The Infant Incubator in The Neonatal Intensive Care Unit: Unresolved Issues and Future Developments

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J. Perinat. Med. 37 (2009) 587598 Copyright by Walter de Gruyter Berlin New York. DOI 10.1515/JPM.2009.109
Review articles
The infant incubator in the neonatal intensive care unit:

unresolved issues and future developments
Roberto Antonucci1,*, Annalisa Porcella2 and
Vassilios Fanos1
Introduction
Neonatal Intensive Care Unit, Department of Pediatrics

and Clinical Medicine, University of Cagliari,
Via Ospedale 119, 09124 Cagliari, Italy
2
Division of Neonatology, Hospital of Sorgono,
Corso IV Novembre, 08038 Sorgono, Italy
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: r.antonucci@unica.it
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588 Antonucci et al., The infant incubator: unresolved issues
transparent section(s) which allow(s) for viewing of the

baby, and provided with means to control the environment of the baby mainly by heated air within the enclosure. Generally, this device includes an AC-powered
heater, a fan to circulate the warmed air, a servocontrol
used to regulate air temperature inside the incubator, a
container for water to add humidity, a control valve
through which oxygen may be added, and access ports
for nursing care.
Air heated incubators are widely used for the care of
low birth weight (LBW) and sick newborns. These
devices have numerous advantages, in particular they
provide a clean, warm environment in which the temperature and humidity may be controlled, and oxygen may
be supplied when necessary. Furthermore, incubators
allow easy observation of the naked neonate, and his/her
isolation. However, infant incubators have also a number
of disadvantages that should be carefully considered. In
fact, these devices are expensive, have high running
costs, and are potentially hazardous to the baby. Additionally, incubators create a barrier between mother and
neonate, which delays bonding and makes breast feeding difficult.
Modern incubators are highly specialized devices,
nonetheless they still need to be improved in many
aspects. This review discusses the major physical factors
influencing the microenvironment to which the newborn
is exposed inside an infant incubator, some unresolved
issues in the development of an ideal incubator, and
possible solutions. Furthermore, specific sections on
infant incubators in developing countries, transport incubators, and developmental care are included. Finally,
practical aspects of the use of the infant incubator are
discussed.
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 microenvironment of the infant incubator

in the Neonatal Intensive Care Unit (NICU)
Optimal physical, psychological and social NICU environment is crucial for the best outcome of the newborn
w78x. The infant incubator, representing the main interface between the newborn and the NICU environment,
creates a particular microenvironment which, in turn,
influences the well-being and health of the newborn. The
main physical variables affecting the incubator microenvironment are temperature, humidity, sound, light, and
electromagnetic fields.
Temperature and humidity

In the late 19th century, Tarniers intern Auvard w8x reported that mortality among infants with birth weights
between 1200 and 2000 g was reduced from 66% to
38% by use of incubators. In 1933, Blackfan and Yaglou
w23x observed that, at a relative humidity of 65%, an air
temperature of about 258C was required to maintain
body temperature equilibrium in a group of preterm
infants and recommended the optimum relative humidity
of 65% for these infants. In 1957, a controlled clinical
trial by Silverman et al. w92x demonstrated that preterm
infants placed in environments of 8090% relative
humidity, as compared with controls in 3060% relative humidity, had more rapid respiratory rates, higher
body temperatures and a lower death rate in the first
5 days of life. One year later, it was documented that
premature infants placed in incubators with an air temperature of 31.78C had a higher survival rate compared
with controls placed at an air temperature of 28.98C w93x.
Taken together, these observations suggest the necessity
to adequately control of temperature and humidity inside
the incubator to favorably influence the survival of preterm infants. Furthermore, temperature and humidity
control in an infant incubator is important to prevent
evaporative water loss w2, 40x.
Like any physical object, the newborn loses heat in
four different ways, namely by conduction, convection,
radiation, and evaporation. Conduction is the heat loss
that occurs from the neonate to the surface on which he
or she lies. Babies are usually laid on a mattress, which
has a relatively low thermal conductivity, so the heat loss
from the baby to the mattress is relatively low. Heat
transfer by convection comprises movement of heat
through a fluid medium. Convective heat loss is dependent upon the infants position, maturity of the skin barrier,
body weight, air speed, and air temperature, and markedly varies with individual infants.
Radiant heat loss, defined as the heat loss between
the infants body and environmental surfaces not in direct
contact with the body (e.g., the walls of the incubator),
is dependent upon a number of factors including the surface area and geometry, surface temperature of the body,
and temperature of the receiving surface area. If the incubator walls are colder than the air inside the canopy, the
neonate may lose a great amount of heat through radiation to the cold walls. The temperature of the incubator
walls depends, in turn, on external environmental factors
(room air temperature, drafts). Heat loss by radiation may
be reduced by covering or clothing the neonate, or by a
double walled incubator w74x.
Evaporation is the total heat transfer by energy-carrying water molecules from the skin surface and respiratory
tract to a drier environment w40x. Evaporative heat loss is
influenced by gestational age, postnatal age, and by differences in the partial pressure of water vapor next to the
skin and in the surrounding air w40x. Heat transfer by


