What to expect if your baby is in the NICU

What is the NICU?

The neonatal intensive care unit (NICU) is a specialized nursery that has all the latest health equipment, plus a well-trained staff to care for the tiniest and sickest of newborns.

The doctors and nurses in the NICU have had extensive training, and work with the very latest technology to care for babies. Babies who were born preterm, before 37 weeks, or at a low weight (less than 5.5 pounds) make up the majority of infants in the NICU, but not all fall into these categories. Others who might need a stay in the NICU include newborns with jaundice, breathing difficulties, heart issues, birth defects, or infections.

NICU vs. PICU: What's the difference?

The NICU is the intensive care unit for neonates or infants less than 28 days old who require the most specialized care. Typically, infants in the NICU have been born prematurely, at a low weight, or with health complications, such as an infection, heart problem or birth defect.

The PICU or pediatric intensive care unit, on the other hand, is the same type of hospital section but is reserved for babies, toddlers, children, and teens up to 17 years, though some NICUs can accommodate children up to age 21. Children who need intensive treatment and constant monitoring are sent to the PICU, especially those who've had major surgery, a heart condition, a serious infection, or breathing difficulty.

Are there different levels of NICU care?

Within a hospital there are several levels of newborn care, depending on the type of treatment your baby needs and the facility you're in. The various levels may be on different floors or different sections of the general NICU area.

In some cases, your baby may need to wait at one level until there's room in another (or at different location) with a higher care level. It's also possible to start at one level and move to another level (either up or down, depending on how your baby is doing).

Here's a look:

• Level I, Well Newborn: This section cares for stable babies between 35 to 40 weeks of age who can breathe on their own and maintain their own body temperature.
• Level II, Special Care: Babies born at or after 32 weeks and weigh more than 3.3 pounds stay here as well as those who need a device to help them breathe (though after a day if they still require respiratory care they'll likely move up to the NICU level).
• Level III, NICU: Infants younger than 32 weeks, weighing less than 3.3 pounds, those who are critically ill, need surgery, or equipment to breathe are at this level.
• Level IV, Regional NICU: This is a more specialized location that provides the highest level of care for the sickest of babies who often need surgery or treatment for birth defects and other health conditions.

What does the NICU look like?

The NICU can seem a bit overwhelming at first, as the room has lots of machines – some of them beeping – and it's usually bright and bustling with staff. Your baby's condition determines what level of the NICU they'll be placed in, and different areas look slightly different to accommodate the different needs of the babies.

You'll notice that some babies rest inside incubators, which are small heated beds covered with clear hard plastic and arm holes on the sides that allow you to reach in. Infants in incubators need an environment free of germs, excess noise and light, and a place with a stable temperature level (if they're not able to regulate their own temperature). A phototherapy device may also be attached to the incubator to treat jaundice.

Some babies may lie in infant warmers that keep them toasty but are also open on top. And other babies, who are able to regulate their own body temperature and breath on their own, will stay in small cribs.

All babies will have various monitors that detect apnea and measure blood pressure as well as tubes and IV lines to administer food, oxygen, blood, fluids, and certain medications. You can always ask the NICU nurses if you're not sure what something is.

Depending on your baby's condition, your baby may have their own little section with a curtain that can be pulled closed while you're visiting or nursing them. Or, if they require extra care or monitoring in a higher-level section, their incubator may be placed closer to other babies so the nurses can monitor them more closely.

In most all NICUs, there are sink and bath areas for visitors to wash their hands, and also for nurses and parents to give their babies baths. And there is also usually a nurse’s area where the NICU nursing staff has computers monitoring each baby.

Common conditions treated in the NICU

If your baby requires a NICU stay, it may be due to one or more of several reasons. Here are some of the most common conditions treated in the NICU:

• Breathing trouble. Whether full term or premature, a ventilator or medication or both can help your baby breathe better or more regularly, as with apnea (breathing stoppage).
• Pneumonia. Preemies and other sick infants may have this lung infection.
• Respiratory distress syndrome (RDS). This condition is treated with surfactant or a C-PAP machine (continuous positive airway pressure) to keep the small air sacs in the lungs open for better breathing.
• Bacterial infections. Certain bacteria such as E.coli can lead to neonatal sepsis, and will require antibiotics.
• Heart conditions. Various defects and heart ailments related to respiration, blood flow, and blockages are also treated here.
• Feeding issues. Babies too small or weak to suckle may need food through a vein or via a tube in the nose or mouth.
• Jaundice. Phototherapy in the NICU treats this condition, which is signaled by a yellow tint to the skin and whites of the eyes. It means the liver is too immature to break down bilirubin, a waste product in the blood.
• Multiples. Twins and triplets (and higher multiples) are often in the NICU since they tend to be born sooner and smaller than their singleton cousins.
• Growth conditions. These include being too small for gestational age (intrauterine growth restriction) or too large (macrosomia) or having low birthweight.
• Difficulty keeping warm. Premature or too-small babies don't have the body fat necessary to control their own temperatures.
• Intestinal problems. The most common one is called necrotizing enterocolitis (NEC) and entails bowel damage that can affect feeding.
• Eye conditions. Retinopathy of prematurity or ROP can develop in babies born earlier than 30 weeks, causing bleeding and scarring that may damage the retina.

