1. Levels of Neonatal Care:WV Guidelines Janet Graeber, MD, Chair Neonatal Guidelines Committee West Virginia Perinatal Partnership

2. Levels of Neonatal Care:WV Guidelines Adapted from Guidelines of the AAP Committee on Fetus & Newborn Pediatrics 2004;114:1341-1347

3. Level I Neonatal Care (Basic) • Provide neonatal resuscitation at every delivery • Evaluate and provide postnatal care to healthy newborns • Stabilize and provide care for infants born at 35-37 wks who remain physiologically stable • Stabilize newborn infants who are ill and those born at <35 wks until transfer to a facility providing an appropriate level of care

4. Level II Neonatal Care (Specialty) Special Care Nursery: level II units subdivided into IIA and IIB based on ability to provide assisted ventilation including CPAP

5. Level IIA Neonatal Care • Resuscitate and stabilize preterm and/or ill infants before transfer to a facility providing newborn intensive care • Provide care for infants born at >32 wks and weighing ≥ 1500 gm - with physiologic immaturity such as apnea of prematurity, inability to maintain body temperature, and/or inability to take oral feedings - who are moderately ill with problems anticipated to resolve rapidly and are not anticipated to need subspecialty services urgently - who are convalescing after intensive care

6. Level IIA continued • Maternal care of term and preterm gestations that are maternal risk appropriate • Supervised by Board-certified obstetricians • Nursery supervised by Board-certified pediatricians • Conventional mechanical ventilation limited to immediate stabilization of the neonate • No pediatric subspecialty or neonatal surgical specialty services • Do not receive primary infant or maternal transfers

7. Level IIB Neonatal Care • All capabilities of level IIA • Provide mechanical ventilation for brief durations (<24 hrs) or CPAP • Neonatal units supervised by Board- certified neonatologist • Limited pediatric subspecialty services • No neonatal surgical specialty services • No primary infant or maternal referrals

8. Level III (Subspecialty) NICU Level III NICUs are subdivided into 2 categories based on the availability of ECMO and cardiac surgery

9. Level III NICU • Comprehensive care for ELBW(≤1000 g and ≤ 28 wks gestation • Advanced respiratory support such as HFV and inhaled NO as long as needed • Prompt and on-site access to a full range of pediatric medical subspecialists • Advanced imaging, interpretation urgently, CT, MRI, Echocardiography • Ped surgical specialist and anesthesiologists on site or at closely related institution to perform major surgery such as PDA ligation, abdominal wall defects, NEC with perforation, TE fistula ± esophageal atresia, myelomeningocele

10. Level III+ NICU • All capabilities of Level III NICU • Capability to provide ECMO and surgical repair of complex congenital heart malformations requiring cardiopulmonary bypass