Antonucci et al., The infant incubator: unresolved issues 589
evaporation is the prominent source of heat loss and

often exceeds total heat production in very low birth
weight (VLBW) infants, particularly during their first days
of life. In VLBW infants, high evaporative losses are
due to the inadequate keratinization of the skin, which
becomes functionally mature at 3234 weeks gestation
w40x. This high transepidermal water loss (TEWL) may
result in hypothermia w16, 52x, dehydration and hyperosmolarity w15, 36x, thus adversely affecting neonatal outcome. Postnatal life has a stimulating effect on epidermal
development of the preterm infant so that the histological
structure of the epidermis resembles that of a full-term
infant a few weeks after birth w43x. Similarly, the high
evaporative water loss in very preterm infants rapidly
declines during the first week of life and then decreases
further with increasing postnatal age w53x.
The most important environmental factor affecting
TEWL is ambient relative humidity, with TEWL being
inversely related to this factor w51x. Accordingly, TEWL is
substantially reduced if preterm infants are nursed at high
relative humidity w51x. Furthermore, the skin temperature
increases and the distribution of surface temperature
becomes more even with rising ambient relative humidity
in LBW infants w54x. Thus, very preterm infants should be
cared at high ambient relative humidity (80%90%)
until their skin barrier function is fully developed, in order
to achieve adequate temperature control and water
balance.
Despite the proven benefits of humidifying the incubator baby compartment, humidification involves possible disadvantages, including condensation of moisture
on the inside of the canopy (rain-out) and infection.
Condensation, occurring at high levels of relative humidity, may be reduced by using a high room temperature or
a double-walled incubator. The concern of most neonatologists about the risk of infection has made them reluctant to employ humidified incubators for a long time. In
1985, Harpin and Rutter w55x recommended the use of
incubator humidification for neonates of -30 weeks
gestation in the first week of life, but pointed out that the
humidifier reservoir frequently became contaminated with
bacteria, e.g., pseudomonas. Fortunately, modern infant
incubators may now incorporate heating devices that
elevate the water temperature to a level that destroys
most organisms and prevents introduction of bacteria
into the air of the incubator.
Evaporative water loss in neonates placed in closed
incubators may also be reduced by using heat shields
such as a plexiglass shield w44x, or a plastic bag wrapping around the neonate w13x.
Thermoregulation for neonates is a complex process.
A fundamental concept for understanding this process is
that of the thermal neutral zone a narrow range of environmental temperatures within which the neonate may
control body temperature near normal exclusively by
mechanisms of physical regulation (e.g., vasoconstric-
tion), without increasing metabolic rate w30x. Beyond the

