Looking after children and babies requires some of the most complex care with specialized equipment. Advanced training and qualifications for crew are essential, as well as unique technology to accommodate the wide range of diseases and physical sizes of neonatal and pediatric patients. A challenge for air ambulance services is that neonatal and pediatric transports are not frequent because roads are deemed a safer option, but the equipment and training must still be current. That equipment can range from a simple child restraint system for a stretcher normally used for an adult to a complex incubator with temperature control and other functions, but it still needs to be managed and maintained for the infrequent occurrences.

UK-based Neonatal Transport Specialist Dr Lee Collier said: “[Neonatal or pediatric flights are] a relatively small part of any organization.” He finds that there is not a vast amount of specialist kits for children for air medical transport beyond making sure they can be strapped down safely. For babies, an incubator-style pod on a stretcher can be enough. “We have what’s called BabyPod,” Dr Collier explained. “This is a UK-designed system that’s used globally. It’s kind of a mini-incubator and it’s made out of carbon fiber.”

Otherwise, a fully-fledged incubator may be needed, but these can weigh 100kg. If a BabyPod is sufficient, this can have a ventilator, syringe pumps and other equipment added to it on the stretcher. A pod like this can be used in a wide range of aircraft.

However, regardless of specially trained crew and complex equipment, often simple entertainment is what is needed. “Something like an iPad with some cartoons on it or a Nintendo Switch with some games on it for a kid that’s awake. Being able to give them something to play with that is age-appropriate helps,” Dr Collier said.

Entertainment can help the patient when the trip is hundreds of miles; Medway Air Ambulance in the US state of Georgia often provides transport for these kinds of distances. “Let’s say a neonatal pediatric hospital doesn’t want to do the transport – they’re like, ‘This is a long trip, can you do it for us?’” said Medway Air Ambulance Business Development Vice President Mark Chapman. Medway’s medical director is a neonatologist and the firm has ongoing clinical training for its staff. It is currently working on a project for new equipment for neonatal ear protection.

“We’re doing a study as we speak about hearing protection and neonates,” Chapman explained. “We are partners with a manufacturer. They have done studies, but they haven’t done them in Learjets. They’ve done them on helicopters and on ground ambulances, but never in a Learjet.” Medway operates a Learjet 45 and is now collecting the data and Chapman is confident that this new equipment will be effective. “We need the data to back it up. It’s going to clearly show decreasing noise, both for the white noise effect, but also other noise when the aircraft is at full engine capacity,” he said. Medway’s Learjet 45 normally carries medications, monitors, ventilators and other equipment for adults. But there is also always a BabyPod in the back. For pediatric patients, the firm installs Pedi-Mate restraints when needed.

What has been a recent development is the need for immediate cooling of the newborn

Improving technology

Dr Carlo Bellini works at Giannina Gaslini children’s hospital in Genoa, Italy. He explained that the gas required for neonatal and pediatric patients is usually onboard and the supply will far exceed the likely demand. “Today, modern neonatal turbine ventilators are available that do not require compressed air cylinders, thus reducing the need for gas supplies.”

What has been a recent development is the need for immediate cooling of the newborn. “There is much discussion about passive or active cooling. Only recently have devices capable of actively regulating the temperature of the newborn become available,” Dr Bellini said. A problem, however, is that these devices need 220V electricity, which is always available in ground ambulances, but not always in helicopters.

Dr Bellini sees a good incubator as a minimum for neonatal transport and one capable of guaranteeing the temperature as preferable. “To my knowledge, transport incubators capable of guaranteeing humidity are not yet available,” he said. “Regarding pediatric transport, I would say that the equipment that is used for adults is generally also good for pediatrics.”

Ventilation technology has been an important improvement for Dr Bellini. “At the beginning of my activity as neonatal transport, more than 30 years ago, pneumatic-type ventilators were available, extremely simple, I could say indestructible. It is possible today to have ventilators equipped with servo-assisted ventilation,” he explained.

Another significant development for him is isolation devices for infected and contagious patients. “I would say that that is the part that has emerged most recently, the need for both neonatal and pediatric transports [to have that isolation],” he said. When the Covid-19 pandemic took hold, clinicians were unprepared to deal with the transfer of Covid-positive patients.

Before the team even goes out, the neonatologist can actually have eyes on the child virtually and give advice before we get there or while we’re going out there

The Shock Trauma Air Rescue Service (STARS) has been operating since 1985 and started in Alberta, Canada. “We’re doing a lot more virtual care,” said STARS’ Saskatchewan Provincial Director, Darcy McKay. “Before the team even goes out, the neonatologist can actually have eyes on the child virtually and give advice before we get there or while we’re going out there.” With the online link, the STARS team can talk to the clinicians caring for the young patient and this, McKay said, “has been a huge game changer for getting the right type of care before we get there”.

The virtual is also a part of STARS’ training, or simulation to be precise. “We’ve always done Neonatal Resuscitation Program (NRP) training every year. But we’ve put quite a lot more emphasis on it for our in-house training, so there’s lots of simulation,” McKay explained. “We call them high acuity, low occurrence just because you don’t deliver neonates every day on the helicopter. [We train] so the muscle memory is there, and the experience is there for when that emergency does happen, and you can deal with it.” He added that the STARS medical crew consists of a critical care paramedic and a flight nurse.

We train so the muscle memory is there, and the experience is there for when that emergency does happen, and you can deal with it

Special considerations

STARS only operates helicopters, Airbus H145 in particular, and for these aircraft, journeys should be, in McKay’s view, between 16 and 250km. Anything beyond 250km would need a fixed-wing aircraft, and below 60km is a trip best made by road. Whether it is rotary, fixed-wing or ambulance, a key requirement in Canada is warmth. “Keeping the child warm is especially important in the winter,” said McKay. “I’m sure you’ve heard [our] winters can be very, very cold.”

In Australia, the temperature challenge is very different for Brisbane-based Avcair, which provides a Learjet 60 for air ambulance. The company provides flights for pediatric patients, but not neonatal, as its Business Development and Relationship Manager, Shaun Andrews, explained. “The size of the [doorway], depending on the aircraft you’re going to go with, is sometimes the challenge. Safely moving a neonate unit in and out of the Learjet 60, we don’t deem that at the moment to be a safe option, so we don’t actually deal with neonatal [transfers].”

Avcair rarely sees pediatric patients: Andrews estimates that the company had only carried out the air medical transport role for children “two or three times in the last year”. Despite that, the company wants to offer this special service and it uses specialized pediatric teams “to achieve the best outcome for the patient”, as he explained it. The rarity of the pediatric transport is such that Avcair does not have in-house medical teams; it draws upon contract staff. Hospitals’ own medical crew will be onboard with the patient in many cases anyway.

Avcair does own stretchers, monitoring equipment and restraint systems.

“We use Spectrum [Aeromed] stretcher bases on our stretchers,” Andrews said. “The medical monitoring equipment is all there. We use Spectrum stretcher systems and oxygen tanks and things like that.”

At Children’s Wales Air Ambulance (a department within Wales Air Ambulance), since full-time operations in 2017, the same incubators have been in use, albeit with some modification. Andrew Morris is a Helicopter Transfer Practitioner with Children’s Wales Air Ambulance. “The majority of our work is based around neonates, where we will take children from maybe 26 weeks and up in incubator transfers. I would say we would probably do about two or three a month of the incubator transfers,” he explained. Morris and his colleagues work with advanced neonatal transport nurses and consultant neonatologists who have undertaken extra training for neonatal transfers.