General information about the NICU

Neonatal care units differ with regard to the level of care they provide. Terms and definitions differ between countries, regions and even hospitals. Usually, the levels can roughly be categorised in basic, special, and intensive neonatal care.

Basic neonatal care units usually provide postnatal care for healthy newborn infants. Late preterm born babies, born at a gestational age between 34 weeks, and 36 weeks and 6 days, without any serious health problems may also be admitted to these units. Sometimes mild diseases such as mild jaundice can be treated here.

Moderately preterm (born between 32 and 34 weeks of pregnancy) or ill babies with problems expected to resolve quickly are admitted to a special neonatal care unit. Infants usually require more attention and care, e.g. continuous monitoring of heart rate, breathing, and oxygen saturation, oxygen supplementation, or tube feeding.

Some units on a higher level may additionally offer breathing support, e.g. CPAP (continuous positive airway pressure), intravenous therapy, and parenteral nutrition. Infants who need time to recover from intensive care are usually transferred to this kind of unit as an intermediate step before their discharge. Therefore, these units are called intermediate care or transitional units in some regions.

Neonatal Intensive Care Units (NICU) provide the highest level of care to extremely preterm born and severely ill babies who need sustained life support. These units allow immediate access to the full range of special equipment (e.g., advanced imaging such as radiography or ultrasound) and subspecialty consultants (e.g., surgical specialists, anaesthesiologists, or ophthalmologists). NICUs provide intensive medical care such as conventional mechanical ventilation or high-frequency ventilation in addition to the care provided in the lower levels. Babies who require neonatal surgery may also be transferred to these units.

There is a variety of rooms in a neonatal intensive care unit (NICU) to care for the baby and the family and to provide facilities to the NICU team.

The rooms have different functions, but most of them are patient and treatment rooms. The number of rooms, the number of beds per room and the design differ from unit to unit depending on space, construction, and care concept.

The open-bay NICU model allows the NICU team to care for several infants at the same time in one room. Sometimes, an additional treatment unit for examinations is placed in the room. Spaces for parents can be provided next to each incubator or infant care bed.

Some units offer settings, also called double-occupancy or semi-private rooms, where two babies are cared for in one room. NICUs with this type of concept usually provide comfortable chairs for the parents. In some units the mother or father are able stay together with the child in their own bed. This concept increases privacy for the family and offers a more comfortable environment to the parents.

The design and construction of single family rooms in NICUs offers a private room for each baby and the family. It allows parents to be together with their child 24 hours a day from admission to discharge.

They are usually equipped with one or two beds for the parents in addition to the infant care bed or incubator and with space to take care for the child (including for example a baby bathtub and a nappy-changing table with a radiant warmer). Sometimes, hospitals can also provide a private bathroom for parents. Single family rooms can be beneficial for parents and their baby by reducing noise and stress for both of them. Parents have privacy for breastfeeding and skin-to-skin care. Additionally, single family rooms may increase parental participation in the care for their child and staff satisfaction.

Double-occupancy or semi-private rooms as well as single family rooms are often provided together with couplet care and family-centred care.

Depending on the size and design of the unit, further rooms can be included in the facility. Breastfeeding or lactation rooms for example offer more privacy to mothers who would like to breastfeed or express breast milk. Additional treatment or therapy rooms can be integrated to provide space for medical interventions, e.g., surgeries or diagnostic procedures. There can also be rooms to prepare medications, infusions, and nutrition following strict hygiene practices. Several rooms for the medical team may be offered for meetings, paperwork, or for taking a break. Some units provide rooms for parents, where they can meet each other, take a short break, or prepare some food for themselves.

If a local hospital is not able to provide the appropriate level of care for a preterm born or ill newborn baby, this baby needs to be transferred to another unit or hospital. Transferring the baby can be very stressful for the child and the parents. Specialist staff and equipment take care of the baby before, during, and after the transfer with special attention to the child’s safety. There are different options to transport the baby and the mother.

If a pregnant woman or her unborn child requires enhanced care, the expectant mother will ideally be transferred to the most appropriate unit already before birth. This process is referred to as a prenatal or an in-utero transfer and is presenting the safest option if the baby is likely to be born preterm. The medical team will decide what is best for mother and child. Before the transfer, the obstetric and neonatal team will provide counselling to the mother. Usually, she needs to give formal consent before being transferred.

