How do neonatology nurses explain to Spanish-speaking parents why a premature baby who looks alert and pink cannot go home?

The parent of a premature infant in the NICU often describes their baby as “looking fine” — the baby is pink, moves, sometimes cries, sometimes has eyes open. The disconnect between what the parent sees and what the clinical team sees is not a failure of observation on the parent’s part. It is the absence of a framework for what “premature” means as a physiological state rather than simply a size category. A 28-week infant looks like a baby — has fingers, a face, responds to touch — because the architectural blueprint of a human being is largely laid down in the embryonic period. What has not been laid down at 28 weeks are the functional systems that allow a baby to survive outside the womb without continuous mechanical and thermal support. There are four of these, and each has a clinical milestone that must be reached before discharge is possible. The first is the respiratory system. At 28 weeks, the alveoli — the tiny air sacs where gas exchange occurs — have not yet produced adequate surfactant, the detergent-like protein that prevents them from collapsing with each exhalation. Without surfactant, the work of breathing becomes impossibly high — the infant must re-open collapsed alveoli with each breath. CPAP (continuous positive airway pressure) provides constant low-level pressure through the nose that keeps the alveoli open between breaths, doing the job surfactant normally does. The betamethasone administered before a preterm delivery accelerates surfactant production by one to two weeks but rarely eliminates the need for respiratory support at 28 weeks. The clinical milestone is sustained room-air or low-flow oxygen breathing without apnea for five to seven consecutive days. The second is apnea of prematurity. The brainstem center that sends the rhythmic signal “breathe” is not mature enough at 28 weeks to do so reliably and continuously. The signal fails intermittently, producing apneic spells — pauses in breathing that require a nurse to provide tactile stimulation to resume. Caffeine citrate, the neonatal version of the world’s most common stimulant, is given daily to all very preterm infants to increase brainstem respiratory drive. Apnea of prematurity resolves as the brainstem matures, typically around 34 to 36 weeks corrected gestational age. The discharge criterion for apnea is a period free of clinically significant apneic events, typically five to seven days. A baby who is still having apneic spells cannot go home, regardless of how alert they look, because a parent at home cannot provide the stimulation that resumes breathing and does not have a saturation monitor that alarms. The third is suck-swallow-breathe coordination. Feeding safely by mouth requires the simultaneous, coordinated execution of three distinct rhythmic activities: sucking, which requires the lips and tongue to create negative pressure; swallowing, which requires the pharynx to close the airway and propel a bolus toward the esophagus; and breathing, which must continue throughout. This coordination is a neurological milestone that does not develop until approximately 34 weeks gestational age. Before it develops, any attempt to feed by bottle or breast is dangerous — milk enters the airway instead of the esophagus. The NG tube that delivers milk directly to the stomach bypasses this entirely. The mother pumping is providing the nutrition; the NG tube is delivering it safely until the coordination to bottle or breastfeed arrives. The fourth is thermoregulation. Term newborns have brown adipose tissue distributed throughout the chest and around the organs, which generates heat through non-shivering thermogenesis when body temperature drops. At 28 weeks this fat is not present. The preterm infant also loses heat far more rapidly than a term infant because the skin is thin (low insulating capacity), the surface-area-to-volume ratio is high, and insensible water losses through the skin are enormous. The isolette maintains a controlled temperature and humidity that substitutes for the thermal environment of the womb. The infant will graduate to an open crib when they consistently maintain a normal body temperature in the open air, which typically happens around 35 to 36 weeks corrected age. The neonatology nurse explaining this in Spanish must give all four milestones and their expected timeline: “ ‘La razón por la que Mateo no puede ir a casa todavía no es porque esté enfermo en el sentido de que algo salió mal. Es porque hay cuatro sistemas del cuerpo que a las 28 semanas todavía no están terminados, y esos cuatro sistemas son los que lo van a mantener con vida en casa sin máquinas. No podemos mandarlo a casa hasta que esos cuatro sistemas estén funcionando solos. El primero son los pulmones — la CPAP está haciendo el trabajo que el surfactante todavía no puede hacer solo. El segundo es la respiración continua — todavía tiene episodios donde el cerebro se olvida de mandar la señal de respirar, y yo estoy aquí para recordarle. En casa no habría nadie. El tercero es la alimentación por boca — la coordinación de succionar, tragar y respirar al mismo tiempo no está lista antes de las 34 semanas de edad gestacional corregida. El tubo que le lleva su leche al estómago es la solución mientras esa coordinación llega. El cuarto es la temperatura — la incubadora mantiene la temperatura que el útero iba a mantener once semanas más. Cuando Mateo pueda mantener su temperatura solo en el aire, sale de la incubadora. ’ ” (The reason Mateo cannot go home yet is not because he is sick in the sense that something went wrong. It is because there are four body systems that at 28 weeks are not yet finished, and those four systems are the ones that will keep him alive at home without machines. We cannot send him home until those four systems are working on their own. The first is the lungs — the CPAP is doing the job that the surfactant cannot yet do on its own. The second is continuous breathing — he still has episodes where the brain forgets to send the signal to breathe, and I am here to remind it. At home there would be no one. The third is mouth feeding — the coordination of sucking, swallowing, and breathing at the same time is not ready until 34 weeks corrected gestational age. The tube delivering your milk to the stomach is the solution while that coordination arrives. The fourth is temperature — the isolette is maintaining the temperature the womb was going to maintain for eleven more weeks. When Mateo can maintain his own temperature in the open air, he comes out of the isolette.)

How do NICU nurses explain normal weight loss in premature infants to Spanish-speaking parents who are concerned about declining weight?

The weight chart outside the isolette showing twelve consecutive days of declining or stagnant weight is one of the most distressing things a NICU parent can look at, and it is especially distressing for a mother who has been pumping milk every three hours for twelve days and believes her milk is not being used or is not sufficient. The NICU nurse explaining the weight trajectory to a Spanish-speaking parent needs to address four distinct elements. First, physiologic neonatal weight loss is universal. All newborns — term and preterm — lose weight in the first days of life. This loss is water: in the first days after birth, the kidneys excrete the excess fluid that circulated in fetal tissue under the influence of the amniotic environment. Term babies lose five to ten percent of birth weight, reaching a nadir around day four to five, and return to birth weight by day ten to fourteen. Premature infants at 28 to 32 weeks have much higher insensible water losses because their skin is thin and permeable (water evaporates through it continuously), their respiratory rate is high (exhaled air carries water), and their fluid management requires careful balance to avoid pulmonary edema from the respiratory support they’re receiving. A premature infant losing 12 to 15 percent of birth weight in the first ten days is not starving. They are shedding the excess fluid that was appropriate in utero and is no longer appropriate outside of it. Second, TPN provides complete nutrition through the IV. The umbilical catheter or peripheral IV delivering TPN — total parenteral nutrition — contains glucose, amino acids, lipids, electrolytes, vitamins, and minerals calibrated to the infant’s weight and gestational age. The infant is not receiving insufficient nutrition because they are not yet feeding from the breast or a bottle. The IV is providing everything the infant needs for brain growth, organ development, and cellular repair. Third, trophic feeds are the mother’s milk going through the NG tube — in tiny volumes, not for nutrition, but for gut priming. The premature gut at 28 to 32 weeks is physiologically immature — the brush border enzymes that digest nutrients are not fully present, the microbiome that assists digestion has not been established, and the motility pattern that propels milk toward the colon is uncoordinated. Exposing the gut lining to small volumes of human milk — 10 to 20 mL per kg per day — stimulates the development of these systems without placing a nutritional burden on an immature digestive tract. For a 1,380-gram infant, this is roughly 14 to 28 mL of milk per day. That is the milk the mother is pumping. It is going in. Fourth, feeds advance slowly because necrotizing enterocolitis (NEC) is the most dangerous complication of premature feeding. NEC is an inflammatory injury to the intestinal wall that can progress to perforation in hours in very preterm infants — it is one of the primary causes of death and severe morbidity in the NICU. The primary risk factor is advancing enteral feeds too rapidly in very preterm infants with immature gut defenses. The NICU advances feeds by ten to twenty mL per kg per day, monitoring for feeding intolerance signs (abdominal distension, bilious residuals, bloody stools) before the next increase. At 30 weeks, this advance takes ten to fourteen days before the infant is receiving full enteral nutrition and the TPN can come out. The weight nadir — the lowest point on the chart — typically occurs between day five and day ten; the weight gain phase begins in the second week and accelerates as feeds increase. The goal is fifteen to twenty grams per day — the same rate the fetus gains in utero at this gestational age. The NICU nurse explaining in Spanish: “ ‘La pérdida de peso que está viendo en la tabla no significa que Valentina esté sin comida. Significa que está perdiendo el líquido extra que tenía cuando nació — ese es un proceso normal que pasa en todos los bebés, nacidos en término o prematuros, en los primeros días de vida. La nutrición que necesita llega por el suero — proteínas, grasas, azúcar, vitaminas, minerales — todo calculado para su peso. Y la leche que usted saca cada tres horas la estamos dando — en porciones pequeñas, para entrenar el intestino, que a las 30 semanas no está listo para recibir todo su volumen. Si le diéramos más leche más rápido, el riesgo de una complicación muy seria del intestino sube. El punto más bajo del peso suele ser entre el día cinco y el día diez. Valentina está en el día doce y el peso no bajó más en las últimas 24 horas. En los próximos días, mientras los aportes de leche suben, vamos a ver los primeros días de aumento.’ ” (The weight loss you are seeing on the chart does not mean Valentina is without food. It means she is losing the extra fluid she had when she was born — that is a normal process that happens in all babies, term or premature, in the first days of life. The nutrition she needs is coming through the IV — protein, fat, sugar, vitamins, minerals — all calculated for her weight. And the milk you pump every three hours is being given — in small portions, to train the intestine, which at 30 weeks is not ready to receive full volume. If we gave more milk faster, the risk of a very serious intestinal complication rises. The lowest point of the weight usually falls between day five and day ten. Valentina is on day twelve and the weight did not drop further in the last 24 hours. In the coming days, as the milk volumes increase, we are going to see the first days of gain.)