What to expect if your baby is in the NICU

Every baby is different, which means your infant might not require as many or the same interventions as other babies in the NICU. But it's a good idea to read up on the process since up to 15 percent of babies born in the U.S. need NICU care.

You may know prior to delivery that your baby will be in the NICU, or there may be an unexpected complication during birth. Either way, here are the ins and outs of the NICU in case your baby needs to spend some time there.

Your baby is likely to be on a schedule

Even though your baby was just born, the nurses in the NICU will likely have a feeding, napping and visitation schedule in mind so your little one gets enough rest and the amount of nutrition taken in can be tracked carefully.

You can jump in to participate in the schedule, from offering bottles of formula, pumping breastmilk for future use, singing songs, and talking to and holding your newborn, especially via kangaroo care (skin to skin contact) if they're well enough for it.

You can visit your baby in the NICU

In a lot of cases, parents may visit their baby at almost any time in the NICU. But strict health protocols are required, which means washing hands and sometimes wearing protective gear like gowns, gloves, a mask or face shield.

Other family members may visit to, though you can probably expect a cap on the number of people at one time. And know that siblings (or anyone who's feeling under the weather) need to be monitored for illness and even stay home so that germs don't make their way into the NICU.

There is a NICU team to help your baby

Many different specialists and staff work in the NICU and they all play different roles in providing your baby with the care they need. You might receive a direct phone number to the NICU nurse's line so you can check on your baby at any time. You may also receive calls from any of the following providers too, as many of them do regular check-ins with your baby. Feel free to ask them any questions you have, either in person or on the phone.

• Neonatologists and newborn hospitalists. These providers are the main pediatricians in charge, and have specialized training in premature and sick babies. A neonatal fellow may also join this doctor to run tests, and pediatric residents may also step in to learn and help out with your baby's care.
• Neonatal nurse. A registered nurse with specialized training caring for NICU newborns. These nurses staff the NICU around the clock and provide the bulk of your babies' care.
• Various therapists. These folks help with things like respiratory issues and feeding, helping your baby learn to eat by mouth. A dietitian may also monitor your baby's growth and nutrition.
• Lactation consultant. This person can help you learn to pump, feed your baby, and maintain a healthy milk supply.
• Social worker. This staffer can support you emotionally as well as practically with such tasks as arranging home health care, transportation and financial issues. 

You will discuss a feeding plan with your baby's doctors

Parents with babies in the NICU can play a role when it comes to feeding. Some babies, particularly those who are premature or sick, won't be able to breastfeed or take a bottle right away (they'll be fed via a feeding tube).

But when your baby is strong enough, you can take turns offering bottles of formula. Or if you plan to pump and breastfeed, let the NICU staff know this so you can store your milk and then bring it in for you baby, either through the feeding tube or in bottles when your baby is physically ready.

If you're unable to breastfeed or pump, many NICUs work with Milk Banks, or organizations that screen and pasteurize donor breast milk for babies to use. Your lactation consultant or NICU nurse can walk you through the process if you're interested in using donated milk from a Milk Bank for your baby.

They may have regular testing done

Many NICU babies undergo regular testing to check their health during their stay in the NICU. You'll be asked to give permission for each and you can ask any questions you have about the testing your physician is planning. Here are some that your baby may have regularly:

• Blood draws. These common tests check for anemia and other newborn conditions.
• CAT scan. A CAT scan is like an X-ray, but it uses 3D technology. Other X-rays may also be given to view your baby's lungs and organs.
• Ultrasounds. These are often used to check for bleeding in the brain, though this same type of test (echocardiogram) can also view the heart to find defects.
• EKG and MRI. An electrocardiogram (EKG) records the heart's activity (beats, rhythm). MRI or magnetic resonance imaging offers a more detailed look at the body.
• Hearing and eye exams. Your baby may wear tiny earphones for a hearing test and an eye doctor may check the retinas to be sure they're developing correctly.
• Urine test. Good kidney function is the goal with this diagnostic.
• Weight check. Most NICU babies have daily weigh-ins to note gains.

