Category: Feature Articles

Dr Karanjeet Chauhan ^1,2, Dr Simone Huntingford ³, Dr Sineth Wickramaarachchi ^1,4, Dr Mustafa Siddiqui ^1,5

1. Faculty of Medicine, Monash University, Victoria, Australia
2. Royal Melbourne Hospital, Victoria, Australia
3. Department of Neonatology, The Royal Children’s Hospital, Victoria, Australia
4. Monash Health, Victoria, Australia
5. Goulburn Valley Health, Victoria, Australia

Available Online: 18/06/2024

Abstract

Summary: This article aims to provide guidance for medical students embarking on these rotations, often for the first time. The authors identify some of their own personal challenges in neonatal medicine and provide practical tips and resources to help students to maximise their learning experience. Introduction: It is essential that medical students and junior doctors develop an understanding of common and important medical conditions presenting in the neonatal period. Time pressure within the medical curriculum limits the amount of time that can be dedicated to paediatric and neonatal student placements. Rotations within a Neonatal Intensive Care Unit or Special Care Nursery can provide medical students with a wide range of learning opportunities; however, these experiences can sometimes be perceived by medical students as brief or overwhelming.

Introduction

The identification of newborn medicine as a subspecialty began relatively recently with the term “neonatology” being first introduced in 1960 [1]. A neonate refers to an infant less than 28 days of age, and the discipline of neonatology has rapidly expanded in recent decades. In Australia, around 18% of babies are admitted to a Neonatal Intensive Care Unit (NICU) or Special Care Nursery (SCN) [2]. NICUs are located in major maternity and paediatric hospitals. NICUs can provide babies with intensive care therapies such as invasive and non-invasive respiratory support, central vascular access, haemodynamic support, and perioperative management. SCNs provide fewer intensive therapies such as non-invasive respiratory support, intravenous antibiotics, gavage feeding, and phototherapy. Babies are often admitted to the NICU due to prematurity (from 22 weeks’ gestation onwards), respiratory distress, sepsis, Hypoxic Ischaemic Encephalopathy (HIE), and congenital malformations [3]. Babies are often admitted to the SCN due to prematurity (30-36 weeks’ gestation), mild respiratory distress, suspected sepsis, feeding difficulties or jaundice.

The importance of paediatric teaching within the medical curriculum has become increasingly recognised globally [4]. All medical students in Australia are required to undertake a paediatric rotation, often comprising time spent in the NICU/SCN. Despite a steady shift to online-based teaching, bedside teaching remains a crucial component of medical education for students worldwide [5] and there is much to be gained from clinical placements in the NICU/SCN.

To optimise learning and the acquisition of required proficiencies, students need guidance and a directed curriculum [6]. This paper is aimed to be used in conjunction with guidance from clinical educators, and with the student’s own medical school curriculum. The role of clinical educators has been extensively studied, however the role of the student in driving their own learning is also paramount. A study by Chipchase et al. looked at the characteristics of allied health students that served as indicators for their degree of preparedness for clinical learning as perceived by clinical educators [7]. “Willingness” was a major theme that emerged with student characteristics including willingness to ask questions and clarify their understanding, and willingness to take responsibility for their own learning. However the challenges and complexities in intensive care environment can be intimidating for medical students [8]. When anticipating a placement in the Intensive Care Unit, one study reported medical students using terms such as “scary”, “terrifying”, “intimidating”, and “nerve-wracking” [9].

The experiences from the authors below provide some of their own reflections from time spent as a medical student in the NICU/SCN. This will hopefully reassure the reader that they are not alone if sharing in some of these reactions. The article then aims to familiarise students with some aspects of the intensive care environment to lessen apprehensive about the rotation. Finally, the article directs students towards some useful learning opportunities in the NICU/SCN and some supporting resources.