lower and upper limits of this range, termed critical
temperatures, the infant can maintain a constant body
temperature by an increased metabolic rate of heat production (measured by oxygen consumption) as a thermoregulatory response. An environmental temperature
decrease exceeding the bodys compensatory capacity
for increased heat production results in inevitable body
cooling (hypothermia). Conversely, an environmental
temperature increase exceeding the infants ability to dissipate body heat, results in the vant Hoff effect with inevitable body warming.
In an individual newborn, the thermoneutral environment can be determined by measuring oxygen consumption (mL/kg/min) at different environmental temperatures and an open flow-through system with a mass
spectrometer for gas analysis has been used for this
purpose w50, 70x.
For the reasons indicated above, the thermoneutral
environment is clearly an estimate for an individual baby
at a given time point. As a tool for clinical practice, thermoneutral temperatures have been reported for different
birth weights and gestational ages w58, 89x, and these
may be used to set the incubator temperature (air temperature servocontrol).
In healthy preterm infants of 2934 weeks gestation,
the thermoneutral temperature is dependent on gestational age and postnatal age during the first week of life,
after which time it depends on body weight and postnatal
age w89x. In addition, the thermoneutral range varies
widely depending on whether the baby is naked or
dressed. Other factors including the neonates size, air
humidity, air velocity, thermal properties of the mattress
and of incubator walls, and incubator wall temperatures,
influence the heat exchanges between the neonate and
the surroundings, and accordingly modify the achievement of thermoneutrality w69x. Studies of the physiological mechanisms regulating body heat storage in the
newborn suggest that metabolic rate, behavior, vigilance
level, heater control processes w69x, and nursing care
w69, 77x should also be taken into account.
The influence of air velocity needs to be emphasized,
since increasing air velocity enhances the heterogeneity
in regional skin cooling, which may contribute to the
neonates thermal discomfort w12x, and the small eddies
produced between the neonate and the mattress could
interfere with convective and evaporative heat transfers
from the neonate. Therefore, the design of future infant
incubators should consider the necessity of eliminating
eddies around the neonate w62x.
The structural characteristics of incubators may also
play a role in maintaining an optimal thermal environment
for the newborn. A recent Cochrane review provided evidence that double-wall incubators compared to singlewall incubators decrease both heat loss and oxygen
consumption in VLBW infants, but was unable to support


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.
Neutral thermal environment may be defined as body

temperature consistent with minimal oxygen consumption, and operationalized as infant skin temperatures
between 36.4 and 37.28C w14, 75, 102x. Therefore, the
neonates abdominal skin temperature should be maintained within this range when a skin servocontrol incubator is used.
Skin and air temperature servocontrol have been
shown to produce different thermal environments. Skin
temperature servocontrol produces a more stable infant
skin temperature, whereas incubator air temperatures
are extremely variable, often displaying a lag effect in
response to infant temperature changes and overshoots
or undershoots. The variable air temperatures observed
in skin servocontrol incubators are also related, in part,
to the discrepancy between air temperature, measured
at the site of the thermostat, and the incubator temperature as a whole, and in part to probe artefacts w102x.
Conversely, a greater variability in infant skin temperature
and a relatively constant air temperature are observed
when air temperature servocontrol is used.
Few studies investigated oxygen consumption in relation to incubator temperature control mode. Bell et al.
w14x compared air servocontrol, skin servocontrol, and
manual control in preterm infants of 2833 weeks gestation. No differences were found in mean air, skin, and
rectal temperatures as well as in metabolic heat production, or in body heat loss. Leblanc et al. w66x found similar
oxygen consumption in VLBW infants nursed in a skin
servocontrolled incubator vs. those nursed in a computercontrolled incubator, which combined skin, incubator air,
and wall temperatures.
Skin temperature servocontrol has some disadvantages such as lack of control when a neonate with very
high insensible water loss is nursed in an incubator with
low humidity w11x, and masking of the hypothermia or
hyperthermia associated with infection. In fact, when a
neonate who is under skin temperature servocontrol
becomes febrile, the incubator temperature decreases,
while body temperature does not change. For this reason, both the neonate and the incubator temperatures
must be compared together when skin temperature servocontrol is used.
Special attention should be given to the possible dislodgment of the infants skin thermistor or its accidental
placement between the body and the mattress which
may cause over- or underheating, respectively.
In short, skin temperature servocontrol effectively
maintains the reference temperature within a narrow
range, but may expose the neonate to both heat and cold
stress in an unstable thermal environment w41x. This can
result in increased oxygen consumption, poor weight
gain, and apnea.
Mixed servocontrol systems combine the positive
effects of skin temperature servocontrol and air temperature servocontrol. These modes of servocontrol use the


