A neonatal intensive care unit (NICU), also known as an intensive care nursery (ICN), is an
intensive care unit
220px, Intensive care unit
An intensive care unit (ICU), also known as an intensive therapy unit or intensive treatment unit (ITU) or critical care unit (CCU), is a special department of a hospital or health care facility that provides intensiv ...
(ICU) specializing in the care of ill or premature newborn
infants
An infant or baby is the very young offspring of human beings. ''Infant'' (from the Latin word ''infans'', meaning 'unable to speak' or 'speechless') is a formal or specialised synonym for the common term ''baby''. The terms may also be used to ...
. Neonatal refers to the first 28 days of life. Neonatal care, as known as specialized nurseries or intensive care, has been around since the 1960s.
The first
American
American(s) may refer to:
* American, something of, from, or related to the United States of America, commonly known as the "United States" or "America"
** Americans, citizens and nationals of the United States of America
** American ancestry, pe ...
newborn intensive care unit, designed by
Louis Gluck
Louis Gluck (1924–1997) was an American neonatologist who made many important contributions to the care of newborns, and who is considered "the father of neonatology."
Career overview
Gluck designed the modern neonatal intensive care unit (N ...
, was opened in October 1960 at
Yale New Haven Hospital
Yale New Haven Hospital (YNHH) is a 1,541-bed hospital located in New Haven, Connecticut. It is owned and operated by the Yale New Haven Health System. YNHH includes the 168-bed Smilow Cancer Hospital at Yale New Haven, the 201-bed Yale New Haven ...
.
NICU is typically
directed
Director may refer to:
Literature
* ''Director'' (magazine), a British magazine
* ''The Director'' (novel), a 1971 novel by Henry Denker
* ''The Director'' (play), a 2000 play by Nancy Hasty
Music
* Director (band), an Irish rock band
* ''Di ...
by one or more
neonatologists
Neonatology is a subspecialty of pediatrics that consists of the medical care of newborn infants, especially the ill or premature newborn. It is a hospital-based specialty, and is usually practised in neonatal intensive care units (NICUs). The ...
and staffed by
resident
Resident may refer to:
People and functions
* Resident minister, a representative of a government in a foreign country
* Resident (medicine), a stage of postgraduate medical training
* Resident (pharmacy), a stage of postgraduate pharmaceuti ...
physician
A physician (American English), medical practitioner (Commonwealth English), medical doctor, or simply doctor, is a health professional who practices medicine, which is concerned with promoting, maintaining or restoring health through th ...
s,
nurse
Nursing is a profession within the health care sector focused on the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life. Nurses may be differentiated from other health c ...
s,
nurse practitioner
A nurse practitioner (NP) is an advanced practice registered nurse and a type of mid-level practitioner. NPs are trained to assess patient needs, order and interpret diagnostic and laboratory tests, diagnose disease, formulate and prescribe m ...
s,
pharmacists
A pharmacist, also known as a chemist (Commonwealth English) or a druggist (North American and, archaically, Commonwealth English), is a healthcare professional who prepares, controls and distributes medicines and provides advice and instructi ...
,
physician assistants
A physician assistant or physician associate (PA) is a type of mid-level health care provider. In North America PAs may diagnose illnesses, develop and manage treatment plans, prescribe medications, and may serve as a principal healthcare prov ...
,
respiratory therapists
A respiratory therapist is a specialized healthcare practitioner trained in critical care and cardio-pulmonary medicine in order to work therapeutically with people who have acute critical conditions, cardiac and pulmonary disease. Respirator ...
, and
dietitian
A dietitian, medical dietitian, or dietician is an expert in identifying and treating disease-related malnutrition and in conducting medical nutrition therapy, for example designing an enteral tube feeding regimen or mitigating the effects of ca ...
s. Many other
ancillary disciplines and specialists are available at larger units.
The term ''neonatal'' comes from ''neo'', "new", and ''natal'', "pertaining to birth or origin".
Nursing and neonatal populations
![Nurse checking triplets](https://upload.wikimedia.org/wikipedia/commons/8/84/Nurse_checking_triplets.jpg)
Healthcare institutions have varying entry-level requirements for neonatal nurses. Neonatal nurses are
registered nurse
A registered nurse (RN) is a nurse who has graduated or successfully passed a nursing program from a recognized nursing school and met the requirements outlined by a country, state, province or similar government-authorized licensing body to o ...
s (RNs), and therefore must have an
Associate of Science in Nursing
An Associate of Science in Nursing (ASN) is a tertiary education nursing degree which typically takes 2–3 years to complete. In the United States, this type of degree is usually awarded by community colleges or similar nursing schools. Some fou ...
(ASN) or
Bachelor of Science in Nursing
The Bachelor of Science in Nursing (BSN, BScN) also known in some countries as a Bachelor of Nursing (BN) or Bachelor of Science (BS) with a Major in Nursing is an academic degree in the science and principles of nursing, granted by an accredited ...
(BSN) degree. Some countries or institutions may also require a
midwifery
Midwifery is the health science and health profession that deals with pregnancy, childbirth, and the postpartum period (including care of the newborn), in addition to the sexual and reproductive health of women throughout their lives. In many cou ...
qualification.
Some institutions may accept newly graduated RNs having passed the
NCLEX
The National Council Licensure Examination (NCLEX) is a nationwide examination for the nurse licensure, licensing of nurses in the United States, Canada and Australia since 1982, 2015 and 2020 respectively. There are two types, the NCLEX-RN and t ...
exam; others may require additional experience working in adult-health or medical/surgical nursing.
Some countries offer postgraduate degrees in neonatal nursing, such as the
Master of Science in Nursing
A Master of Science in Nursing (MSN) is an advanced-level postgraduate degree for registered nurses and is considered an entry-level degree for nurse educators and managers. The degree also may prepare a nurse to seek a career as a nurse administr ...
(MSN) and various
doctorates
A doctorate (from Latin ''docere'', "to teach"), doctor's degree (from Latin ''doctor'', "teacher"), or doctoral degree is an academic degree awarded by universities and some other educational institutions, derived from the ancient formalism ''l ...