Experience of the NICU as a medical student

Karanjeet Chauhan

I undertook a NICU placement in the fourth year of undergraduate medicine as part of the paediatrics rotation.  Prior to this, I had not stepped foot in an intensive care unit. Across medical school, the message has been clear that “you get out what you put in” when it comes to clinical rotation. However, my enthusiasm was quickly juxtaposed with tiny babies connected to dozens of wires, worried parents and complex medicine; all within the fast-paced intensive care environment.  I initially felt overwhelmed and disoriented, which was heightened by the COVID-19 pandemic which was concurrently in full swing. Senior doctors were agreeable to teaching students, and were generous with their time. However, there seemed to be fewer learning objectives specific to the NICU compared with other areas of paediatrics. Without a sense of direction, I often felt lost and soon realised that my previous experience taking histories and performing physical examinations on adult patients was challenging to apply to tiny complex babies and their worried families. This was a common theme experienced by many of my colleagues who rotated through a NICU. However, as the placement progressed, I grew more confident in my ability to examine babies and interact with families. One of my colleagues on NICU with me reiterated this and said, “I never truly grasped the impact that good communicational skills could have on the experiences of patients and their families until my NICU rotation.”  By the end of my term, I developed a newfound appreciation for the NICU. I strongly felt that it would have been useful to have had a medical student guide to the NICU environment and the learning opportunities within it.

Experiences of a neonatologist

Dr. Simone Huntingford

As a medical student, I completed a brief run through the NICU as part of my paediatric rotation. Despite being interested in paediatrics, and having tried to prepare for the placement, the NICU was different to what I had expected. Tiny babies in incubators connected to ventilators and pumps. An endless array of cords, monitors, numbers and alarms. Some of the things were familiar to me like heart rate and oxygen saturations. Most of them were a mystery. The doctors were kind, calm, and clever. But they often spoke a language that I did not understand. The nurses were skilled and gentle. They knew every detail about their patients. Sometimes it felt like they were fiercely protective of the little person that they cared for. I felt interested to learn but didn’t know where to start. NICU; a place I’ll probably never work….

I am now working as a neonatologist. I become fascinated with newborns. Their physiology. Their resilience. Their families. The NICU is now a familiar place for me, but I will always remember my first impressions as a student.

Strategies to get the most out of your NICU rotation

Familiarise yourself with the team

Introduce yourself to the team as early as possible and familiarise yourself with how the team usually functions. Every team is different. Make contact with students who have previously completed their rotation in the unit and ask for specific advice. Arrange to meet with your supervising clinician and discuss your university learning objectives and personal learning goals.

Safety is key

All neonates (especially those born prematurely) have an immature immune system and are yet to complete their childhood immunisation schedule. Therefore, neonates are susceptible to infection. Even common viral infections can be life-threatening. Before entering the unit, ensure you are “bare below the elbows” (a plain wedding band is generally acceptable) and wash your hands thoroughly. On the unit, ensure excellent hand hygiene and follow any PPE guidelines carefully. Stay home if you are unwell or have cold sores.

Seek support if needed

Although the majority of babies discharged from NICU/SCN go on to lead healthy lives [10], some babies may die or experience significant morbidity. As a student, it may be distressing to be involved in the care of babies who are acutely unwell or have adverse outcomes. NICU is a challenging environment, and health professionals have been found to experience moral distress at times in NICU [11]. It is important to seek appropriate support if needed. A number of support services will be available through your university or placement hospital. Have a plan for who you might reach out to if you need support.

Focus on the basics

The NICU is packed with opportunities to learn physiology and skills which will be relevant to all areas of medicine. Think and ask about lung mechanics, cardiac output, oxygen delivery, shock, sepsis, blood gas interpretation and chest X-ray interpretation. If you feel overwhelmed by the complexity of a patient, focus back on the basics.  It can be useful to write down any questions you have during the ward round and discuss them afterwards.

Review key paediatric topics

Review the university paediatric curriculum and learning objectives. Learning objectives cover clinically important topics and likely examination content. It is useful to read up on paediatric and perinatal history taking (Table 1) and common conditions presenting in the newborn period. Familiarise yourself with the commonly used terms in NICU listed in Table 2. Various studies have clearly shown that students who prepare ahead for rotations perform significantly better both in terms of academic performance and clinical competence [12,13]. Table 3 provides a framework of high yield questions to ask to further ones learning in a NICU/SCN. Before the end of your rotation, review complete the NICU quiz under Table 4 and consider reading around these topics. If you have an opportunity to attend births, review the Apgar scoring system and newborn resuscitation pathway.