How do neonatology nurses explain neonatal jaundice and phototherapy to Spanish-speaking parents of a full-term newborn who looks healthy?

The full-term newborn under phototherapy is one of the most counterintuitive NICU situations for parents who have not been given the physiological framework. The baby looks pink and vigorous — feeding, crying, moving — and is under blue lights in a unit where other babies have ventilators and central lines. The parent cannot understand why a baby who looks healthy needs a hospital intervention. The explanation requires three components. First, where bilirubin comes from and why it rises in all newborns. Fetal hemoglobin — the specialized form of hemoglobin that carries oxygen in the fetal circulation — has a higher affinity for oxygen than adult hemoglobin, which allows it to extract oxygen from the maternal circulation across the placenta. At birth, fetal hemoglobin is no longer needed and the body begins breaking it down, converting it to adult hemoglobin production over the first weeks of life. Fetal red blood cells have a shorter lifespan than adult red cells (70 to 90 days versus 120 days), so they break down more rapidly in the neonatal period. When red blood cells break down, hemoglobin is released and degraded to bilirubin. This bilirubin is unconjugated (fat-soluble) — it must be processed by the liver through conjugation (the addition of glucuronic acid, which makes it water-soluble) before it can be excreted in bile. The neonatal liver’s conjugation enzyme — UDP-glucuronosyltransferase — is immature at birth, even at term. For the first three to five days of life, bilirubin production from fetal hemoglobin breakdown exceeds the liver’s ability to conjugate and excrete it. Bilirubin accumulates in the blood. At levels above approximately five milligrams per deciliter, it deposits in the skin, producing jaundice. This is why almost all newborns become visibly yellow in the first three to five days — it is the universal result of the transition from fetal to neonatal hemoglobin physiology. Second, what bilirubin does at high levels and why 19.2 at 36 hours requires intervention. Unconjugated bilirubin is fat-soluble. It is normally bound to albumin in the blood, which prevents it from crossing the blood-brain barrier. When bilirubin levels rise high enough that the albumin binding capacity is saturated, free unconjugated bilirubin crosses the blood-brain barrier and deposits in the basal ganglia and brainstem — a condition called acute bilirubin encephalopathy, which at its most severe produces kernicterus, a permanent form of brain damage causing choreoathetoid cerebral palsy, sensorineural hearing loss, and abnormal gaze patterns. The American Academy of Pediatrics provides a phototherapy threshold nomogram based on age in hours, birth weight, and risk factors. A total bilirubin of 19.2 at 36 hours falls above the phototherapy threshold for a term low-risk infant on that nomogram. The intervention is not optional — it is the treatment for a laboratory value that will continue to rise if untreated. Third, why the baby’s appearance is not a reliable guide to the serum bilirubin level. Skin jaundice becomes visible when bilirubin rises above approximately five milligrams per deciliter and progresses in a cephalocaudal pattern (face first, then trunk, then extremities). But the relationship between visible skin color and the actual serum level is nonlinear and unreliable — skin pigmentation, lighting conditions, and the location of assessment all introduce error. A baby who “doesn’t look that yellow” to the parent may have a bilirubin of 19.2 that is rising. The nurse explaining in Spanish: “ ‘El problema con la bilirrubina no se ve tan fácil por la piel — el color de la piel nos dice que hay bilirrubina, pero no nos dice cuánta. El número que importa es el del análisis de sangre, y ese número en Lucas a las 36 horas de vida está por encima del límite en que la bilirrubina que circula en la sangre puede empezar a acumularse en el cerebro. La luz azul convierte la bilirrubina que tiene en la piel en una forma que el cuerpo puede eliminar por la orina y la bilis sin que el hígado tenga que procesarla. Eso baja el número antes de que llegue a un nivel donde represente un riesgo para el cerebro. Lucas está recibiendo el tratamiento correcto para lo que muestra el análisis.’ ” (The problem with bilirubin is not easy to see from the skin — the skin color tells us there is bilirubin, but it does not tell us how much. The number that matters is the one from the blood test, and that number in Lucas at 36 hours of life is above the threshold at which the bilirubin circulating in the blood can start to accumulate in the brain. The blue light converts the bilirubin in the skin to a form the body can eliminate through urine and bile without the liver having to process it. That lowers the number before it reaches a level where it poses a risk to the brain. Lucas is receiving the correct treatment for what the test shows.)

What is apnea of prematurity and how do NICU nurses explain it in Spanish to parents who are alarmed by the monitor alarms?

Apnea of prematurity is one of the most alarming events a NICU parent witnesses. The monitor alarms, the nurse hurries to the isolette, touches or stimulates the baby, and breathing resumes. The parent who has no framework for why this is happening often interprets the alarm as a sign that something dangerous occurred — that the baby “stopped breathing” in a way that indicates deterioration. The explanation the neonatology nurse must give has three parts. First, the mechanism: the brainstem contains a cluster of neurons called the respiratory center that sends rhythmic signals to the diaphragm and intercostal muscles — “contract, breathe, expand.” This center is functionally immature in premature infants before 34 to 36 weeks gestational age. The immaturity means the signal fails intermittently, producing central apnea — a complete pause in respiratory effort, usually lasting 15 to 20 seconds, during which oxygen saturation falls and heart rate slows (bradycardia). Tactile stimulation — the nurse touching the baby’s foot or chest — sends a sensory signal that restimulates the brainstem and resumes breathing within seconds. Second, the treatment: caffeine citrate, administered intravenously or orally once daily, is a methylxanthine that stimulates the brainstem respiratory center and significantly reduces the frequency of apneic events. It is the most effective pharmacological treatment for apnea of prematurity and is administered to virtually all very preterm infants in the NICU from the first day of life. Third, the discharge criterion: infants cannot be discharged home while they are having clinically significant apneic events, because the tactile stimulation that resumes breathing is not something a parent at home can reliably provide safely, and because a home without a cardiorespiratory monitor does not alarm. Apnea of prematurity resolves as the brainstem matures, typically by 34 to 36 weeks corrected gestational age. The infant must demonstrate a period free of clinically significant events — typically five to seven days — before discharge. The nurse explaining in Spanish: “ ‘La alarma que escuchó no significa que algo salió mal. Significa que el centro del cerebro que manda la señal de respirar — que en los bebés prematuros todavía no está totalmente maduro — se olvidó de mandar esa señal por unos segundos. Lo que hago yo es tocarle el pie o el pecho para recordarle, y respira. Eso pasa en casi todos los bebés prematuros hasta aproximadamente las 34 a 36 semanas de edad gestacional corregida. La cafaína que le damos todos los días ayuda a que pase menos seguido. Pero tiene que pasar sin esos episodios varios días seguidos antes de que pueda irse a casa, porque en casa yo no estaría ahí para recordarle.’ ” (The alarm you heard does not mean something went wrong. It means the center in the brain that sends the signal to breathe — which in premature babies is not yet fully mature — forgot to send that signal for a few seconds. What I do is touch the foot or chest to remind it, and it breathes. That happens in almost all premature babies until approximately 34 to 36 weeks corrected gestational age. The caffeine we give every day helps it happen less often. But the baby must go several consecutive days without those episodes before he can go home, because at home I would not be there to remind it.)

