>> Not too long ago, premature infants had little chance of survival.

But now 90% of all babies born at 28 weeks gestation are surviving.

Stay with us as we talk with neonatologist doctor Peter de Giannoni Jr about how changes in neonatology are saving premature babies.

Next on Kentucky Health.

>> Kentucky Health is funded in part by a grant from the Foundation for a Healthy Kentucky.

[MUSIC] >> In the United States, the rate of preterm babies, that is, those born prior to 37 weeks of gestation has been rising.

There are many possible contributing factors, and these include maternal diabetes, obesity, and hypertension, older mothers, stress, and limited or no preterm care.

Preterm babies, when delivered, often require more care than the typical term baby, and worse yet, they also have a lower chance of survival.

During the early 1970s, infants born at 28 weeks gestation had less than a 20% chance of surviving.

Now, thanks in large part to changes in neonatal care, 90% of these babies are going home with mom and dad.

This change is a consequence of the efforts of the men and women who staff our neonatal intensive care units, or, as they're more commonly known, the NICU.

By any measure, the work being done in the NICU is nothing short of miraculous.

To give us a better insight into the causes of premature birth, what is being done to save these fragile patients?

Their long term outcome?

The support that's given to families of these infants, and what goes on in the NICU.

We have as our guest today, Dr.

Peter J. Giannone Jr.

doctor Giannoni earned his medical degree from the State University of New York Health Science Center at Syracuse College of Medicine.

He then did a residency in pediatrics at the Macon& Joan Brock Virginia Health Sciences Eastern Virginia medical School at Old Dominion University.

After completion of his residency, he then did a fellowship in neonatology at the Brown University Women and Infants Hospital of Rhode Island and Providence, Rhode Island.

Doctor Giannoni is the chief of the Division of Neonatology at Golisano Children's at University of Kentucky, and a professor in the Department of Pediatrics at the University of Kentucky.

Doctor Giannoni.

Peter, thank you for being with us today.

>> Well, thank you for having me.

>> What in the world is a neonatologist?

>> So what a neonatologist is, is a pediatrician who's done specialized training in the care of newborns, particularly to care for premature babies and ill newborns.

>> How did you get into that?

What was that light bulb moment that said, hey, I want to be a pediatrician, and then B, I want to take care of these little tiny things.

>> Sure.

I think I always wanted to be a pediatrician growing up.

Obviously, I wasn't exposed to the NICU as a child, but once I did my residency and spent time in the NICU, that's really when the lightbulb went off and said, gosh, I really want to care for these babies.

>> These little tiny things.

So when we talk about gestational gestational age, what are we really referring to and what are some of the landmarks associated with those time timelines?

>> Sure.

So gestational age is basically the time in weeks of a pregnancy.

So a term pregnancy usually lasts about 40 weeks.

We count the beginning of gestation from the first day of the pregnant patients last menstrual cycle, up until either the current date or when that baby delivers some big milestones for us.

As neonatologists include when we think a baby can really first survive outside the womb with significant medical assistance.

I'm at the University of Kentucky.

That's 22 weeks gestational age.

>> Really.

>> And then another big milestone is really when the baby can do well without a lot of medical intervention.

And usually that's about 35 weeks or greater that those babies can go on to.

Just need some routine newborn care after delivery.

>> That's a pretty broad range there from 22 to 35 weeks.

What is taking place from week 22 to week 35?

To make that baby able to survive outside of the womb and do well?

>> Yep.

So during that time period, there's a lot of rapid growth of the fetus and maturation of the organs, kind of the last organ to mature in a fetus are the lungs.

And that's really one of the biggest reasons why these tiny babies, or even somewhat late preterm babies, end up in the NICU, is because their lungs aren't quite ready for breathing outside the womb, and they need some extra support, so they end up coming to the NICU.

>> What's the problem?

>> So a lot of times is that they're not making a substance called surfactant yet.

And that's a substance that we make in our lungs all the time.

And really that keeps our lungs nice and compliant, able to open and close without much of a problem and not get stuck together when it closes too much in.

Premature babies are not making that substance yet.

