Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Perspective
  • Published:

Do small baby units improve extremely premature infant outcomes?

Journal of Perinatology volume 42, pages 281–285 (2022)Cite this article

Subjects

Abstract

Increasing numbers of neonatal intensive care units have formed small baby units or small baby teams with the intention to optimize care of extremely premature infants. Considerable time, energy, and resources are required to develop and sustain complex quality improvement constructs, so legitimate questions about effectiveness, unintended consequences, and lost opportunity costs warrant scrutiny. The small baby unit literature is diminutive. Errors of chance, bias, and confounding secondary to insufficient definitions of process and outcome metrics, overlapping quality improvement projects, and limited cost analyses restrict firm conclusions. Well-established quality improvement methodologies such as evidence-based guidelines, standardized variability reduction using measurement-and-adjust techniques, family-integrated focus, and developmentally sensitive care, reliably improve outcomes for all-sized premature infants. There is not compelling published evidence that adding specialized small baby units or designated teams for extremely premature infants further enhances short- or long-term health if robust quality improvement fundamentals are already imbedded within local culture.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Fig. 1: Pyramid of quality improvement constructs and strategies related to the care of extremely premature infants.

Similar content being viewed by others

References

  1. Morris M, Cleary JP, Soliman A. Small baby unit improves quality and outcomes in extremely low birthweight infants. Pediatrics. 2015;136:e1007–e1014.

    Article  Google Scholar 

  2. Nankervis CA, Martin EM, Crane ML, Samson KS, Welty SE, Nelin LD. Implementation of a multidisciplinary guideline-driven approach to the care of the extremely premature infant improved hospital outcomes. Acta Paediatr. 2010;99:188–93.

    CAS  PubMed  Google Scholar 

  3. Lester BM, Salisbury AL, Hawes K, Dansereau LM, Bigsby R, Laptook A, et al. 18-month follow-up of infants cared for in a single-family room neonatal intensive care unit. J Pediatr. 2016;177:84–89.

    Article  Google Scholar 

  4. Vohr B, McGowan E, McKinley L, Tucker R, Keszler L, Alksninis B. Differential effects of the single-family room neonatal intensive care unit on 18-to-24 month Bayley scores of preterm infants. J Pediatr. 2017;185:42–8.

    Article  Google Scholar 

  5. O”Brien K, Robson K, Bracht M, Cruz M, Lui K, Alvaro R, et al. Effectiveness of family integrated care units on infant and parent outcomes: a multicentre, multinational, cluster-randomised controlled trial. Lancet Child Adol Health. 2018;2:245–54.

    Article  Google Scholar 

  6. O’Callaghan N, Dee A, Philip RK. Evidence-based design for neonatal units: a systematic review. Matern Health Neon Perinat. 2019;5:6 https://doi.org/10.1186/s40748-019-0101-0

    Article  Google Scholar 

  7. Erdei C, Inder TE, Dodrill P, Woodward LJ. The growth and development unit: a proposed approach for enhancing infant neurodevelopment and family-centered care in the neonatal intensive care unit. J Perinatol. 2019;39:1684–7.

    Article  Google Scholar 

  8. van Veenendaal NR, Heideman WH, Limpens J, van der Lee JH, van Goudoever JB, van Kempen AA, et al. Hospitalising preterm infants in single family rooms versus open bay units: a systematic review and meta-analysis. Lancet Child Adol Health. 2019;3:147–57.

    Article  Google Scholar 

  9. van Veenendaal NR, van Kempen AA, Franck LS, O’Brien K, Limpens J, van der Lee JH, et al. Hospitalising preterm infants in single family rooms versus open bay units: a systematic review and meta-analysis of impact on parents. E Clin Med. 2020;23:100388.

    Google Scholar 

  10. White RD. Recommended standards for newborn ICU design, 9th edition. J Perinatol. 2020;40:2–4.

    Article  Google Scholar 

  11. Lehtonen L, Lee SK, Kusuda S, Lui K, Norman M, Bassler D, et al. Family rooms in neonatal intensive care units and neonatal outcomes: an international survey and linked cohort study. J Pediatr. 2020;226:112–7.

    Article  Google Scholar 

  12. Hei M, Gao X, Li Y, Gao X, Li Z, Xia S, et al. Family integrated care for preterm infants in China: a cluster randomized controlled trial. J Pediatr. 2021;228:36–43.

    Article  Google Scholar 

  13. Kaempf JW, Morris M, Austin J, Steffen E, Wang L, Dunn M. Sustained quality improvement collaboration and composite morbidity reduction in extremely low gestational age newborns. Acta Paediatr. 2019. https://doi.org/10.1111/apa.14895

    Article  PubMed  Google Scholar 

  14. Kaempf J, Morris M, Steffen E, Wang L, Dunn M. Continued improvement in morbidity reduction in extremely premature infants. Arch Dis Child FNN. 2020. https://doi.org/10.1136/archdischild-2020-319961

    Article  Google Scholar 

  15. Soghier L, Short BL. The secret sauce: secrets of high performing neonatal intensive care units. Arch Dis Child FNN. 2018. https://doi.org/10.1136/archdischild-2018-314844

    Article  Google Scholar 

  16. Kaempf JW, Wang L, Dunn M. Using a composite morbidity score and cultural survey to explore characteristics of high proficiency neonatal intensive care units. Arch Dis Child FNN. 2018. https://doi.org/10.1136/archdischild-2017-313715

    Article  Google Scholar 

  17. Zeitlin J, Manktelow BN, Piedvache A, Cuttini M, Boyle E, van Heijst A, et al. Use of evidence based practices to improve survival without severe morbidity for very preterm infants: results from the EPICE population based cohort. BMJ. 2016;354:i2976.

