On today's episode of Raise the Line with host Lindsey Smith, you’ll get a revealing look inside the workings of a top tier Neonatal Intensive Care Unit from Lindsay Howard, a veteran NICU nurse from Children's Memorial Hermann Hospital in Houston. Tune in to learn how advances in medicine have created a need for NICU nurses to develop specialized skills. You'll also hear about approaches to care that support healthy neurodevelopment, and how her own experience as a mother with twins needing NICU care impacted her work.
With nearly one in ten newborns in the US requiring care in a Neonatal Intensive Care Unit, the importance of NICUs has never been more clear. On today's episode of Raise the Line, we're shining a light on the extraordinary world of NICUs with Lindsay Howard, a veteran nurse with over 17 years of experience caring for premature and critically ill infants. She currently works in a Level IV NICU at Children's Memorial Hermann Hospital in Houston, one of the most advanced neonatal units in the country. “We call ourselves ‘the ER of the neonate world’ because we're never full. We have to make space no matter what comes in off the street, and at the biggest medical center in the world, we see all the things,” she explains. In this enlightening conversation with host Lindsey Smith, Howard describes how advances in medicine have made it possible to provide more types of care for younger and smaller babies, creating a need for NICU nurses to develop subspecialties. In her case, Howard is on a dedicated team that handles the placement and maintenance of all central line IVs, and has earned certifications in neonatal and pediatric chemotherapy and biotherapies. “We see babies that we may not have seen before being born with cancerous tumors who need chemotherapy to try and eliminate it, or just give them more time with their family.” This is a revealing look inside the workings of a top tier NICU where you’ll learn about approaches to care that support healthy neurodevelopment, how clinical staff handle the emotional challenges of the job, and how her own experience as a mother with twins needing NICU care impacted her work.
Mentioned in this episode:
Children's Memorial Hermann Hospital
Howard Trans CGPT
Lindsey Smith
Hi, I'm Lindsey Smith, welcoming you to Raise the Line with Osmosis from Elsevier, an ongoing exploration about how to improve health and healthcare.
With nearly one in ten newborns in the US requiring care in a neonatal intensive care unit and recent data showing that number is rising, the importance of NICUs has never been more clear. These specialized units are lifelines for the most vulnerable patients, delivering highly advanced around-the-clock care in some of the most critical moments of life.
On today's episode, we're shining a light on the extraordinary world of NICU with Lindsay Howard, a veteran NICU nurse with over seventeen years of experience caring for premature and critically ill infants in high-pressure environments.
Lindsay has served as a subject matter expert in nursing education for Elsevier and currently works in a Level IV NICU at Children's Memorial Hermann Hospital in Houston, Texas, one of the most advanced neonatal units in the country. Her career spans major hospitals in New York City and Houston, and she holds multiple specialized certifications in neonatal intensive care nursing, neonatal and pediatric resuscitation, and pediatric chemotherapy and biotherapies.
Outside the hospital, Lindsay is just as busy. She lives in Houston with her wife and their energetic six-year-old twins and two dogs, balancing a full family life with her deep commitment to neonatal care.
Thank you so much for joining us today, Lindsay.
Lindsay Howard
Thank you for having me.
Lindsey Smith
So let's get started with learning more about you and what got you first interested in nursing.
Lindsay Howard
Well, I am the oldest sister in my family. I have two younger brothers, and when my middle brother was born, he got sick. I was four, so the details are fuzzy, but I do very specifically remember going to visit him at the NICU because he came home, got readmitted, and was there maybe for like a week or so.
I remember going to visit him and seeing him in the NICU — like seeing him through the glass — and the nurses were so kind to him and so kind to me, you know, the big sister who didn't know what was going on. That really left an impression on me. And, you know, I liked to play with dolls and all that stuff growing up, so I was like, I'm taking care of the babies like the nurses were taking care of my baby brother.
That's kind of how it started, I think. And then as I got older and was like, what do I want to do with my life, that always kept popping back up for me.
Lindsey Smith
It's clear from your personal connection there that those nurses made a big impact on you, similar to the impact that you're making on other people today as well. You went to nursing school. Can you talk about what led you into pediatrics critical care?
Lindsay Howard
Well again, like I said, I was the oldest sister, so I was always around kids and younger kids. You know, all of my jobs growing up, I was a babysitter. I worked at the nursery in the YMCA. In high school, I worked at an art studio for children. So I was just always kind of with kids, and I just knew that I wanted to keep focusing on them. I always got along really well. It was always easy. Adults are messy, as we all know, and trying to put all that together was always a no-brainer for me. I very specifically knew if I wanted to do nursing, I wanted to work with the littles — my chosen population.
