neonatal intensive care unit neonatal intensive care unit a neonatal intensive care unit (nicu), also known as an intensive care nursery (icn), is an intensive care unit (icu) specializing in the care of ill or premature newborn infants. the nicu is divided into several areas, including a critical care area for babies who require close monitoring and intervention, an intermediate care area for infants who are stable but still require specialized care, and a step down unit where babies who are ready to leave the hospital can receive additional care before being discharged. "nicu" redirects here. for neurological units, see neurointensive care. neonatal intensive care unita premature infant in an incubator. 1978, usaspecialtyneonatology neonatal refers to the first 28 days of life. neonatal care, as known as specialized nurseries or intensive care, has been around since the 1960s. the first american newborn intensive care unit, designed by louis gluck, was opened in october 1960 at yale new haven hospital. nicu is typically directed by one or more neonatologists and staffed by resident physicians, nurses, nurse practitioners, pharmacists, physician assistants, respiratory therapists, and dietitians. many other ancillary disciplines and specialists are available at larger units. the term neonatal comes from neo, "new", and natal, "pertaining to birth or origin". nursing and neonatal populations a pediatric nurse checking recently born triplets in an incubator at ecwa evangel hospital, jos, nigeria healthcare institutions have varying entry-level requirements for neonatal nurses. neonatal nurses are registered nurses (rns), and therefore must have an associate of science in nursing (asn) or bachelor of science in nursing (bsn) degree. some countries or institutions may also require a midwifery qualification. some institutions may accept newly graduated rns having passed the nclex exam; others may require additional experience working in adult-health or medical/surgical nursing. some countries offer postgraduate degrees in neonatal nursing, such as the master of science in nursing (msn) and various doctorates. a nurse practitioner may be required to hold a postgraduate degree. the national association of neonatal nurses recommends two years' experience working in a nicu before taking graduate classes. as with any registered nurse, local licensing or certifying bodies, as well as employers, may set requirements for continuing education. there are no mandated requirements to becoming an rn in an nicu, although neonatal nurses must have certification as a neonatal resuscitation provider. some units prefer new graduates who do not have experience in other units, so they may be trained in the specialty exclusively, while others prefer nurses with more experience already under their belt. intensive-care nurses undergo intensive didactic and clinical orientation in addition to their general nursing knowledge in order to provide highly specialized care for critical patients. their competencies include the administration of high-risk medications, management of high-acuity patients requiring ventilator support, surgical care, resuscitation, advanced interventions such as extracorporeal membrane oxygenation or hypothermia therapy for neonatal encephalopathy procedures, as well as chronic-care management or lower acuity cares associated with premature infants such as feeding intolerance, phototherapy, or administering antibiotics. nicu rns undergo annual skills tests and are subject to additional training to maintain contemporary practice. history the problem of premature and congenitally ill infants is not a new one. as early as the 17th and 18th centuries, there were scholarly papers published that attempted to share knowledge of interventions. it was not until 1922, however, that hospitals started grouping the newborn infants into one area, now called the neonatal intensive care unit (nicu). stéphane tarnier before the industrial revolution, premature and ill infants were born and cared for at home and either lived or died without medical intervention. in the mid-nineteenth century, the infant incubator was first developed, based on the incubators used for chicken eggs. dr. stephane tarnier is generally considered to be the father of the incubator (or isolette as it is now known), having developed it to attempt to keep premature infants in a paris maternity ward warm. other methods had been used before, but this was the first closed model; in addition, he helped convince other physicians that the treatment helped premature infants. france became a forerunner in assisting premature infants, in part due to its concerns about a falling birth rate. after tarnier retired, dr. pierre budin, followed in his footsteps, noting the limitations of infants in incubators and the importance of breastmilk and the mother's attachment to the child. budin is known as the father of modern perinatology, and his seminal work the nursling (le nourisson in french) became the first major publication to deal with the care of the neonate. another factor that contributed to the development of modern neonatology was dr. martin couney and his permanent installment of premature babies in incubators at coney island. a more controversial figure, he studied under dr. budin and brought attention to premature babies and their plight through his display of infants as sideshow attractions at coney island and the world's fair in new york and chicago in 1933 and 1939, respectively. infants had also previously been displayed in incubators at the 1897, 1898, 1901, and 1904 world fairs. early years children's hospital at the oskar-ziethen hospital, berlin, in 1989 doctors took an increasing role in childbirth from the eighteenth century onward. however, the care of newborn babies, sick or well, remained largely in the hands of mothers and midwives. some baby incubators, similar to those used for hatching chicks, were devised in the late nineteenth century. in the united states, these were shown at commercial exhibitions, complete with babies inside, until 1931. dr a. robert bauer md at henry ford hospital in detroit, mi, successfully combined oxygen, heat, humidity, ease of accessibility, and ease of nursing care in 1931. it was not until after the second world war that special-care baby units (scbus, pronounced scaboo) were established in many hospitals. in britain, early scbus opened in birmingham and bristol, the latter set up with only £100. at southmead hospital, bristol, initial opposition from obstetricians lessened after quadruplets born there in 1948 were successfully cared for in the new unit. incubators were expensive, so the whole room