ICU and You · Journal Club · Number 97
A three-page letter proposing a new kind of intensive care unit — and asking a question worth arguing about
Mohakud NK, Mishra R. Infant intensive care unit: a new critical care identity for the first year of life. Journal of Pediatric Critical Care 2026;13(4):246–8.
Read it (open access)Free to read and share under CC BY-NC-ND 4.0, provided it is properly cited. Three pages, one figure, ten minutes.
Because they are the news. Not the formal, ceremonial version of reading — the daily kind. The journals are our news pages, our opinion columns, our form guide and our sports results. People who would not dream of going a week without knowing what happened in the world will go a year without knowing what happened in their own specialty, and then wonder why the registrar knows something they do not.
It does not have to be a session. You do not need an hour, a highlighter or a plan. Read the abstracts. Skim the contents page of one journal while the kettle boils. Open the one paper in ten that looks interesting and abandon it at paragraph three if it is not. Nobody is marking this.
What matters is staying curious rather than staying current — nobody is current, and the people who claim to be are reading less than they say. What you are actually maintaining is the habit of noticing: that a question is open, that a practice has shifted, that somebody has published the thing you were arguing about last month.
And then do the part that makes it stick. Mention it on a ward round. Argue about it with somebody who disagrees. Ask what the study could not have shown. A paper read alone is half a paper.
Publish or perish is the line we all know. The quieter one is this: absorb it, or lose your edge.
Newborns have a unit. Children have a unit. The infant between one month and one year has neither — they are admitted to a paediatric intensive care unit built around the physiology of older children, and looked after by people whose training and equipment were designed for someone else. Mohakud and Mishra argue that this interval is not a transition to be passed through but a distinct population, and that it deserves a distinct unit: an infant intensive care unit, staffed by an infant intensivist.
Their case rests on the observation that on nearly every axis, the infant sits closer to the neonate than to the child.
0–28 days
Neonatal physiology, unique airway characteristics, milk-based nutrition, early neurodevelopment. Cared for in a NICU by a neonatologist.
1 month – 1 year
Transitional physiology, closer to neonatal. A distinct infant airway and lung. Rapid growth with feeding support crucial. Peak brain growth. Family needs very high.
Over 1 year
Mature paediatric physiology, more developed airway anatomy, diverse diet, relatively advanced development. Cared for in a PICU.
From that they propose something more than a rebadged bed: scaled micro-equipment, pharmacological modelling for the transient pharmacokinetics of infancy, and — the most interesting element — continuous neurodevelopmental surveillance timed to the window of peak brain growth, extending through nutritional rehabilitation and post-discharge follow-up. A PICU, they say, is reactive and informed by data from older children; this would be proactive and built on infant physiology.
They are realistic about cost. Standalone units need infrastructure, equipment and a fellowship pathway that does not yet exist, and they acknowledge this bites hardest in resource-limited settings. So they propose a phased route: designated infant zones inside existing PICUs, cross-training between neonatologists and paediatric intensivists, and evolution into independent units only where the evidence and the money allow.
The observation at its centre is sound and it matches the mind map for this topic exactly. The infant is not a small child. Rate-dependent cardiac output, a compliant chest wall, tiny airways where a millimetre of oedema halves the lumen, no reserve of glycogen or oxygen — none of that is described by paediatric physiology, and a unit calibrated to a four-year-old will be calibrated wrongly.
The neurodevelopmental argument is the strongest and the least often made. Critical illness during the period of most rapid brain growth is not merely survived; it is carried. If an infant intensive care unit did nothing but institute structured developmental follow-up for its survivors, it would probably justify itself.
And the historical analogy has force. Neonatology exists because somebody insisted that newborns were not small children and were being managed by people trained for someone else. That argument was once considered eccentric too.
This is a letter, not a study. Three pages of advocacy with no new data, no cohort, no comparison. The authors say themselves that multicentre studies should quantify the burden of critical illness, mortality and long-term outcomes in this age group — which is a candid admission that the evidence justifying the proposal has not yet been gathered. The proposal precedes its evidence, and that is worth saying out loud in a journal club.
And subspecialisation has a cost the letter does not weigh. Every new unit boundary is a new handover, a new transfer, a new place for a child to fall between two services. A third unit between NICU and PICU creates two boundaries where there was one. The paper cites work on neonatal-to-paediatric transfers without confronting the possibility that its own proposal would multiply them.
Then there is the question of who this is for. Bhubaneswar has tertiary paediatric services; so does Sydney. We do not. In a regional Australian unit the argument lands somewhere quite different — we are not choosing between a PICU and an infant ICU, we are the interval before either. Which makes the useful question not should this unit exist but what would an infant intensivist know that we could learn without building anything?
Would a separate infant intensive care unit help — or add another boundary for a child to fall across?
Tap where you land and add a sentence. I am genuinely unsure about this one, which is usually the sign of a good journal club paper.
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