Sixty years of neonatal intensive care: We’ve come a long way, baby!

Posted by Stephani Monhollon on May 31, 2022 7:00:00 AM
9 minute read

As expected in most facets of medicine, neonatal intensive care units (NICUs) have undergone extensive transformations during the last 60 years. What used to be a bright, noisy, hectic environment that primarily excluded families from participating in the care of their babies has become a calm, family-centered unit within a hospital.

Along with numerous environmental changes, various technologies, medications, treatments and best practices have revolutionized today’s NICUs, leading to far better patient outcomes.

In addition, today’s NICUs center around keeping babies and families together from the start and involving parents in the care of their babies. Looking back through history, it’s evident how every advancement in the NICU can profoundly impact these vulnerable babies and their families.

NICUs of the past

Prior to October 1960, when the first NICU in the United States was established at Yale New Haven Hospital in Connecticut, premature and ill newborns received limited hospital care in “special-care baby units.” The units were formed after World War II. Before then, these fragile babies were sent home without medical intervention, many of whom didn’t live to their first birthday.

Several aspects of the early NICUs contradicted today’s best practices. Let’s look at the early NICU years and how far they’ve come with the modern NICU.

Environment

Early on, premature and sick neonates were kept in isolation, with the notion they would contaminate each other. Once it was discovered that the real threat came from healthy adults whose hands weren’t clean, hospitals started keeping babies together in larger rooms. At the same time, it became a requirement for all adults to wash their hands thoroughly before handling newborns, a practice that carries on today.

The large rooms, which eventually became NICUs, were bright with overhead lights, lots of noise and chaos. All the noise and bright lights caused the babies to be overstimulated, resulting in physical reactions, such as excessive crying, low blood-oxygen levels and a drop or increase in heart rate.

“When I started in the 1970s, we had these big open rooms with lots of babies,” said Robert White, M.D., neonatologist and practice medical director at Pediatrix® Neonatology of Indiana and Beacon Children’s Hospital in South Bend. “They were very bright and noisy, and, in retrospect, it was an awful place for a sick little baby. At that time, we had to have bright lights on 24 hours a day to see if babies were pink or blue. That was one of few ways we could tell if they needed more oxygen. And we excluded families almost completely. They could come in for 15 minutes a day and touch the baby, but the idea of having them hold their baby who was critically ill was totally against our better instincts back then.”

Nutrition

Breast milk wasn’t used in NICUs several decades ago. Formula was thought to be better than breast milk because it was believed that breast milk wasn't sterile and didn't have all the nutritional additions that could be added to formula. However, during the latter part of the 1800s and early 1900s, some obstetricians recommended breast milk for at-risk neonates, and if it wasn’t available, they opted for sterile cow’s milk.

Breast milk has been debated for centuries. During the late ‘50s and early ‘60s, the breastfeeding rate was only around 20%. It wasn’t until later in the 20th century that breast milk was deemed the best source of nutrition for all babies, including those in the NICU.

Today, a mother’s breast milk is always encouraged. If it’s not available, donor breast milk is the next best option for NICU babies.

Mother/baby separation

Decades past, premature and ill newborns were separated from their mothers. While the babies were taken to the NICU, the moms stayed on the other side of the hospital in the postpartum unit with all the other mothers who had healthy babies in their rooms. For these mothers, this set the stage for stress, anxiety and depression. For the babies, they were missing the physical contact we recognize today as a vital need.

The modern NICU

Over time, through research and practice, health care professionals and scientists realized that many NICU practices weren’t in the best interest of NICU babies or their families. While improvements will always be sought after, today’s NICUs have come a long way.

Ambiance

With the advent of saturation monitors alerting medical professionals to oxygen levels, it was no longer necessary to have bright lights. Modern NICUs are dimly lit at night with modest light levels during the day, including natural sunlight in some units. Today, instead of a constant barrage of monitor and equipment alarms, most of these alerts are transmitted electronically to the nurses’ personal communication device, similar to a cell phone, eliminating the constant noise pollution in the NICU.