was often kept warm instead. cross-infection between babies was greatly feared. strict nursing routines involved staff wearing gowns and masks, constant hand-washing and minimal handling of babies. parents were sometimes allowed to watch through the windows of the unit. much was learned about feeding—frequent, tiny feeds seemed best—and breathing. oxygen was given freely until the end of the 1950s, when it was shown that the high concentrations reached inside incubators caused some babies to go blind. monitoring conditions in the incubator, and the baby itself, was to become a major area of research. the 1960s were a time of rapid medical advances, particularly in respiratory support, that were at last making the survival of premature newborn babies a reality. very few babies born before thirty two weeks survived and those who did often had neurological impairments. herbert barrie in london pioneered advances in resuscitation of the newborn. barrie published his seminal paper on the subject in the lancet in 1963. one of the concerns at this time was the worry that using high pressures of oxygen could be damaging to newborn lungs. barrie developed an underwater safety valve in the oxygen circuit. the tubes were originally made of rubber, but these had the potential to cause irritation to sensitive newborn tracheas: barrie switched to plastic. this new endotracheal tube, based on barrie's design, was known as the 'st thomas's tube'. most early units had little equipment, providing only oxygen and warmth, and relied on careful nursing and observation. in later years, further research allowed technology to play a larger role in the decline of infant mortality. the development of pulmonary surfactant, which facilitates the oxygenation and ventilation of underdeveloped lungs, has been the most important development in neonatology to date. increasing technology neonatal intensive-care unit from 1980 by the 1970s, nicus were an established part of hospitals in the developed world. in britain, some early units ran community programmes, sending experienced nurses to help care for premature babies at home. but increasingly technological monitoring and therapy meant special care for babies became hospital-based. by the 1980s, over 90% of births took place in hospital. the emergency dash from home to the nicu with baby in a transport incubator had become a thing of the past, though transport incubators were still needed. specialist equipment and expertise were not available at every hospital, and strong arguments were made for large, centralised nicus. on the downside was the long travelling time for frail babies and for parents. a 1979 study showed that 20% of babies in nicus for up to a week were never visited by either parent. centralised or not, by the 1980s few questioned the role of nicus in saving babies. around 80% of babies born weighing less than 1.5 kg now survived, compared to around 40% in the 1960s. from 1982, pediatricians in britain could train and qualify in the sub-specialty of neonatal medicine. neonatal intensive-care unit in 2009. not only careful nursing but also new techniques and instruments now played a major role. as in adult intensive-care units, the use of monitoring and life-support systems became routine. these needed special modification for small babies, whose bodies were tiny and often immature. adult ventilators, for example, could damage babies' lungs and gentler techniques with smaller pressure changes were devised. the many tubes and sensors used for monitoring the baby's condition, blood sampling and artificial feeding made some babies scarcely visible beneath the technology. furthermore, by 1975, over 18% of newborn babies in britain were being admitted to nicus. some hospitals admitted all babies delivered by caesarian section or under 2500 g in weight. the fact that these babies missed early close contact with their mothers was a growing concern. the 1980s saw questions being raised about the human and economic costs of too much technology, and admission policies gradually became more conservative. changing priorities a new mother holds her premature baby at kapiolani medical center nicu in honolulu, hawaii nicus now concentrate on treating very small, premature, or congenitally ill babies. some of these babies are from higher-order multiple births, but most are still single babies born too early. premature labour, and how to prevent it, remains a perplexing problem for doctors. even though medical advancements allow doctors to save low-birth-weight babies, it is almost invariably better to delay such births. a premature infant weighing 990 grams (35 ounces), intubated and requiring mechanical ventilation in the neonatal intensive-care unit over the last 10 years or so, scbus have become much more 'parent-friendly', encouraging maximum involvement with the babies. routine gowns and masks are gone and parents are encouraged to help with care as much as possible. cuddling and skin-to-skin contact, also known as kangaroo care, are seen as beneficial for all but the frailest (very tiny babies are exhausted by the stimulus of being handled; or larger critically ill infants). less stressful ways of delivering high-technology medicine to tiny patients have been devised: sensors to measure blood oxygen levels through the skin, for example; and ways of reducing the amount of blood taken for tests. some major problems of the nicu have almost disappeared. exchange transfusions, in which all the blood is removed and replaced, are rare now. rhesus incompatibility (a difference in blood groups) between mother and baby is largely preventable, and was the most common cause for exchange transfusion in the past. however, breathing difficulties, intraventricular hemorrhage, necrotizing enterocolitis and infections still claim many infant lives and are the focus of many new and current research projects. the long-term outlook for premature babies saved by nicus has always been a concern. from the early years, it was reported that a higher proportion than normal grew up with disabilities, including cerebral palsy and learning difficulties. now that treatments are available for many of the problems faced by tiny or immature babies in the first weeks of life, long-term follow-up, and minimising long-term disability, are major research areas. besides prematurity and extreme low birth-weight, common diseases cared for in a nicu include perinatal asphyxia, major birth defects, sepsis, neonatal jaundice, and infant respiratory distress syndrome due to immaturity of the lungs. in general, the leading cause of death in nicus is necrotizing enterocolitis. complications of extreme prematurity may