Concept of neuroprotective NICU
Authors: Gaffari Mohammed , Jindal Pranay 
Published: December 2019

Neurodevelopmental outcomes are of paramount importance for every clinician as the survival rates of term and preterm babies have continued to improve. We aim to provide a framework for developing a Neuroprotective Neonatal Intensive Care Unit (NICU) by describing five main domains below. We achieve this in our NICU by a multidisciplinary team consisting of neonatologists, respiratory therapist, occupational therapist, physiotherapist, social worker, pharmacist, and a dietician. This approach needs to be individualised for each unit based on the resources and services available.

I. Neuro assessment: clinical neuro assessment remains the most important tool with strong predictive value for long-term outcomes. It is important to develop other tools of assessment like comfort and pain scoring. We use COMFORTneo scale as a standard of care. Neuroimaging is another important factor as part of the assessment. We have a local guideline to decide on the frequency and the timing of the neuroimaging such as cranial ultrasound and MRI.

II. Neuroprotection: antenatal magnesium sulphate and antenatal steroids have become an established treatment in most units. Interventions like total body cooling have significantly improved the outcomes for babies with hypoxic ischemic injury. One challenge faced in these babies is the ability to provide active cooling during transport when these babies are born outside cooling centres. Optimal nutrition is another important element for the developing brain. We developed neonatal nutritional guidelines in collaboration with the clinical pharmacist and a dietician. Introduction of starter parenteral nutrition bags for out of hours use in line with evidence-based feeding guidelines are known to improve the outcomes. We practice the golden hour protocol for all babies born before 28 weeks gestation and have introduced intraventricular haemorrhage (IVH) prevention bundles for the same cohort of babies. Even though individual components of these bundles do not have strong evidence, there is some benefit when these interventions are offered as a bundle. Our care bundle involves midline positioning, using log roll, minimal handling, maintaining normothermia, avoiding IV boluses, and maintaining normal CO2 levels etc.

III. Neuromonitoring: tools like amplitude-integrated electroencephalogram (aEEG), near-infrared spectroscopy (NIRS), and onsite MRI are gaining popularity. eEEG should be routinely used in hypoxic ischemic encephalopathy (HIE) babies when available. All team members should be trained in its application and interpretation. NIRS is a developing modality used by only a few units to monitor the cerebral oxygenation. We have recently started to pilot these machines.

IV. Neurodevelopment: the environment of the NICU has been shown to affect the developing brain. Strategies should be developed to optimise babies sleeping by reducing lighting and noise levels. We use positioning tools like boundaries and midliners as part of their neurodevelopment.

V. Neurointervention: we use therapeutic techniques like auditory, tactile, visual, and vestibular (ATVV) stimulation. It is an evidence-based technique used to increase alertness in medically stable preterm infants. We use Prechtl's Qualitative Assessment of General Movements observational tool. It is the most predictive tool (98% sensitivity) for detecting cerebral palsy. This helps provide targeted treatment at an earlier stage.