. A
nurse practitioner
A nurse practitioner (NP) is an advanced practice registered nurse and a type of mid-level practitioner. NPs are trained to assess patient needs, order and interpret diagnostic and laboratory tests, diagnose disease, formulate and prescribe m ...
may be required to hold a postgraduate degree.
The National Association of Neonatal Nurses recommends two years' experience working in a NICU before taking graduate classes.
As with any registered nurse, local licensing or certifying bodies, as well as employers, may set requirements for continuing education.
There are no mandated requirements to becoming an RN in an NICU, although neonatal nurses must have certification as a
neonatal resuscitation
Neonatal resuscitation, also known as newborn resuscitation, is an emergency procedure focused on supporting approximately 10% of newborn children who do not readily begin breathing, putting them at risk of irreversible organ injury and death. Th ...
provider. Some units prefer new graduates who do not have experience in other units, so they may be trained in the specialty exclusively, while others prefer nurses with more experience already under their belt.
Intensive-care nurses undergo intensive
didactic
Didacticism is a philosophy that emphasizes instructional and informative qualities in literature, art, and design. In art, design, architecture, and landscape, didacticism is an emerging conceptual approach that is driven by the urgent need to ...
and clinical orientation in addition to their general nursing knowledge in order to provide highly specialized care for critical patients. Their competencies include the administration of high-risk medications, management of high-acuity patients requiring ventilator support, surgical care, resuscitation, advanced interventions such as
extracorporeal membrane oxygenation
Extracorporeal membrane oxygenation (ECMO), also known as extracorporeal life support (ECLS), is an extracorporeal technique of providing prolonged cardiac and respiratory support to persons whose heart and lungs are unable to provide an adequat ...
or
hypothermia therapy for neonatal encephalopathy
Mild total body hypothermia, induced by cooling a baby to 33-34°C for three days after birth, is nowadays a standardized treatment after moderate to severe hypoxic ischemic encephalopathy in fullterm and near to fullterm neonates. It has recently ...
procedures, as well as chronic-care management or lower acuity cares associated with premature infants such as feeding intolerance,
phototherapy
Light therapy, also called phototherapy or bright light therapy is intentional daily exposure to direct sunlight or similar-intensity artificial light in order to treat medical disorders, especially seasonal affective disorder (SAD) and circadi ...
, or administering antibiotics. NICU RNs undergo annual skills tests and are subject to additional training to maintain contemporary practice.
History
The problem of premature and congenitally ill infants is not a new one. As early as the 17th and 18th centuries, there were scholarly papers published that attempted to share knowledge of interventions. It was not until 1922, however, that hospitals started grouping the newborn infants into one area, now called the neonatal intensive care unit (NICU).
![Stéphane Tarnier](https://upload.wikimedia.org/wikipedia/commons/e/ee/St%C3%A9phane_Tarnier.jpg)
Before the
industrial revolution
The Industrial Revolution was the transition to new manufacturing processes in Great Britain, continental Europe, and the United States, that occurred during the period from around 1760 to about 1820–1840. This transition included going f ...
, premature and ill infants were born and cared for at home and either lived or died without medical intervention.
In the mid-nineteenth century, the infant
incubator
An incubator is anything that performs or facilitates various forms of incubation, and may refer to:
Biology and medicine
* Incubator (culture), a device used to grow and maintain microbiological cultures or cell cultures
* Incubator (egg), a de ...
was first developed, based on the incubators used for chicken eggs.
Dr. Stephane Tarnier is generally considered to be the father of the incubator (or isolette as it is now known), having developed it to attempt to keep premature infants in a Paris maternity ward warm.
Other methods had been used before, but this was the first closed model; in addition, he helped convince other physicians that the treatment ''helped'' premature infants. France became a forerunner in assisting premature infants, in part due to its concerns about a falling birth rate.
After Tarnier retired,
Dr. Pierre Budin, followed in his footsteps, noting the limitations of infants in incubators and the importance of breastmilk and the mother's attachment to the child. Budin is known as the father of modern
perinatology, and his seminal work ''The Nursling'' (''Le Nourisson'' in French) became the first major publication to deal with the care of the neonate.
Another factor that contributed to the development of modern neonatology was
Dr. Martin Couney and his permanent installment of premature babies in incubators at
Coney Island
Coney Island is a peninsular neighborhood and entertainment area in the southwestern section of the New York City borough of Brooklyn. The neighborhood is bounded by Brighton Beach and Manhattan Beach, Brooklyn, Manhattan Beach to its east, L ...
. A more controversial figure, he studied under Dr. Budin and brought attention to premature babies and their plight through his display of infants as sideshow attractions at Coney Island and the World's Fair in New York and Chicago in 1933 and 1939, respectively.
Infants had also previously been displayed in incubators at the
1897,
1898
Events
January–March
* January 1 – New York City annexes land from surrounding counties, creating the City of Greater New York as the world's second largest. The city is geographically divided into five boroughs: Manhattan, B ...
,
1901
Events
January
* January 1 – The Crown colony, British colonies of New South Wales, Queensland, South Australia, Tasmania, Victoria (Australia), Victoria and Western Australia Federation of Australia, federate as the Australia, ...
, and
1904
Events
January
* January 7 – The distress signal ''CQD'' is established, only to be replaced 2 years later by ''SOS''.
* January 8 – The Blackstone Library is dedicated, marking the beginning of the Chicago Public Library system.
* ...
World Fairs.
