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). 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.
Stephane Tarnier is generally considered to be the father of the incubator (or
isolette as it is now known), having developed it in 1880 to attempt to keep premature infants in a Paris maternity ward warm. Budin is known as the father of modern
perinatology, and his seminal work
The Nursling ( in French) became the first major publication to deal with the care of the neonate. The incubator was improved in 1890 in Marseilles by Alexandre Lion, who founded in 1891 the Œuvre Maternelle des Couveuses d'Enfants in Nice and in January 1896 in Paris. Another factor that contributed to the development of modern neonatology was
Martin Couney and his permanent installment of premature babies in incubators at
Coney Island. A more controversial figure, he studied under 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.
Early years 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. A. Robert Bauer, at
Henry Ford Hospital in Detroit, Michigan, 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 'scaboos') 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 irritate sensitive newborn tracheas: Barrie switched to plastic. This new
endotracheal tube, based on Barrie's design, was known as the "St Thomas's tube". In 1964, pediatric radiologist
William Northway – while conversing with neonatologist
Philip Sunshine at Stanford University Medical Center – noted a consistent pattern of cystic changes in the lungs on the
radiographs of premature babies. Northway found that all of the babies had received high concentrations of oxygen and mechanical ventilation,
causing damage. His 1967 paper in which the term
bronchopulmonary dysplasia was coined described the disease and
comorbidities. This led to worldwide reductions in supplemental oxygen levels and ventilation pressure, improving the health outcomes of premature infants. The paper has been called "one of the most important, most cited, and influential articles in the history of
neonatology". 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 By the 1970s, NICUs were an established part of hospitals in the developed world. In Britain, some early units ran community programs, 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 hospitals. The emergency dash from home to the NICU with the 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, centralized NICUs. On the downside was the long traveling time for frail babies and 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. 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 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. weighing , 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 extremely 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 include
intracranial hemorrhage, chronic
bronchopulmonary dysplasia (and
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. 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 , usually about 30 weeks gestation, rarely survived. Today, infants of at 26 weeks have a fair chance of survival. , the world record for the lowest gestational age newborn to survive is held by Curtis Zy-Keith Means, who was born on July 5, 2020, in the United States, at 21 weeks and 1 day gestational age, weighing . 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. 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. An 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 includes information on the different types of equipment used in the NICU, such as incubators, monitors, and ventilators, and how they help to support babies' health and well-being. Parental orientation to the NICU helps reduce parental anxiety and improve satisfaction with care. Effective communication between health care providers and parents in the NICU is critical for promoting parental involvement and reducing stress. Parents are given information on who their primary point of contact is and how they can communicate with the medical staff caring for their baby. 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 ==