What are the most important Spanish phrases for neonatology nurses working with Spanish-speaking families in the NICU?

Neonatology nursing involves four foundational communication gaps with Spanish-speaking families that directly shape whether parents understand the clinical timeline, whether the mother continues pumping through the weight loss phase, whether parents participate in care rather than watching from a distance, and whether the family of a term newborn under phototherapy understands the intervention rather than experiencing it as an unexplained separation. The first is developmental readiness at 28 weeks: “ ‘Mateo no está listo para irse a casa todavía porque cuatro sistemas del cuerpo no terminan de desarrollarse hasta cerca de las 35 a 36 semanas de edad gestacional. Los pulmones, la respiración continua, la coordinación para comer por boca, y la temperatura — esos cuatro los estamos apoyando nosotros mientras que el cuerpo de Mateo los termina. El que se vea bien no quiere decir que están listos. Quiere decir que la NICU está funcionando.’ ” (Mateo is not ready to go home yet because four body systems do not finish developing until around 35 to 36 weeks corrected gestational age. The lungs, continuous breathing, the coordination to eat by mouth, and temperature — those four we are supporting while Mateo’s body finishes them. Looking good does not mean they are ready. It means the NICU is working.) The second is weight loss and TPN: “ ‘La pérdida de peso que ve en la tabla es líquido, no tejido. Todos los bebés — nacidos en término y prematuros — pierden el líquido extra en los primeros días de vida. La nutrición que necesita llega por el suero, y la leche que usted saca está entrando por el tubo al estómago en las cantidades correctas para la madurez del intestino.’ ” (The weight loss you see on the chart is fluid, not tissue. All babies — term and premature — shed the extra fluid in the first days of life. The nutrition she needs is coming through the IV, and the milk you pump is going through the tube to the stomach in the amounts appropriate for gut maturity.) The third is the NEC risk and why feeds advance slowly: “ ‘No podemos subir el volumen de leche más rápido porque a las 30 semanas el intestino no está maduro y si avanzamos demasiado rápido el riesgo de una inflamación muy seria del intestino — que se llama enterocolitis necrotizante — sube. Cada vez que toleramos bien una dosis, subimos un poco al día siguiente. No es falta de comida. Es el intestino aprendiendo a recibir más cada día.’ ” (We cannot increase the milk volume faster because at 30 weeks the intestine is immature and if we advance too quickly the risk of a very serious intestinal inflammation — called necrotizing enterocolitis — rises. Each time a dose is tolerated well, we increase a little the next day. It is not a lack of food. It is the intestine learning to receive more each day.) The fourth is bilirubin and phototherapy for the term newborn: “ ‘La bilirrubina de Lucas a las 36 horas de vida está en el nivel en que si sigue subiendo puede cruzar al cerebro y causar daño permanente. El color de la piel no nos dice cuánta hay — el análisis de sangre sí. La luz azul convierte la bilirrubina de la piel en una forma que el cuerpo elimina solo. En uno o dos días el número baja, revisamos, y si está por debajo del límite, la luz se apaga. Lucas puede estar contigo mientras tanto en todos los momentos en que no está bajo la luz.’ ” (Lucas’s bilirubin at 36 hours of life is at the level where if it continues to rise it can cross to the brain and cause permanent damage. The skin color does not tell us how much there is — the blood test does. The blue light converts the bilirubin in the skin to a form the body eliminates on its own. In one or two days the number falls, we check, and if it is below the threshold, the light turns off. Lucas can be with you during all the moments when he is not under the light.)

July 30, 2026 · Clinical Spanish · Neonatology · NICU · Neonatal Nursing

Spanish for neonatology nurses — the mother whose 28-week baby is pink and alert and asks why he cannot come home, the mother who has pumped every three hours and watched her daughter’s weight drop for twelve days, and the father whose full-term newborn is under phototherapy lights and looks completely normal

Carmen Reyes is 26 years old. She is a home health aide from East Los Angeles, someone whose daily work is the business of attending to bodies in distress — bathing, repositioning, monitoring, watching for the sign that something is shifting. She is not unfamiliar with medical equipment. She is not someone who panics without cause.

She did not expect to be pregnant for only six and a half months.

Her son Mateo was born at 28 weeks and 3 days, seven days after her cervix began dilating without warning. She received one dose of betamethasone before the delivery — not the full course. Mateo weighed 1,095 grams. He was intubated at birth for respiratory distress, given surfactant, extubated to CPAP within twelve hours, and transferred to the neonatal intensive care unit.

That was five days ago.

Carmen is at the NICU every morning by 7 a.m. She holds Mateo’s hand through the isolette porthole. She knows the sound of each monitor alarm. She pumps in the family room every three hours, twelve times a day. She has not slept more than four consecutive hours since the delivery.

Yesterday she asked neonatology nurse Gabriela Torres the question Gabriela has heard from every NICU parent in the first two weeks: “He looks okay to me. His eyes open sometimes. He moves. He cried a little this morning. Why can’t he come home?”

What this post covers

This post covers three conversations that recur in neonatology nursing when the family speaks Spanish. The first is Carmen’s — the mother of a 28-week infant five days into the NICU who is looking at her son, who is pink and moving and sometimes crying, and cannot understand why the timeline to discharge is weeks away rather than days. The second is Marta Gutiérrez, 32, a nursing technician from Phoenix who has been pumping milk every three hours since her daughter Valentina was born at 30 weeks and 1 day, and who is standing at the isolette on day 12 looking at a weight chart that has gone from 1,380 grams to 1,225 grams and cannot understand why the team is not feeding her infant enough. The third is Jorge Peña, whose son Lucas was born at 39 weeks and 2 days, vigorous and breastfeeding from the first hour, transferred to the NICU at 36 hours of life because his total bilirubin is 19.2 milligrams per deciliter — and Jorge cannot understand why a baby who looks completely normal to him is under phototherapy lights while his wife recovers two floors above.

In each case the communication failure has the same shape: the parent’s eyes are giving them information their brain has no framework to interpret. Carmen sees a baby who is pink and moving and sometimes awake — and has no model for what “premature” means as a physiological state rather than simply a size category. Marta sees a declining weight chart and has no model for what the first two weeks of preterm nutritional transition look like or why the IV in the umbilical cord is providing full nutrition while the stomach learns to receive milk. Jorge sees a son who looks healthy from three feet away and has no model for what bilirubin does in the brain when it reaches the level at which albumin binding is saturated, or why the color of skin jaundice tells you very little about the actual serum level.

Scenario one: Carmen and the baby who looks fine

Gabriela Torres has been a NICU nurse for eleven years. She has taken Carmen’s question in a hundred different forms. She knows that answering “because he’s premature” is not an answer — it is a label applied to a concept the parent has no model for. She pulls a chair next to the isolette and sits at Carmen’s level before she speaks.

Carmen: — Se ve bien. Los ojos se abren. Se mueve. Esta mañana lloró. No entiendo por qué no puede venir a casa todavía.

He looks fine. His eyes open. He moves. This morning he cried. I do not understand why he cannot come home yet.

Gabriela: — Lo que ve es real. Mateo está vivo y respondiendo. Pero lo que se ve — el color de la piel, que los ojos se abran, que llore — eso lo tenía todo desde mucho antes de las 28 semanas. El cuerpo humano arma esas partes temprano. Lo que no está listo a las 28 semanas son los cuatro sistemas que lo van a mantener con vida fuera sin máquinas. Y hasta que esos cuatro sistemas funcionen solos, las máquinas son su cuerpo. ¿Le explico cuáles son?

What you see is real. Mateo is alive and responsive. But what you see — the skin color, the eyes opening, the crying — he had all of that long before 28 weeks. The human body builds those parts early. What is not ready at 28 weeks are the four systems that will keep him alive outside without machines. And until those four systems work on their own, the machines are his body. May I explain what they are?

Carmen: — Sí. Necesito entenderlo.

Yes. I need to understand it.

