In this article, I will talk about the Neonatal Intensive Care Unit or NICU. I will describe the environment that you are likely to encounter in NICU during your baby’s stay. For most stressed-out parents coming to NICU for the first time is an overwhelming experience. Parents have to face a new place with many unknown people and plenty of strangely looking pieces of equipment. The goal of this article is to ease those anxieties.
NICU – stands for the Neonatal Intensive Care Unit. NICU is the place where the sickest newborn babies are cared for. Usually, this name is reserved for the type of nurseries where the highest level of care can be provided to newborn babies. At the minimum, that includes cardiorespiratory monitoring (in other words, heart and respiratory rate monitoring) and respiratory support such as ventilators and CPAP machines.
Most commonly, in the USA, NICUs are run by pediatric sub-specialists called neonatologists. In rare situations or particularly outside of the USA, pediatric intensivists or pediatric anesthesiologists may be in charge of patients in these units.
ICN stands for Intermediate Care Nursery; it is a place where less severely sick newborn babies are cared for. Usually, babies located in ICN will not have any life-threatening conditions and will not need ventilatory support anymore, but they will still require monitoring and medical care. ICNs are units that are in between NICU and a regular Nursery. Sometimes, ICN is also called a step-down unit, which means that patients there will be less sick than in NICU.
In some areas, people use term SCN (Special Care Nursery) to describe hospital wards where sick newborn babies are cared for. However, term SCN is not a very frequently used word, and it is less specific than terms NICU or ICN.
Nursery – may mean a place where any type of newborns (both healthy and sick) are placed. In most hospitals, this term is used to describe a ward where only healthy full-term or near-full term babies are cared for.
What does the “NICU level of care” mean in newborn medicine?
Parents should pay particular attention to the designated level of care for the unit where their baby is receiving treatment. In the USA and many western countries, hospitals receive or assign to themselves the level of care in the nursery based on available personnel, equipment, clinical capabilities, and experience.
Some states have strict criteria regarding this matter, and others are more relaxed about it. American Academy of Pediatrics developed guidelines regarding how to decide about the levels of neonatal care; however, those guidelines are not strictly followed by all states.
Nurseries may receive level designation ranging from 1 to 4, with level – 1 being the lowest and level – 4 being the highest level of care possible.
Nursery – level 1
Level 1 nursery typically provides care for stable term newborn infants and for premature babies born at 35 weeks or later who also remain physiologically stable. Babies who do not meet the criteria mentioned above need to be stabilized and transferred to the facility with a higher level of care.
Usually, Level 1 nursery is staffed by pediatricians, family physicians, and nurse practitioners. It would be rare for a neonatologist to practice at such a place. However, a neonatologist may be available for consults over the phone.
Nursery – level 2
Level 2 nursery, by some, also called Special Care Nursery will have all capabilities of level 1 nursery and also, will be able to provide care for:
- babies born at 32 weeks or more of gestational age or with a weight of more than 1500 grams. Those babies may have physiologic immaturity and be moderately ill. Medical problems faced by those babies are expected to resolve relatively quickly.
- babies who “graduated” from NICU level 3
- babies who require mechanical ventilation or CPAP for no more than 24 hrs.
Newborns who are born in level 2 nursery and are younger than 32 weeks of gestational age or their birth weight is below 1500 grams or will require prolonged mechanical ventilation need to be stabilized and transferred to level 3 or level 4 facility.
Level 2 nurseries are staffed by pediatric hospitalists, neonatal nurse practitioners, and neonatologists.
Nursery – level 3
Level 3 nursery, also called Neonatal Intensive Care Unit, is capable of providing continuous life support for all kinds of premature and term babies without a lower limit in gestational age. They will treat babies starting from 22 or 23 weeks of gestational age, although more typical is 23 weeks as the lowest limit to treat preemies.
It is expected that level 3 NICU is staffed by neonatologists and have other pediatric subspecialists such as pediatric anesthesiologists, pediatric surgeons, and pediatric ophthalmologists.
Nursery – level 4
Level 4 nursery is called Regional Neonatal Intensive Care Unit. This type of NICU, in addition to neonatologists, will be staffed by all pediatric sub-specialists, even including pediatric surgical sub-specialists, and will be able to treat complicated congenital heart defects and other congenital and genetic abnormalities. Level 4 NICU should have continuous transport availability and be actively involved in outreach education for other institutions.
You can read more about the NICU levels of care in the statement published by the American Academy of Pediatrics Committee on Fetus and Newborn.
Ideally, if you are at risk of having a very premature baby (born at less than 32 weeks of gestational age), you should deliver your baby at level 3 hospital, but that is not always the case. I heard of some future parents who, when knowing that they are at risk of having a premature baby, would relocate temporarily to be close to their chosen level 3 hospital until their baby is born. On the other hand, I have seen a lot of parents who resist the transfer of their baby to a higher level of care unit due to the distance that they would need to travel while visiting.
I understand that each family has a unique situation, and we have to respect that. Still, experience and level of care provided to your baby in the nursery matter, so sometimes the transfer of your baby to another institution is in the best interest of your little one.
Who are people working in the Neonatal Intensive Care Unit (NICU)?