Lindsey Smith
Thank you so much for sharing that. So today you work in a Level IV NICU unit. Can you talk us through the different levels?
Lindsay Howard
Yeah, so NICUs, the neonatal levels of care, are determined by the Texas Department of State Health Services, and they go from one to four — four being the most severe, most critical; one being the least critical, maybe just some full-term infants who need a little extra support for a transition period.
So yeah, one to four. Like I said, one is for babies who just need a little bit of help. Level two NICUs really don't take care of babies younger than like thirty-two weeks gestation and then up from there. So then three is kind of like a little bit more sick, and then four is the most critical, the most severe, the most complex cases that need twenty-four-seven care — not just neonatal care, but also access to pediatric surgery twenty-four-seven. All those specialty teams that you find are always there on site in the Level IV NICU. It's not like some doctors are at home and need to be called in. There are always surgeons, specialists, neonatologists there twenty-four-seven.
Lindsey Smith
That's a really helpful breakdown, and understanding the different distinctions between those levels really helps give some great context behind the complexity and the intensity that your team and you provide. I'd like to dig a little deeper into what your day-to-day looks like.
Lindsay Howard
Boy, well... I actually do two roles in our NICU. The first one is my standard NICU nurse bedside role. As a nurse, you would take care of anywhere from one to three babies, depending on acuity. So if you have three, they're pretty stable — maybe just former preemies that are still learning to feed and growing and getting closer to that going-home point. Versus if you only had one, that would be a very sick, very critical baby needing one-to-one attention all shift long.
Our NICU is huge. Our census likes to hover around one hundred thirty to one hundred forty babies.
Lindsey Smith
Wow.
Lindsay Howard
Yeah, which is a lot of babies and therefore a lot of nurses. And you never know what you're coming into. You could be coming into that really sick, critical assignment, or you could be coming into two or three babies, just working on some feeds and helping get the family ready for discharge. So there's that — the general baby care — but also all the inpatient stuff: labs, medical team rounds, changing orders, fluids, consults from specialty teams, diagnostic imaging, and more lab work. All of that happens in twelve hours.
I also am on our central line team, which is a specialty team of nurses that deal with central lines, so like PICC lines and Broviac lines. What they found through lots of research — some of which was actually at our hospital — is that when you have a specific group of people dedicated to accessing the lines, maintaining them, dressing changes, inserting them, you can really do good quality control. That leads to fewer central line-associated bloodstream infections. CLABSIs are a big concern. Nobody wants that — as a patient, as a hospital, as a healthcare system. And for babies, it's an even bigger risk because they have no immune system, so a central line infection can be really bad news.
When I'm on our line team that day, instead of being at the bedside assigned to one to three patients, I'm all over the unit going to all the central lines, doing dressing changes, giving medications, changing fluids, helping with insertion. I just kind of bop around all day long. So my shifts are split up between those two roles.
Lindsey Smith
It sounds like a lot of variety and also very demanding throughout the day.
Lindsay Howard
Yeah, it keeps it interesting. We're never bored at work. We always say that. There's always something.
Lindsey Smith
Yes. No, that's good. So let's talk about some of the misconceptions about NICUs — anything you'd like to clear up there.
Lindsay Howard
Yeah, I think, you know, in the medical field — well, it does happen sometimes — but I've found that people think if you're a NICU nurse, you're just holding babies, changing diapers, feeding babies all day, which would be great, because who doesn't love to hold a baby and cuddle with them? And sometimes, when we do have those less sick babies that are just working toward discharge, you do get to do some of that.
But the NICU is really an ICU. I think people don't realize that. It's just like the adult world with all the ventilators and special pumps, ECMO, life-saving bypass, ten medication pumps at a bedside — all that stuff, but for a tiny human.
Yeah, so it's less cuddling and fun times — though they do happen — and more serious critical care, critical thinking, use all your skills, get everything done, and get the best outcome for your patient and their family.
Lindsey Smith
That's a really important clarification. So thank you so much for sharing that with us. How has delivery of care changed in NICUs in recent years?
Lindsay Howard
It's interesting because when I first started, what we call viability for a fetus — where they can typically survive outside of the uterus — was about twenty-five weeks, which is still incredibly early when you consider that a full-term pregnancy is about forty weeks.
