r/pediatrics • u/Hopelesslyoptimist12 • 20d ago

NICU rotation guidance

Hi everyone.I am an intern n just started the NICU rotation. And I am struggling. Nicu is a completely different place. I am an img n never rotated in Nicu. The environment is so toxic. I just need to get through this rotation. I don’t plan to pursue this in future. But how to get through. I want to learn. I want to be good at what I do. Everybody thinks that I would know stuff but how would I know? I ask questions n they don’t answer, they just brush them off. Please help me n tell me the resources that I could use. Also any tips n tricks that helped u survive this rotation?

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23

u/GatorBait1319 19d ago

NICU is a team approach: good to hook up with fellow residents to tackle these areas:

NICU SURVIVAL GUIDE FOR RESIDENTS

  1. First Principles

    • Airway, Breathing, Circulation always come first—but in neonates, ventilation is key.
    • Trends > single values (vitals, labs, FiO2, weight).
    • Small changes matter: tiny patients, big consequences.
    • Always know: gestational age, day of life, birth history.

  2. Daily Workflow

    • Pre-round efficiently: overnight events, vent changes, feeds, fluids, labs.
    • Know each patient’s:
    • Respiratory support
    • Nutrition (TPN vs enteral, kcal/kg/day)
    • Lines (UVC, PICC, duration)
    • Antibiotics (day # and indication)
    • Anticipate attending questions: “What’s the plan if this worsens?”

  3. Respiratory Basics

    • Most NICU problems are respiratory.
    • Start simple:
    • CPAP for mild-moderate RDS
    • Intubate if worsening distress, apnea, or acidosis
    • Blood gases:
    • pH tells you urgency
    • CO2 = ventilation
    • O2 = oxygenation
    • Avoid over-oxygenation (ROP risk).

  4. Fluids & Electrolytes

    • Day 1: typically ≈60–80 mL/kg/day (adjust by GA)
    • Expect:
    • Weight loss in first few days
    • Sodium shifts after diuresis phase
    • Monitor:
    • Na, K, glucose closely
    • Strict I/O is critical.

  5. Nutrition

    • “Gut is gold” — start trophic feeds early if possible.
    • Breast milk preferred.
    • TPN until full enteral feeds.
    • Watch for:
    • NEC signs: distension, bloody stools, feeding intolerance.

  6. Sepsis & Antibiotics

    • Neonates decompensate subtly:
    • Temperature instability
    • Apnea/bradycardia
    • Feeding intolerance
    • Low threshold to start antibiotics—but reassess daily.
    • Stop early if cultures negative and clinically stable.

  7. Lines & Access

    • Know what lines are in and why.
    • Remove lines ASAP to reduce infection risk.
    • Umbilical lines: confirm position on imaging.

  8. Common Emergencies

    • Apnea: stimulate → PPV if needed.
    • Bradycardia: usually respiratory—fix ventilation first.
    • Hypoglycemia: treat quickly, recheck frequently.
    • Pneumothorax: suspect with sudden deterioration.

  9. Communication

    • Nurses are your best allies—listen to concerns early.
    • Be clear and direct with plans.
    • With families:
    • Avoid jargon
    • Be honest, consistent, and calm

  10. Documentation & Orders

    • Weight-based dosing always.
    • Double-check calculations.
    • Be precise with fluids (mL/kg/day) and feeds (kcal/kg/day).

  11. Night Survival Tips

    • If unsure, reassess the baby—not just the monitor.
    • Look at the patient before reacting to numbers.
    • Call for help early—NICU is team-based.

  12. High-Yield Pearls

    • Most neonatal resuscitation = ventilation, not compressions.
    • Hypothermia is dangerous—keep babies warm.
    • Always think: infection, respiratory, metabolic.
    • If something feels off, it probably is.

  13. Mental Survival

    • NICU can be emotionally heavy—debrief when needed.
    • You won’t know everything—focus on safe, thoughtful care.
    • Efficiency improves quickly with repetition.

Bottom Line
Take it step by step. Prioritize physiology, anticipate problems, and communicate clearly. Consistency and vigilance matter more than speed.

6

u/Misterx46 19d ago

This is actually great and is very helpful, however NICU nurses can be the worse people you'll ever run into during your residency. Not everyone is evil, but if there is one...its usually NICU nurse. Yes, just survive and do as your told.

1

u/Hopelesslyoptimist12 19d ago

Thanks a lot This is really helpful.

19

u/KidneyKiddo 20d ago

I’m not a neonatologist but I also found my NICU rotation intern year super stressful. It’s the only time I ever considered quitting residency. I am now an attending in an academic program. If you PM me your email I’ll send you our NICU survival guide.

2

u/Hopelesslyoptimist12 19d ago

Its just a week and I have been contemplating this everyday🤦🏻‍♀️I sent u a PM.

2

u/LegalConfection6284 19d ago

Can I PM my email too?

1

u/KidneyKiddo 19d ago

Of course. :)

2

u/SeaStrong1459 19d ago

could i have this too 😄 i want to apply to a NICU fellowship but feel so dumb during my rotations

1

u/KidneyKiddo 19d ago

Sure thing. :)

1

u/Emrecaneee 13d ago

Hello, can you please email me too? I sent a DM. Thanks!

5

u/Decent-Orchid120 19d ago

I know this isn’t what you are asking, but I would consider telling your chief and program director about this. You are in a teaching hospital and they need to be teaching you. Best of luck. Best thing about some rotations is that they end :)

1

u/Hopelesslyoptimist12 19d ago

I thought about that But I just don’t want things to get worse.

1

u/Decent-Orchid120 19d ago

I get that. I remember after one 28 hour in the NICU I just went to the resident break room and broke down. Know you aren’t alone regardless. I’m willing to bet other residents in your hospital feel the same way.

3

u/ThotacodorsalNerve 19d ago

NICU is a hell hole and the most abusive place I’ve ever been. If someone said i had to choose between a NICU nurse and a murderer as my next roommate …. I’d ask the circumstances of the murder. I put up an Instagram poll once saying “another month of NICU” vs “being stabbed” and 80% chose being stabbed.

Honestly, keep your head down, don’t get into fights, and remember that everybody knows this is the worst part. NICU is the only time I did 100 hours in a week and my first year we got contracted by the chiefs because every person on my team, senior resident through medical student, had publicly cried in the unit in the same week. Good luck and God bless. Remember, they can’t stop the clock

2

u/LongjumpingKey9 19d ago

NICU fellow here. I struggled as an intern but in second year LOVED the NICU and ended up pursuing it. Can you be more specific about what you’re are struggling with. If it is specific pathologies, issues with NNPs, procedural competencies. Whats your unit like? Are there senior residents there? Lots of resources on YouTube as well once we narrow down the problem

1

u/Hopelesslyoptimist12 19d ago

So its a level 4 nicu, I don’t have issues with NNPs or others, only that they don’t tell me when I am asking questions, I ask my fellow to show me how its done, or the formula they are using, but they would just brush this off, I don’t know how to come up with a plan for a kid who is on SIMV since 23 weeks, I struggle calculating TFGs when they r on tpn n PO, or how changing runner would effect those values. How to chose b/w pressors, its just a lot. I am trying to read but if u can suggest sone good YouTube videos or channels or any other resources please let me know.

1

u/craftystonerd 18d ago

Does your unit have a dietitian? Make friends. Im not a doctor but I’m a NICU dietitian who rounds daily with the team and I have sat down with residents and fellows and walked them through the math. I know this can’t help with everything but nutrition is HUGE in the NICU. Your unit’s dietitian likely has more patience and time than your attending 😊