So they have a lot of trouble with the breathing, and that causes them to come to the NICU.

>> Wow.

During the course of a pregnancy, are there signs that you and or your obstetric colleagues get to say, hey, this may be a baby that's going to have trouble and or may be born prematurely.

>> Sure.

I mean, there's going to be certain medical conditions that the mother may have that may not allow her to carry the baby to term, and they may have to deliver her early.

And also, there could be signs of preterm labor where the mother's having early contractions.

That may be a sign that the baby may be coming out early as well.

>> Are there things that you can do to prepare the baby to exist outside of the womb?

>> Yeah.

So one of the big things and one of the big strides that we have in neonatal medicine is the administration of steroids to the mother prior to delivery of that baby.

And what that those steroids do is they also help mature those lungs and to help the baby breathe outside the womb when they're born.

And makes it also easier if we need to give any extra support to the baby to help support them through that breathing period if they're in the NICU.

>> This isn't the kind of steroids that can have that baby come out all bulked up or something like that, now is it?

>> No, not at all.

Not at all.

But they just want their lungs bulked up.

>> But it actually helps them start making some surfactant or something.

>> Helps them make them some surfactant and helps their lungs act a little more mature, helps their skin act a little more mature, and their kidneys act a little more mature, which helps them get through that time in the NICU.

>> So what are some of the risk factors that may cause a baby to be born prematurely?

>> Sure.

You touched on some of them earlier in the introduction, but a lot of them would be number one would be a mother who has high blood pressure or a condition like diabetes.

That may be they may need to deliver that baby early.

Carrying more than one baby at a time.

So having twins or triplets, those babies are much more likely to deliver early.

Maternal age plays a factor mothers older than 35 years of age, and actually younger mothers less than 17 years of age are at higher risk of delivering preterm.

Having pregnancies too close together can cause those subsequent pregnancies to be delivered early.

>> Are you referring to the old Irish twins thing where every nine months.

>> Every nine months?

>> So that can be a it's too frequently, too close, too close okay.

Absolutely.

>> I mean, the rule of thumb is usually we like to see about 18 months between pregnancies to decrease that risk of pre-term labor.

>> Wow.

What particular problems may be going on with the baby that may lead to premature birth?

>> Yeah.

So a big one would be an infection that the baby may experiencing and the amniotic fluid, or even down in the birth canal that can cause inflammation that may lead to premature contractions and delivery of that baby.

>> We have somewhat of an epidemic of drug abuse, though.

It's getting better, of course, nowadays, thankfully.

What impact does that have on premature delivery?

>> Sure.

So both maternal smoking of cigarettes and illicit drug use have been tied to preterm birth.

>> Really?

Really.

And you know, we just came out of Covid, but we still have the flu.

Do these kinds of infections increase the maternal risk or the baby's risk of being born prematurely?

>> Yeah, really any type of infection where it can increase inflammation in the mother can really put the baby at risk of delivery.

>> Yeah.

Are you aware of any environmental pollutants or things that may even give rise to problems?

>> A lot of the environmental type of problems are really social.

Maternal stress is a big chronic stress in the mother is a big determinant of delivering early.

Socioeconomic factors.

It's been preterm.

Birth has been linked to poverty, food insecurities, things like that.

>> Okay.

So are you surprised when a baby is coming out prematurely, or is there usually some warning?

Obviously the mother's not going to call up and say, hey, I'm going to deliver prematurely in two weeks, we'll be ready.

But are there things, you know, are there any way conversations that take place to say, hey, this might come.

So we need to have our team ready?

>> Yeah, absolutely.

So we have a team ready on the ready all the time to be in the delivery room in the event of an emergency.

But we do huddle every morning with the OB specialists who are taking care of the mom to get an idea of which patients may be at risk for delivering early and any particular special problems or needs that that maybe, maybe may need in the delivery room.

>> So this is contributing to why that prenatal care is so very important.

>> In prenatal care is extremely important.

That's another risk factor.

So late or no prenatal care has been tied also to pre-term delivery.

>> Right now, as good as you are, you have a team working with you.

>> Absolutely.

>> Tell me about what is the team in the neonatal intensive care unit?