temperature of skin, air, and incubator wall as input

variables to a computerized algorithm which controls
heater output w40x. Telliez et al. w100x described a servocontrolled skin temperature derivative (SCS) heating
device designed to control the thermal environment in
closed incubators without the necessity of setting air or
skin reference temperature. The thermal environment
obtained with the SCS program was controlled only by
the neonates skin temperature changes and allowed the
attainment of a specific individual thermal equilibrium for
each neonate. When compared with on/off heating programs, the SCS system reduced the thermal stress of
preterm infants, as judged by reduced body movements
and by greater quiet sleep occurrence. This type of control may be particularly suitable for sick and very preterm
newborns in the first days of life since their limited thermoregulatory ability and higher body heat exchanges
increase the risks of hypothermia or hyperthermia.
More recently, Lyon et al. w73x reported a computer
program (HeatBalance) that used basic physical principles to calculate heat gains and losses, and indicated
incubator temperature and humidity settings to keep
babies in thermal balance. This program suggests initial
incubator settings, but continuous monitoring of the
babys thermal state is required.
Routine nursing procedures disrupt the environmental
temperature control in preterm infants resulting in temperature instability w76x, and thus should be modified to
minimize temperature fluctuations.
Sound environment
In the last two decades, there has been an increasing
interest in the impact of sound environment on the preterm infants health. The deleterious effects of early noise
exposure on the health of premature infants, the sources
of noise in the NICU, and the role of the incubator both
as a barrier to external noise and as a generator of noise
are herein discussed.
Newborns hospitalized in the NICU are exposed to
continuous noise, without intervening quiet periods w22,
33, 79, 101x. Since the maturation of auditory pathways
continues in the postnatal period w65x, the exposure of
these newborns to noise may adversely affect the development and maturation of the sense of hearing.
Hearing loss was found in children previously hospitalized in the NICU w7, 21x. An approximately tenfold
higher risk of developing a sensorineural or mixed hearing loss has been documented in neonates admitted to
NICU compared to those who were not w35x. Noise exposure in NICU, either acting alone or in synergy with other
risk factors such as hypoxia or ototoxic drugs, has been
suspected of contributing to hearing loss w97x. Other
adverse health effects have been observed in preterm
babies exposed to noise in NICU, particularly somatic
effects (tachycardia, tachypnea, apnea, oxygen desatu-
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