Table 1. Key History Taking Areas for Medical Students in the NICU 

History	Importance	Example admission note
Antenatal
Gravity and parity	History of fetal/neonatal death	G2 P2
Blood group and antibodies	Risk of haemolytic disease	O+ve, antibody negative
Hepatitis, HIV and Rubella serology +/- Toxoplasma/CMV/HSV/Parvovirus	Risk of vertical transmission +/-congenital infection	Serology negative Rubella immune
Group B Streptococcus (GBS) status	Septic risk factor	GBS negative
First trimester combined screening (FTCS) or non-invasive prenatal test (NIPT)	Risk of genetic abnormalities	Low risk first trimester screening and NIPT
Gestational diabetes (GDM) oral glucose tolerance test (OGTT)	Risks for new-born (especially hypoglycaemia)	Gestational diabetes – on insulin
Morphology Ultrasound	Fetal abnormalities	Morphology – small ventricular septal defect, otherwise normal
Complications or medications in the pregnancy	Identify other factors which may affect the new-born	No other complications or medications in pregnancy
Social, smoking, alcohol and drug history	Social and pharmacological risks	Mother is teacher, no partner No smoking/alcohol/drugs
Birth
Weeks’ gestation	Prematurity?	39+2 weeks gestation
Labour – induced or spontaneous or no labour	Reason for induction?	Induction of labour for fetal macrosomia
Rupture of membranes and liquor	Prolonged rupture >18 hours is septic risk factor Meconium liquor is risk factor for meconium aspiration syndrome (MAS)	Membranes ruptured 24 hours prior to delivery, clear liquor
Antibiotics given?	Antibiotics often given if GBS+ve or prolonged rupture of membranes	Benzylpenicillin administered 4H prior to delivery
Mode of delivery – vaginal, instrumental, caesarean section	Reason for assisted or caesarean section?	Vaginal birth assisted by forceps for fetal distress
Maternal fever	Septic risk factor	No maternal fever
Neonatal
APGARS	Condition of newborn at birth	APGARS 5 (1min) and 8 (5min)
Resuscitation at birth	Newborn compromise and interventions	CPAP with FiO2 50% for respiratory distress and desaturation in delivery room Weaned off by 10min life
Vitamin K injection	Reduces risk of Haemorrhagic Disease of Newborn (HDN)	Vitamin K given
Hepatitis B immunisation	Routine immunisation	Hepatitis B given

Table 2. Neonatal Intensive Care (NICU) Glossary terms

NICU Glossary

Usual pregnancy 40 weeks >/= 37 weeks: Full term <37 weeks: Preterm <28 weeks: Extremely preterm   Usual birthweight at term: 2.5-4kg Approximate weight gain 150g/week (full term baby) Small for Gestational Age (SGA) <10th centile for gestation Large for Gestational Age (LGA) >90th centile for gestation   Total Fluid Intake (TFI): Daily fluid requirement in mL/kg/day Used to prescribe milk or intravenous fluid amount   Respiratory Support Cot oxygen: increased FiO2 in incubator Low Flow Oxygen (LFO2) High Flow Nasal Prongs (HFNP) Continuous Positive Airway Pressure (CPAP) Endotracheal tube (ETT)   Jaundice Serum Bilirubin (SBR) Direct Antiglobulin Test (DAT)

Table 3. Top 10 Questions to Ask in the Neonatal Intensive Care Unit or Special Care Nursery

1. What are some signs of sepsis in the newborn? 2. How do I approach the respiratory or cardiac exam in a newborn? 3. Could you show me a CXR demonstrating: Transient Tachypnoea of the Newborn? Respiratory Distress Syndrome? 4. Could you help me to interpret this blood gas? 5. What is a normal bloods sugar for a newborn? How do you manage hypoglycaemia? 6. What are the different types of respiratory support provided to newborns? 7. May I assist to perform a baby check? 8. What causes jaundice in the newborn?  Could I plot this newborn’s jaundice level on a treatment chart? 9. Could I join the team who attend deliveries? TIP: Revise the Newborn Resuscitation Pathway, and calculate the APGARS 10. What is the prognosis for this patient?