The first system: lungs and the CPAP

Gabriela: — El primer sistema son los pulmones. A las 28 semanas, los sacos de aire dentro de los pulmones — que se llaman alvéolos — no producen todavía suficiente surfactante. El surfactante es como un jabón dentro del alvéolo que impide que se colapse cada vez que Mateo exhala. Sin surfactante suficiente, cada vez que exhala, los alvéolos se cierran y tiene que volver a abrirlos con la siguiente inhalación. Eso requiere tanto esfuerzo que los músculos respiratorios se agotan muy rápido. La CPAP — el dispositivo que le pasa aire por la nariz — mantiene una presión constante dentro de los alvéolos que los mantiene abiertos entre respiraciones. Está haciendo el trabajo que el surfactante normalmente haría. El inyectable que le dimos a usted antes del parto aceleró la producción de surfactante, pero a las 28 semanas sigue siendo insuficiente para que los pulmones funcionen solos. El criterio para salir del CPAP es que los pulmones mantengan buena oxigenación solos, sin presión, varios días seguidos.

The first system is the lungs. At 28 weeks, the air sacs inside the lungs — called alveoli — do not yet produce enough surfactant. Surfactant is like a soap inside the alveolus that prevents it from collapsing each time Mateo exhales. Without enough surfactant, every time he exhales the alveoli close and he must reopen them with the next inhalation. That requires so much effort that the breathing muscles exhaust very quickly. The CPAP — the device that passes air through his nose — maintains a constant pressure inside the alveoli that keeps them open between breaths. It is doing the job that surfactant would normally do. The injection we gave you before the delivery accelerated surfactant production, but at 28 weeks it is still insufficient for the lungs to work on their own. The criterion for coming off the CPAP is that the lungs maintain good oxygenation on their own, without pressure, for several consecutive days.

The second system: continuous breathing and apnea of prematurity

Carmen: — ¿Y la alarma que a veces suena? Hay veces que corre la enfermera a tocarlo y después la alarma para.

And the alarm that sometimes sounds? Sometimes a nurse runs to touch him and then the alarm stops.

Gabriela: — Eso es el segundo sistema: la respiración continua. En el tronco del encéfalo — la parte del cerebro que controla las funciones automáticas como respirar — hay un grupo de neuronas que manda la señal “respira, exhála, respira, exhála” de forma continua. Ese centro no termina de madurar hasta aproximadamente las 34 a 36 semanas de edad gestacional. En los bebés prematuros, la señal falla a veces — el cerebro simplemente no la manda por unos segundos — y el bebé deja de respirar. Eso se llama apnea del prematuro. Cuando yo le toco el pie o el pecho, le mando una señal sensorial que llega al tronco del encéfalo y lo reactiva. El bebé respira. No es que algo salió mal. Es que el cerebro todavía no es lo suficientemente maduro para no olvidarse. La cafaína que le damos todos los días — sí, la misma molécula que está en el café — estimula ese centro del tronco del encéfalo y reduce mucho la frecuencia con que pasa. Pero el criterio para irse a casa es que pase varios días consecutivos sin un episodio de apnea que necesite estimulación. En casa no estaría yo para tocarlo.

That is the second system: continuous breathing. In the brainstem — the part of the brain that controls automatic functions like breathing — there is a group of neurons that sends the signal “breathe, exhale, breathe, exhale” continuously. That center does not finish maturing until approximately 34 to 36 weeks gestational age. In premature babies, the signal fails sometimes — the brain simply does not send it for a few seconds — and the baby stops breathing. That is called apnea of prematurity. When I touch his foot or chest, I send a sensory signal that reaches the brainstem and reactivates it. The baby breathes. It is not that something went wrong. It is that the brain is not yet mature enough not to forget. The caffeine we give every day — yes, the same molecule that is in coffee — stimulates that brainstem center and greatly reduces how often it happens. But the criterion to go home is that several consecutive days pass without an episode that requires stimulation. At home I would not be there to touch him.

Carmen is quiet for a moment.

Carmen: — Entonces cuando corre usted a la incubadora no es una emergencia. Es rutina.

So when you run to the isolette it is not an emergency. It is routine.

Gabriela: — Es el trabajo de ser su cerebro por él hasta que su cerebro esté listo. Sí.

It is the work of being his brain for him until his brain is ready. Yes.

The third system: feeding coordination

Gabriela: — El tercer sistema es la alimentación. Comer por boca — por pecho o biberón — requiere tres cosas al mismo tiempo: succionar, tragar y respirar. Succionar requiere que los labios y la lengua creen presión negativa. Tragar requiere que la faríngea cierre la vía aérea en el momento exacto en que pasa el líquido. Respirar tiene que seguir pasando durante todo ese proceso. Esa coordinación de tres ritmos simultáneos no existe como habilidad neurológica antes de aproximadamente las 34 semanas de edad gestacional. Antes de eso, si intentamos darle leche por boca, entra a la vía aérea en lugar del esófago. Por eso tiene el tubo que lleva su leche directamente al estómago. El tubo no es porque Mateo no quiera comer o no pueda comer — es porque el circuito neurológico que hace esa coordinación segura todavía no está. Cuando llegue, empezamos a practicar en pecho. La leche que está sacando usted es la que le estamos dando ahora y será la que le dará en pecho cuando el momento llegue.

The third system is feeding. Eating by mouth — from breast or bottle — requires three things simultaneously: sucking, swallowing, and breathing. Sucking requires the lips and tongue to create negative pressure. Swallowing requires the pharynx to close the airway at the exact moment the liquid passes. Breathing must continue throughout that entire process. That coordination of three simultaneous rhythms does not exist as a neurological skill until approximately 34 weeks gestational age. Before that, if we try to give him milk by mouth, it goes into the airway instead of the esophagus. That is why he has the tube that carries your milk directly to the stomach. The tube is not because Mateo does not want to eat or cannot eat — it is because the neurological circuit that makes that coordination safe is not there yet. When it arrives, we begin practicing at the breast. The milk you are pumping is what we are giving him now and will be what you give him at the breast when the moment comes.

Carmen: — ¿Entonces la leche que estoy sacando sí la está recibiendo?

So the milk I am pumping he is actually receiving?

Gabriela: — Cada millilitro. Entra por el tubo al estómago. No se desperdicia nada. Y tiene propiedades que ningún sustituto tiene — anticuerpos, factores de crecimiento intestinal, proteínas específicas que preparan el intestino. Lo que está haciendo ahora mismo — sacarse leche doce veces al día — es una de las cosas más importantes que puede hacer por Mateo desde donde está.

Every milliliter. It goes through the tube to the stomach. Nothing is wasted. And it has properties no substitute has — antibodies, intestinal growth factors, specific proteins that prepare the gut. What you are doing right now — pumping twelve times a day — is one of the most important things you can do for Mateo from where you are.

The fourth system: temperature

Gabriela: — El cuarto sistema es la temperatura. Los bebés nacidos a término tienen un tipo de tejido graso que se llama grasa parda, distribuida en el pecho y alrededor de los órganos. Esa grasa genera calor cuando la temperatura del cuerpo baja — sin temblores, directamente como calor. A las 28 semanas esa grasa no está presente. Mateo tampoco puede generar calor haciendo esfuerzo físico porque es demasiado pequeño y usaría toda su energía en eso en lugar de en crecer. La incubadora mantiene la temperatura y la humedad que iba a mantener el útero once semanas más. Sale de la incubadora a una cuna abierta cuando mantiene su propia temperatura estable en el aire, sin apoyo, durante varios días. Eso suele pasar alrededor de las 35 a 36 semanas de edad gestacional corregida.

The fourth system is temperature. Term babies have a type of fatty tissue called brown fat, distributed in the chest and around the organs. That fat generates heat when body temperature drops — without shivering, directly as heat. At 28 weeks that fat is not present. Mateo also cannot generate heat through physical effort because he is too small and would use all his energy on that instead of on growing. The isolette maintains the temperature and humidity the womb was going to maintain for eleven more weeks. He leaves the isolette for an open crib when he maintains his own stable temperature in the open air, without support, for several days. That typically happens around 35 to 36 weeks corrected gestational age.

Carmen: — Entonces no está enfermo. Todavía se está desarrollando.

So he is not sick. He is still developing.

Gabriela: — Exactamente eso. La NICU es el útero que no pudo terminar. Esos cuatro sistemas los estamos completando aquí. Cuando estén listos, Mateo puede irse a casa. No hay un número de días fijo — hay criterios, y cada vez que cumple uno, está más cerca. Usted ya sabe ahora qué buscar. Y puede preguntarme todos los días cómo está cada uno de los cuatro.

