Patient Care

To Protect the Brains of Newborns

November 2011Diana Austin

Clinical coordinator Susan Peloquin (MSN 1988, PNP 1992) and her colleagues in the UCSF Neurological Intensive Care Nursery (NICN) at UCSF Benioff Children’s Hospital are determined to head off the neurological complications that are the leading cause of cognitive impairment and cerebral palsy in the United States.

To that end, in the first intensive care unit in the country dedicated to protecting neurological function in brain-injured newborns, clinicians use advanced monitoring equipment and have developed new protocols that enable early diagnoses, improved treatment and informed counseling of families regarding treatment options for their at-risk infants.

A Career in Pediatric Neonatal Intensive Care

After receiving her BSN from Southeastern Massachusetts University in 1981, Peloquin began her career as a pediatric intensive care nurse in Rhode Island. The following year, she moved to California and became a staff nurse in UCSF’s level III Intensive Care Nursery, also serving as a pediatric neonatal transport nurse.

While working on her master’s degree – and then her pediatric nurse practitioner (PNP) certificate at the School of Nursing – Peloquin worked in the Intensive Care Nursery (ICN) at UCSF Medical Center as the clinical nurse specialist. In that role, she cared for both full-term and premature infants, including infants at risk for brain injury, for whom therapies at the time were limited. After receiving her PNP certificate in 1992, she became the director of San Francisco General Hospital’s Early Parenting Project, which provided early intervention for infants at risk for abuse.

In 2007, Peloquin was invited to help form a new committee to build an innovative program to treat brain-injured neonates, including babies who have suffered stroke and other hypoxic brain injuries, often during or around the time of birth. The program, spearheaded by UCSF neonatologist David Rowitch and pediatric neurologist Donna Ferriero, would draw on existing expertise to develop protocols that would help protect the brains of these critically ill infants, with the aim of improving long-term neurodevelopmental outcomes.

It’s an increasingly important field. As medicine has gotten better at saving the lives of premature infants, the incidence of prematurity-related disorders – including neurological complications – has grown. An estimated 15 percent of babies born extremely prematurely will have cerebral palsy, and between 25 percent and 50 percent are eventually diagnosed with cognitive impairment or learning disabilities.

A New Concept Breeds Innovation

Peloquin holds a cooling blanket used to lower a newborn’s body temperature. After joining the NICN team, Peloquin invited colleagues in the ICN who would be interested in the program and had the clinical skills to care for these fragile patients. Physician specialists in pediatric neurology, neonatology and pediatric neuroradiology did the same. Peloquin believes that the need to build the NICN from scratch helped the development team work across disciplines to capitalize on a range of strengths and experiences.

“There were no experts in developing a neurointensive care nursery, so we really had to listen to one another because this was such new territory for all of us,” Peloquin remembers.

What emerged in 2008 was a groundbreaking effort that has the potential to help hundreds of children each year: Of the approximately 800 patients treated annually in UCSF’s Intensive Care Nursery, the NICN team sees about 200.

NICN clinicians created some of the first protocols for using hypothermia treatment and other modalities to prevent injury or repair neurological damage in newborns. Nurses have been integral to the development and improvement of these protocols because they are uniquely positioned to see how easily overlooked workflow elements can affect care.

“Everything from the amount of time it takes to get an antiepileptic medicine from the hospital pharmacy to training on the aEEG [a specialized monitor that measures brain activity] can have an impact,” says Peloquin.

Workflow is especially important in the NICN because of the intense need to catch problems early and move quickly. Patients are continuously monitored to evaluate vital signs, including body temperature and brain activity. Most neonatal ICUs monitor neonates only after there is evidence of a seizure, but the information gleaned from continuous monitoring can tell the bedside nurse whether there are changes that indicate an impending or clinically silent seizure.

A copy of the UCSF-developed seizure protocol appears at every NICN bedside, and bedside nurses have been educated to recognize changes in brain activity (such as seizures) on the aEEG and to institute the protocol, which includes communicating with the physician, anticipating and administering medications within a specific period of time, and monitoring the effects on the brain once medications are given.

In addition, research is an integral part of the program. The Newborn Brain Research Institute at UCSF Benioff Children’s Hospital is at the forefront of translational research in the field. As the clinical NICN staff works to improve outcomes, researchers are using the data they provide to investigate what works to help brain-injured infants thrive, both immediately and years down the line.

“I’ve seen lots of babies, and I’ve often wondered about neurological long-term outcomes,” says Peloquin. Thanks to the work she and her colleagues are doing, the outlook for these most vulnerable infants is improving.