Early years
![Bundesarchiv Bild 183-1989-0712-025, Berlin, Krankenhaus](https://upload.wikimedia.org/wikipedia/commons/d/dd/Bundesarchiv_Bild_183-1989-0712-025%2C_Berlin%2C_Krankenhaus_%22Oskar-Ziethen%22%2C_Kinderkrankenhaus.jpg)
Doctors took an increasing role in childbirth from the eighteenth century onward. However, the care of newborn babies, sick or well, remained largely in the hands of mothers and midwives. Some baby incubators, similar to those used for hatching chicks, were devised in the late nineteenth century. In the United States, these were shown at commercial exhibitions, complete with babies inside, until 1931. Dr A. Robert Bauer MD at Henry Ford Hospital in Detroit, MI, successfully combined oxygen, heat, humidity, ease of accessibility, and ease of nursing care in 1931. It was not until after the
Second World War
World War II or the Second World War, often abbreviated as WWII or WW2, was a world war that lasted from 1939 to 1945. It involved the vast majority of the world's countries—including all of the great powers—forming two opposin ...
that special-care baby units (SCBUs, pronounced ''scaboo'') were established in many hospitals. In Britain, early SCBUs opened in Birmingham and Bristol, the latter set up with only £100. At Southmead Hospital, Bristol, initial opposition from obstetricians lessened after quadruplets born there in 1948 were successfully cared for in the new unit.
Incubators were expensive, so the whole room was often kept warm instead. Cross-infection between babies was greatly feared. Strict nursing routines involved staff wearing gowns and masks, constant hand-washing and minimal handling of babies. Parents were sometimes allowed to watch through the windows of the unit. Much was learned about feeding—frequent, tiny feeds seemed best—and breathing.
Oxygen
Oxygen is the chemical element with the symbol O and atomic number 8. It is a member of the chalcogen group in the periodic table, a highly reactive nonmetal, and an oxidizing agent that readily forms oxides with most elements as wel ...
was given freely until the end of the 1950s, when it was shown that the high concentrations reached inside incubators
caused some babies to go blind. Monitoring conditions in the incubator, and the baby itself, was to become a major area of research.
The 1960s were a time of rapid medical advances, particularly in respiratory support, that were at last making the survival of premature newborn babies a reality. Very few babies born before thirty two weeks survived and those who did often had neurological impairments.
Herbert Barrie
Herbert Barrie (9 October 1927 – 20 March 2017), was a British consultant paediatrician and a leading figure in neonatology. He was a pioneer in the emerging specialty of paediatrics and neonatal medicine; and he developed one of the first ne ...
in London pioneered advances in resuscitation of the newborn. Barrie published his seminal paper on the subject in ''The Lancet'' in 1963. One of the concerns at this time was the worry that using high pressures of oxygen could be damaging to newborn lungs. Barrie developed an underwater safety valve in the oxygen circuit. The tubes were originally made of rubber, but these had the potential to cause irritation to sensitive newborn tracheas: Barrie switched to plastic. This new endotracheal tube, based on Barrie's design, was known as the 'St Thomas's tube'.
Most early units had little equipment, providing only oxygen and warmth, and relied on careful nursing and observation. In later years, further research allowed technology to play a larger role in the decline of infant mortality. The development of
pulmonary surfactant
Pulmonary surfactant is a surface-active complex of phospholipids and proteins formed by type II alveolar cells. The proteins and lipids that make up the surfactant have both hydrophilic and hydrophobic
In chemistry, hydrophobicity is t ...
, which facilitates the oxygenation and ventilation of underdeveloped lungs, has been the most important development in neonatology to date.
Increasing technology
![Neonatal Jacoplane](https://upload.wikimedia.org/wikipedia/commons/f/f8/Neonatal_Jacoplane.jpg)
By the 1970s, NICUs were an established part of hospitals in the developed world. In Britain, some early units ran community programmes, sending experienced nurses to help care for premature babies at home. But increasingly technological monitoring and therapy meant special care for babies became hospital-based. By the 1980s, over 90% of births took place in hospital. The emergency dash from home to the NICU with baby in a transport incubator had become a thing of the past, though transport incubators were still needed. Specialist equipment and expertise were not available at every hospital, and strong arguments were made for large, centralised NICUs. On the downside was the long travelling time for frail babies and for parents. A 1979 study showed that 20% of babies in NICUs for up to a week were never visited by either parent. Centralised or not, by the 1980s few questioned the role of NICUs in saving babies. Around 80% of babies born weighing less than 1.5 kg now survived, compared to around 40% in the 1960s. From 1982, pediatricians in Britain could train and qualify in the sub-specialty of neonatal medicine.
![UCIN HCM](https://upload.wikimedia.org/wikipedia/commons/f/f0/UCIN_HCM.JPG)
Not only careful nursing but also new techniques and instruments now played a major role. As in adult intensive-care units, the use of monitoring and life-support systems became routine. These needed special modification for small babies, whose bodies were tiny and often immature. Adult ventilators, for example, could damage babies' lungs and gentler techniques with smaller pressure changes were devised. The many tubes and sensors used for monitoring the baby's condition, blood sampling and artificial feeding made some babies scarcely visible beneath the technology. Furthermore, by 1975, over 18% of newborn babies in Britain were being admitted to NICUs. Some hospitals admitted all babies delivered by
Caesarian section
Caesarean section, also known as C-section or caesarean delivery, is the surgical procedure by which one or more babies are delivered through an incision in the mother's abdomen, often performed because vaginal delivery would put the baby or mo ...
or under 2500 g in weight. The fact that these babies missed early close contact with their mothers was a growing concern. The 1980s saw questions being raised about the human and economic costs of too much technology, and admission policies gradually became more conservative.
Changing priorities
![Mom and Premature Baby at Kapiolani](https://upload.wikimedia.org/wikipedia/commons/2/20/Mom_and_Premature_Baby_at_Kapiolani.jpg)
NICUs now concentrate on treating very small, premature, or congenitally ill babies. Some of these babies are from higher-order multiple births, but most are still single babies born too early. Premature labour, and how to prevent it, remains a perplexing problem for doctors. Even though medical advancements allow doctors to save low-birth-weight babies, it is almost invariably better to delay such births.
![Premature infant with ventilator](https://upload.wikimedia.org/wikipedia/commons/3/3e/Premature_infant_with_ventilator.jpg)
Over the last 10 years or so, SCBUs have become much more 'parent-friendly', encouraging maximum involvement with the babies. Routine gowns and masks are gone and parents are encouraged to help with care as much as possible. Cuddling and skin-to-skin contact, also known as
Kangaroo care
Kangaroo care also called skin-to-skin contact (SSC), is a technique of newborn care where babies are kept chest-to-chest and skin-to-skin with a parent, typically their mother (occasionally their father).