“The saturation monitors and cellphones represent two big changes in technology that allowed us to get the lighting and sound levels more suitable for babies in NICUs,” said Dr. White. “These changes are also beneficial to staff and families. It’s a much more calming environment now.”

The family-friendly NICU

These days, families are welcome in the NICU 24/7. They can stay with their baby and participate in the baby’s care as much as possible, promoting parent/child bonding and keeping families together with their babies.

“We still need to improve at encouraging parents and facilitating direct hands-on care of their baby,” said Dr. White. “For the most part, it involves rocking them, talking to them, reading them a book, singing them a lullaby and such. These are things that come instinctively to parents of healthy, full-term babies. Parents who have premature or ill babies are often afraid to interact with them, so they need our encouragement and assurances that this is an important aspect of their baby’s care that no one can do as well as they can.”

Modern NICUs strive to incorporate parents into the baby’s care to a greater extent. They can give feedings, assist during bath time and change diapers. Some parents are even taught to adjust the baby’s oxygen concentrations. Typically, a nurse will see the monitor go off because the baby’s oxygen is too high or low, then she will have to drop what she’s doing with a different baby and adjust the other baby’s oxygen concentration.

“We use the same criteria to train parents that we use when training our staff,” said Dr. White. “Now, if the oxygen is too high or low, parents can adjust it by 2% to 5% at a time to get the baby’s saturation level where we want it. It takes training and it takes parents who are committed and trustworthy. By involving parents in the care of their baby, they really do feel like team members now instead of only being allowed to do minimal care practices.”

More advanced training is essential because, at some point, parents will take their babies home. For example, if a baby has a tracheostomy for breathing support or requires tube feeding, families can be trained how to properly care for the tracheostomy or effectively tube feed the baby early on, so by the time they take their baby home, they have the necessary skills to care for their baby independent of medical staff.

While providing medical care is imperative, the baby needs extensive physical contact with the parents. When a baby is in the womb, there is constant contact with the mother. The baby hears her voice and feels the security she provides, which is equally vital once the baby is born. Babies thrive when they have ample direct interaction with their parents.

“If we do a good job at making sure parents understand that physical contact is something they can do better than anyone else and that their baby relies on it, we can help them overcome much of the initial reluctance to participate in the baby’s care and physically engage often with the baby,” said Dr. White. “It really is critical to the development, well-being and overall outcomes of the baby.”

Couplet care and single-family rooms

Taking NICU care to another level, some hospitals offer couplet care, where the mother and her baby are cared for together from the onset. Couplet care helps create a stronger mother/baby bond, builds the baby’s immunity and increases success rates for breastfeeding. It also gives families a home-away-from-home experience.

“Our couplet-care rooms enable us to care for moms and their babies together from the beginning, starting the whole message to the family that we want them to be with their baby and we're going to facilitate that for them,” said Dr. White, who has been instrumental in the design of family-centered NICUs. “From there, we have single-family rooms and, operationally, we do everything we can to keep babies and families together. We still have room to improve, but we work hard to keep mothers, fathers and babies together and get them holding the babies as soon as possible, for as long as possible, because we know that's good for the sensory and emotional development of babies.”

Of course, that helps families, too. They now feel like they have something to offer to help their premature or sick baby, whereas otherwise, they may feel helpless. Encouraging them to be a part of their baby's care and life from the start is vital to their development.

On the NICU horizon

Many hospitals across the country don’t offer couplet care or single-family rooms for premature or ill newborns. A significant step toward improving care for these babies is implementing this type of care in all hospitals, benefiting both babies and their families.

“If we can get couplet-care rooms in all NICUs and single-family rooms so parents never have to be separated from their babies, and then facilitate an operational culture that encourages families to be there and help take care of their babies, we’ll be in a much better place,” said Dr. White. “We’re well on the way already, so the completion of those initiatives is what I foresee for the next 10 years. It’s going to take time and require extra effort on everyone’s part to change the mindset of us being the caretakers and families being the visitors, but we’ll get there for the sake of our tiniest babies and their families.”

Additional Resources

Topics: Neonatology, Newborn Nursery, Newborn