Neonatal intensive care unit
A neonatal intensive-care unit (NICU) is an intensive-care unit specializing in the care of ill or premature newborn infants. The first official ICU for neonates was established in 1961 at Vanderbilt University by Professor Mildred Stahlman, officially termed a NICU when Stahlman was the first to use a ventilator off-label to assist a baby with breathing difficulties.
A NICU is typically directed by one or more neonatologists and staffed by nurses, nurse practitioners, pharmacists, physician assistants, resident physicians, and respiratory therapists. 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".
- 1 Nursing and neonatal populations
- 2 History
- 3 Equipment
- 4 Patient populations
- 5 Levels of care
- 5.1 Canada
- 5.2 India
- 5.3 United Kingdom
- 5.4 United States
- 6 See also
- 7 References
- 8 External links
Nursing and neonatal populations
Healthcare institutions have varying entry-level requirements for neonatal nurses. Neonatal nurses are Registered Nurses (RNs), and therefore must have an Associate of Science in Nursing (ASN) or Bachelor of Science in Nursing (BSN) degree. Some countries or institutions may also require a midwifery qualification. Some institutions may accept newly graduated RNs having passed the NCLEX 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 (MSN) and various doctorates. A nurse practitioner 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 a NICU, although neonatal nurses must have certification as a Neonatal Resuscitation 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 endure intensive didactic and clinical orientation, in addition to their general nursing knowledge, 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 or hypothermia therapy for neonatal encephalopathy procedures, as well as chronic-care management or lower acuity cares associated with premature infants such as feeding intolerance, phototherapy, or administering antibiotics. NICU RNs undergo annual skills tests and are subject to additional training to maintain contemporary practice.
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).
Before the industrial revolution, 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 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 thanks to Dr. Martin Couney and his permanent installment of premature babies in incubators at Coney Island. 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.
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 that special-care baby units (SCBUs) were established in many hospitals. In Britain, early SCBUs opened in Birmingham and Bristol. At Southmead Hospital, Bristol, initial opposition from obstetricians lessened after quadruplets born there in 1948 were successfully cared for in the new unit. More resources became available: The first unit had been set up with £100. Most early units had little equipment and relied on careful nursing and observation.
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 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. Although incubators provided oxygen and warmth, science in the 1950s was limited and it was not until later that technology played a larger role in the decline of infant mortality. The development of pulmonary surfactant is the most important development in neonatology to date, allowing the oxygenation and ventilation of underdeveloped lungs.
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.
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, 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 the economic costs of too much technology. Admission policies gradually changed. In addition, treating low-birth-weight infants is expensive, especially when there are much cheaper ways of ensuring healthy babies. The key is prevention. Money can be spent on programs educating mothers on staying healthy during their pregnancy. One program (one that encourages women to stop smoking) is one-third the price of neonatal intensive care and has been proven to work. During this program, a significant number of women often quit.
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.
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, 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, 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 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 diseases cared for in a NICU include perinatal asphyxia, major birth defects, sepsis, neonatal jaundice, and Infant respiratory distress syndrome due to immaturity of the lungs. In general, the leading cause of death in NICUs is necrotizing enterocolitis. Complications of extreme prematurity may include intracranial hemorrhage, chronic bronchopulmonary dysplasia (see Infant respiratory distress syndrome), or retinopathy of prematurity. An infant may spend a day of observation in a NICU or may spend many months there.
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.
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. 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 and obstetric residency programs, but NICU experience is encouraged by other specialty residencies, such as family practice, surgery, Pharmacy, and emergency medicine.
Possible functions of a neonatal incubator are:
- Oxygenation, through oxygen supplementation by head hood or nasal cannula, or even continuous positive airway pressure (CPAP) or mechanical ventilation. Infant respiratory distress syndrome is the leading cause of death in preterm infants, and the main treatments are CPAP, in addition to administering pulmonary surfactant and stabilizing the blood sugar, blood salts, and blood pressure.
- Observation: Modern neonatal intensive care involves sophisticated measurement of temperature, respiration, cardiac function, oxygenation, and brain activity.