noise control and abatement w49x. General principles of

designing a quiet NICU and recommended acoustical criteria for walls, background noise, vibration, and reverberation have also been suggested w81x. Nonetheless,
noise levels in modern NICUs continue to be high w103x,
ranging from 60 to 90 dB with maximal levels of up to
120 dB w96x.
A crucial issue concerns the noise environment inside
the incubator in the NICU. Studies focused on sound
measurement inside the incubator found higher sound
levels within the incubator than in the open NICU environment w10, 28, 90x. Higher sound levels within the incubator are dependent on four factors: noise in the NICU
environment, noise from the motor in the incubator, noise
from caregiving equipment, and noise from the newborn
w90x.
NICU environmental sounds are the most important
contributors to noise levels recorded within the neonatal
incubator w20, 32x. The transmission of sound into incubators was evaluated by Robertson et al. w87x, who documented that signal transmission loss was greater for the
standing-talker position rather than for the sitting-talker
position, and with front incubator portholes closed.
Benini et al. w20x reported that human-related source of
noise recorded inside incubators consisted of impulsive
events beyond 80 dB. Furthermore, varying noise levels
have been measured inside different incubator models in
a NICU w24x, demonstrating that the acoustic properties
of each incubator model are different.
It is noteworthy that the incubator by itself is a noise
generator. The background noise from the incubator
motor has been found to vary from 74.2 to 79.9 dB w20x.
The noise level within the baby compartment, measured
during normal operation, should be below the 60 dBA
limit set by the standard.
A number of studies have examined how noise levels
can be reduced inside the incubators. The implementation of a double plexiglass incubator wall may provide a
barrier to the NICU environmental noises, sheltering preterm infants from adverse noise effects. The attenuation
of sound by modern infant incubators was measured by
Robertson et al. w86x, who documented that caring for
neonates inside modern incubators reduced averaged
sound exposure to levels near those recommended for
the NICU. The use of acoustical foam pieces placed in
each of the four corners of the incubator w60x, and covering incubator w90x have been demonstrated to be good
methods to decrease environmental noise levels inside
the incubator. Additionally, the use of sound-absorbing
panel has been found to reduce noisy incubator reverberating w19x.
In conclusion, further efforts are needed to minimize
the exposure of the newborns in NICU to elevated noise
levels. Designing quiet NICUs, sensitizing the NICU
staff to adopt a low-noise behavior, using low-noise
incubators and ventilators, and managing alarms correctly may be effective measures for this purpose.
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.
Infant incubators in developing countries

In developing countries, neonatal complications including prematurity and LBW are common, and thus the use
of infant incubators may considerably contribute to
reducing infant morbidity and mortality. Unfortunately, the

limited access to modern, high-tech incubators along
with the lack of infrastructure and replacement parts
render such devices worthless in these regions.
Recently, a fully functioning, low cost incubator
prototype, the Life Raft Incubator, has been developed
for infant care in developing countries. This device is
optimized for accessibility and ease of use. The bunting
heating trap keeps the baby warm, while a safety strap
secures him/her in place. On its base, the incubator has
handles for easy transportability and a digital display
showing temperature and humidity levels. This device is
designed for easy assembly and repair as it has a
detachable heated water bed (heat backup), modular
electronics, and a cylindrical canopy consisting of a double wall of plastic. The electronic temperature control
system consists of stationary thermistors, which are
mounted to the exterior and interior of the incubator with
a third mounted on a probe taped to the infants abdomen. This incubator has no forced air circulation system,
but uses the natural convection of air w38x.
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.
Infant incubator and developmentally

supportive care
The great technological progress made in the development of more comfortable and safer infant incubators
does not guarantee by itself an optimum microenvironment for premature and at risk neonates in NICU. In fact,
conventional noxious NICU environments and practices
such as the exposure to bright lights, high noise levels,


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,


Table 1 Infant incubators: unresolved issues and possible solutions.

Factor
Unresolved issues
Possible solutions
Temperature control
Heat loss from the newborn
To develop advanced temperature control systems

To use double-walled incubators
Appropriate air temperature (22268C) in the NICU
To develop advanced air circulation systems
Eddies around the newborn

Noise environment
High noise levels inside the incubator

(external and internal sources)
To attenuate environmental sound

(acoustical foam, sound absorbing panels)
To reduce the noise generated within the incubator (motor)
To reduce human-related sources (NICU staff) of noise
Light environment
Continuous lighting and bright light

(NICU environment)
To promote circadian lighting

To reduce the amount of light within the incubator (covers)
Electromagnetic fields
Relevant EMF levels within the

incubator
To redesign the position of various incubator components

To implement ferromagnetic panels
To increase the distance between incubator and electronic
equipment
EMFselectromagnetic field, NICUsNeonatal Intensive Care Unit.
which can harbor harmful microorganisms and cause

infection in the newborn.
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.
Received July 2, 2008. Revised March 25, 2009. Accepted June

2, 2009. Previously published online July 10, 2009.


The Infant Incubator in The Neonatal Intensive Care Unit: Unresolved Issues and Future Developments

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The Infant Incubator in The Neonatal Intensive Care Unit: Unresolved Issues and Future Developments

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Article in press - uncorrected proof