A Parent’s Guide to the NICU

A NICU is a neonatal intensive care unit, which is a hospital unit for sick newborns. Babies who are admitted to NICUs include those who are born prematurely (before 37 weeks’ gestation), have surgical conditions, birth defects, genetic syndromes, metabolic problems, and/or any other unexpected complications that arise during the newborn period, such as sepsis (infection), hypoglycemia (low blood sugar), or severe hyperbilirubinemia (jaundice).

There are different “levels” of NICUs that newborns can be admitted to after delivery. The designation of a NICU as a Level 2, 3, or 4 depends on both the hospital system and the state/region in which the NICU is located. For the most part, the differentiation of NICU levels is as follows:

Level 2 NICU: Takes care of newborns who require intensive, but not critical care. Babies in Level 2 NICUs are often late preemies (born between 34-36 weeks’ gestation) or newborns with unexpected complications after delivery, such as low blood sugar or a possible infection.

Level 3 NICU: Has the ability to take care of extremely premature babies (as young as 22-23 weeks’ gestation) who require ventilators and very close monitoring. Some Level 3 NICUs are in large medical centers and others are located in community hospitals and more rural settings.

Level 4 NICU: Level 4 NICUs have the ability to care for all sick newborns, including extremely preterm infants, babies who need subspecialty care for surgical conditions, have complex medical problems, or need ECMO (heart-lung bypass). Most Level 4 NICUs are associated with large academic medical centers and children’s hospitals.

NICU care teams are often large and contain individuals from several different health care disciplines. These include the following: 

Neonatologists: Physicians (MD/DO) who are board-certified in neonatal-perinatal medicine. To become neonatologists, doctors go through four years of medical school, followed by a three-year pediatric residency, and then a three-year neonatal-perinatal medicine fellowship. Neonatologists lead NICU care teams and are patients’ main doctors. 

NICU hospitalists: Other doctors, often general pediatricians, who help neonatologists take care of patients. 

Neonatal nurse practitioners (NNPs): Former NICU nurses who go through advanced training (often a doctorate degree) to be able to take care of sick newborns. Many NNPs work hand-in-hand with neonatologists. There are also physician assistants (PAs) who specialize in newborn medicine.

NICU Nurses: Nurses, usually RNs, who have “hands-on” care of NICU patients. Nurses make up the backbone of every NICU and often get the know their patients’ parents and families very well.

Respiratory therapists (RTs): RTs support newborns who have problems with their lungs and breathing. They manage patients’ oxygen, ventilators (breathing machines), and other equipment to help babies breathe.

Social workers: Provide support to NICU parents and make sure that NICU families’ financial, mental health, transportation, and other essential needs are taken care of. 

Pharmacists: Provide input and ensure that patients’ doses and regimens of medications and IV fluids and nutrition are correct and safe.

Dieticians (nutritionists): Closely monitor NICU babies’ weight gain and growth and make sure patients’ diets have enough calories, fat, protein, vitamins, and other important nutrients.

Lactation consultants: Assist with all aspects of lactation and making milk, including breastfeeding, pumping, and supplementing with donor breast milk.

Occupational and physical therapists (OTs and PTs): Make sure that NICU patients have developmentally appropriate environments, promote muscle strength and range of motion, enhance motor skills, and assist in assessing oral feeding readiness. 

Other important NICU team members include pediatric residents (doctors who are training to become pediatricians), medical students, milk room technicians, phlebotomists, nursing assistants, palliative care specialists, and music therapists.

NICU patients have continuous monitoring of their heart rates and breathing to make sure that they do not have dangerous drops in their heart rate (bradycardia) or pauses in breathing that are too long (apnea). Most babies in the NICU also have pulse oximetry, which gives a reading of their blood oxygen levels. Other vital signs that are closely monitored include temperature and blood pressure. The most common tests that babies in the NICU have performed are x-rays, glucose levels, bilirubin checks, blood cell counts, and blood gases.

Babies who are born prematurely are often unable to maintain their body temperature and get cold easily. When this happens they are placed in isolettes (incubators) which provide warmth. Babies no longer need isolettes when they reach around the 4 lb. mark and/or 35-weeks’ gestation.  Full-term NICU patients do not usually need to be placed in isolettes because they are able to thermoregulate (maintain their body temperature) in open cribs.

Most NICU babies are too sick and/or premature to directly breastfeed, at least initially. This requires NICU moms to have to pump. For more information on breastfeeding and pumping in the NICU please refer to our “Pumping for Preemies” blog.

There is a huge range in the lengths of stay in the NICU. Some newborns only have to stay for a few days, while others may need to be in the NICU for months and months. We usually tell parents of preemies to expect that their baby will need to be in the NICU until around their actual due date.

Parents often wonder how they can be a part of their baby’s life in the NICU. Here are some simple ideas for how to get involved!

• Take advantage of the ability to visit 24/7 so that you can be with your baby in the NICU as often as you can.
• Do “kangaroo care,” or skin-to-skin care, with your baby frequently. Benefits of holding your baby skin-to-skin include bonding, increased breast milk production, and stabilization of your baby’s temperature, breathing, and heart rate.
• Try to be present during NICU “rounds” every day, either in person or by phone. NICU medical teams usually round in the morning and this is when the daily care plan for your baby is made. Rounds are the perfect time to be able to ask questions to your baby’s health care providers and share important information.
• Pump breast milk, if you are able. It is very beneficial for NICU babies to receive their mom’s milk because it is easy to digest, protects against infection, and improves growth and developmental outcomes.
• As your baby stabilizes you can become increasingly “hands-on” in participating in his or her care. This can include changing diapers, taking their temperature, and/or giving your baby a bath. 
• Read and learn about your baby’s medical problems and special health care needs. You can find information about common NICU problems via books, websites, podcasts, videos, and/or phone apps geared toward NICU parents.

Project NICU: www.projectnicu.com

Project Sweet Peas: www.projectsweetpeas.com

March of Dimes: www.marchofdimes.org

Graham’s Foundation: www.grahamsfoundation.org

September is NICU Awareness Month, which honors NICU patients, their parents, and the healthcare professionals who work in NICUs. The symbol for NICU Awareness Month is a purple flag because the color purple has traditionally been associated with prematurity. Prematurity Awareness Day, which is November 17th, is also symbolized by a purple flag.