- Protection from cold temperature, infection, noise, drafts and excess handling: Incubators may be described as bassinets enclosed in plastic, with climate control equipment designed to keep them warm and limit their exposure to germs.
- Provision of nutrition, through intravenous catheter or NG tube.
- Administration of medications.
- Maintaining fluid balance by providing fluid and keeping a high air humidity to prevent too great a loss from skin and respiratory evaporation.
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 to a larger medical facility with a proper neonatal intensive-care unit. It usually has a miniature ventilator, cardio-respiratory monitor, IV pump, pulse oximeter, and oxygen supply built into its frame.
Common diagnosis and pathologies in the NICU include:
- Bronchopulmonary dysplasia (BPD)
- Intraventricular hemorrhage (IVH)
- Necrotizing enterocolitis (NEC)
- Patent ductus arteriosus (PDA)
- Periventricular leukomalacia (PVL)
- Infant respiratory distress syndrome (RDS)
- Retinopathy of prematurity (ROP)
- Transient tachypnea of the newborn (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 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.
Level 1: Basic neonatal care
- Level 1a: Evaluation and postnatal care of healthy newborn infants; and Phototherapy
- Level 1b:
- Care for infants with corrected gestational age greater than 34 weeks or weight greater than 1800 g who have mild illness expected to resolve quickly or who are convalescing after intensive care
- Ability to initiate and maintain intravenous access and medications
- Nasal oxygen with oxygen saturation monitoring (e.g., for infants with chronic lung disease needing long-term oxygen and monitoring).
Level 2: special care newborn nursery
- Level 2a:
- Care of infants with a corrected gestational age of 32 weeks or greater or a weight of 1500 g or greater who are moderately ill with problems expected to resolve quickly or who are convalescing after intensive care
- Peripheral intravenous infusions and possibly parenteral nutrition for a limited duration
- Resuscitation and stabilization of ill infants before transfer to an appropriate care facility
- Nasal oxygen with oxygen saturation monitoring (e.g., for infants with chronic lung disease needing long-term oxygen and monitoring).
- Level 2b: Mechanical ventilation for brief durations (less than 24 h) or continuous positive airway pressure. Intravenous infusion, total parenteral nutrition, and possibly the use of umbilical central lines and percutaneous intravenous central lines.
Level 3: Intensive neonatal care
- Level 3a: Care of infants of all gestational ages and weights; Mechanical ventilation support, and possibly inhaled nitric oxide, for as long as required Immediate access to the full range of subspecialty consultants.
- Level 3b: Comprehensive on-site access to subspecialty consultants; Performance and interpretation of advanced imaging tests, including computed tomography, magnetic resonance imaging and cardiac echocardiography on an urgent basis Performance of major surgery on site but not extracorporeal membrane oxygenation, hemofiltration and hemodialysis, or surgical repair of serious congenital cardiac malformations that require cardiopulmonary bypass.
- Level 3c: Extracorporeal membrane oxygenation, hemofiltration and hemodialysis, or surgical repair of serious congenital cardiac malformations that require a cardiopulmonary bypass.
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 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 are 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.
Special Care (SCBU)
In a special care baby unit a nurse can be assigned up to 4 babies to care for.
High Dependency (NHDU)
In the second level of care, a nurse is assigned up to two babies.
Intensive Care (NICU)
Typically in the third level of care a nurse is assigned one baby only and in some cases may be 2 nurses to 1 baby.
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 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 care. Required provider types for well newborn nurseries include pediatricians, family physicians, 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. 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 have pediatric hospitalists, neonatologists, and neonatal nurse practitioners in addition to Level I health care providers.
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 opthalmologists. 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 opthalmologists
- 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 NICU's, 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 NICU's have all of the capabilities of Level I, II, and III units. In addition to providing the higest level of care, level IV NICU's:
- Are located within an institution with the capability to provide surgical repair of comlpex congential 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
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- Neonatal Nurse Practitioner
- Neonatal nursing
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