But now we routinely get babies that are twenty-two weeks, which is still crazy, and they’re like four hundred grams — less than a pound. Very, very tiny. That has obviously come with advances in medical care from the maternal side: taking care of moms with high-risk, complex pregnancies and getting them closer to that point where they can deliver and hopefully bring their baby home.
But there are still limitations because, like I said, they're four hundred grams. Our smallest breathing tube is a two-French, which is literally a tiny straw — that’s the smallest they can make. There’s no way to manufacture it smaller. So if you can’t get that breathing tube in, we’re limited by those physical product things. If you can’t get IV access with the smallest catheter, then you can’t resuscitate and help that baby get bigger and further along.
We joke that there’ll probably be robots one day in the NICU. They’ve even done studies — I think it was with sheep — where they made a fake womb, a fake uterus, and a sheep survived in there. I don’t know how long it’ll be, but maybe it’ll come one day.
Lindsey Smith
Who knows? Yeah, who knows. It’s kind of exciting to hear about innovation and how things are constantly evolving. The twenty-two weeks is mind-boggling to me, and I’m sure the stakes are so high at that point. I want to talk about how family members deal with that incredible stress if their babies are in the NICU. How do you handle the emotional dynamics of your work day-to-day?
Lindsay Howard
Well, it can be a lot. You have to have good, strong boundaries, because being empathetic is obviously part of nursing. You don’t want some cold nurse who just does the things and leaves while you’re sitting there alone and your baby’s in this box. But at the same time, you can’t be the nurse that’s falling apart when something sad or stressful is happening — you have to be on top of your stuff.
So you have to be able to turn that emotional part off for a little bit to focus and do what needs to be done. I’m pretty good at that, so it works well for me.
We also have a lot in place at work that helps. A few years ago — probably after COVID — they came up with a “Code Lilac,” sort of playing off what you see on hospital TV shows like a Code Blue. A Code Lilac is for healthcare workers when there’s been maybe a death or a cluster of deaths or just a really stressful time. It’s led by the chaplains, some of our nursing management, and nurses with extra training in supportive communication and counseling.
They’ll hold those after a rough shift or period, and it’s a place where you can debrief and talk about how you’re feeling if you want to, or just sit quietly. They usually have lower lighting — you can’t have candles in a hospital, but there are fake ones — aromatherapy, little activities to help you unwind and process.
Lindsey Smith
Yeah, so maybe to play that back, you help deal with the stresses you face at work through having clear boundaries — really striking that balance between continuing to do your job and managing that emotional piece — maybe even compartmentalizing what’s happening, and then leaning into workplace resources that are helpful. I think that’s a great tip for healthcare providers everywhere.
Lindsay Howard
Yeah.
Lindsey Smith
I want to come back to something you mentioned: COVID-19 — a stressful time for a lot of healthcare workers, to put it lightly. You were in the NICU during the height of the pandemic. Can you take us through what that was like, how your team handled it, and how family visitation policies came into play?
Lindsay Howard
Well, yeah, like you said, COVID was awful for everyone in healthcare — super stressful, lots of unknowns, product shortages, reusing masks. We in the NICU were fortunate that we weren’t quite as frontline as the ER or adult ICU folks — that was extra crazy.
But we also call ourselves the ER of the neonate world because we’re never full. If a mom comes in and a baby’s coming out, we can’t say no. We have to take them, make space — anything can come in off the street in Houston, the biggest medical center in the world. So there was still frontline-level stress.
Most of the babies who were positive ended up doing pretty well — it was mild for them, which was good. But that wasn’t always the case with the mothers. Pregnant women and COVID — I think a lot of people brushed it off, but it really had some devastating outcomes. Sometimes we’d have a baby whose mother didn’t survive. The baby’s okay, but now we’re caring for a family that just lost their daughter, their wife — on top of everything else.
Visitation was tough because we had to limit the number of visitors for everyone’s safety. Nobody wants to say you can’t visit your baby, but if you have COVID or have been exposed, you can’t come into our ICU.
What we did — and I think many places did — was use iPads to facilitate Zoom calls with an incubator and families at home. I’m glad we could provide that, but it added stress because, again, our census is one hundred forty babies. We didn’t have one hundred forty iPads — maybe five. Tracking them down, setting up Zoom for families who weren’t familiar with it, all while doing your nursing care — it was a lot. I’m glad it’s over.