Kangaroo care, named for the similarity ...
, are seen as beneficial for all but the frailest (very tiny babies are exhausted by the stimulus of being handled; or larger critically ill infants). Less stressful ways of delivering high-technology medicine to tiny patients have been devised: sensors to measure blood oxygen levels through the skin, for example; and ways of reducing the amount of blood taken for tests.
Some major problems of the NICU have almost disappeared.
Exchange transfusions
An exchange transfusion is a blood transfusion in which the patient's blood or components of it are exchanged with (replaced by) other blood or blood products. The patient's blood is removed and replaced by donated blood or blood components. This ...
, in which all the blood is removed and replaced, are rare now.
Rhesus incompatibility (a difference in blood groups) between mother and baby is largely preventable, and was the most common cause for exchange transfusion in the past. However, breathing difficulties, intraventricular hemorrhage, necrotizing enterocolitis and infections still claim many infant lives and are the focus of many new and current research projects.
The long-term outlook for premature babies saved by NICUs has always been a concern. From the early years, it was reported that a higher proportion than normal grew up with disabilities, including
cerebral palsy
Cerebral palsy (CP) is a group of movement disorders that appear in early childhood. Signs and symptoms vary among people and over time, but include poor coordination, stiff muscles, weak muscles, and tremors. There may be problems with sensa ...
and learning difficulties. Now that treatments are available for many of the problems faced by tiny or immature babies in the first weeks of life, long-term follow-up, and minimising long-term disability, are major research areas.
Besides prematurity and extreme low birth-weight, common
disease
A disease is a particular abnormal condition that negatively affects the structure or function of all or part of an organism, and that is not immediately due to any external injury. Diseases are often known to be medical conditions that a ...
s cared for in a NICU include
perinatal asphyxia
Perinatal asphyxia (also known as neonatal asphyxia or birth asphyxia) is the medical condition resulting from deprivation of oxygen to a newborn infant that lasts long enough during the birth process to cause physical harm, usually to the brain. ...
, major
birth defect
A birth defect, also known as a congenital disorder, is an abnormal condition that is present at birth regardless of its cause. Birth defects may result in disabilities that may be physical, intellectual, or developmental. The disabilities can ...
s,
sepsis
Sepsis, formerly known as septicemia (septicaemia in British English) or blood poisoning, is a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage is follo ...
,
neonatal jaundice
Neonatal jaundice is a yellowish discoloration of the white part of the eyes and skin in a newborn baby due to high bilirubin levels. Other symptoms may include excess sleepiness or poor feeding. Complications may include seizures, cerebral pals ...
, and
infant respiratory distress syndrome
Infantile respiratory distress syndrome (IRDS), also called respiratory distress syndrome of newborn, or increasingly surfactant deficiency disorder (SDD), and previously called hyaline membrane disease (HMD), is a syndrome in premature infants c ...
due to immaturity of the
lung
The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side of t ...
s. In general, the leading cause of death in NICUs is
necrotizing enterocolitis
Necrotizing enterocolitis (NEC) is a devastating intestinal disease that affects premature or very low birth weight infants.Gephart S.M., Quinn M. A call to action to fight for equity and end necrotizing enterocolitis disparities. ''Adv. Neonata ...
. Complications of extreme prematurity may include
intracranial hemorrhage
Intracranial hemorrhage (ICH), also known as intracranial bleed, is bleeding within the skull. Subtypes are intracerebral bleeds ( intraventricular bleeds and intraparenchymal bleeds), subarachnoid bleeds, epidural bleeds, and subdural bleeds. ...
, chronic bronchopulmonary dysplasia (see
Infant respiratory distress syndrome
Infantile respiratory distress syndrome (IRDS), also called respiratory distress syndrome of newborn, or increasingly surfactant deficiency disorder (SDD), and previously called hyaline membrane disease (HMD), is a syndrome in premature infants c ...
), or
retinopathy of prematurity
Retinopathy of prematurity (ROP), also called retrolental fibroplasia (RLF) and Terry syndrome, is a disease of the eye affecting prematurely born babies generally having received neonatal intensive care, in which oxygen therapy is used due to ...
. An infant may spend a day of observation in a NICU or may spend many months there.
![Mcmaster NICU infant 6978](https://upload.wikimedia.org/wikipedia/commons/f/fb/Mcmaster_NICU_infant_6978.jpg)
Neonatology and NICUs have greatly increased the survival of very low birth-weight and extremely premature infants. In the era before NICUs, infants of birth weight less than 1400 grams (3 lb, usually about 30 weeks gestation) rarely survived. Today, infants of 500 grams at 26 weeks have a fair chance of survival. As of 2022, the world record for the lowest gestational age newborn to survive is held by Curtis Zy-Keith Means, who was born on 5 July 2020 in the United States, at 21 weeks and 1 day gestational age, weighing 420 grams.
The NICU environment provides challenges as well as benefits. Stressors for the infants can include continual light, a high level of noise, separation from their mothers, reduced physical contact, painful procedures, and interference with the opportunity to
breastfeed
Breastfeeding, or nursing, is the process by which human breast milk is fed to a child. Breast milk may be from the breast, or may be expressed by hand or pumped and fed to the infant. The World Health Organization (WHO) recommends that brea ...
. To date there have been very few studies investigating noise reduction interventions in the NICU and it remains uncertain what their effects could be on babies' growth and development. A NICU can be stressful for the staff as well. A special aspect of NICU stress for both parents and staff is that infants may survive, but with damage to the brain, lungs or eyes.
NICU rotations are essential aspects of
pediatric
Pediatrics ( also spelled ''paediatrics'' or ''pædiatrics'') is the branch of medicine that involves the medical care of infants, children, adolescents, and young adults. In the United Kingdom, paediatrics covers many of their youth until the ...
and
obstetric
Obstetrics is the field of study concentrated on pregnancy, childbirth and the postpartum period. As a medical specialty, obstetrics is combined with gynecology under the discipline known as obstetrics and gynecology (OB/GYN), which is a surgic ...
residency programs, but NICU experience is encouraged by other specialty residencies, such as
family practice
Family medicine is a medical specialty within primary care that provides continuing and comprehensive health care for the individual and family across all ages, genders, diseases, and parts of the body. The specialist, who is usually a primar ...
