The Best NICUs Have These 5 Things

Before she starts to break down what parents with sick newborns should look for in a neonatal intensive care unit (NICU), neonatologist Rachel Chapman, MD, says she first needs one key piece of information.

“It depends on why you need a NICU,” she says—meaning, how serious is your baby’s condition?

Dr. Chapman is Medical Director of the Steven & Alexandra Cohen Foundation Newborn and Infant Critical Care Unit (NICCU) at Children’s Hospital Los Angeles. As a Level IV unit, the NICCU provides the highest quality of neonatal care available. The American Academy of Pediatrics (AAP) grades neonatal intensive care units from Level I to Level IV, according to the depth of services and expertise they offer. The more serious a child’s case, the higher level of NICU needed.

“If you have a typical pregnancy, you just want to make sure the hospital where you deliver has a NICU—just in case,” says Dr. Chapman. On the opposite end, a baby that was identified in utero as high risk or diagnosed with serious birth defects will require a team capable of treating it.

“Choosing a NICU is very relevant to families who have a fetal diagnosis. You’ll want a NICU that has all the services you might need.”

To help parents determine if their baby is in the right place, Dr. Chapman names the five features found at the best NICUs.

1) All the subspecialties. The most common reason babies require a stay in a NICU is prematurity: They were born early and need to be monitored as they develop. For micro-preemies (born earlier than 26 weeks) or babies who need critical medical attention, having access to pediatric subspecialists and an around-the-clock neonatologist can be reassuring.

“If you have a 32-weeker without complications, a community NICU should meet your needs and allow your baby to remain closer to home,” Dr. Chapman says. “This can facilitate breastfeeding and parent involvement in supporting growth and development.”

But if the baby has a particular birth defect or a complex condition—or perhaps several of them, as preemies often have—families need access to a whole slate of experts that only a Level IV unit can provide.

“In that case your baby will likely benefit from a NICU that has the full complement of subspecialists and nurses trained for this level of complex pediatric care. A community NICU will not have access to pediatric hematologists, cardiac surgeons, neurosurgeons, interventional radiologists—and also pediatric-trained anesthesiologists.”

At CHLA, specialization goes yet another layer deep, as a feature of the hospital’s neonatal care is the Small Baby Unit, a portion of the NICCU devoted to treating high-risk preemies. There are also teams dedicated for infants who are struggling with complex medical disorders, such as chronic lung disease or cardiac abnormalities.

2) Multipurpose patient rooms. “When I started training 25 years ago, most NICUs were a large room with small spaces for individual patients,” Dr. Chapman says. “There was like a horse-barn stall for each baby. Very little space for families.”

Characteristic of many Level IV units, CHLA’s NICCU offers private or semi-private rooms, each outfitted with a couch that converts to a bed to assist parents staying overnight and to enable them to stay involved. “We've had parents who stay every night for three or four months until their baby goes home,” Dr. Chapman says.

Plus, in an emergency, the bigger space can transform into an operating room without having to transport the tiny patient.

“We can do surgery in any patient room. For example, if we have a preemie who comes in with a bowel perforation, the whole OR team comes right to the baby and does the surgery right there. We don't want to be moving a 1-pound baby down to the operating room whenever possible, to avoid exposure to cold as well as potential instability during transport.”

We can do surgery in any patient room. ... We don't want to be moving a 1-pound baby down to the operating room whenever possible, to avoid exposure to cold as well as potential instability during transport.

Rachel Chapman, MD

Dr. Chapman says the patient rooms now have the size to accommodate multiple treatments and machines. “We sometimes have babies who are not just on ECMO but also on continuous dialysis and a ventilator and may require frequent procedures. The footprint you need to be able to do all of that in the room is large.”

3) The latest and greatest technologies. The best NICUs will employ the most advanced technologies. According to Dr. Chapman, that includes the following:

• A cardiac catheterization lab to allow for interventional procedures
• Extracorporeal membrane oxygenation (ECMO) machines, which circulate blood through the baby’s heart and lungs when those organs are too weak to function on their own
• Equipment to perform therapeutic hypothermia, a cooling treatment for babies born with hypoxic-ischemic encephalopathy—an injury that occurs when the brain doesn’t get enough oxygen or blood flow

“Another big one,” Dr. Chapman says, “is having all the modalities of dialysis, which many Level III NICUs and all Level IVs will have. All of the different types of ventilators, too. And the same goes for inhaled nitric oxide, which is a gas that's used for babies who have high blood pressure in the lungs. Some Level IIIs have that, but all Level IVs will have access to it.”

4) Access to continuing care. An additional advantage of being at a Level IV facility is that, once their baby is discharged, a family can continue to receive care from the same specialists who provided treatment in the NICU.

“You're not going to need to go somewhere else,” Dr. Chapman says. “If your baby has a heart problem, you're going to come back to CHLA to see the cardiologist. Same thing if the baby has chronic lung disease—you're going to come back here.”

She adds that CHLA has a Newborn Follow-up Program for high-risk babies who are either premature or have other significant complications. “We can follow patients until they're 3 years old. We can assess their growth and development and access additional services as needed. That’s another plus—you're not starting over.”

5) Psychosocial support. Dr. Chapman says that the best NICUs offer psychosocial care for families to help them through the acute stress of having a newborn in the hospital for an extended time. “Psychologists, social workers, a chaplain—all of those things that you don't think you're going to need but are really critical in supporting families.”

She cites CHLA as an example. “We have an infant-family mental health program focused on supporting parents—and also supporting the developing relationship between the parent and child. When you have a really sick baby, how do you bond with your baby and how do you develop attachment?”

The support runs beyond professional counseling, Dr. Chapman says. “We also have parent support groups run by our social workers or our psychologists, or even our art and music therapy teams. The sicker the baby, the more support the families need.”

“We have families who stay for several months. Having these resources reduces the level of stress and anxiety and the feeling of falling apart. It's a good thing.”