The Infant Incubator in The Neonatal Intensive Care Unit: Unresolved Issues and Future Developments
The Infant Incubator in The Neonatal Intensive Care Unit: Unresolved Issues and Future Developments
J. Perinat. Med. 37 (2009) 587598 Copyright by Walter de Gruyter Berlin New York. DOI 10.1515/JPM.2009.109
Review articles
Einführung
Temperature regulation is one of the most important factors affecting survival in the newborn. Premature infants,
as compared to term infants, are at a disadvantage in
temperature maintenance, because of a larger skin surface area to body mass ratio, decreased subcutaneous
fat, and low supplies of brown fat.
Since the first half of the 19th century, devices termed
incubators were developed in order to maintain thermal
stability in preterm infants and sick newborns. The first
provision of warmth in an incubator probably took place
at a Russian hospital in 1835. This incubator consisted
of a double-walled zinc tub with an open top: the space
between the walls was filled with warm water, so an
infant placed in the tub could be kept warm w34, 63x. The
first closed and heated-air incubator was developed by
the French obstetrician Stephane Tarnier, who was
inspired by a visit to the incubator for hatching eggs of
exotic birds at the Paris Zoo w9x. Tarniers first incubator,
which could accommodate four babies, came into regular use in 1881 in the nursery of the Maternite of Port
Royal in Paris. This incubator had a tank of hot water
beneath the mattress that heated the air, and included a
double-glass cover which allowed visual monitoring w42x.
Incubators based on the Tarnier design were shown to
cut mortality by half in infants under 2000 g, but had the
potential to be dangerous due to overwarming. Seven
years later Tarniers pupil, the obstetrician Pierre Budin,
modified the incubator for solving the problem of overwarming. This incubator, designed to house a single
infant, was provided with a monitoring device which activated an electric bell to warn against overwarming w91x.
A more sophisticated incubator, the Lion incubator, was
shown at the Omaha exposition in 1898. This device consisted of a large metal apparatus with glass doors in the
front and hot water circulating through a spiral pipe in the
bottom, warming the air inside. It was equipped with a
thermostat and an independent forced ventilation system, where pipes drew air from the outside, filtering it
before delivering it to the base of the incubator w9, 91x.
In 1931, a new incubator model was introduced at the
Sarah Morris Premature Infant Station in Chicago. It was
equipped with an oxygen tank which was able to administer oxygen in concentrations of 4055% for more than
1 day w91x.
A modern infant incubator is a device with a rigid boxlike enclosure intended to contain a baby and having
Abstract
Since the 19th century, devices termed incubators were
developed to maintain thermal stability in low birth weight
(LBW) and sick newborns, thus improving their chances
of survival. Remarkable progress has been made in the
production of infant incubators, which are currently highly
technological devices. However, they still need to be
improved in many aspects. Regarding the temperature
and humidity control, future incubators should minimize
heat loss from the neonate and eddies around him/her.
An unresolved issue is exposure to high noise levels in
the Neonatal Intensive Care Unit (NICU). Strategies
aimed at modifying the behavior of NICU personnel,
along with structural improvements in incubator design,
are required to reduce noise exposure. Light environment
should be taken into consideration in designing new
models of incubators. In fact, ambient NICU illumination
may cause visual pathway sequelae or possibly retinopathy of prematurity (ROP), while premature exposure to
continuous lighting may adversely affect the rest-activity
patterns of the newborn. Accordingly, both the use of
incubator covers and circadian lighting in the NICU might
attenuate these effects. The impact of electromagnetic
fields (EMFs) on infant health is still unclear. However,
future incubators should be designed to minimize the
EMF exposure of the newborn.
Keywords: Body temperature regulation; electromagnetic fields (EMFs); incubators, infant; infant, newborn;
intensive care units, neonatal; light; noise.
*Corresponding author:
Roberto Antonucci, MD
Neonatal Intensive Care Unit
University of Cagliari
Via Ospedale 119
09124 Cagliari
Italy
Tel.: q39 070 6093438
Fax: q39 070 6093430
E-mail: [email protected]
Methods
A Medline search has been carried out in order to identify the
literature concerning the microenvironment of the infant incubator, and open issues in the development of more comfortable
and safe incubators. The available data were reviewed with special emphasis on clinical aspects.
the proposition that double-wall incubators have a beneficial effect on long-term outcomes including mortality or
the duration of hospitalization w64x.
Newborns, especially VLBW infants, are at increased
risk of heat loss due to large body surface area in relation
to weight, large head in proportion to the body, and little
subcutaneous fat. When heat loss exceeds the neonates
ability to produce heat, its body temperature drops below
the normal range (hypothermia). A neonates primary
response when acutely exposed to a cold environment
includes increased voluntary muscular activity, vasoconstriction, and non-shivering thermogenesis w4x. Vasoconstriction, a first line of defence for newborns, decreases
heat loss by reducing skin blood flow, while the increase
of muscular activity and of non-shivering thermogenesis
results in increased heat production.