,
surgery
Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pat ...
,
pharmacy
Pharmacy is the science and practice of discovering, producing, preparing, dispensing, reviewing and monitoring medications, aiming to ensure the safe, effective, and affordable use of medicines. It is a miscellaneous science as it links heal ...
, and
emergency medicine
Emergency medicine is the medical speciality concerned with the care of illnesses or injuries requiring immediate medical attention. Emergency physicians (often called “ER doctors” in the United States) continuously learn to care for unsche ...
.
Equipment
Incubator
![Baby incubator, A-Y-P, Seattle, 1909](https://upload.wikimedia.org/wikipedia/commons/1/1c/Baby_incubator%2C_A-Y-P%2C_Seattle%2C_1909..jpg)
An incubator (or ''isolette'' or ''humidicrib'') is an apparatus used to maintain environmental conditions suitable for a
neonate
An infant or baby is the very young offspring of human beings. ''Infant'' (from the Latin word ''infans'', meaning 'unable to speak' or 'speechless') is a formal or specialised synonym for the common term ''baby''. The terms may also be used to ...
(newborn baby). It is used in
preterm birth
Preterm birth, also known as premature birth, is the Childbirth, birth of a baby at fewer than 37 weeks Gestational age (obstetrics), gestational age, as opposed to full-term delivery at approximately 40 weeks. Extreme preterm is less than 28 we ...
s or for some ill full-term babies.
There is additional equipment used to evaluate and treat sick neonates. These include:
Blood pressure monitor: The blood pressure monitor is a machine that's connected to a small cuff which is wrapped around the arm or leg of the patient. This cuff automatically takes the blood pressure and displays the data for review by care providers.
Oxygen hood: This is a clear box that fits over the baby's head and supplies oxygen. This is used for babies who can still breathe but need some respiratory support.
Ventilator: This is a breathing machine that delivers air to the lungs. Babies who are severely ill will receive this intervention. Typically, the ventilator takes the role of the lungs while treatment is administered to improve lung and circulatory function.
Possible functions of a neonatal incubator are:
* Oxygenation, through
oxygen supplementation by head hood or nasal cannula, or even
continuous positive airway pressure
Continuous positive airway pressure (CPAP) is a form of positive airway pressure (PAP) ventilation in which a constant level of pressure greater than atmospheric pressure is continuously applied to the upper respiratory tract of a person. The ap ...
(CPAP) or
mechanical ventilation
Mechanical ventilation, assisted ventilation or intermittent mandatory ventilation (IMV), is the medical term for using a machine called a ventilator to fully or partially provide artificial ventilation. Mechanical ventilation helps move air ...
.
Infant respiratory distress syndrome
Infantile respiratory distress syndrome (IRDS), also called respiratory distress syndrome of newborn, or increasingly surfactant deficiency disorder (SDD), and previously called hyaline membrane disease (HMD), is a syndrome in premature infants c ...
is the leading cause of death in preterm infants, and the main treatments are CPAP, in addition to administering
pulmonary surfactant
Pulmonary surfactant is a surface-active complex of phospholipids and proteins formed by type II alveolar cells. The proteins and lipids that make up the surfactant have both hydrophilic and hydrophobic
In chemistry, hydrophobicity is t ...
and stabilizing the
blood sugar
Glycaemia, also known as blood sugar level, blood sugar concentration, or blood glucose level is the measure of glucose concentrated in the blood of humans or other animals. Approximately 4 grams of glucose, a simple sugar, is present in the blo ...
,
blood salts, and
blood pressure
Blood pressure (BP) is the pressure of circulating blood against the walls of blood vessels. Most of this pressure results from the heart pumping blood through the circulatory system. When used without qualification, the term "blood pressure" r ...
.
* Observation: Modern neonatal intensive care involves sophisticated measurement of temperature, respiration, cardiac function,
oxygenation
Oxygenation may refer to:
* Oxygenation (environmental), a measurement of dissolved oxygen concentration in soil or water
* Oxygen saturation (medicine), the process by which concentrations of oxygen increase within a tissue
* Water oxygenation, t ...
, and
brain activity
Electroencephalography (EEG) is a method to record an electrogram of the spontaneous electrical activity of the brain. The biosignals detected by EEG have been shown to represent the postsynaptic potentials of pyramidal neurons in the neocortex ...
.
* Protection from cold temperature, infection, noise, drafts and excess handling:
[neonatology.org --> Equipment in the NICU]
Created 1/25/2002 / Last modified 6/9/2002. Retrieved on September 2, 2009 Incubators may be described as
bassinet
A bassinet, bassinette, or cradle is a bed specifically for babies from birth to about four months. Bassinets are generally designed to work with fixed legs or caster wheels, while cradles are generally designed to provide a rocking or gliding ...
s enclosed in plastic, with climate control equipment designed to keep them warm and limit their exposure to germs.
* Maintaining
fluid balance
Fluid balance is an aspect of the homeostasis of organisms in which the amount of water in the organism needs to be controlled, via osmoregulation and behavior, such that the concentrations of electrolytes (salts in solution) in the various body ...
by providing fluid and keeping a high
air humidity
Humidity is the concentration of water vapor present in the air. Water vapor, the gaseous state of water, is generally invisible to the human eye. Humidity indicates the likelihood for precipitation, dew, or fog to be present.
Humidity depe ...
to prevent too great a loss from skin and respiratory evaporation.
[Humidity control tool for neonatal incubator]
1998: Abdiche M; Farges G; Delanaud S; Bach V; Villon P; Libert J P, Medical & biological engineering & computing 1998;36(2):241-5.