Lindsey Smith
Yeah, that must’ve been a really challenging time. And to your point, giving them that gift of being able to FaceTime or Zoom in to see their little one must have meant the world, but it just added onto your already full plate. I actually had my youngest in March 2020 — born on March second — and a few days later the world shut down. We didn’t know how quickly things would escalate, and I remember trying to get out of there as quickly as we could because we didn’t really know what COVID-19 was at that point.
Lindsay Howard
Yeah. And even though we weren’t frontline, there was so much unknown — how does it spread, to what extent? I’d come home and change in the garage, take off all my clothes and shoes, run to the shower. It was just a lot for everyone.
Lindsey Smith
Yeah, for sure. So I want to switch gears a little bit. As I noted in the introduction, you earned a specialized certificate in administering pediatric chemotherapy and biotherapies. Can you talk us through what’s involved in that work?
Lindsay Howard
Yeah, so to get certified you need a certain number of years of experience, a handful of content classes — some in person, some online — skills labs, and then a certification test to prove you can administer it safely.
That certification really reflects advances in medical care. Babies with tumors or other findings that once wouldn’t have survived to delivery now do. Also, with restrictions on women’s healthcare — particularly in Texas — some families no longer have the option to terminate nonviable or extremely complex pregnancies. So we’re seeing more babies born with complicated, sometimes cancerous conditions that require chemotherapy.
Chemotherapy has to be specially handled and administered through central lines, not regular IVs. That’s where our line team comes in. Several of us got chemo-certified so we can give chemo through those central lines, since we’re the only ones who can access them.
Before, these patients might have gone to a pediatric unit, but they still need neonatal care. Now we can keep them in the environment best suited for them — with NICU teams — while giving the chemotherapy or biotherapies they need through central lines or implanted ports if they’re big enough.
Lindsey Smith
Just coming back to the chemotherapy part — how young of a patient have you administered chemotherapy to?
Lindsay Howard
I mean, newborns. Sometimes they know prenatally that a baby has a tumor or diagnosis. Usually there’s surgical debulking first, then healing for a couple of weeks, then chemo. There’s also a higher risk of certain leukemias with trisomy 21 — Down syndrome — so we sometimes see those babies. Maybe they have a cardiac issue, and in their labs we discover a white count through the roof. Then hematology-oncology gets involved and it turns out to be leukemia.
So literal newborns — a week or two old — which is crazy. Sometimes families know going in, sometimes they don’t. Imagine: you just had a baby and now you’re told they have cancer and need chemotherapy. As hard as that is, if you want them to have the best shot at life, we have to give this extremely caustic, harsh therapy. It’s a lot.
Lindsey Smith
Yeah, it is. I’m sure there are stressful, challenging times, but talk a little about the rewarding parts of your job. Why would someone consider being a NICU nurse? What makes the role so special?
Lindsay Howard
I think the greatest reward — and always the ultimate goal — is to get these babies home with their families. Nobody wants to be in the NICU. We love our jobs, but every family wants to go home with a healthy baby they can hold.
Any time we get to send someone home is great, and a lot of times they come back to visit — partly for developmental follow-up, partly because they just like us. You become like family. They bring the babies back, and we get to see them healthy and thriving, doing normal baby things. That’s super rewarding.
Even if we don’t see them, sometimes they’ll send photos to a certain nurse, and that nurse will go around showing everyone — “Look, baby so-and-so is three now, doing great!” It really makes you feel that all the stress, long days, and hard work are worth it.
I also love that the NICU is so niche. You need a specialized skill set because babies can’t tell you where it hurts or that they’re having trouble breathing. They’re just there, so your assessment skills have to be sharp — catching subtle vital-sign changes and details.
I’m super detail-oriented, and if you like control and high-precision work, the NICU is great for that. With a four-hundred-gram baby, medication doses are in micrograms, measurements in millimeters — the attention to detail has to be there. So if you thrive on details and high-stress situations, the NICU could be perfect for you.
Lindsey Smith
It’s such an important job and such a meaningful way to support families and babies at probably the most critical time in their lives. Thank you for all you do. I want to talk about your personal story with your high-risk pregnancy. You had twins, and they ended up needing NICU support. Can you talk about that experience and how it affected your perspective on neonatal care?
Lindsay Howard
Yeah, we always joke in the NICU — it’s the NICU curse. Of course I had the high-risk pregnancy that needed all the follow-ups and a NICU stay. I feel very fortunate because we were in the best place. I wouldn’t have had them anywhere else. I know our neonatologists and nurses are the best — I work with them every day, so that comforted me. My family was freaking out, but I said, “We got this.”