Exactly that. The NICU is the womb that could not finish. We are completing those four systems here. When they are ready, Mateo can go home. There is no fixed number of days — there are criteria, and each time he meets one, he is closer. You know now what to look for. And you can ask me every day how each of the four is doing.

Carmen: — Voy a hacer eso. Gracias por explicarme.

I am going to do that. Thank you for explaining.

Scenario two: Marta and the weight that will not stop falling

Marta Gutiérrez has been a nursing technician for nine years. She knows medical environments. She knows charts. She knows that a number that goes down for twelve consecutive days on a chart is a number that is going wrong.

Her daughter Valentina was born at 30 weeks and 1 day after an abruption — placental separation during the night, emergency cesarean at 3 a.m. Valentina weighed 1,380 grams. Marta has been pumping every three hours since the day of delivery, even through the night, the way the lactation consultant instructed. She has produced more than enough milk. She has been told it is going to Valentina.

On day 12, Valentina weighs 1,225 grams. Down 155 grams from birth. Marta has kept her own weight log on her phone. She shows it to NICU nurse Pedro Álvarez before he has a chance to speak.

Marta: — Doce días. Baja todos los días. Me dicen que está recibiendo leche. Me dicen que está bien. Pero el peso baja. No me puede decir que está todo bien y mostrarme este número al mismo tiempo.

Twelve days. It goes down every day. They tell me she is receiving milk. They tell me she is fine. But the weight goes down. You cannot tell me everything is fine and show me this number at the same time.

Pedro: — Tiene razón en preguntar. Y voy a explicarle exactamente qué significa ese número, porque es diferente a lo que parece.

You are right to ask. And I am going to explain exactly what that number means, because it is different from what it appears to be.

The weight that is falling is fluid, not tissue

Pedro: — Todos los recién nacidos — nacidos en término o prematuros — pierden peso en los primeros días de vida. No porque no estén comiendo. Porque el cuerpo expulsa el líquido extra que tenía dentro del útero. Cuando el bebé estaba dentro de usted, el ambiente era líquido — flotaba, los tejidos estaban saturados de líquido. Después del parto, los riñones tienen que eliminar ese exceso. En un bebé nacido a término, eso es el cinco al diez por ciento del peso de nacimiento, y pasa en los primeros cuatro o cinco días. En Valentina, que nació a las 30 semanas, pasa por más tiempo y en mayor cantidad, por tres razones: la piel a las 30 semanas es delgada y permeable — el agua se evapora a través de ella continuamente. La frecuencia respiratoria es alta — cada vez que exhala, pierde agua. Y el manejo de líquidos que necesita la respiración asistida requiere control muy cuidadoso para no sobrecargar los pulmones. La pérdida del doce por ciento del peso de nacimiento en doce días en un bebé de 30 semanas es esperada. Es líquido, no tejido. No significa que esté desnutrida.

All newborns — term or premature — lose weight in the first days of life. Not because they are not eating. Because the body expels the extra fluid it had inside the womb. When the baby was inside you, the environment was liquid — she floated, the tissues were saturated with fluid. After delivery, the kidneys must eliminate that excess. In a term baby, that is five to ten percent of birth weight, and it happens in the first four or five days. In Valentina, born at 30 weeks, it happens for longer and in greater proportion, for three reasons: the skin at 30 weeks is thin and permeable — water evaporates through it continuously. The respiratory rate is high — every time she exhales she loses water. And the fluid management required for assisted breathing requires very careful control to avoid overloading the lungs. A loss of twelve percent of birth weight over twelve days in a 30-week baby is expected. It is fluid, not tissue. It does not mean she is undernourished.

Marta: — Pero entonces, ¿qué está comiendo? ¿Cómo está nutrida si está perdiendo peso?

But then, what is she eating? How is she nourished if she is losing weight?

TPN: complete nutrition through the IV

Pedro: — Todo lo que Valentina necesita para que su cerebro crezca y sus órganos se desarrollen llega por el suero. Eso se llama nutrición parenteral total, o NPT. Es una solución que contiene proteínas, grasas, azúcar, electrolitos, vitaminas y minerales — todo calculado exactamente para su peso y su edad gestacional. No está con hambre. Su cerebro está recibiendo los nutrientes que necesita. Lo que no está haciendo es crecer en términos de peso todavía — porque el peso del líquido que pierde supera todavía el peso de tejido que gana. En la segunda semana eso se invierte.

Everything Valentina needs for her brain to grow and her organs to develop is coming through the IV. That is called total parenteral nutrition, or TPN. It is a solution that contains protein, fat, sugar, electrolytes, vitamins, and minerals — all calculated exactly for her weight and gestational age. She is not hungry. Her brain is receiving the nutrients it needs. What she is not doing is growing in terms of weight yet — because the weight of fluid she is losing still exceeds the weight of tissue she is gaining. In the second week that reverses.

Marta: — ¿Y la leche que estoy sacando?

And the milk I am pumping?

Trophic feeds: gut priming with her own milk

Pedro: — La leche que usted saca está entrando a Valentina. Todos los días, por el tubo que va al estómago. Pero la cantidad es pequeña ahora — alrededor de 14 a 28 mililitros por kilo por día, que para el peso de Valentina son porciones múy pequenñas. Esas cantidades no son suficientes para ser la fuente principal de nutrición — para eso está el suero. La función de esa leche ahora es diferente: es entrenar el intestino. El intestino de un bebé de 30 semanas no está listo para recibir y digerir el volumen completo de leche que necesita para su nutrición. Las enzimas que digieren la leche no están plenamente activas todavía. El movimiento intestinal que propulsa la leche hacia el colon no es coordinado todavía. Cuando le damos esas pequeñas cantidades de su leche, las células del intestino las reciben, las reconocen, y empiezan a prepararse. Le decimos al intestino: esto viene, prepárate. Cada día que tolera bien la dosis de hoy, subimos un poco mañana.

The milk you pump is going into Valentina. Every day, through the tube that goes to the stomach. But the quantity is small now — around 14 to 28 milliliters per kilogram per day, which for Valentina’s weight are very small portions. Those amounts are not enough to be the main source of nutrition — that is what the IV is for. The function of that milk now is different: it is to train the gut. The intestine of a 30-week baby is not ready to receive and digest the full volume of milk it needs for its nutrition. The enzymes that digest milk are not yet fully active. The intestinal movement that propels milk toward the colon is not yet coordinated. When we give those small amounts of your milk, the intestinal cells receive them, recognize them, and begin to prepare. We tell the intestine: this is coming, get ready. Each day she tolerates today’s dose well, we increase a little tomorrow.

Marta: — ¿Entonces no es que no estén dándole suficiente porque no hay suficiente o porque la leche no es buena? ¿Es que el intestino no está listo para más?

So it is not that they are not giving her enough because there is not enough or because the milk is not good? It is that the intestine is not ready for more?

Pedro: — Exactamente. Su leche es la ideal. Tiene anticuerpos que ningún sustituto tiene, y factores de crecimiento específicos para el intestino prematuro que la leche de donante tiene menos y la fórmula no tiene. El límite no es la leche. Es la velocidad a la que el intestino puede aprender a recibirla sin que eso le haga daño. Y ese límite está ahí por una razón muy importante.

Exactly. Your milk is the ideal one. It has antibodies that no substitute has, and growth factors specific to the premature intestine that donor milk has less of and formula does not have. The limit is not the milk. It is the rate at which the intestine can learn to receive it without harm. And that limit is there for a very important reason.

Why feeds advance slowly: the NEC risk

Pedro: — Si avanzamos los volúmenes de leche demasiado rápido en un bebé prematuro, el riesgo de una complicación muy seria sube. Se llama enterocolitis necrotizante — NEC en inglés. Es una inflamación del intestino que en casos severos puede perforar la pared del intestino en horas. Es una de las principales causas de mortalidad en la NICU en bebés prematuros. Los bebés de 28 a 32 semanas tienen el mayor riesgo porque el intestino es menos maduro y las defensas de la pared intestinal son más débiles. La velocidad de avance de los aportes entérales — 10 a 20 mililitros por kilo por día, cuando está tolerando bien — está basada en evidencia de qué velocidades reducen ese riesgo. No es lentitud por precaución excesiva. Es la velocidad que protege a Valentina mientras el intestino aprende.

