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. premature infant in the nicu at mcmaster children's hospital 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 1,400 grams (3.1 pounds), usually about 30 weeks gestation, rarely survived. today, infants of 500 grams at 26 weeks have a fair chance of survival. as of 2022, the world record for the lowest gestational age newborn to survive is held by curtis zy-keith means, who was born on 5 july 2020 in the united states, at 21 weeks and 1 day gestational age, weighing 420 grams. 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. to date there have been very few studies investigating noise reduction interventions in the nicu and it remains uncertain what their effects could be on babies' growth and development. 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. when parents arrive at the nicu, they will have the availability to tour the unit and orientation to the various areas and equipment. this tour should include information on the different types of equipment used in the nicu, such as incubators, monitors, and ventilators, and how they help to support the health and well-being of the babies. parental orientation to the nicu is essential in reducing parental anxiety and improving satisfaction with care. effective communication is critical in the nicu. parents will be given information on who their primary point of contact is and how they can communicate with the medical staff caring for their baby. parents should ask questions when given tour of the nicu just incase anything was misunderstood. the gynecologic and neonatal nursing found that effective communication between health care providers and parents in the nicu is critical for promoting parental involvement and reducing stress 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. equipment incubator an early incubator, 1909. dräger isolette c2000 at the hospital regional de apatzingán in apatzingán, michoacán, mexico. an incubator (or isolette or humidicrib) is an apparatus used to maintain environmental conditions suitable for a neonate (newborn baby). it is used in preterm births or for some ill full-term babies. there is additional equipment used to evaluate and treat sick neonates. these include: blood pressure monitor: the blood pressure monitor is a machine that's connected to a small cuff which is wrapped around the arm or leg of the patient. this cuff automatically takes the blood pressure and displays the data for review by care providers. oxygen hood: this is a clear box that fits over the baby's head and supplies oxygen. this is used for babies who can still breathe but need some respiratory support. ventilator: this is a breathing machine that delivers air to the lungs. babies who are severely ill will receive this intervention. typically, the ventilator takes the role of the lungs while treatment is administered to improve lung and circulatory function. 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. 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. pain management many parents with newborns in the nicu have expressed that they would like to learn more about what types of pain their infants are feeling and how they can help relieve that pain. parents want to know more about things such as; what caused their child's pain, if the pain that we feel is different than what they feel, how to possibly prevent and notice the pain, and how they could help their child through the pain they were struggling with. another main worry that was mentioned was the long-term effects of their pain. would it mentally affect the child in the future, or even affect the relationship they have with their parents? relieving pain there are multiple ways to manage pain for infants. if the mother is able to help, holding the infant in kangaroo position or breastfeeding can help calm the baby before a procedure is done. other simple things that can help ease pain include; allowing the infant to suck on a gloved finger, gently binding the limbs in a flexed position, and creating a quiet and comfortable environment. mother uses the common skin to skin technique with her infant. patient populations us navy 090814-n-6326b-001 a mock set-up of the new pod design in the neonatal intensive-care unit (nicu) at naval medical center san diego (nmcsd) is on display during an open house further information: neonatal infection common diagnoses and pathologies in the nicu include: anemia apnea bradycardia bronchopulmonary dysplasia (bpd) hydrocephalus intraventricular hemorrhage (ivh) jaundice necrotizing enterocolitis (nec) patent ductus arteriosus (pda) periventricular leukomalacia (pvl) infant respiratory distress syndrome (rds) retinopathy of prematurity (rop) neonatal sepsis 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. neonatal care is split into categories or "levels of care". these levels apply to the type of care needed and is determined by the governing body of the area. india 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 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. united kingdom the terminology used in the united kingdom can be confusing because different criteria are used to designate 'special' and 'intensive' neonatal care locally and nationally. level 1 neonatal units also known as 'special care baby units' (scbu). these look after babies who need more care than healthy newborns but are relatively stable and mature. scbu might provide tube-feeding, oxygen therapy, antibiotics to treat infection and phototherapy for jaundice. in a scbu, a nurse can be assigned up to four babies to care for. level 2 neonatal units also known as 'local neonatal units', these can look after babies who need more advanced support such as parenteral nutrition and continuous positive airway pressure (cpap). confusingly, they may also look after babies who need short-term intensive care such as mechanical ventilation. babies who will need longer-term or more elaborate intensive care, for example extremely preterm infants, are usually transferred to a level 3 unit. babies in a level 2 unit may be classified for nursing purposes as 'special care', 'high dependency' (hdu) (in which a nurse will be assigned up to two babies) or 'intensive care' (where nursing is one-to-one, or sometimes even two-to-one). level 3 neonatal units also known as 'neonatal intensive care units' (nicu) - although level 2 units may also have their own nicu. these look after the smallest, most premature and most unwell babies and often serve a large geographical region. therapies such as prolonged mechanical ventilation, therapeutic hypothermia, neonatal surgery and inhaled nitric oxide are usually provided in level 3 units, although not every unit has access to all therapies. some babies being cared for in level 3 units will require less intensive treatment and will be looked after in hdu or scbu nurseries on the same site. nhs england recommended in december 2019 that these units should care for at least 100 babies weighing less than 1.5 kg, and usually perform more than 2,000 intensive care days per year. united states 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