Who's there and what are they doing?

>> So we have a large team that takes care of these little tiny babies.

So if you're a parent in the NICU, one of the first people that you're going to meet in the NICU are going to be the nurses there at the bedside 24 over seven, caring for that baby, learning those baby's cues, really being the first people to get an idea.

Tell us maybe something might be a little wrong or off today with that baby.

On the medical side of the team, there is the neonatologist, who's the attending physician and the leader of the medical team.

There's usually some doctors in training also on that team.

And we also have on the medical team, physician assistants and nurse practitioners who really only take care of NICU babies.

Wow.

On that team.

Other members of the team include specialty pharmacists that help us with the medications, making sure we're getting the correct dosing for those tiny little babies.

Yeah, nutritionists.

To make sure that the babies are meeting their caloric needs to grow.

We also have special therapists such as physical therapists, occupational therapists, music therapists, all to help with the baby's development.

We have speech therapists in the NICU.

Not so much because the babies are speaking yet, but really to help with when they're ready to start taking feeds orally and help take bottle or breast safely.

And then we also have NICU psychologists and social workers to help with any psychosocial needs that the parents may need.

>> Tell me what the respiratory therapist how does that person work?

Because all I can imagine is you mentioned that lungs are a problem.

So how much pressure can you deliver oxygen to a baby without blowing the lungs out?

I mean, how, boy, I don't want to imagine it.

Tell me.

>> So the respiratory therapists are specialists in the NICU.

Help us with the respiratory equipment and caring for the baby.

And so what we try to do is try very hard not to intubate a baby after delivery if they're having breathing problems.

>> Okay.

>> So what we try to do is that we utilize something called nasal CPAp, where with some nasal prongs, we'll deliver oxygen and pressure through the nose down into the lungs to help try to keep those lungs open.

Gotcha.

Now, unfortunately, some babies do still need to go on to need intubation and need a breathing machine.

And when we do have to place those babies on that breathing machine, like you said, we try to use as gentle pressure as possible to help keep those lungs open to avoid any popping, and also to avoid any lung injury that may occur with the breathing machine.

>> You mentioned the nutritionist, but and then you also mentioned how the speech therapist is looking at the baby can swallow.

So before that time when the baby can swallow, how are you getting nutrients into them?

>> Yeah.

So a lot of times right away the intestines aren't quite ready yet in premature babies to take all the food in there at once.

So a lot of babies need some IV nutrition to start.

And then what we'll do is we'll start slowly introducing feeds through a feeding tube that goes down to the tummy.

Okay.

And over the first several days of life will slowly increase those feeds until we get to a full volume where the baby's getting enough calories into their tummy to grow.

>> You talked about the psychologist being involved, and I must admit immediately, what comes to my mind is that the psychologist is for your staff.

You.

But the parents?

>> Absolutely the parents.

>> How does that work?

Tell me about that interaction.

>> Well, the NICU is a stressful place.

And also parents also may have had previous stresses or traumas in their life that could be triggered by having a baby in the NICU.

So having a NICU psychologist available for those parents to help them get through the struggling times, the stressful times has really been helpful and really helps those parents get through the tough times in the NICU and help bond help better bond with their baby.

>> But when we look at pictures or we think about the NICU, there's this baby in this isolated environment, I guess you got to keep it warm.

You're providing these nutrients.

How do parents bond and what from your experience, what are parents telling you are and how do you make them feel part of the team or the integral part of the team?

>> Yeah.

So I mean, the NICU can be a scary place.

And, you know, those babies are tiny and fragile.

So when parents first get there, it is a bit of a scary place.

But with some time and support with especially with those bedside nurses who do a great job, we definitely encourage the mothers and fathers to be reading to their baby, talking to their baby, touching their baby.

We want the baby, the parents and the baby to be doing skin to skin therapy where the parents will be in a chair.

The baby will be on their chest.

>> Even in the NICU.

>> Oh, absolutely.

In the NICU.

Wow.

Yes.

As soon as possible.

As soon as the baby's ready for it, we we want to start doing that because that's been shown to help with the baby's sleep, improve the baby's growth, and get the baby home sooner with the parents.

