What is a Neonatal Intensive Care Unit?

According to the charity Bliss which supports babies who are born prematurely or sick, more than 90,000 babies each year are cared for in neonatal units either because they are poorly or due to prematurity. To put that into context, it equates to 1 in every 7 babies in the UK. Around 60% of babies who are admitted to neonatal care are classed as full-term (i.e., they were born after 37 weeks’ gestation).

What is a neonatal intensive care unit?

A neonatal intensive care unit (often shortened to NICU) is an intensive care unit for recently born babies who require high support. Often, babies in the neonatal intensive care unit of a hospital will have been born before 28 weeks of pregnancy but sometimes they are admitted to the NICU because they are very unwell after they are born.

Not all hospitals have a NICU and therefore babies can be transferred to neighbouring hospitals where they have the facilities and staff to support a baby who needs intensive care.

Babies are admitted to the NICU because they may:

• Need ventilation and/or continuous positive airway pressure (CPAP) breathing support.
• Have a severe illness that affects their breathing.
• Are waiting for surgery or have just had surgery.
• Have a severe infection.

What are the different levels of neonatal care?

Neonatal intensive care units are there to look after and support the very sickest of babies. However, there are different levels of neonatal care depending on a baby’s needs and condition. Babies who need no extra care are usually discharged at the same time as the mother either directly from the delivery suite or a post-natal ward.

Special Care Baby Unit (SCBU)

Babies who need a little extra support are admitted to the special care baby unit (shortened to SCBU). This level of support is sometimes called low dependency and is for babies who do not need intensive care. Often, babies who are born after 32 weeks’ gestation will go to SCBU.

Babies who are admitted to SCBU may have the following:

• Heart rate and breathing monitoring.
• Additional oxygen support.
• Treatment for low body temperature.
• Treatment for low blood sugar levels.
• Help with feeding, often with a feeding tube.
• Treatment for illnesses that happen soon after birth.
• Treatment for jaundice such as phototherapy.

Local Neonatal Unit (LNU)

For babies who need an elevated level of care compared to those in SCBU, particularly for babies born between 28 and 32 weeks’ gestation, they are transferred to a local neonatal unit (LNU).

For babies admitted to an LNU, they may receive the following support:

• Breathing support such as continuous positive airway pressure (CPAP) or ventilation.
• Short-term intensive care.
• Care as a result of apnoea (short periods of not breathing).
• Parenteral nutrition (feeding via a drip into their vein).
• Cooling treatment after difficult births or if unwell soon after they’re born.

Neonatal Intensive Care Unit (NICU)

As mentioned, the most severely ill or premature babies need Level 1 intensive care in the neonatal intensive care unit (NICU). After this, babies who require a little less support receive what is called Level 2 intensive care. Support in NICU usually includes ventilation.

Transitional Care

When a baby has transitioned down the different levels of neonatal care or if they were just admitted to SCBU rather than more intensive care, the level of care before they are discharged from the hospital back home is called transitional care.

Transitional care means that a baby stays in the hospital with his/her parents either in the post-natal ward or a special room on the neonatal unit with support from the hospital staff.

Transitional care helps parents and caregivers by allowing them to take over their baby’s care gradually with support from the professionals to ease them gently into taking their baby home. This is especially important if a baby is being discharged needing extra medical support or equipment such as a feeding tube or oxygen support.

Why are there different levels of neonatal care?

Babies need different levels of care depending on their condition. The level of care that a baby needs will dictate whether a baby is admitted to SCBU, LNU or NICU. In each of these settings, the staff members have different roles and responsibilities.

In the SCBU, a nurse can be assigned up to four babies to care for at any one time. This is because the babies do not need as much care or monitoring as babies in LNUs or NICUs as they are relatively stable and mature.

In LNUs, babies need more support such as CPAP or parenteral nutrition. In this unit, babies may be assigned as needing special care or high dependency. With high dependency babies, a nurse will be assigned a maximum of two babies to care for at any one time.

In NICUs, each baby has at least one nurse caring for him or her at any one time. Sometimes, some babies will have two nurses caring for them due to their needs. This is because these units look after the sickest and smallest babies and provide complex treatments such as ventilation, neonatal surgery, and therapeutic hypothermia.

Essentially, there are different levels of neonatal care because babies needing extra care in comparison to healthy new borns do not all have the same care needs with some requiring much more intense care than others.

Who can visit the neonatal intensive care unit?

Almost all neonatal intensive care units in the United Kingdom allow the baby’s parents to visit them no matter the time of day or night. However, individual hospitals or NHS trusts have their own policies regarding other visitors such as siblings and grandparents. They also have limits on the number of visitors at any one time.

For example, a hospital may allow a maximum of two visitors by a baby’s cot, but visitors may swap over. They may only allow other visitors during a set time, such as between 2:00 pm and 7:00 pm. Some units also specify that the baby’s parent must also be present during the visit.