The metabolic consequences of cold stress may be
devastating and potentially fatal to the neonate. Oxygen
requirements and glucose use increase, lactic acid is
released into the blood-stream (metabolic acidosis), and
surfactant production decreases. Hypothermia, even if
moderate, is associated with an increased risk of death
in VLBW infants. Prolonged hypothermia may result in
impaired growth and may render the newborn more vulnerable to infections. Therefore, VLBW infants should be
nursed in a stable environment at the optimal ambient
temperature needed to minimize metabolic stress w57x.
This can be achieved by using closed incubators or radiant warmer beds.
In closed incubators, heat supply is assured by convective air flow whereas radiant warmer beds use radiant
power density warming w40, 69x. Radiant warmers generally use skin temperature servocontrol w40x and result
in increased insensible water loss in newborn infants
when compared to convective incubators w40, 46x. In
closed incubators, temperature control is based on the
use of a heating unit (on/off cycling or adjustable
proportional control) that is activated by an error signal
calculated from the difference between a controlled temperature and a reference value preset by the clinician.
The controlling variable can be either the incubator air
temperature or the skin temperature of the anterior
abdominal region of the neonate w40, 69, 94x. Most modern incubators allow the caregivers to choose among air
temperature servocontrol, skin temperature servocontrol,
and manual control.
Under air temperature servocontrol, the air temperature is sensed and used to provide the feedback to the
system to turn on or off according to the set value (thermoneutral temperature). Therefore, the patient is omitted
from the thermal feedback loop. In skin temperature servocontrol, a thermistor probe is attached to the skin,
preferably in the upper abdomen, and the heater cycles
to keep the skin temperature constant at all times.
Deciding on the skin temperature at which the incubator should be servocontrolled is of critical importance.
ration and sudden increase in mean arterial blood pressure), and sleep disturbance w78, 97x.
The NICU noise environment is characterized by continuous background noise and peak noises. Human
behavior factors cause most of the peak noises recorded
in NICU w31x and inside incubators w20, 32x. They include
opening and closing of doors, banging the incubator
hood, staff conversation, nursing activity inside the incubator, tearing and opening paper or bags, opening and
closing trash can lids, and bumping metal carts or other
apparatus w32x, voluntary and involuntary contacts with
the incubators plexiglass surface, or the abrupt opening
and closing of their access ports w20x. Even a careful
incubator manipulation has been found to generate a
strong noise level w88x. On account of its decibel levels
and frequency, the human-related component of noise is
considered an important source of stress to newborns
and it might be reduced by a modification of staff behavior w31, 32, 72x.
Noise levels in NICU seem also to be influenced by
non-human related sources such as ventilators and other
NICU equipments. Surenthiran et al. w97x demonstrated
that noise levels high enough to cause hearing loss could
be transmitted to the inner ear in preterm infants receiving nasal continuous positive airways pressure (nCPAP),
especially when higher flow rates were used. Moreover,
nCPAP drivers have been found to generate a large
amount of noise that is flow-dependent but not devicedependent w61x. In contrast, neonatal high-frequency
ventilators do not provide a major contribution to noise
levels in the NICU w59x.
The spectral analysis of noise in a level III NICU documented that both individual equipments (ventilators,
monitors, phototherapy units, nebulizers, incubators) and
activities (phone ringing, hand dryer, handling of trays,
vacuum cleaning, mother talking) generate unacceptably
high noise levels w71x. The major contributors to higher
sound levels have been shown to be respiratory therapy
equipment, alarms, staff talking and infant fussiness w27x.
Interestingly, different types of neonatal units appear to
be associated with different noise levels. In fact, mean
noise amounts are significantly higher in level III NICUs
than in level II NICUs w68x, whereas a renovated NICU is,
on average, 46 A-weighted decibel (dBA) quieter than a
comparable non-renovated NICU w27x.
Considering the possible consequences of noise exposure on premature infants and caregivers, the American
Academy of Pediatrics has used recommendations for
monitoring sound in the NICU and within incubators, and
maintaining the noise level at or below 45 decibel (dB)
w6x. A number of strategies have been proposed to adjust
NICU sound levels. Simple measures to minimize the
noise in the nursery such as careful closing of incubator
doors and using soft shoes have been recommended w6x.
Moreover, NICUs should incorporate regular noise
assessment, and develop and maintain a program of
Light environment
The majority of NICUs are brightly and continuously lit to
facilitate intensive care. Prolonged exposure to this light
environment may have adverse effects in hospitalized
preterm infants.