Neonatologist – is a physician who is specialized in the care of newborn babies. After graduating from medical school He/She did three years long pediatric residency training and later an additional three years of fellowship in neonatology. These physicians have the highest level of training in newborn medicine, allowing them to take care of extremely sick and premature babies that are hospitalized in NICUs. Frequently, they also attend high-risk deliveries and provide consultations to pediatricians who may have questions regarding their patients who are “normal” regular full-term newborns. If you are curious about levels of training and certification of your physician, you can check it on the “American Board of Pediatrics” web site. (https://www.abp.org). You can practice it by entering my name there: “Wlodzimierz Wisniewski.”
Neonatal Nurse Practitioner
NNP – Neonatal Nurse Practitioner. NNP is sometimes called a “mid-level health care provider.” Neonatal Nurse Practitioners are providers who first used to work as nurses in the NICU, and later on, decided to obtain additional training in neonatology so that they could provide more independent care to newborn babies in all kinds of settings.
Neonatal Nurse Practitioners usually hold master’s degrees or recently even doctorate degrees, and they are required to obtain at least two additional years of training in neonatology before graduating from NNP programs. They are extremely valuable members of the NICU team and together with neonatologists provide care for all types of sick newborn babies. In complex situations, NNPs are required to obtain a consultation from neonatologists because, most of the time, they work under neonatologist’s supervision.
RT – or Respiratory Therapist is a person who is trained in the use of different devices to support breathing and oxygenation in a patient. Those devices include breathing machines, also called ventilators, CPAP devices, face masks, nasal cannulas, and oxygen tents.
Respiratory therapists know how to set up equipment for use, what adjustments in settings should be made in different situations, and how to clear secretions from the airway in a baby. Respiratory Therapists are essential members of the NICU team, particularly during the first days of life in fragile newborn babies who are treated for severe respiratory distress symptoms due to their immature lungs.
PharmDs – Pharmacy Doctors are professionals trained in the use of various medicines. They are needed in NICU because premature babies have a very different and unique physiology. Responses of newborn babies to pharmaceuticals differ from those in adult patients or even from those in children. Also, frequent use of intravenous nutrition called hyperalimentation necessitates the presence of PharmDs because they are the experts in this area.
RNs – Registered Nurses are skilled caretakers that spend the most time with your baby. In my humble opinion, they are THE MOST IMPORTANT team members in NICU. Usually, they take care of 1-4 babies, depending on their acuity level. They know your baby best. I do not know any good neonatologists who would not take very seriously a concern brought to their attention by an experienced RN.
Frequently RNs are the first people to notice that the baby is getting into trouble and needs additional attention, such as diagnostic tests or treatments. To say that they are the best advocates and guardian angels for your baby, when you are not present at your baby’s bedside, would not be an overstatement.
Pediatric subspecialists such as cardiologists, pulmonologists, ID specialists, pediatric surgeons. Those are pediatricians with additional training in their subspecialty that are frequently called by neonatologists to provide their expertise regarding a narrow problem that your baby may be going through. They examine your baby when asked and discuss with neonatologists what is the best course of action to tackle the problem.
OT/PT – Occupational and Physical Therapists: they evaluate and help stimulate appropriate development of motor and feeding skills in your baby. Frequently they are also involved in the care of your baby after discharge. They participate in developmental assessments and early intervention programs aimed to ensure the proper motor and intellectual development of your baby after discharge home.
It is only natural to see a lot of students in the NICU. Doctors who practice where your baby is staying are probably treating many very sick babies. Therefore there will be many different people who will be learning the difficult craft of medicine from them. Those may be medical students, nursing students, respiratory therapy students, PharmD students, and residents and fellows.
Residents and fellows
Medical residents are young doctors who graduated from medical school and are in training in their chosen specialty.
Fellows are the physicians who have already obtained one broader specialty training, and now they are learning in a more specialized area; for example, pediatricians who want to become neonatologists.
I know it may be very overwhelming to see so many people around your baby. Hearing their opinions or statements will be confusing. On the surface, it may seem that when they give you information, they contradict each other leading to your frustration and anxiety. My best advice is: try to allow students and younger doctors to learn, however whenever it is too much for you, ask for privacy, or whenever you are not sure what’s going on with your baby, ask to talk to your baby’s nurse and neonatologists in charge.
What types of beds do we use in NICU?
When you come to NICU for the first time, you will see many different pieces of equipment that are used to care for babies.
After birth, your baby will be placed on Radiant Warmer Bed. It is a table with a heat lamp above it to keep babies warm. The advantage of this table/bed is that it provides easy access to your baby from 3 sides. That way, during critical moments, several people can treat your baby at the same time.
After all the procedures are done, and your baby is stabilized, we will put your baby in an isolette or incubator. We do not keep babies on radiant warmer beds for a long time because a baby would be exposed to frequently changing environmental temperatures, drafts, and noise. Additionally, babies tend to lose a lot of water with evaporation from their immature skin while being under a radiant warmer.
Isolette or incubator is a plastic box with double walls that provides a controlled environment for your baby. It allows doctors to continuously regulate air temperature and humidity inside the box to cater to the individual needs of your baby.