Other units may allow visitors between 8:00 am and 10:00 pm. Visits are often limited to an hour once a day or are limited to one visit per day per baby. Visitors are also not permitted to touch the baby in many units due to the risks of infections.

Of course, the recent Covid-19 pandemic has affected many hospitals and neonatal intensive care units, particularly when it comes to visiting.

At the height of the pandemic, parents with babies in NICUs often had restricted visiting themselves, with strict time limits or with only one parent being allowed to visit at any one time. Thankfully, most NICUs relaxed their visiting policies since the vaccination programmes were introduced.

Who works in the neonatal intensive care unit?

When you have a baby in the neonatal intensive care unit, it can be overwhelming. There is often a lot of information to try to get your head around as well as getting used to all the sights and sounds. Thankfully, NICUs are staffed with highly trained, specialised staff who are there to support parents throughout their baby’s stay.

Nurses

Nurses in the NICU provide the majority of the daily care for babies. They answer parents’ questions and show caregivers how to wash and feed their babies. They also arrange for parents to speak to the specialist doctors who are caring for their babies. Some nurses often have more specialist roles such as nurse consultants or advanced neonatal nurse practitioners (ANNPs).

These nurses can often provide similar care to doctors and supervise teams of nursing staff. There is also usually a matron who coordinates the care for the babies in the NICU. Nurses help parents with skin-to-skin/kangaroo care when their babies are in the NICU. They also support with breastfeeding.

Doctors

The doctors in the NICU coordinate a baby’s medical treatment. They also answer parents’ questions and concerns in more detail including their treatment, condition and prognosis. Doctors who work in the NICU are supported and overseen by a consultant neonatologist or consultant paediatrician. There are also surgeons who work specifically with the NICU and they are led by a separate consultant.

Nursery Nurses

Some units have specialist nursery nurses who help support the running of the unit and assist the nurses with tasks. They also work as an outreach and assist the discharge team to support parents and babies when they are preparing to go home.

Pharmacists

Pharmacists prescribe a baby’s medication. New and sick babies have different medication requirements to older children and adults, so specialist pharmacists are needed.

Therapists

Many different therapists help babies in NICUs. Physiotherapists, as well as occupational therapists, often support parents and staff in SCBUs, LNUs and NICUs to help with a baby’s physical and/or social development. Speech and Language Therapists (SALTs) assist with babies’ abilities to swallow and feed.

Dieticians

Dieticians support babies in NICUs to ensure that they have the best possible nutrition. There are also specialist feeding support staff that can help with breastfeeding and expressing breast milk for premature and sick babies.

Radiographers

Radiographers perform x-rays and scans. If a baby needs a scan (such as an ultrasound scan, CT scan, MRI scan) or an x-ray, a radiographer will perform the scan and interpret the results.

Psychotherapists, Psychologists, Counsellors

These professionals support parents in their journey in the NICU. Having a poorly or premature baby is a very difficult time and parents may need psychological support. Mothers may also have an increased likelihood of suffering from post-natal depression.

Community and Discharge Nurses

In some units, there are staff specifically dedicated to supporting parents with leaving the unit and establishing their baby’s care once they arrive home.

Family Support Workers or Social Workers

These professionals assist parents with any non-medical needs that arise due to having a baby in the NICU. This can include support for incurred costs due to needing to relocate closer to the hospital or for any equipment that is needed. They also support parents emotionally during what can be an incredibly difficult time.

Cleaners and Porters

This team of staff helps to maintain the NICU’s cleanliness standards and maintain the equipment in the unit. Porters also help to transport sick babies from one unit to another.

Clerical Staff

Each unit usually has a number of people who perform administrative tasks and manage the office work required when running such a unit.

Chaplains and Faith Leaders

Parents with sick babies in the NICU often need emotional and well-being support. For those with a particular faith, support often comes from a faith leader or a chaplain. Hospitals often have faith leaders from different religions that can be arranged via the nursing staff. Sometimes, parents wish to bless or baptise their babies if they are extremely poorly and/or are not expected to recover.

What equipment may be seen in the neonatal intensive care unit?

For many parents, it is a shock when they first enter the neonatal intensive care unit. There is a lot of equipment, wires, leads, monitors and sounds that can overwhelm the senses. It can be helpful for parents to know a little more about the equipment that they can see in the NICU.

Incubators

An incubator is a small, clear box that keeps a baby warm. These are used because sick or premature babies can struggle to regulate their body temperature.

Some incubators are fully enclosed with small holes for hands on the sides. This helps to keep the correct humidity within the box as dry air can be damaging to a baby’s skin. Some incubators have open tops with heated mattresses or overhead heaters.

The temperatures in an incubator are controlled either by sensors on the baby’s skin or by a control panel. If the temperature is not correct (or if the sensor falls off a baby’s skin), an alarm sounds to let the nursing staff know.