If we advance the milk volumes too quickly in a premature baby, the risk of a very serious complication rises. It is called necrotizing enterocolitis — NEC. It is an inflammation of the intestine that in severe cases can perforate the intestinal wall in hours. It is one of the primary causes of mortality in the NICU in premature infants. Babies of 28 to 32 weeks have the highest risk because the intestine is less mature and the defenses of the intestinal wall are weaker. The rate of advance of enteral feeds — 10 to 20 milliliters per kilogram per day, when tolerating well — is based on evidence of which rates reduce that risk. It is not slowness from excessive caution. It is the rate that protects Valentina while the intestine learns.

Marta: — ¿Y cuándo empieza a subir de peso?

And when does she start to gain weight?

Pedro: — El punto más bajo del peso — que se llama el nadir — suele ocurrir entre el día cinco y el día diez. Valentina está en el día doce. Mire aquí: en las últimas 24 horas el peso no bajó. Eso es la primera señal de que estamos llegando al punto de inflexión. En los próximos días, conforme los aportes de leche aumentan un poco cada día, el tejido que está formando va a empezar a superar el líquido que sigue perdiendo. La meta cuando lleguemos a alimentación enteral completa es quince a veinte gramos por día — eso es lo que el feto gana dentro del útero a esta edad gestacional. No va a ser drámatico al principio. Pero va a ser hacia arriba.

The lowest weight point — called the nadir — typically occurs between day five and day ten. Valentina is on day twelve. Look here: in the last 24 hours the weight did not fall. That is the first sign that we are reaching the turning point. In the coming days, as the milk volumes increase a little each day, the tissue she is building is going to start to exceed the fluid she is still losing. The goal when we reach full enteral feeding is fifteen to twenty grams per day — that is what the fetus gains inside the womb at this gestational age. It will not be dramatic at first. But it will be upward.

Marta: — Quiero que en el cuaderno que tiene afuera de la incubadora anoten cada día el volúmen de leche que le dieron, el peso, y lo que piensan del intestino. Para que yo lo pueda ver.

I want them to write in the notebook outside the isolette every day the volume of milk given, the weight, and what they think about the intestine. So I can see it.

Pedro: — Ya está anotado. Y desde hoy se lo explico yo directamente cada vez que empiece mi turno. No tiene que interpretar los números sola.

It is already noted. And from today I will explain it directly to you every time I start my shift. You do not have to interpret the numbers alone.

Scenario three: Jorge and the baby under the lights

Lucas Peña was born at 39 weeks and 2 days, eight pounds two ounces, healthy Apgar scores, first cry in the delivery room before the cord was cut. He breastfed in the first hour. His mother, Verónica, was planning to go home in two days.

At 36 hours of life, the routine newborn bilirubin level came back 19.2 milligrams per deciliter. The neonatology team transferred Lucas to the NICU for phototherapy. Verónica was told Lucas needed special lights. Jorge, who had been home getting a few hours of sleep when the transfer happened, drove to the hospital to find his son under blue lights, an eye mask on his face, with IV access placed for fluids, in a room where other babies were on ventilators.

He is standing in the hallway when neonatology nurse Isabel Ramos finds him. His phone is in his hand, displaying a text from his wife: “they won’t let me hold him while he’s under the lights.”

Jorge: — Mi hijo está bien. Lo vi esta mañana. Come, llora, tiene buen color. No entiendo por qué está aquí. ¿Qué es lo que tiene?

My son is fine. I saw him this morning. He eats, cries, looks good color. I do not understand why he is here. What does he have?

Isabel: — Lucas está bien en el sentido de que nació sano y no tiene ninguna enfermedad. Lo que tiene es un nivel de bilirrubina en la sangre que está por encima del límite en que necesita tratamiento. Voy a explicarle qué es la bilirrubina y por qué ese número importa, porque el color de la piel — que usted ve bien — no le dice cuánta hay. Solo el análisis de sangre lo dice.

Lucas is fine in the sense that he was born healthy and has no disease. What he has is a blood bilirubin level that is above the threshold at which it requires treatment. I am going to explain to you what bilirubin is and why that number matters, because the skin color — which looks fine to you — does not tell you how much there is. Only the blood test does.

Why bilirubin rises in every newborn

Isabel: — Durante el embarazo, el bebé usa un tipo especial de hemoglobina — la hemoglobina fetal — que tiene una afinidad más alta por el oxígeno que la hemoglobina adulta. Eso le permite tomar oxígeno de la sangre de usted a través de la placenta. Después del nacimiento, esa hemoglobina fetal ya no se necesita — el bebé ahora respira aire directamente. El cuerpo empieza a descomponer los glóbulos rojos fetales, que tienen una vida más corta que los glóbulos rojos adultos, y esa descomposición produce bilirrubina. La bilirrubina tiene que ser procesada por el hígado — el hígado la transforma en una forma soluble en agua para que pueda salir por la bilis. El problema es que la enzima del hígado que hace ese trabajo — la enzima que conjuga la bilirrubina — no está plenamente activa en los primeros días de vida, ni siquiera en los bebés nacidos a término. La bilirrubina se produce más rápido de lo que el hígado la puede eliminar. Se acumula en la sangre. Cuando el nivel sube por encima de aproximadamente cinco miligramos por decilitro, empieza a depositarse en la piel y produce el color amarillo que llamamos ictericia. Eso pasa en casi todos los recién nacidos en los primeros tres a cinco días de vida — es la biología normal de la transición de la hemoglobina fetal a la adulta.

During pregnancy, the baby uses a special type of hemoglobin — fetal hemoglobin — that has a higher affinity for oxygen than adult hemoglobin. That allows it to take oxygen from your blood through the placenta. After birth, that fetal hemoglobin is no longer needed — the baby now breathes air directly. The body begins breaking down the fetal red blood cells, which have a shorter life than adult red blood cells, and that breakdown produces bilirubin. Bilirubin must be processed by the liver — the liver transforms it into a water-soluble form so it can exit through bile. The problem is that the liver enzyme that does that work — the enzyme that conjugates bilirubin — is not fully active in the first days of life, even in term babies. Bilirubin is produced faster than the liver can eliminate it. It accumulates in the blood. When the level rises above approximately five milligrams per deciliter, it begins to deposit in the skin and produces the yellow color we call jaundice. That happens in almost all newborns in the first three to five days of life — it is the normal biology of the transition from fetal to adult hemoglobin.

Jorge: — Entonces la ictericia es normal. ¿Por qué entonces está en la NICU?

So jaundice is normal. Then why is he in the NICU?

What bilirubin does at high levels: kernicterus

Isabel: — Porque hay un límite hasta el que es normal, y el nivel de Lucas está por encima de ese límite a su edad en horas. La bilirrubina que circula en la sangre normalmente está unida a una proteína llamada albúmina, que la mantiene dentro de los vasos sanguíneos y la impide llegar al cerebro. Cuando el nivel de bilirrubina sube tanto que la albúmina no puede unirse a toda — cuando se satura la capacidad de unión — la bilirrubina libre, que es soluble en grasa, cruza la barrera entre la sangre y el cerebro y se deposita en estructuras específicas del cerebro: los ganglios basales y el tronco del encéfalo. Eso produce un daño que se llama kernicterus — una forma permanente de daño cerebral que causa paralisis cerebral de tipo coreoatetosis, pérdida de audición, y problemas de la visión. El kernicterus no se puede revertir. Por eso el tratamiento no puede esperar a que el bebé “parezca enfermo.” Para cuando el bebé parece enfermo de kernicterus, el daño ya ocurrió.

Because there is a threshold up to which it is normal, and Lucas’s level is above that threshold at his age in hours. The bilirubin circulating in the blood is normally bound to a protein called albumin, which keeps it inside the blood vessels and prevents it from reaching the brain. When the bilirubin level rises so much that albumin cannot bind to all of it — when the binding capacity is saturated — free bilirubin, which is fat-soluble, crosses the barrier between the blood and the brain and deposits in specific brain structures: the basal ganglia and the brainstem. That produces damage called kernicterus — a permanent form of brain damage that causes choreoathetoid cerebral palsy, hearing loss, and vision problems. Kernicterus cannot be reversed. That is why treatment cannot wait for the baby to “look sick.” By the time a baby looks sick from kernicterus, the damage has already occurred.

Jorge is quiet. His jaw tightens.

Jorge: — ¿Entonces el nivel de Lucas es peligroso?

So Lucas’s level is dangerous?

