​​​​​​Levels of Neonatal Care

The ​ American Academy of Pediatrics​ categorizes hospitals into four levels based on the care a facility can provide to newborns. These levels of care correspond ​to the therapies and services provided. Facilities offering neonatal intensive care must meet health care standards through federal/state licensing or certification. 

The four categories are:

• Level I: Well newborn nursery
  
• Level II: Special care nursery
  
• Level III: Neonatal intensive care unit (NICU)
  
• Level IV: Regional neonatal intensive-care unit (regional NICU)
  

Level I (Well Newborn Nursery) 

Level I units are typically referred to as the well baby nursery. These facilities have the capability to provide neonatal resuscitation at every delivery; evaluate and provide postnatal care to healthy newborn infants; stabilize and provide care for infants born at 35 to 37 weeks gestation who remain physiologically stable; and stabilize newborn infants who are ill and those born less than 35 weeks gestation ​until transfer to a facility that can provide the appropriate level of neonatal care. Required provider types for well newborn nurseries include pediatricians, family physicians, nurse practitioners and other advanced practice registered nurses.

Level II (Special Care Nursery) 

Level II units are also known as special care nurseries and have all of the capabilities of a Level I nursery. These facilities are required to have pediatric hospitalists, neonatologists and neonatal nurse practitioners, in addition to Level I health care providers.

Level II units are able to:

• Provide care for infants born at 32 weeks gestation or older and weighing more than or equal to 1,500 grams who have physiologic immaturity or who are moderately ill with problems that are expected to resolve rapidly and are not anticipated to need subspecialty services on an urgent basis
  
• Provide care for infants who are feeding and growing stronger or recovering after intensive care
  
• Provide mechanical ventilation for a brief duration or continuous positive airway pressure
  
• Stabilize infants born before 32 weeks gestation and weighing less than 1,500 grams until transfer to a neonatal intensive care facility
  

Level III (Neonatal Intensive Care Unit) 

Level III units are required to have the same care providers required for Level II facilities (pediatric hospitalists, neonatologists and neonatal nurse practitioners) and Level I facilities (pediatricians, family physicians, nurse practitioners and other advanced practice registered nurses). ​​

In addition, Level III units must provide, either onsite or at a closely related institution by prearranged consultative agreement, the following providers: pediatric surgeons, pediatric medical subspecialists, pediatric anesthesiologists and pediatric ophthalmologists. 

Level III neonatal intensive-care units are able to:

• Provide sustained life support
  
• Provide comprehensive care for infants born at all gestational ages and birth weights with critical illness
  
• Offer prompt access to a full range of pediatric medical subspecialists, pediatric surgical specialists, pediatric anesthesiologists and pediatric ophthalmologists
  
• Provide a full range of respiratory support that may include conventional and/or high-frequency ventilation and inhaled nitric oxide
  
• Perform advanced imaging, with interpretation on an urgent basis, including computed tomography, MRI and echocardiography
  

Level IV (Regional NICU) 

The highest level of neonatal care provided occurs at regional NICUs, or Level IV neonatal intensive care units. These units are required to have pediatric surgical subspecialists on staff in addition to the care providers required for Level III units.

Regional NICUs have all the capabilities of Level I, II and III units. In addition to providing the highest level of care, Level IV NICUs:

• Are located within an institution that has the capability to provide surgical repair of complex congenital or acquired conditions
  
• Maintain a full range of pediatric medical subspecialists, pediatric surgical subspecialists and pediatric anesthesiologists onsite 
  
• Arrange ​transport and provide outreach education
  
• Provide ECMO (Extracorporeal Membrane Oxygenation)