A ''transport incubator'' is an incubator in a transportable form, and is used when a sick or premature baby is moved, e.g., from one hospital to another, as from a
community hospital A community hospital can be purely a nominal designation or have a more specific meaning. When specific, it refers to a hospital that is accessible to the general public, and provides a general or specific medical care which is usually short-term, i ...
to a larger medical facility with a proper neonatal intensive-care unit. It usually has a miniature
ventilator
A ventilator is a piece of medical technology that provides mechanical ventilation by moving breathable air into and out of the lungs, to deliver breaths to a patient who is physically unable to breathe, or breathing insufficiently. Ventilators ...
,
cardio-respiratory monitor,
IV pump,
pulse oximeter
Pulse oximetry is a noninvasive method for monitoring a person's oxygen saturation. Peripheral oxygen saturation (SpO2) readings are typically within 2% accuracy (within 4% accuracy in 95% of cases) of the more accurate (and invasive) reading of ...
, and oxygen supply built into its frame.
[
]
Pain management
Many parents with newborns in the NICU have expressed that they would like to learn more about what types of pain their infants are feeling and how they can help relieve that pain. Parents want to know more about things such as; what caused their child's pain, if the pain that we feel is different than what they feel, how to possibly prevent and notice the pain, and how they could help their child through the pain they were struggling with. Another main worry that was mentioned was the long-term effects of their pain. Would it mentally affect the child in the future, or even affect the relationship they have with their parents?
Relieving pain
There are multiple ways to manage pain for infants. If the mother is able to help, holding the infant in kangaroo position or breastfeeding can help calm the baby before a procedure is done. Other simple things that can help ease pain include; allowing the infant to suck on a gloved finger, gently binding the limbs in a flexed position, and creating a quiet and comfortable environment.
Patient populations
Common diagnoses and pathologies in the NICU include:
* Anemia
Anemia or anaemia (British English) is a blood disorder in which the blood has a reduced ability to carry oxygen due to a lower than normal number of red blood cells, or a reduction in the amount of hemoglobin. When anemia comes on slowly, th ...
* Apnea
Apnea, BrE: apnoea, is the temporal cessation of breathing. During apnea, there is no movement of the muscles of inhalation, and the volume of the lungs initially remains unchanged. Depending on how blocked the airways are ( patency), there ...
* Bradycardia
Bradycardia (also sinus bradycardia) is a slow resting heart rate, commonly under 60 beats per minute (BPM) as determined by an electrocardiogram. It is considered to be a normal heart rate during sleep, in young and healthy or elderly adults, a ...
* Bronchopulmonary dysplasia
Bronchopulmonary dysplasia (BPD; part of the spectrum of chronic lung disease of infancy) is a chronic lung disease in which premature infants, usually those who were treated with supplemental oxygen, require long-term oxygen. The alveoli that are ...
(BPD)
* Hydrocephalus
Hydrocephalus is a condition in which an accumulation of cerebrospinal fluid (CSF) occurs within the brain. This typically causes increased intracranial pressure, pressure inside the skull. Older people may have headaches, double vision, poor ...
* Intraventricular hemorrhage
Intraventricular hemorrhage (IVH), also known as intraventricular bleeding, is a bleeding into the brain's ventricular system, where the cerebrospinal fluid is produced and circulates through towards the subarachnoid space. It can result from phys ...
(IVH)
* Jaundice
Jaundice, also known as icterus, is a yellowish or greenish pigmentation of the skin and sclera due to high bilirubin levels. Jaundice in adults is typically a sign indicating the presence of underlying diseases involving abnormal heme meta ...
* Necrotizing enterocolitis
Necrotizing enterocolitis (NEC) is a devastating intestinal disease that affects premature or very low birth weight infants.Gephart S.M., Quinn M. A call to action to fight for equity and end necrotizing enterocolitis disparities. ''Adv. Neonata ...
(NEC)
* Patent ductus arteriosus
''Patent ductus arteriosus'' (PDA) is a medical condition in which the ''ductus arteriosus'' fails to close after birth: this allows a portion of oxygenated blood from the left heart to flow back to the lungs by flowing from the aorta, which has ...
(PDA)
* Periventricular leukomalacia
Periventricular leukomalacia (PVL) is a form of white-matter brain injury, characterized by the necrosis (more often coagulation) of white matter near the lateral ventricles. It can affect newborns and (less commonly) fetuses; premature infan ...
(PVL)
* Infant respiratory distress syndrome
Infantile respiratory distress syndrome (IRDS), also called respiratory distress syndrome of newborn, or increasingly surfactant deficiency disorder (SDD), and previously called hyaline membrane disease (HMD), is a syndrome in premature infants c ...
(RDS)
* Retinopathy of prematurity
Retinopathy of prematurity (ROP), also called retrolental fibroplasia (RLF) and Terry syndrome, is a disease of the eye affecting prematurely born babies generally having received neonatal intensive care, in which oxygen therapy is used due to ...
(ROP)
* Neonatal sepsis
Neonatal sepsis is a type of neonatal infection and specifically refers to the presence in a newborn baby of a bacterial blood stream infection (BSI) (such as meningitis, pneumonia, pyelonephritis, or gastroenteritis) in the setting of fever. Old ...
* Transient tachypnea of the newborn
Transient tachypnea of the newborn is a respiratory problem that can be seen in the newborn shortly after delivery. It is caused by retained fetal lung fluid due to impaired clearance mechanisms. It is the most common cause of respiratory distres ...
(TTN)
Levels of care
The concept of designations for hospital facilities that care for newborn infants according to the level of complexity of care provided was first proposed in the United States in 1976. Levels in the United States are designated by the guidelines published by the American Academy of Pediatrics
The American Academy of Pediatrics (AAP) is an American professional association of pediatricians, headquartered in Itasca, Illinois. It maintains its Department of Federal Affairs office in Washington, D.C.
Background
The Academy was founded ...
In Britain, the guidelines are issued by The British Association of Perinatal Medicine (BAPM), and in Canada, they are maintained by The Canadian Paediatric Society.
Neonatal care is split into categories or "levels of care". these levels apply to the type of care needed and is determined by the governing body of the area.
India
India has 3-tier system based on weight and gestational age of neonate.