Many level 3 and 4 units have in their disposal a hybrid bed solution called giraffe incubator. It is an incubator that allows a quick elevation of the roof and pulling down the side walls transforming an isolette into a radiant warmer bed and vice versa without a need for moving baby from one place to another.
Once your baby grows bigger and stronger, usually above 3-4 pounds of body weight, a baby will be placed in an open crib. This is done in preparation for the future discharge home and is always a good sign. Usually, it means that your baby is expected to be able to regulate its body temperature just dressed in newborn clothes and covered with a blanket without an additional need for the external heat source.
What types of monitors do we use in NICU?
All premature babies who are admitted to NICU are continuously monitored until the discharge home. Monitors that we have available can measure heart rate, respiratory rate, blood pressure, and amount of oxygen attached to hemoglobin, also called oxygen saturation.
Monitors gather all that information from the baby after leads are placed on the baby’s body, usually on the chest, abdomen, and extremities. Leads need to be made of very soft materials to avoid skin irritation. We try to change the positioning of the leads frequently to allow for skin recovery, especially in babies who have a very immature and sensitive skin.
Respiratory support in NICU
Pretty much all very premature babies require some kind of respiratory support. Depending on the severity of respiratory problems and degree of recovery during hospitalization, you may see your baby first on Ventilator, then on CPAP machine, High Flow Cannula, and finally on Low Flow Cannula.
Ventilators or breathing machines
Ventilator, sometimes called Respirator or Breathing Machine, is a device that provides artificial breathing for your baby. We insert a small plastic breathing tube called the ET tube through the mouth into the windpipe. Then, we connect the tube to the breathing machine. Breathing machine provides breathing for the baby when needed leading to adequate expansion, aeration, and oxygenation of baby’s lungs.
Modern breathing machines contain intelligent sensors and computer software that can decide when a baby can be allowed to breathe on its own and when to intervene by adding external airflow and pressure. Most of the time, sick babies somehow know that they need this support and tolerate being supported with those machines very well.
CPAP device is a less aggressive form of respiratory support. Baby placed on CPAP has a special nasal apparatus inside or around the nose that is connected to a CPAP device. The baby has to be able to breathe on its own while on CPAP because a simple CPAP machine does not provide external breaths. CPAP device provides only additional pressure into the baby’s airways and a mixture of air with supplementary oxygen if needed. With CPAP machines, we can control the amount of oxygen getting to the baby’s lungs and airway pressure at the end of expiration.
Many neonatologists are trying to limit the baby’s exposure to ventilators; hence they invented a hybrid CPAP machine that can provide some external breaths. This newer technique is called non-invasive positive pressure ventilation.
High Flow Nasal Cannulas are used for babies who have already recovered from acute respiratory disease after birth and do not ventilators anymore, or who are less sick but still require some respiratory support. High flow cannula device provides airflow with supplementary oxygen via a small cannula placed in the baby nose.
Low Flow Nasal Cannula is used in babies that do not have severe respiratory problems anymore and just need a little bit of extra oxygen for breathing to maintain proper oxygenation levels in their blood. Sometimes babies with chronic lung disease who need oxygen for breathing but otherwise are ready for home are sent home on low flow cannulas. Low flow cannula provides no more than 1-2 liters per minute of flow into the baby’s nose with additional oxygen if needed.
Other pieces of equipment in the Neonatal Intensive Care Unit.
IV and Medication Pumps
IV fluid pumps and Medication Syringe Pumps are electronic devices that can infuse medications and nutritional fluids at carefully measured rates. During the first weeks and months of life, your baby will be receiving many medications and various IV fluids. IV pumps are used to deliver the exact amount of what doctors prescribed. Pumps may be attached to poles next to an isolette, there may be placed on top of the isolette, or they are attached to isolette parts with special screws. Often one baby will be receiving medications and fluids from 3 or 4 pumps simultaneously.
Phototherapy Lamps are used to treat jaundice in newborn babies. Premature babies are more likely to develop jaundice that will need phototherapy treatment. Phototherapy can be provided using overhead bank lamps, spot lamps that are integrated with baby’s isolette, and bili blankets. Bili blanket has tiny bulbs build into the blanket that you can place under the baby or wrap baby around with it. Phototherapy uses specific light wavelengths to affect the baby’s skin to decrease the severity of jaundice. I will talk more about this particular problem in my other article.
I hope that after reading this article, you will feel more comfortable entering NICU. Of course, it is impossible to talk about every single person or piece of equipment that you may encounter in the NICU. If you have any questions, do not hesitate to ask for clarification in discussion and question forums on my FaceBook Page: NeoPedEdu.
If you have a premature baby born before 32 weeks receiving treatment in the NICU right now, I encourage you to explore my book “Babies Born Early“
If you are interested to know more about different conditions affecting premature babies, check out my other articles here.
If you want to learn about issues affecting full-term babies, you will find more of my articles on these subjects here.
This article is only for general information purposes. It should not be viewed as any kind of medical advice. There is a chance that information here may be inaccurate. You should always discuss all health-related matters with your doctor before making any decisions that may affect your health or health of your family members.