How long will your baby be in the NICU?

The length of your baby's NICU stay usually depends on their weight and size and the other reasons they were sent to the NICU. According to one study of special care nursery admissions, the average time in the NICU for infants was about 13 days. But for those babies born at 39 to 41 weeks, the hospital time clocked in at just 5 days, while the tiniest of babes, less than 32 weeks of age, were there much longer – up to 46 days.

Your newborn can typically be discharged from the NICU when they've reached a number of milestones – and you can use the acronym A.F.T.E.R. to help you remember them (see the following).

Before heading home, hospitals offer parents a discharge class that covers how to use any equipment (including the infant car seat) your baby may need at home. The car seat in particular can be tricky so it's a good idea to have your installation checked by a professional. The discharge class also explains your baby's post-NICU medical care, basic baby care, safe sleep advice, and any follow-up appointments they may need.

Antibiotics. When it's safe, your baby's doctor will discontinue or stop antibiotics prior to discharge.

Feeding. Babies must be off the nasal or oral feeding tube, have mastered how to suck and swallow at the breast or bottle, and have normal blood sugar levels and continued weight gain. (Some babies may still go home with a gastric tube, however, which will be placed in your baby's stomach).

Temperature. Leaving the warm incubator is another milestone. Your infant will need to make the transition to a crib and exhibit a normal body temperature for at least a day before they're able to head home.

Events. These refer to apnea and bradycardic episodes which occur when the heart rate dips under 100 beats per minute. Babies leaving the NICU must show no evidence of these events, including in the car seat – being able to sit in this piece of equipment for an hour and a half is another milestone.

Respiratory. Breathing well, without the aid of a ventilator, is also critical for discharge. If your infant still has a tracheostomy tube at discharge time to aid breathing, you'll be trained on its use and cleaning method. Parents are also required to take an infant CPR class if their baby is still on an apnea monitor at home (it's a good idea for grandparents and caregivers to take it too).

Advocating for your baby in the NICU

As a parent, remember that you can step in at any time and ask questions or advocate for your infant while they're in the NICU. You can always ask questions or seek a second opinion about your baby's level of care, equipment in the NICU, tests being run, and any diagnosis you don't understand.

Be sure the medical team knows your own wishes regarding breastfeeding, offering pumped milk, and anything else you'd like them to know about your baby's care. At the same time, it's important to give the medical staff the space they need to work and run tests while you do your best to take care of yourself. Strive to eat well, rest and relax (as much as you can) since a healthy parent is the best advocate for a NICU baby.

How to cope with the emotional stress of being a NICU parent

Having your baby admitted to the NICU can be worrisome – and it's normal to experience a wide range of feelings, from guilt and fear to anxiety and sadness. To help you deal with the emotional stress that can accompany having a child in the hospital, try the following:

• Express yourself. Share your feelings with the NICU staff, your partner, family and friends so they understand your mindset. If you bottle things up inside, it's hard for others to know what you need and support you. Of course, this may take some time, so do what feels right for you.
• Make connections. Online forums abound as do local meet-ups and other support groups who understand what you're going through and may have advice to give. The BabyCenter Community also has various groups and forums on preemie parenting that you may find helpful. 
• Take care of you. Try not to skip meals or skimp on your sleep. Do all you can to follow your normal routine in and around your visits to the NICU. Be sure to pause for fun too, like going to the movies, taking a yoga class or soaking in a warm bath.
• Get help. If you have other children who need care, reach out to family and friends. Your support system can also fill in gaps with housework, cooking and running errands so you can spend more time with your infant. Or ask others to visit the NICU in your place.
• See a professional. If you're feeling overwhelmed and you're not sure where to turn, ask for a referral to a therapist or counselor who can listen and advise you.

What can I expect once we get home from the NICU?

Once you're home from the NICU you'll have a series of follow-up appointments on your schedule with your baby's pediatrician and other therapists as needed. And if your newborn needs further help, based on any apparent delays, these will be set up with the help of an early intervention program.

In most states, any NICU baby is eligible for an evaluation to begin specialized therapies related to feeding, motor skills or speech and language milestones.

Most babies today won't need to go home with an apnea monitor or extra oxygen, but if yours does you'll be taught how to use this equipment.

Bringing your baby home from the NICU can be exciting, but also nerve wracking if they will need certain monitoring related to breathing or heart problems, or other special care at home, such as extra feedings. Remember, your team of providers is always there to answer any questions. It's also a good idea to have a spouse, family member, or friend home with you to help in the first few days, if possible.