premature and sick neonate, the primary emphasis is on the care of the premature infant without major complications. In the second year, the one-month rotation is directed toward understanding more of the physiology and pathophysiology of the sick neonate. Therefore, this house officer has a primary role in the care of neonates assigned to the intensive care area of the Neonatal Intensive Care Nursery. The goals of their rotation include those noted above and as follows.

• To enhance their knowledge of the mechanisms of neonatal resuscitation and stabilization and recognition of the at-risk fetus in utero based on the maternal antenatal and intrapartum course.
  
  
• To be able to stabilize and initiate care for the very high-risk, very-low-birth-weight neonate (<1500gm) as well as the term infant that requires intensive care.
  
  
• To achieve confidence in the performance of common procedures utilized in the supportive care of the sick neonate, including spinal taps, suprapubic bladder aspirations, placement of umbilical venous and arterial catheters, intubation and resuscitation, placement of chest tubes, performance of chest thoracentesis, and importantly, to understand the indications for these procedures.
  
  
• To thoroughly understand the fluid, electrolyte and metabolic needs of the extremely-low-birth-weight neonate (<1000gm) and how to modify these needs appropriately based on birth weight, gestational age, and postnatal age.
  
  
• To understand the normal development of the lung, common causes of respiratory diseases, mechanisms used to monitor oxygenation, and how to make decisions regarding respiratory management.
  
  
• To understand how to initiate and maintain nutritional needs of the very-low-birth- weight infant, including gavage feeds and parenteral nutrition.
  
  
• To become comfortable with speaking to parents of very high-risk, sick neonates and providing them guidance regarding their neonate and the potential outcomes based on statistics obtained from the Intensive Care Nursery, and where appropriate, learn to discuss with the parents changes in therapy and outcome.
  
  
• To recognize and understand all of the disease processes noted above.