Table 4. NICU Quiz

1. What physiological changes occur after birth that facilitate the transition from fetus to newborn? 2. What are the “normal” feeding, stooling, and voiding patterns of a full-term newborn? 3. How do the newborn’s vital signs differ from children and adults? 4. What are 3 septic risk factors for newborns? What might be the source of sepsis in infants? 5. What are 5 complications of prematurity? 6. What are the causes of: – Unconjugated jaundice? – Conjugated jaundice? 7. What are 4 common and important respiratory causes of respiratory distress in the newborn? 8. Respiratory support modes include Low Flow Oxygen, High Flow Nasal Prongs. Which respiratory support modes provide newborns with: – Oxygen? – Positive End Expiratory Pressure (PEEP)? – Positive Inspiratory Pressure (PIP)? 9. On the baby check, what is the clinical significance of assessing the  – Femoral pulses? – Hip examination? – Red reflexes?

Interacting with newborns and their families

Introduce yourself to families and ask about their baby. Use the baby’s name (referring to a baby as “it” will not be well received!). You may find it surprising to learn that newborns have unique personalities even when born prematurely. Parents will often be able to tell you about their baby’s likes and dislikes; for example, being soothed by a parent’s voice or disliking a nappy change.

Practice your history taking and examination skills

As a doctor, you will encounter neonates in many settings including the general practice clinic, emergency department, paediatric clinic, or hospital ward. Seize this opportunity to gain confidence working with them. In a recent study, medical students who took part in a NICU cuddler curriculum were more prepared for clinical practice by gaining a greater understandings of factors (including medical conditions) leading to NICU admission and of the social and emotional stressors faced by families of infants in the NICU [14].

Some families may stay in the NICU/SCN for many weeks, and they will often be willing to share their journey. Having a child in the NICU is a stressful experience for parents. Studies report a significant risk of mental health issues in NICU parents [15]. Check with the team which families might be suitable to practice history taking, and always use a compassionate and empathetic approach.

How to examine a baby?

You may feel worried about examining patients, especially babies, in the intensive care environment. However, there are many opportunities to develop your examination skills. Most importantly, you will be able to gain much information from observation alone. Check what monitoring and medical equipment the baby is connected to and why. Take note of the baby’s vital signs. Observe the baby’s colour, posture, tone, movements, level of alertness, and breathing effort.

Ask the team which babies are stable enough to be handled for an examination and if they might supervise you. Ask the junior doctors if any babies need a discharge examination. Seek consent from the family and the bedside nurse prior to handling a baby. Disturbing a sleeping baby should always be avoided. It may feel strange, but greet the baby by name and describe to them what you are doing. “Hello Jackson, I’m just going to move your blankets and have a listen to your breath sounds…”.  Undressing or moving a baby may unsettle them, so consider listening for heart and breath sounds first. Warm your hands before feeling the femoral pulses. Never perform a Moro reflex or hip examination without supervision [16–18]. Beware of abdominal palpation in the recently fed baby (or pack a change of clothes!).

It is fascinating and you might see rare or complex conditions

The neonatal period is a truly fascinating time to observe physiological changes and diagnose many rare and complex conditions. You may like to choose an interesting patient and read more about their condition. Be sure to learn the NICU basics but wander down some learning paths that interest you. This may include but is not limited to: shadowing the team during critical moments or procedures, antenatal consults, family meetings, high risk births, intubations and so on.

Conclusion

Time spent in the NICU/SCN was a challenging and rewarding experience for the authors as medical students. The NICU is an ideal environment for learning neonatal medicine and also for fine-tuning skills applicable to all areas of medicine, including communication with families, multi-disciplinary teamwork, and the application of basic sciences. As such, the authors encourage the reader to be proactive when engaging with the healthcare team, and to embrace the unique clinical opportunities they are presented with.

One of the unavoidable challenges that students are bound to face is the limited time they have learning neonatal medicine during their paediatric rotation. This article does not intend to provide an all-encompassing guide. It is always imperative for universities to have a structured curriculum with specific learning objectives to guide learning. However, this paper provides the student reader with practical framework and approach with which to maximise their learning opportunities in the NICU/SCN.

Conflicts of interest

None declared.

Funding

No funds, grants, or other support was received.

Authors’ Contributions

All co-authors were involved in preparing the article and revising it critically for important intellectual content. KC, SW and MS specifically provided their personal accounts as students and SH provided her advice as a former student and current neonatologist. All authors have approved the final version of the article to be published and agreed to be accountable for all aspects of the work.

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