Level I care
Neonates weighing more than 1800 grams or having gestational maturity of 34 weeks or more are categorized under level I care. The care consists of basic care at birth, provision of warmth, maintaining asepsis
Asepsis is the state of being free from disease-causing micro-organisms (such as pathogenic bacteria, viruses, pathogenic fungi, and parasites). There are two categories of asepsis: medical and surgical. The modern day notion of asepsis is deriv ...
and promotion of breastfeeding. This type of care can be given at home, subcenter and primary health centre.
Level II care
Neonates weighing 1200-1800 grams or having gestational maturity of 30–34 weeks are categorized under level II care and are looked after by trained nurses and pediatricians. The equipment and facilities used for this level of care include equipment for resuscitation, maintenance of thermoneutral environment, intravenous infusion, gavage feeding, phototherapy and exchange blood transfusion. This type of care can be given at first referral units, district hospitals, teaching institutions and nursing homes.
Level III care
Neonates weighing less than 1200 grams or having gestational maturity of less than 30 weeks are categorized under level III care. The care is provided at apex institutions and regional perinatal centers equipped with centralized oxygen and suction facilities, servo-controlled incubators, vital signs monitors, transcutaneous monitors, ventilators, infusion pumps etc. This type of care is provided by skilled nurses and neonatologists.
United Kingdom
The terminology used in the United Kingdom
The United Kingdom of Great Britain and Northern Ireland, commonly known as the United Kingdom (UK) or Britain, is a country in Europe, off the north-western coast of the continental mainland. It comprises England, Scotland, Wales and North ...
can be confusing because different criteria are used to designate 'special' and 'intensive' neonatal care locally and nationally.
Level 1 Neonatal Units
Also known as 'Special Care Baby Units' (SCBU). These look after babies who need more care than healthy newborns but are relatively stable and mature. SCBU might provide tube-feeding, oxygen therapy
Oxygen therapy, also known as supplemental oxygen, is the use of oxygen as medical treatment. Acute indications for therapy include hypoxemia (low blood oxygen levels), carbon monoxide toxicity and cluster headache. It may also be prophylactica ...
, antibiotics
An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting bacterial infections, and antibiotic medications are widely used in the treatment and prevention o ...
to treat infection and phototherapy
Light therapy, also called phototherapy or bright light therapy is intentional daily exposure to direct sunlight or similar-intensity artificial light in order to treat medical disorders, especially seasonal affective disorder (SAD) and circadi ...
for jaundice
Jaundice, also known as icterus, is a yellowish or greenish pigmentation of the skin and sclera due to high bilirubin levels. Jaundice in adults is typically a sign indicating the presence of underlying diseases involving abnormal heme meta ...
. In a SCBU, a nurse can be assigned up to four babies to care for.
Level 2 Neonatal Units
Also known as 'Local Neonatal Units', these can look after babies who need more advanced support such as parenteral nutrition
Parenteral nutrition (PN) is the feeding of nutritional products to a person intravenously, bypassing the usual process of eating and digestion. The products are made by pharmaceutical compounding companies. The person receives a nutritional mix ...
and continuous positive airway pressure
Continuous positive airway pressure (CPAP) is a form of positive airway pressure (PAP) ventilation in which a constant level of pressure greater than atmospheric pressure is continuously applied to the upper respiratory tract of a person. The ap ...
(CPAP). Confusingly, they may also look after babies who need short-term intensive care such as mechanical ventilation. Babies who will need longer-term or more elaborate intensive care, for example extremely preterm infants, are usually transferred to a Level 3 unit.
Babies in a Level 2 unit may be classified for nursing purposes as 'Special Care', 'High Dependency' (HDU) (in which a nurse will be assigned up to two babies) or 'Intensive care' (where nursing is one-to-one, or sometimes even two-to-one).
Level 3 Neonatal Units
Also known as 'Neonatal Intensive Care Units' (NICU) - although Level 2 units may also have their own NICU. These look after the smallest, most premature and most unwell babies and often serve a large geographical region. Therapies such as prolonged mechanical ventilation, therapeutic hypothermia
Targeted temperature management (TTM) previously known as therapeutic hypothermia or protective hypothermia is an active treatment that tries to achieve and maintain a specific body temperature in a person for a specific duration of time in an e ...
, neonatal surgery
Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pat ...
and inhaled nitric oxide
Nitric oxide (nitrogen oxide or nitrogen monoxide) is a colorless gas with the formula . It is one of the principal oxides of nitrogen. Nitric oxide is a free radical: it has an unpaired electron, which is sometimes denoted by a dot in its che ...
are usually provided in Level 3 Units, although not every unit has access to all therapies.
Some babies being cared for in Level 3 units will require less intensive treatment and will be looked after in HDU or SCBU nurseries on the same site. NHS England
NHS England, officially the NHS Commissioning Board, is an executive non-departmental public body of the Department of Health and Social Care. It oversees the budget, planning, delivery and day-to-day operation of the commissioning side of the ...
recommended in December 2019 that these units should care for at least 100 babies weighing less than 1.5 kg, and usually perform more than 2,000 intensive care days per year.
United States
The definition of a neonatal intensive-care unit (NICU) according to the National Center for Statistics is a "hospital facility or unit staffed and equipped to provide continuous mechanical ventilatory support for a newborn infant". In 2012, the American Academy of Pediatric updated their policy statement delineating the different levels of neonatal care. One major difference in the 2012 updated policy statement from the AAP compared to the 2004 policy statement is the removal of subspeciality nurseries for levels II and III with the addition of a level IV NICU. The four distinct levels of neonatal care defined in the most recent policy statement from the AAP are:
# Level I, Well newborn nursery
# Level II, Special care nursery
# Level III, Neonatal intensive-care unit (NICU)
# Level IV, Regional neonatal intensive-care unit (Regional NICU)
Level I (well newborn nursery)
Level I units are typically referred to as the well baby nursery. Well newborn nurseries have the capability to provide neonatal resuscitation at every delivery; evaluate and provide postnatal care to healthy newborn infants; stabilize and provide care for infants born at 35 to 37 weeks' gestation
Gestation is the period of development during the carrying of an embryo, and later fetus, inside viviparous animals (the embryo develops within the parent). It is typical for mammals, but also occurs for some non-mammals. Mammals during pregna ...
who remain physiologically stable; and stabilize newborn infants who are ill and those born less than 35 weeks' gestation until transfer to a facility that can provide the appropriate level of neonatal
An infant or baby is the very young offspring of human beings. ''Infant'' (from the Latin word ''infans'', meaning 'unable to speak' or 'speechless') is a formal or specialised synonym for the common term ''baby''. The terms may also be used to ...
care. Required provider types for well newborn nurseries include pediatricians
Pediatrics ( also spelled ''paediatrics'' or ''pædiatrics'') is the branch of medicine that involves the medical care of infants, children, adolescents, and young adults. In the United Kingdom, paediatrics covers many of their youth until the ...