Isabel: — El nivel de Lucas, a las 36 horas de vida, está por encima del umbral de tratamiento que la Academia Americana de Pediatría establece para un bebé nacido a 39 semanas sin factores de riesgo adicionales. No está en un nivel de emergencia. Está en el nivel en que el tratamiento con fototerapia lo baja antes de que llegue al nivel que sería peligroso. Por eso está aquí ahora, no después. El tratamiento que está recibiendo es el correcto para el número que tiene.

Lucas’s level, at 36 hours of life, is above the treatment threshold that the American Academy of Pediatrics establishes for a baby born at 39 weeks without additional risk factors. It is not at an emergency level. It is at the level where phototherapy treatment lowers it before it reaches the level that would be dangerous. That is why he is here now, not later. The treatment he is receiving is the correct one for the number he has.

How phototherapy works

Jorge: — Y esas luces azules, ¿cómo bajan la bilirrubina?

And those blue lights — how do they lower the bilirubin?

Isabel: — La bilirrubina que no puede procesar el hígado es soluble en grasa y se deposita en la piel. La luz de fototerapia — que emite en un rango de longitud de onda específica, alrededor de 460 a 490 nanómetros, lo que lo hace azul — penetra en la piel y llega a la bilirrubina depositada ahí. La luz convierte la bilirrubina de la forma que solo el hígado puede procesar a una forma diferente — se llama lumirubina — que es soluble en agua y que el cuerpo puede eliminar por la bilis y la orina sin que el hígado tenga que conjugarla primero. Eso reduce el nivel en la sangre desde fuera, independientemente de la madurez de la enzima del hígado. En uno o dos días, el nivel baja por debajo del umbral de tratamiento y la luz se apaga.

The bilirubin the liver cannot process is fat-soluble and deposits in the skin. The phototherapy light — which emits at a specific wavelength range, around 460 to 490 nanometers, which makes it blue — penetrates the skin and reaches the bilirubin deposited there. The light converts the bilirubin from the form only the liver can process to a different form — called lumirubin — that is water-soluble and that the body can eliminate through bile and urine without the liver having to conjugate it first. That reduces the level in the blood from outside, independently of the maturity of the liver enzyme. In one or two days, the level falls below the treatment threshold and the light turns off.

Jorge: — ¿Y la máscara que tiene en los ojos?

And the mask he has on his eyes?

Isabel: — La luz de fototerapia puede dañar la retina si entra directamente a los ojos. La máscara los protege. Cuando lo saca de las luces para alimentarlo — porque puede salir de las luces para las tomas de leche — la máscara se saca y puede ver sus ojos. Lucas puede estar contigo y con su mamá en todos los momentos en que no está bajo la luz.

The phototherapy light can damage the retina if it enters the eyes directly. The mask protects them. When he comes out of the lights for feeding — because he can come out for feeding sessions — the mask comes off and you can see his eyes. Lucas can be with you and his mother during all the moments when he is not under the light.

Jorge: — ¿Cuándo lo revísan de nuevo?

When do they check him again?

Isabel: — En cuatro a seis horas hacemos otro análisis de sangre. Si el nivel bajó y está respondiendo a la luz, seguimos igual. Si está respondiendo bien, en 24 a 48 horas lo revisamos con el nivel por debajo del umbral de tratamiento. Eso es lo que esperamos. ¿Quiere estar aquí cuando lleguen los resultados?

In four to six hours we do another blood test. If the level fell and he is responding to the light, we continue the same. If he is responding well, in 24 to 48 hours we expect to see the level below the treatment threshold. That is what we expect. Would you like to be here when the results arrive?

Jorge: — Sí. Voy a quedarme.

Yes. I am going to stay.

Eight practical phrases for neonatology nurses

These are the phrases that recur in neonatology nursing when the family speaks Spanish. Each one addresses a communication gap that directly shapes whether the parent understands the clinical timeline and the machinery of the NICU, whether the mother continues pumping through a weight loss phase that looks like her milk is not getting to her baby, and whether the father of a healthy-looking jaundiced newborn understands the intervention before the bilirubin level climbs further.

1. What the parent sees is real — what they cannot see is which systems are finished

Lo que ve es real — el color rosado, el movimiento, que a veces llore — eso lo tiene desde mucho antes de las 28 semanas. Lo que no se ve es qué sistemas del cuerpo están terminados. A las 28 semanas, cuatro no lo están: los pulmones, la respiración continua, la coordinación para comer por boca, y la temperatura. Esos cuatro los estamos apoyando nosotros. El que el bebé se vea bien es la señal de que la NICU está funcionando, no de que está listo para irse.

What you see is real — the pink color, the movement, the occasional cry — he had all of that long before 28 weeks. What you cannot see is which body systems are finished. At 28 weeks, four are not: the lungs, continuous breathing, the coordination to eat by mouth, and temperature. Those four we are supporting. The baby looking well is the sign that the NICU is working, not that he is ready to leave.

2. The CPAP is keeping the alveoli open between breaths — it is doing the job the surfactant is not yet doing

La CPAP no es respiración asistida en el sentido de que respira por el bebé. Mantiene una presión constante dentro de los sacos de aire del pulmón para que no se colapsen entre una respiración y la siguiente. A las 28 semanas, el surfactante — la proteína que normalmente hace ese trabajo — no está en cantidad suficiente todavía. El criterio para salir del CPAP es que los pulmones mantengan buena oxigenación solos, sin presión, varios días consecutivos.

The CPAP is not assisted breathing in the sense that it breathes for the baby. It maintains a constant pressure inside the air sacs of the lung so they do not collapse between one breath and the next. At 28 weeks, surfactant — the protein that normally does that job — is not yet present in sufficient quantity. The criterion for coming off CPAP is that the lungs maintain good oxygenation on their own, without pressure, for several consecutive days.

3. Apnea of prematurity is the brainstem forgetting to send the breathing signal — it is expected, treated with caffeine, and a discharge criterion

Cuando suena la alarma y yo corro a tocarle el pie, no es que algo salió mal. El centro del tronco del encéfalo que manda la señal de respirar olvidó mandarla por unos segundos. El toque sensorial lo reactiva. Eso pasa en casi todos los bebés prematuros antes de las 34 a 36 semanas de edad gestacional corregida. La cafaína que le damos todos los días reduce cuánto pasa. Pero tiene que pasar varios días sin esos episodios antes de poder irse a casa, porque en casa no estaría yo.

When the alarm sounds and I run to touch the foot, it is not that something went wrong. The brainstem center that sends the breathing signal forgot to send it for a few seconds. The tactile touch reactivates it. That happens in almost all premature babies before 34 to 36 weeks corrected gestational age. The caffeine we give every day reduces how often it happens. But several days must pass without those episodes before going home, because at home I would not be there.

4. Suck-swallow-breathe coordination does not develop until 34 weeks corrected — the NG tube is the safe option until then, not a sign that something is wrong with feeding

Comer por boca requiere succionar, tragar y respirar al mismo tiempo — tres ritmos coordinados simultáneamente. Esa coordinación neurológica llega alrededor de las 34 semanas de edad gestacional corregida. Antes de eso, dar leche por boca pone la vía aérea en riesgo porque la faringe no cierra el momento correcto. El tubo que lleva su leche al estómago no es porque el bebé no quiera comer o no pueda — es la solución segura mientras el cerebro termina de conectar ese circuito.

Eating by mouth requires sucking, swallowing, and breathing simultaneously — three rhythms coordinated at the same time. That neurological coordination arrives around 34 weeks corrected gestational age. Before that, giving milk by mouth puts the airway at risk because the pharynx does not close at the right moment. The tube delivering your milk to the stomach is not because the baby does not want to eat or cannot — it is the safe solution while the brain finishes connecting that circuit.

5. The weight loss in the first two weeks of NICU is fluid, not tissue — TPN is providing complete nutrition through the IV

La pérdida de peso que ve en la tabla es líquido extra que los riñones están eliminando — en todos los recién nacidos, no solo en los prematuros, aunque en prematuros dura más tiempo porque las pérdidas por la piel y la respiración son mayores. El bebé no está desnutrido. La nutrición completa — proteínas, grasas, azúcar, vitaminas, minerales — llega por el suero, calculada para su peso y su edad gestacional. El punto más bajo del peso suele ocurrir entre el día cinco y el día diez. Cuando los aportes de leche aumentan y el intestino los recibe bien, el peso empieza a subir.