Still, it’s stressful. One of my twins was there for a day, one for a week. It’s hard to be in two places at once. Luckily my mom was here — she’d planned to help postpartum — so she stayed with the twin at home while I spent time with Rory, our daughter, in the NICU. I’d go see her during the day, come home to feed her brother, pretend to sleep for a bit, then go back in the morning.
I already felt empathetic for our families, but being there myself really kicked it up a notch — especially having a wife who isn’t medical. It highlighted gaps in our teaching and communication. I know all these things; she had no idea, and most families have no idea.
She’d hear something and panic — “Why is he making that sound?” — and I’d realize, oh right, she doesn’t know what’s normal. It reinforced how important education is for families, and re-education too. It’s so stressful — you’re focused on your baby, on recovering, on your partner — you’re not going to remember every question when the doctor comes.
It really underscored the importance of revisiting education and communication, and keeping family-centered care at the forefront of what we do, alongside caring for the baby.
Lindsey Smith
Well, thank you for sharing that personal story. We’re sorry you had the NICU curse, but glad your twins are thriving.
Lindsay Howard
We always tell families they won’t remember this. Just take it one day at a time. The sun will rise tomorrow. You’ll get there, and one day it’ll just be a blurry memory — hopefully not too bad — but nobody wants their child in a hospital.
Lindsey Smith
For sure. So I want to pick up on that education piece you talked about and how important it is. As you know, Osmosis is a teaching company — we love to fill knowledge gaps. Is there a topic you think Osmosis should make a video about?
Lindsay Howard
Yeah, I’ve looked over the Osmosis NICU and newborn offerings — lots of great content on physiology and disease processes — but a big part of the NICU is developmental care, and that’s very specific to infants and newborns. It’s about giving them the best developmental and neuro outcomes.
As a fetus you’re in the dark, in fluid, sound is muffled — we try to replicate those conditions, but it’s not the same. Our incubators are heated, humidified, covered. We use special positioning products to keep them midline — arms and legs close to the body — because in the womb they feel the boundaries of the uterus, which is key for development. If they’re flailing freely, it’s bad for neurofeedback.
We keep them contained with specialized products — straps, bean bags — and structure our care around that. We practice “clustered care,” doing everything at once so we disturb them less. It’s stressful for them, so we do one grouped interaction — repositioning, diaper, vitals, maybe labs — then leave them alone as long as possible to rest and develop.
I didn’t really see content on that. It’s very NICU-specific but a big part of what we do, and if you’re not familiar, you’d have no idea.
Lindsey Smith
I think that’s a great suggestion, and we’ll pass it along to our content team. We’ll keep you posted if something gets created. Also, at Osmosis, many students and early-career health professionals listen to this show. What advice would you give them about meeting the challenges of this moment and approaching their healthcare careers?
Lindsay Howard
Hmm, that’s a good question. Like I said earlier, I always knew I wanted to do pediatrics and babies. There’s nothing wrong if you don’t know — try different things and see where you land. But there’s also nothing wrong with knowing what you want and going for it.
I knew I wanted this, so in nursing school I chose pediatric rotations whenever I could. I did my community health rotation as a school nurse.
There used to be a lot of chatter that you had to start in med-surg before specializing, but that’s not true anymore. The NICU is so specific, and much of the adult world doesn’t apply to us — and vice versa. So my advice: if you know what you want, do it. Don’t feel like you have to try everything.
Also, find other opportunities related to your field — volunteer work, community engagement. In my case, kid stuff. The more comfortable you are with your patient population, the better resource you become for them, and the better healthcare provider you’ll be.
Lindsey Smith
So get exposure early if you know what you want, and find those opportunities to make sure it’s a good fit. I know our listeners will appreciate your advice. Thank you so much, Lindsay, for being with us today.
Lindsay Howard
Thank you so much for having me. It was great.
Lindsey Smith
That wraps up today’s episode of Raise the Line. A heartfelt thank you to Lindsay Howard for joining us and sharing her deep expertise, compassion, and perspective on the critical role of NICUs. Her dedication to caring for the tiniest patients and educating the next generation of nurses is truly inspiring. We’re grateful for the work she does every day to support families and improve outcomes in some of the most challenging moments of life.
I’m Lindsey Smith. Thanks for checking out today’s show. Remember to do your part to raise the line and strengthen the healthcare system. We’re all in this together.