Rivkees et al. w85x documented that premature infants
exposed to low-intensity cycled lighting in the hospital
nursery progress more quickly in their rest-activity patterns. To date, the role of the ambient lighting level of the
NICU in the development of retinopathy of prematurity
(ROP) is controversial. As noted by Fielder et al. w45x,
early exposure to ambient NICU illumination is not a factor in the development of ROP, but may be involved in
the development of more subtle visual pathway sequelae. Other studies support the finding that retinal ambient
light exposure in preterm infants does not play a role in
the development of ROP w3, 80, 82, 83, 99x. Moreover,
no effect of light reduction on the incidence of ROP was
found in newborns weighing -1600 g w25x. In contrast,
evidence exists that photoexcitation can result in an
increased production of free radicals in the retina constantly exposed to light w37, 104x that could lead to
developing retinal vessels injury and ROP w39x. Glass et
al. w48x observed a higher ROP incidence in infants
exposed to a brighter nursery light compared with those
exposed to reduced light levels. More recently, other
authors reported a reduced incidence of ROP w104x, or
an improvement in its clinical course w47x in preterm
infants exposed to limited ambient light.
At present, some measures seem to be helpful to minimize adverse effects of the NICU light environment.
Ambient lighting in the patient care area should be indirect without direct light visible to the premature infant.
Furthermore, the levels of ambient lighting should be
flexible, to allow day-night cycling.
The use of incubator covers, evaluated by HellstromWestas et al. w56x, appears to have some short-term
effects on sleep patterns in stable premature infants, but
the clinical significance and possible long-term effects of
this measure are unknown. In a recent study, several
types of commonly used incubator covers were compared as to efficacy of light reduction. Dark-colored
covers were found to provide greater light reduction than
bright/light-colored covers when covers identical in fabric
type were compared. Additionally, covers provided less
light reduction under conditions of higher ambient light
levels w67x.
In conclusion, available data suggest that exposure
to circadian light and limitation of ambient light may be
beneficial for preterm infants hospitalized in the NICU.
Electromagnetic fields
There are few published data on the EMF exposure of
the baby inside the infant incubator. Cermakova w29x
pointed out a possible association between the extremely
low frequency EMF exposure of the newborn in the incubator and the occurrence of leukemia or other diseases.
On the other hand, the study by Soderberg et al. w95x
provided little evidence that exposure to EMFs inside the
infant incubators was associated with an increased risk
of childhood leukemia. Furthermore, the effects of light
and EMFs on pineal function might implicate long-term
risk of breast cancer, reproductive irregularities, or depression w26x.
In a recent study, EMFs produced by incubators were
found to alter heart rate variability of newborns by influencing their autonomous system w17x.
In modern incubators with a plastic supporting frame,
the extremely low frequency EMFs have been found to
be more than two orders lower than the European Union
reference values. However, considering that the European reference values are intended for the adult human
population, the newborn kept in incubator should receive
a special care, on account of his/her much smaller
dimensions and higher electric conductivity w29x. Moreover, the use of ferromagnetic panels has been shown to
significantly reduce the EMF to which neonates and caregivers are exposed w18x. Aasen et al. w1x registered and
mapped magnetic flux density (MFD) in and around incubators of a neonatal intensive care unit. The field levels
varied depending on the type of equipment, the positioning of the electronics and the position of the 240-volt
main plugs. The positioning of the infant in the incubator
affected MFD to a great extent, as did the positioning of
the electronic monitoring and treatment equipment. A
reduction of the magnetic field levels was achieved by
reducing the field from the incubators but also by changing the electronic equipment around the incubators or
increasing the distance to the incubator. Riminesi et al.
w84x described MFD distribution in a NICU and MFD
values inside the incubators. Higher MFD values
were detected close to medical equipment, while MFD
decreased with increasing distance. Measured values
were reduced to background (i.e., general environment)
levels 2030 cm away from the sources. Field levels
inside incubators were shown to depend on the position
of the electronic control system, of the heating power
generator and its winding conductor, and of the 220 V
main plug.
In conclusion, it is difficult to say whether the magnetic
field levels inside incubators may have a detrimental
impact on infants. However, a prudent avoidance strategy should be adopted, mainly through redesign of the
various incubator components.
Transport incubators
During transport, the thermal control of the neonate
becomes very difficult due to the less controlled environment, cold weather, high winds, high altitude, travel over
a long period of time, and less efficient equipment. Transport incubators are designed to transfer neonates within
a hospital or to another facility. These devices are generally less sophisticated than nursing incubators and
most are not furnished with a means of controlling
humidification level within the enclosure. Transport incubators are smaller and lighter than stationary incubators
in order to facilitate their maneuvering both in and out of
emergency vehicles, and must ensure the protection of
the neonate physically and from elements such as cold.
Furthermore, transport incubators may be operated on
different power sources (e.g., 220 VAC, 12 VDC, and 24
VDC) and usually carry their own backup power supplies.