The weight loss you see on the chart is extra fluid the kidneys are eliminating — in all newborns, not only premature ones, although in premature infants it lasts longer because losses through the skin and breathing are greater. The baby is not malnourished. Complete nutrition — protein, fat, sugar, vitamins, minerals — is coming through the IV, calculated for her weight and gestational age. The lowest weight point typically occurs between day five and day ten. When milk volumes increase and the intestine receives them well, the weight starts to rise.

6. The milk the mother is pumping is going in through the NG tube — trophic feeds are gut priming, not nutrition replacement

La leche que está sacando sí está llegando al bebé — por el tubo al estómago, en cantidades pequeñas. Esas cantidades pequeñas no son insuficientes: tienen una función específica en este momento, que es entrenar el intestino. Le estamos diciendo al intestino que esto viene, que se prepare, que desarrolle las enzimas y el movimiento que necesita para recibir más. Cada día que tolera bien la dosis de hoy, subimos un poco mañana. La leche que saca tiene propiedades que ningún sustituto tiene — siga sacándosela.

The milk you are pumping is reaching the baby — through the tube to the stomach, in small amounts. Those small amounts are not insufficient: they have a specific function at this moment, which is to train the intestine. We are telling the intestine that this is coming, to prepare, to develop the enzymes and movement needed to receive more. Each day that today’s dose is tolerated well, we increase a little tomorrow. The milk you pump has properties no substitute has — keep pumping.

7. Neonatal jaundice is normal biology in the first days — the phototherapy threshold is the level at which it stops being safe

Casi todos los recién nacidos se ponen amarillos en los primeros tres a cinco días de vida porque el hígado todavía no procesa la bilirrubina tan rápido como el cuerpo la produce. Eso es fisiología normal. El problema empieza cuando el nivel sube hasta el punto en que la albúmina de la sangre no puede unirse a toda la bilirrubina que circula, y la bilirrubina libre cruza al cerebro. El umbral de tratamiento de la Academia Americana de Pediatría identifica el nivel — según las horas de vida y los factores de riesgo — en que la fototerapia previene que siga subiendo antes de que llegue al nivel peligroso. El nivel de Lucas está por encima de ese umbral. Por eso está recibiendo tratamiento ahora.

Almost all newborns turn yellow in the first three to five days of life because the liver does not yet process bilirubin as fast as the body produces it. That is normal physiology. The problem begins when the level rises to the point at which the albumin in the blood cannot bind to all the circulating bilirubin, and free bilirubin crosses to the brain. The American Academy of Pediatrics treatment threshold identifies the level — based on hours of life and risk factors — at which phototherapy prevents it from continuing to rise before it reaches the dangerous level. Lucas’s level is above that threshold. That is why he is receiving treatment now.

8. The skin color tells you there is bilirubin — it does not tell you how much; only the blood test does

El color amarillo de la piel aparece cuando el nivel de bilirrubina sube por encima de aproximadamente cinco miligramos por decilitro. Pero la intensidad del color en la piel no sigue de forma confiable el nivel en la sangre — el tono de piel, la iluminación, y la zona del cuerpo donde se mira introducen error. Un bebé que “no parece tan amarillo” puede tener un nivel de 19. La única forma de saber cuánta hay es el análisis de sangre. Por eso medimos, no miramos.

The yellow skin color appears when the bilirubin level rises above approximately five milligrams per deciliter. But the intensity of the skin color does not reliably follow the level in the blood — skin tone, lighting, and the body area being assessed all introduce error. A baby who “does not look that yellow” can have a level of 19. The only way to know how much there is is the blood test. That is why we measure, not look.

Why these three conversations share the same underlying structure

Carmen, Marta, and Jorge arrived at their conversations in very different situations — Carmen on day five of a NICU stay she did not expect to last weeks, holding a son whose responsiveness seems to contradict every clinical timeline she has been given; Marta on day twelve of a weight chart that has gone in only one direction, holding a phone with numbers that appear to show her daughter is getting smaller despite everything the team is telling her; Jorge in a hospital hallway holding a photo of his son under blue lights, looking at a baby who appears to him to be receiving an intervention he does not need.

In each case the communication failure has the same architecture: the parent was given an outcome without the biological framework that makes that outcome interpretable. Carmen was told Mateo was doing well and would stay for several weeks. She was not given the four developmental systems that are not complete at 28 weeks, what clinical milestone each one requires, or what the CPAP and the apnea monitor and the NG tube and the isolette are each actually doing. Marta was told Valentina was receiving her milk and that the weight was expected to fall before it rose. She was not told that the weight loss represents fluid and not tissue, that TPN is providing complete nutrition independently of the gut, that the small volumes of her milk are doing a biologically specific job rather than simply being insufficient for nutrition, or that the NEC risk is the constraint governing how quickly feeds advance. Jorge was told Lucas had high bilirubin and needed phototherapy. He was not told where bilirubin comes from in a newborn, what the difference is between the level at which jaundice is normal physiology and the level at which the albumin binding capacity is saturated and free bilirubin begins to cross the blood-brain barrier, what phototherapy does to convert fat-soluble bilirubin to a form the body can excrete, or why the color of Lucas’s skin tells him nothing about where the number actually is.

The neonatology nurse who provides that framework in Spanish does not change any clinical outcome. What she changes is the parent’s capacity to participate in the experience rather than endure it without comprehension. Carmen does not need the CPAP to fail for two weeks to understand what the CPAP is doing — she needs to be told what the CPAP is doing before the second morning, so that every day she checks on the lung system, the apnea system, the feeding coordination system, and the temperature system, and understands what progress in each one looks like. Marta does not need two more weeks of watching the weight chart to learn that the loss is fluid and the nutrition is in the IV — she needs to be told before the twelfth day, so she does not spend eleven days assuming her milk is insufficient or the team is rationing something her daughter urgently needs. Jorge does not need Lucas to be discharged home before understanding what the phototherapy is treating — he needs to be told what bilirubin is, what it does at high levels, and what the blue lights are doing, before he leaves the hallway for the waiting room.

In neonatology, clinical Spanish is not a list of words for machines. It is the language of developmental biology, nutritional physiology, and hepatic maturation. Carmen does not need the word for “surfactant.” She needs to hear that the CPAP is doing the job surfactant normally does and that the criterion for coming off it is a specific clinical milestone that she can ask about every day. Marta does not need the word for “necrotizing enterocolitis.” She needs to hear that the reason feeds advance slowly is that a very serious intestinal complication is prevented by the speed, and that every day that Valentina tolerates the current volume, the team increases it — and that her pumping is the most valuable thing she can do for Valentina from where she is. Jorge does not need the word for “kernicterus.” He needs to hear that bilirubin at the level Lucas has it, at the hour of life he has it, is above the threshold at which the brain becomes a target — and that the blue lights are already converting the bilirubin to a form the body can eliminate without the liver, and in one to two days the number will fall below the threshold and the lights will come off.

Those are the explanations. The machines and the protocols are the scaffold. The mechanism is what the family needs to carry when they leave the NICU at the end of visiting hours and sit in a car in the parking lot, alone with whatever they understood.

Practice these conversations

ClinicaLingo’s scenario library includes roleplay practice for neonatology conversations with Spanish-speaking families, covering developmental readiness explanations for premature infants, NICU weight loss and nutritional transition, phototherapy and neonatal jaundice, and apnea of prematurity education. The AI roleplay tool lets you practice these conversations before they happen — speaking the phrases, hearing the parent respond, adjusting your framing in real time.

The free 50-phrase PDF includes the most common clinical-Spanish phrases for NICU and perinatal conversations. And the full blog library covers NICU nursing communication failures and discharge teaching, the first hold, breastfeeding transition, and grade III IVH family meetings, labor and delivery nursing, postpartum nursing, and over 165 other clinical specialties where Spanish-speaking patients and families frequently encounter information gaps that nurses are positioned to close.

All clinical scenarios in this post are composite and anonymized. Named patients and families are fictional constructs for educational illustration. The clinical content — surfactant physiology, apnea of prematurity brainstem mechanism, suck-swallow-breathe developmental timeline, trophic feeds and NEC risk, physiologic neonatal weight loss, bilirubin metabolism, phototherapy mechanism, and the AAP phototherapy nomogram — reflects standard neonatology practice at the time of publication and is not a substitute for institutional protocols, neonatal nurse training programs, or individual clinical judgment. Bilirubin thresholds and phototherapy criteria should always be applied using the current institutional version of the AAP nomogram accounting for gestational age, age in hours, and individual risk factors.