Breathing Machines and Ventilators

Babies who are premature or who are ill often struggle to breathe on their own and need support. Depending on their needs, a baby might need either CPAP or high-frequency ventilation.

• Positive pressure ventilators blow air into a baby’s lungs and inflate them. This means that the machine pushes air into a baby’s lungs through a tube via their nose which inflates their lungs due to the pressure. This means that their breathing is controlled and kept regular.
• High-frequency oscillating ventilators are used when a baby needs more breathing support. These ventilators blow small amounts of air or air with added oxygen into a baby’s lungs very quickly, sometimes hundreds of times each minute. Quite often, it appears as though the baby’s chest is vibrating.
• CPAP stands for continuous positive airway pressure. This air (with or without added oxygen) passes via two small tubes or a mask over the baby’s nose. CPAP increases the pressure of the air to help keep a baby’s lungs inflated.

Some babies may need support with their breathing but do not need the intense breathing support that a ventilator or CPAP machine would provide. In this case, High-flow air/oxygen is provided via a nasal cannula. This air is heated and humified and flows into the baby’s lungs via small tubes inserted into the baby’s nose.

Endotracheal Tubes

Endotracheal tubes are tubes that are inserted into a baby’s trachea – the medical term for a windpipe. These are inserted into a baby’s mouth or through their nose. This tube is what passes air from the ventilator to a baby’s lungs.

Vital Signs Monitor

This machine monitors a baby’s heart rate and breathing rate via small pads attached to a baby’s chest. If anything is not quite right with the baby’s heart rate, an alarm sounds.

Oxygen Saturation Monitor

This is a tiny sensor that is usually taped to a baby’s foot or toe. It monitors the oxygen saturation of the baby’s blood via a light sensor shining through the skin.

Intravenous Drips

Babies sometimes have small tubes going into the blood vessels in their hand, foot, leg or arm. These tubes administer fluids and medication such as antibiotics.

Feeding Tubes

If a baby is unable to suckle due to prematurity or tiredness, they may have a feeding tube that goes into their stomach via their nose (a nasogastric, or NG, tube) or mouth (an orogastric, or OG tube). Breast milk or formula is given to the baby via the tube.

Umbilical Catheter

This is a long, thin tube that is put into a baby’s blood vessel in the baby’s belly button. Umbilical catheters are often used initially as the umbilical cord is still attached to a baby after it is born.

There are two types of umbilical catheters. One of them goes into the artery and is used to take blood samples and measure blood pressure. The other type is inserted into a vein and is used to administer medicine or nutrition. There can be more than one type of tube attached to an umbilical catheter as this means that a baby is not disturbed too much each time.

Long Lines

A long line is a thin tube that is passed into a baby’s vein. These procedures can be quite complicated and often they are fitted during an operation. Long lines are used to give nutrition as well as administer medication.

Phototherapy Lamps and Light Blankets

Babies often need phototherapy to help with their jaundice levels after birth. Light therapy helps to break down bilirubin in a baby’s blood that builds up after birth when the liver cannot remove it as quickly as it should. This often happens in SCBU or transitional care.

How long will a baby be in the neonatal intensive care unit?

How long a baby stays in the neonatal intensive care unit depends on a few factors and whether they are premature and/or sick. Premature babies are often expected to stay in hospital until around the time of their due date but, of course, not all of this time would be spent in the NICU.

According to research, the average stay in NICU for babies in the UK is around seven days. However, this statistic includes both premature and full-term babies. Some of the more premature babies will spend considerably more time in the NICU than their full-time counterparts.

Medical research studying 23,551 babies revealed a trend based on a baby’s birth weight and their length of time in hospital until discharge. Babies who did not survive were not included in the sample.

For babies who weighed less than 1kg, their median length of stay in hospital was 79 days. For those weighing between 1kg and 1.5kg, the median length of stay was 46, for those weighing 1.5kg to 2kg it was 21 days, and for those weighing over 2.5kg the median stay was 8 days.

A further study that was published in the British Medical Journal shows that for babies born at 30 and 31 weeks, their median length of stay is a month less than the time that would have remained until their due date, i.e. they are discharged around what would have often been the 36–37 weeks’ gestation mark. Babies born between 26 and 28 weeks tended to leave hospital shortly before their due date. However, babies who were born at 24 weeks and who survived to discharge tended to stay in hospital for a week or so past what would have been their expected date of delivery.

The best people to estimate a baby’s length of stay in the NICU are always the treating clinicians. However, as is often the case with neonates, their stays can be unpredictable.

Final thoughts

For most people, a stay in the NICU for their baby is a very worrying time. However, with good support from the hospital, most people take home their babies in as short a time as possible. Thanks to medical advances, more babies are surviving neonatal illnesses and prematurity than ever before.