>> And that helps the bonding for the parent, too, because it's no longer this extraterrestrial sitting in this thing.

>> Yeah.

I mean, it helps both the mother and father and the baby.

So.

>> So given the stakes, high stakes that are involved here, what are some of the tasks that you can give a parent in the NICU so that when they go home with their child, they're more familiar with how to do things?

And cleaning a diaper is nothing.

>> Right.

So, I mean, we want to start that in the NICU.

So doing things such as diaper changes, working with the nurses to do the cares on the baby will help prepare them for getting home with the baby and importantly, learning those babies cues while they're in the NICU.

So they may have showing those same cues if they're not feeling well or not having a good day at home, those parents will be able to pick up on those.

>> What about cost to those parents?

Are there some systems or their programs that help as far as when the parent goes home?

Because in NICU you got tons of people, but now this baby's going home.

Now, obviously they're not going to need NICU care when they go home.

But are there resources available to help parents help their child?

>> So for us, we have NICU graduate follow up clinic, which all of our.

Yeah.

Which all of our babies attend.

Yeah.

And that's a really important clinic because number one, it follows the baby's development to make sure that they're meeting those developmental milestones on time as they should, as they grow and develop at home.

And also they're social workers and other resources available in those clinics to help those parents in that way.

>> Tell me about the transition from the NICU to, I guess they go to a regular floor.

>> No, they get discharged straight.

Yeah, we just charge babies home straight from the NICU.

>> Wow.

>> Yeah, because we are the specialists of taking care of those babies.

So we keep them the whole time in NICU.

The parents are comfortable in the NICU, and we get them home straight from the.

>> What is your relationship with the pediatrician?

Then when the patient goes home and the baby goes home?

>> Sure.

So at the at the time of discharge, when that baby's getting ready to go home, we'll send over to the pediatrician.

Detailed report of the baby's stay in the hospital, their current medical needs, and what to be expecting in the future from the baby.

And often we'll give them a call ahead of time also.

>> Yeah.

When introducing you.

I made a point of talking about in the 70s, 28 weeks was a freaky time and babies didn't do well.

And all of a sudden, in the 2028 weeks, it's anticipated, baby's going home.

But you started off by saying 22 weeks now here at the University of Kentucky, what are the changes that are taking place that allow you to get a 22 week gestation baby out the door?

>> So, like we talked about earlier, one of the big changes in neonatology that really started allowing us to start taking care of those smaller, sicker babies was that we were able to give exogenous surfactant to the baby.

So after the baby was born, we were able to give surfactant down that breathing tube to the baby's lungs to help those lungs act more mature, and we'd be able to ventilate them and get them through that period immediately after birth, and allow them to start growing and forming in the NICU to be able to get home.

And over the last several years, we've been able to start as we've gotten better at what we're doing, we've been able to decrease the gestational age at where we can really start trying to save those babies.

>> Since the baby's not talking to you, I take that back.

I'm assuming that baby's down there at UK aren't talking to you.

You may be giving them their graduate degree.

It's earlier.

How do you monitor these babies?

To tell what's going on?

>> So we have all the babies on continuous monitoring.

So we'll monitor their heart rate, their breathing rate.

We'll be watching their blood pressure.

And we also continuously monitor their oxygen level all non-invasively with no discomfort to the baby to help give us clues as to how that baby's doing that day non-invasively.

>> Why do you make it a point of saying that?

>> Well, anytime in a premature baby, when you do have to put a tube in or a central line in to give IV fluid, that's a really a risk of infection for the baby.

>> Oh I see.

>> So we try to do everything we can as non-invasively as possible to decrease that risk of infection, because those tiny ones cannot fight off infections as well as you and I. And they're very prone to getting infections.

So we try to be as careful as possible as we can.

Lots of handwashing.

So we're not giving our germs to those babies to make sure that we decrease any risk of infection.

>> What about kidney function?

Is that, you know, how do you keep an eye on that if you're having to give, you know, infusions for their calories or things through the tube and things?

>> So most importantly, we're watching their urine output to make sure that they are making urine.

Those kidneys are working.