The mother is transported by an ambulance car or helicopter and accompanied by an experienced team of healthcare professionals. After arriving in the unit the healthcare teams exchange information about health status of mother and child and ongoing care plans, also called handover.

The mother becomes a patient of the new unit until she is either discharged, or transferred back to the local unit.

If the newborn baby needs to be transferred to another unit after delivery it is usually the decision of the neonatologist or obstetrician present during birth. The neonatologist examines the baby and assesses the need of for transferring the baby. The baby will be transferred by an ambulance or helicopter in a transport incubator. This allows for the regulation of the temperature, oxygen level, and humidity and for the administration of required medicine during the transfer.

The transfer is led by a dedicated and specially trained transfer team. This team cares for the baby throughout the whole transport and hands over all important information and therapy plans to the healthcare team in the new unit. Ideally, the mother or the father can accompany their baby during transport. If the mother needs continued medical treatment in the hospital, it is sometimes possible to transfer her together with her baby. Healthcare professionals will decide together with the parents to assure the optimal care for the infant and the mother.

Babies in the neonatal intensive care unit are very vulnerable to infection. Therefore, hygiene is a very important issue. Parents receive clear instructions from their baby’s healthcare team how they should behave correctly when they are present in the neonatal unit. To keep rooms and surfaces clean, all NICUs have special cleaning staff.

One of the most effective ways to prevent hospital-acquired infections is a correct hand washing and hand hygiene procedure. Because many infections can be spread in various ways, among others through unclean hands, it is important for healthcare professionals and parents to follow strict rules for hand hygiene. Parents are usually advised by the NICU team how to use antiseptic soap and alcohol-based hand sanitisers to remove and to kill germs on their hands, wrists, and arms. In addition, healthcare professionals and parents should take off any jewellery that could get in contact with the baby e.g. rings, bracelets, watches, or necklaces. The reason for this is that germs can stick to the jewellery and spread to the baby. Finger nails should be clean and cut as short as possible. Nail polish and artificial finger nails should be removed, because they can support the growth of larger numbers of germs on finger nails.

It is of utmost importance to use water and soap after using the toilet, after wiping the nose, before and after eating, and after changing the infant’s nappy. Additionally, the NICU team and the family should always use hand sanitiser before and after every contact with the baby, before and after every care procedure, and before and after they use a mobile phone or a camera.

In some units, parents are asked to put their phones in a plastic bag when entering the NICU. This is because germs can stick to the smooth surface of mobile phones. Therefore, it is important to follow the hygiene procedures for mobile phones in the interest of the safety of the baby.

Usually, the healthcare team wears gloves for every care intervention to reduce the risk of transmitting germ from one baby to another. Parents do not need to wear them. However, masks, overshoes, and/or protective gowns and hoods are sometimes required when entering the NICU. Healthcare professionals may instruct parents how to correctly put on protective clothing if needed. They will also explain to parents what to do before bringing things from home to the hospital, e.g. baby clothing.

It is in the best interest of the child’s health that healthcare professionals as well as parents should minimise the risk for unnecessary infections by strictly following all rules for hygiene and safety in the NICU.

The senses of a preterm born baby are still immature and will further develop while the child is in the NICU. The prenatal period is very sensitive and important for the brain development of a child. If a baby is born too soon, the development processes that would normally take place inside the womb are altered or interrupted. The environment of a NICU heavily influences the sensory developmental process which is critical for attachment and later life. Noise and light can disturb the baby’s sleep which is important for growth and tissue repair, brain and sensory development, as well as for memory and learning processes. Disrupted sleep can stress and distracts the infant during feeding and social interaction and may cause developmental problems.

Therefore, many NICUs monitor environmental noise and adapt sound levels. The sound levels reaching the baby should be not higher than 45 decibel (dB), which is a common measure for the volume (loudness) of a sound. It can be measured by a decibel meter or a computer.

Interventions to reduce noise in the NICU can include reducing the volume of alarms, closing of the bins quietly, or switching pagers on vibration mode. Parents should also support a noise reduced environment for their baby, e.g., by talking quietly or in a separate room and switching their mobile phone off or on vibration mode.

Additionally, the healthcare team protects the eyes of the preterm infant from direct light exposure, and tries to maintain low levels of ambient light, e.g., by using spotlights for medical procedures and incubator covers/canopies, and by avoiding frequent fluctuations in light levels until the baby reaches 39 to 40 weeks of gestation. Parents can also be guided to cover the infant’s eyes during medical interventions or to avoid direct lightning during skin-to-skin care.