Strength requirements for ground and air travel, an adequate insulation from external noise and vibration, and
limited electromagnetic emissions are needed to allow
this type of incubator to be used on aircrafts.
and frequent noxious interventions may negatively influence the development of the neonatal brain. Therefore,
a wider approach toward the care of preterm infants in
NICU, whereby a range of medical and nursing interventions is used to decrease the neonates stress (developmental care), should be considered w98x. These
interventions may include the control of noxious stimuli
(auditory, vestibular, visual, tactile, etc), the clustering of
nursery care activities, and swaddling or positioning the
baby.
The advent of Neonatal Individualized Developmental
Care and Assessment Program (NIDCAP) has led to a
greater emphasis on developmental care for high-risk
neonates and their families to improve neuro-developmental outcomes. In fact, growth and development were
enhanced by providing infants and their families with
family-centered, developmentally supportive care w5x.
Practical considerations
The basic technical specifications of a modern convectionwarmed infant incubator are listed below:
computer-assisted temperature control circuit of the
proportional type;
electronic regulation of temperature to determine
thermostatically the air temperature within the baby
chamber (air temperature control mode), or the
infants skin temperature (skin temperature servocontrol mode);
forced air circulation system with renewal of microfiltered air, designed to minimize the infants heat loss;
humidity control system that automatically controls
humidification to a preselected setting to precisely
maintain the relative humidity in the incubator at a
constant level, within the range of 3095%;
visual and auditory alarms for: air temperature, air
overtemperature (398C), sensor fault, air circulation
fault, electronic circuit fault, line power failure, and
empty water supply;
double wall canopy, with hand ports and access
doors to allow medical or nursing procedures;
adequate thermal properties of mattress and incubator walls;
biocompatible materials;
low internal noise level (below the 60 dBA limit during
normal operation);
attenuation of environmental noise and noisy incubator reverberating effects;
low level of EMFs at extremely low frequencies within
the incubator baby compartment;
oxygen connector which allows delivering supplemental oxygen to the baby, if necessary;
integrated infant scale, designed for fast, and accurate baby weighing in a warm environment with minimal disturbance.
Moreover, the procedures for cleaning and disinfection
of all parts of the device should be as simple as possible,
and incubator maintenance service and spare parts
should be locally available.
A correct management of infant incubators is essential
to maximize their benefits while minimizing their hazards,
since the care environment needs to be individually
tailored on the basis of clinical conditions, maturity at
birth and postnatal age of the neonate. From a practical
standpoint, some of the central issues are briefly discussed below.
First of all, the babys temperature and the air temperature inside the incubator should be strictly monitored.
Skin temperature servocontrol has now become the
standard of care for regulating incubator heating in many
nurseries. Generally, a set point of 36.58C abdominal
skin temperature is appropriate to maintain the temperature of the baby within the normal range.
Ambient relative humidity plays a critical role in the
temperature regulation and water balance of neonates,
particularly of very preterm infants. To prevent or minimize excessive evaporative heat loss and dehydration in
very preterm infants, elevated levels of relative humidity
(80%90%) within the canopy of the incubator are
required during the first 24 weeks of life.
Another relevant issue in the incubator management
concerns the modes of access to the neonate. Staff
should handle the neonate through specially designed
hand ports, and avoid opening the main lid or canopy of
the incubator as far as possible to prevent much of the
warm air from escaping and the baby from being
exposed to cold. When the incubator is opened for procedures, a portable overhead warmer with temperature
probe should be used in order to prevent hypothermia.
The environment in which the incubator is placed is
also very important. The NICU should be designed to
provide an air temperature of 22268C and a relative
humidity of 3060%. In a cold room, heat is radiated
from the surface of the baby to cold surfaces such as
windows and walls. Under these conditions, radiant heat
loss may exceed heat generated by the incubator, so
dressing the newborn or placing a plastic shield over
him/her may be helpful to minimize this mode of heat
loss. On the contrary, exposing the incubator to direct
sunlight or phototherapy lights can result in dangerous
overheating of the baby.
Finally, incubators should be cleaned and disinfected
regularly, in particular after each infant is discharged and
before being used again, or whenever the baby is cared
for in an incubator for more than 7 days. Special attention
should be given to the cleaning of the water reservoir,
Unresolved issues
Possible solutions
Temperature control
Light environment
Electromagnetic fields
Conclusions
Since the 19th century, remarkable progress has been
made in the design and production of infant incubators,
contributing to reduce the neonatal morbidity and
mortality. Modern incubators are highly technological
devices, nevertheless a number of issues in the development of an ideal infant incubator remain unresolved
(Table 1). In particular, future incubators should provide a
more comfortable and safe microenvironment for the
newborn by improving temperature and humidity control
and reducing his/her exposure to noise, light, and EMFs.
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The authors stated that there are no conflicts of interest regarding the publication of this article.