And then also we're seriously serially checking some labs to make sure that the kidneys are functioning properly.

>> I'm glad you mentioned about the lab work because, you know, as an adult, we're drawing a tube of blood about the size of our finger.

I imagine if you draw that much blood out of one of these babies, you.

Yeah.

You done shot the whole wad.

It's gone.

Right?

Yeah.

So?

So how can you.

How much little blood are you getting and how accurate are your numbers?

>> Yeah.

So luckily, our lab is great and they can work with very small blood volumes.

So we take out as little as possible blood that we can.

Unfortunately, after birth, these babies aren't making their own red blood cells quite yet.

So even though we're trying to minimize the amount of blood that we're taking from the babies, a lot of times these babies still may need a blood transfusion during their time in the NICU because of that.

>> All right.

Now let's assume that not all births are taking place at the main hospital here at University of Kentucky.

They may be in one of our community hospitals.

How do you you know what?

How do they get from some place to get to a location where a NICU is located?

I'm assuming that a NICU of which you all have is not everywhere.

>> Now we're only one of two what we call level four NICU in the state of Kentucky.

The other one is the University of Louisville, where we really have the capacity to take care of any type of baby.

And there are other NICU throughout the state of Kentucky, but they may not have the capacity to take care of the tiniest and the sickest of sick babies.

So we have a specialized neonatal transport team that can get to those other hospitals, pick up those babies and bring them back to the university.

>> So is there some coordination that the Golisano Children's Hospital here at UK has with another facility?

>> Yes, we.

>> Have worked out.

>> Yeah.

Okay.

So our catchment area is really kind of Frankfort east to the edge of Kentucky.

And we have an affiliate network with those hospitals where we help support them by doing education and training.

In the case of a delivery of a premature or sick baby, and also so they can care for those babies during that time while we're on our way to pick up those babies.

>> We've got about a minute and a half or so.

Would you tell me the three things you think that are important for us when talking about these premature babies?

What do you want us to make sure we keep in the back of our minds?

>> So I think, and this is going to be directed towards parents.

Okay.

That's okay.

>> As long you don't do it to me, that's.

I'm fine.

>> But I think number one, the best medicine that we have for premature babies is breast milk.

So we really want to encourage breastfeeding in the NICU and encourage mother.

You know, obviously babies can't breastfeed, especially if they're teeny teeny tiny.

But mothers expressing their breast milk and saving that breast milk and then feeding that breast milk to the baby has lots of extra growth factors and also protects that baby's from infections.

So that's really one of the best medicines that we have.

And then NICU for the babies, number two is going to be we talked about it earlier.

But I just want to reiterate is really bonding with the baby.

That's going to be very important during that NICU stay.

Doing as much kangaroo care as you can, doing that skin to skin with that baby, to care for that little one.

And then thirdly, the NICU journey is going to be a roller coaster ride.

There's going to be good days and there's going to be bad days.

And that, you know, it's okay to for the parents to to have a bad day.

So that's why we have lots of support and the psychologists and the social workers around to help them.

But importantly, if you're going to be a NICU parent, you must take care of yourself.

Make sure that you're getting sleep and eating right so you can help in the care of that newborn.

>> Well, I am sure that the your staff and colleagues at the Golisano Children's Hospital NICU unit are going to be very happy that you've represented them well.

Thank you for being with us today.

And most fascinating and thank you for being with us today.

I think that we all have a better understanding of the level and intensity of care that is required to save and help our littlest patients survive and thrive.

While it is good to know that if needed, the NICU is there, it is incumbent upon us all to do all that we can to minimize or eliminate those things that adversely impact the health of the developing baby.

If you wish to watch this show again or watch an archived version of past shows, please go to ket.org.

[MUSIC] If you have a question or comment about this or other shows, we can be reached at KY Health at ket.org.

I look forward to seeing you on the next Kentucky Health.

And for those of you who are thinking about pregnancy or are now pregnant, please get your prenatal care.

It saves a lot of time at the end.

Thank you for being with us.

See you again next week.

>> Kentucky Health is funded in part by a grant from the Foundation for a Healthy Kentucky.