    Article  Google Scholar 

  18. Horbar JD, Edwards EM, Greenberg LT, Morrow KA, Soll RF, Buus-Frank ME, et al. Variation in performance of neonatal intensive care units in the United States. JAMA Peds. 2017. https://doi.org/10.1001/jamapediatrics.2016.4396

    Article  Google Scholar 

  19. Lee SK, Shah PS, Singhal N, Aziz K, Synnes A, McMillan D, et al. Association of a quality improvement program with neonatal outcomes in extremely premature infants: a prospective cohort study. CMAJ. 2014;186:E485–E494.

    Article  Google Scholar 

  20. Franck LS, O’Brien K. The evolution of family-centered care: from supporting parent-delivered interventions to a model of family integrated care. Birth Defects Res. 2019. https://doi.org/10.1002/bdr2.1521

    Article  PubMed  Google Scholar 

  21. Burke S. Systematic review of developmental care interventions in the neonatal intensive care unit since 2006. J Child Health Care. 2018;22:269–86.

    Article  Google Scholar 

  22. Griffiths N, Spence K, Loughran-Fowlds A, Westrup B. Individualised developmental care for babies and parents in the NICU: evidence-based best practice guideline recommendations. Ear Hum Dev. 2019. https://doi.org/10.1016/j.earlhumdev.2019.104840

    Article  Google Scholar 

  23. Rizzolo A, Shah PS, Boucorian I, et al. Cumulative effect of evidence-based practices on outcomes of preterm infants born at <29 weeks gestational age. Am J Obstet Gynecol. 2020;222:181.e1–10.

    Article  CAS  Google Scholar 

  24. Twilhaar ES, Wade RM, de Kieviet JF, van Goudoever JB, van Elburg RM, Oosterlaan J. Cognitive outcomes of children born extremely or very preterm since the 1990s and associated risk factors: a meta-analysis and meta-regression. JAMA Peds. 2018. https://doi.org/10.1001/jamapediatrics.2017.5323

    Article  Google Scholar 

  25. Myrhaug HT, Brurberg KG, Hov L, Markestad T. Survival and impairment of extremely premature infants: a meta-analysis. Pediatrics. 2019;143:e20180933.

    Article  Google Scholar 

  26. Lien R. Neurocritical care of premature infants. Biomed J. 2020;43:259–67.

    Article  Google Scholar 

  27. Thurow LC. Learning to say “No”. NEJM. 1984;311:1569–72.

    Article  CAS  Google Scholar 

  28. Chassin MR, Loeb JM. High-reliability health care: getting there from here. Milbank Quart. 2013;91:459–90.

    Article  Google Scholar 

  29. Braithwaite J, Herkes J, Ludlow, Testa L, Lamprell G. Association between organisational and workplace cultures, and patient outcomes: systematic review. BMJ Open. 2017;7:e017708.

    Article  Google Scholar 

  30. Berwick DM. The moral determinants of health. JAMA. 2020;324:225–6.

    Article  Google Scholar 

  31. Berlin I. The proper study of mankind. Farrar, Strauss and Giroux. New York, NY 1998.

  32. Shrank WH, Rogstad TL, Parekh N. Waste in the US health care system estimated costs and potential for savings. JAMA. 2019. https://doi.org/10.1001/jama.2019.13978

    Article  PubMed  PubMed Central  Google Scholar 

  33. Beam AL, Fried I, Palmer N, et al. Estimate of healthcare spending for preterm and low-birthweight infants in a commercially insured population: 2008-2016. J Perinatol. 2020;40:1091–9.

    Article  Google Scholar 

  34. Culbertson L, Dukhovny D, Lapcharoensap W. Examining the relationship between cost and quality of care in the neonatal intensive care unit and beyond. Children. 2020. https://doi.org/10.3390/children7110238

  35. Lu D, Ruan B, Lee M, Yilmaz Y, Chan TM. Good practices in harnessing social media for scholarly discourse, knowledge translation, and education. Perspect Med Educ. 2021:23-32.

Download references

Funding

Manuscript preparation was supported by Women and Children’s Services, Providence Health System, Portland, OR. Providence Health System had no role in the content of the manuscript.

Author information

Authors and Affiliations

  1. Providence Health System, Women and Children’s Services, Providence St. Vincent Medical Center, 9205 SW Barnes Road, Portland, OR, 97225, USA

    Joseph W. Kaempf

  2. Baylor College of Medicine, Texas Children’s Hospital, 6621 Fannin St, Suite W6104, Houston, TX, 77030, USA

    Kanekal Gautham

Authors
  1. Joseph W. Kaempf
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Kanekal Gautham
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

JW Kaempf and K Gautham conceived the original manuscript concept. JW Kaempf drafted the initial version. JW Kaempf and K Gautham reviewed subsequent revisions, and both attest to the veracity of the final manuscript content.

Corresponding author

Correspondence to Joseph W. Kaempf.

Ethics declarations

Conflict of interest

The authors declare no competing interests.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Special Thanks: Alison Leiataua, Providence Heart Institute, Portland, OR, assisted expertly preparing the manuscript figure.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kaempf, J.W., Gautham, K. Do small baby units improve extremely premature infant outcomes?. J Perinatol 42, 281–285 (2022). https://doi.org/10.1038/s41372-021-01076-9

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/s41372-021-01076-9

Search

Advanced search

Quick links