, family physicians
Family medicine is a medical specialty within primary care that provides continuing and comprehensive health care for the individual and family across all ages, genders, diseases, and parts of the body. The specialist, who is usually a primary ...
, nurse practitioners, and other advanced practice registered nurses.
Level II (special care nursery)
Previously, Level II units were subdivided into 2 categories (level IIA & level IIB) on the basis of their ability to provide assisted ventilation including continuous positive airway pressure
Continuous positive airway pressure (CPAP) is a form of positive airway pressure (PAP) ventilation in which a constant level of pressure greater than atmospheric pressure is continuously applied to the upper respiratory tract of a person. The ap ...
. Level II units are also known as special care nurseries and have all of the capabilities of a level I nursery. In addition to providing level I neonatal care, Level II units are able to:
* Provide care for infants born ≥32-week gestation and weighing ≥1500 g who have physiologic immaturity or who are moderately ill with problems that are expected to resolve rapidly and are not anticipated to need subspecialty services on an urgent basis
* Provide care for infants who are feeding and growing stronger or convalescing after intensive care
* Provide mechanical ventilation for a brief duration (<24 h) or continuous positive airway pressure
* Stabilize infants born before 32-week gestation and weighing less than 1500 g until transfer to a neonatal intensive-care facility
* Level II nurseries are required to be managed and staffed by a pediatrician, however many Level II special care nurseries are staffed by neonatologists
Neonatology is a subspecialty of pediatrics that consists of the medical care of newborn infants, especially the ill or premature newborn. It is a hospital-based specialty, and is usually practised in neonatal intensive care units (NICUs). The ...
and neonatal nurse practitioner
A neonatal nurse practitioner (NNP) is an advanced practice registered nurse (APRN) with at least 2 years experience as a bedside registered nurse in a Level III NICU, who is prepared to practice across the continuum, providing primary, acute ...
s.
Level III (neonatal intensive-care unit)
The 2004 AAP guidelines subdivided Level III units into 3 categories (level IIIA, IIIB & IIIC). Level III units are required to have pediatric surgeons in addition to care providers required for level II (pediatric hospitalists, neonatologists, and neonatal nurse practitioners) and level I (pediatricians, family physicians, nurse practitioners, and other advanced practice registered nurses). Also, required provider types that must either be on site or at a closely related institution by prearranged consultative agreement include pediatric medical subspecialists, pediatric anesthesiologists, and pediatric ophthalmologists. In addition to providing the care and having the capabilities of level I and level II nurseries, level III neonatal intensive-care units are able to:
* Provide sustained life support
* Provide comprehensive care for infants born <32 wks gestation and weighing <1500 g
* Provide comprehensive care for infants born at all gestational ages and birth weights with critical illness
* Provide prompt and readily available access to a full range of pediatric medical subspecialists, pediatric surgical specialists, pediatric anesthesiologists, and pediatric ophthalmologists
* Provide a full range of respiratory support that may include conventional and/or high-frequency ventilation and inhaled nitric oxide
* Perform advanced imaging, with interpretation on an urgent basis, including computed tomography, MRI, and echocardiography
Level IV (regional NICU)
The highest level of neonatal care provided occurs at regional NICUs, or Level IV neonatal intensive-care units. Level IV units are required to have pediatric surgical subspecialists in addition to the care providers required for Level III units. Regional NICUs have all of the capabilities of Level I, II, and III units. In addition to providing the highest level of care, level IV NICUs:
* Are located within an institution with the capability to provide surgical repair of complex congenital or acquired conditions
* Maintain a full range of pediatric medical subspecialists, pediatric surgical subspecialists, and pediatric anesthesiologists at the site
* Facilitate transport and provide outreach education.
See also
* Neonatology
Neonatology is a subspecialty of pediatrics that consists of the medical care of newborn infants, especially the ill or premature newborn. It is a hospital-based specialty, and is usually practised in neonatal intensive care units (NICUs). The ...
* Pediatric intensive-care unit
A pediatric intensive care unit (also paediatric), usually abbreviated to PICU (), is an area within a hospital specializing in the care of critically ill infants, children, teenagers, and young adults aged 0-21. A PICU is typically directed by ...
* Embrace (organization)
Embrace is a non profit organization which provided low-cost incubators to prevent neonatal deaths in rural areas in developing countries. The organization was developed in 2008 during the multidisciplinary Entrepreneurial Design For Extreme Affo ...
* Neonatal nurse practitioner
A neonatal nurse practitioner (NNP) is an advanced practice registered nurse (APRN) with at least 2 years experience as a bedside registered nurse in a Level III NICU, who is prepared to practice across the continuum, providing primary, acute ...
* Neonatal nursing
Neonatal nursing is a sub-specialty of nursing care for newborn infants up to 28 days after birth. The term neonatal comes from neo, "new", and natal, "pertaining to birth or origin". Neonatal nursing requires a high degree of skill, dedication an ...
* Bubble CPAP
References
External links
Life in the NICU: what parents can expect
NeonatalICU.com - Expecting a Preterm Infant in the NICU
Equipment used in the NICU -- interactive parent friendly information
Association of Women's Health, Obstetric and Neonatal Nurses
The Academy of Neonatal Nursing
Neonatal Nurse Practitioner
{{Authority control
Neonatology
Intensive care medicine
Hospital departments
Nursing
Infancy