Trends in Neonatal Intensive Care Unit (NICU) Admission Rates in the United States

Between 2008 and 2018, NICU admission rates in the United States increased across all racial and ethnic groups and birthweights (Y. Kim et al., 2021).

Change in NICU Admissions, by Race and Ethnicity, Between 2008 and 2018
Race and Ethnicity	NICU admission rates (%)		Increase (%)
	2008	2018
Overall	6.62	9.07	37.0
Black	9.09	12.03	32.4
Hispanic	5.70	8.63	51.4
White	6.58	8.50	29.1

 

Change in NICU Admissions, by Birthweight, Between 2008 and 2018
Birthweight	NICU admission rates (%)		Increase (%)
	2008	2018
< 1,500 g	81.44	89.42	9.8
1,500–2,499 g	36.74	44.67	21.6
≥ 2,500 g	3.47	5.36	54.5

NICU Admissions by Gestational Age

The breakdown of NICU admissions by gestational age (GA) in 2021 was as follows (Centers for Disease Control and Prevention, 2021):

• 0% were born at less than 28 weeks’ gestation.
• 9% were born between 28 and 31 weeks’ gestation.
• 8% were born between 32 and 36 weeks’ gestation.
• 35% were born between 37 and 39 weeks’ gestation.
• 2% were born at 40 or more weeks’ gestation.

Common Diagnoses Among NICU Admissions, Extremely Preterm Neonates, and Term Infants

Incidence of a condition refers to the number of new cases identified in a specified time period.

Prevalence refers to the number of people who are living with a condition in a given time period.

Rates of Pediatric Feeding Disorders

Approximately 33%–36% of preterm infants admitted to the NICU have a feeding disorder (Rolnitsky et al., 2023; Senekki-Florent & Walshe, 2021). Prevalence rates range from 24.6% for low-birthweight infants (1,501–2,500 g) to 68.9% for very-low-birthweight infants (1,000–1,500 g) and 100% for extremely-low-birthweight infants (< 1,000 g). Among infants with a feeding disorder, nearly half (47.4%) have one co-occurring medical condition, 36% have two co-occurring conditions, and 16.6% have three or more. The most common co-occurring conditions are respiratory difficulties, neonatal jaundice, bronchopulmonary dysplasia, intrauterine growth restriction, congenital heart disease, sepsis, and anemia of prematurity (Senekki-Florent & Walshe, 2021).

Rates of Hearing Loss and Auditory Neuropathy Spectrum Disorder

Prevalence rates of hearing loss vary widely depending on the thresholds used to diagnose hearing loss (e.g., > 25 dB vs. > 35 dB) and the types of hearing loss included in the estimates (e.g., unilateral, bilateral).

The rate of hearing loss for those admitted to the NICU is approximately 7 times higher than the general neonatal population (Bussé et al., 2020; Butcher et al., 2019). The average prevalence of hearing loss in NICU infants is about 5.9 per 1,000 for countries with high per capita gross national income and 15.77 per 1,000 worldwide (Busse et al., 2020; Butcher et al., 2019). Among those with hearing loss, 78% of NICU infants have bilateral loss compared to 66% of those in the general infant population (Busse et al., 2020). The rate of auditory neuropathy spectrum disorder in the NICU is estimated to be 5 per 10,000 births and is higher than the rate in the well-baby nursery of 0.9 per 10,000 births (Boudewyns et al., 2016; Mahomva et al., 2022).

Visit Common Terminology and Diagnoses in the Neonatal Intensive Care Unit for birthweight and gestational age classifications and additional diagnoses.

Practice Environments and Levels of Care

Medical Equipment

NICU medical equipment may share similarities with that of other intensive care units, such as mechanical ventilators, leads and monitors, and infusion pumps, but much of the equipment is specialized to fit the needs of the developing or ill neonate. The speech-language pathologist (SLP) is aware of what the NICU infant’s physiologic and equipment needs are, how the equipment differs from adult intensive care settings, and how to interact with specialized medical equipment during provision of therapeutic services (National Association of Neonatal Therapists [NANT] Professional Collaborative, 2022). Examples of NICU-specific medical equipment are as follows:

• incubators to support thermoregulation
• high-frequency mechanical ventilation used in cases of severe respiratory distress
• therapeutic hypothermia, including cooling blankets and esophageal temperature probes, used in the case of asphyxia during the labor and delivery process

Level I Newborn Nursery

The newborn nursery provides postnatal care to stable term infants. The interprofessional team typically includes a pediatrician or family physician, advanced practice providers such as nurse practitioners or physician assistants, maternal-newborn nurses, and lactation consultants. Newborn nurseries can manage late preterm infants born between 35 and 37 weeks’ gestation who are medically stable and stabilizing premature or sick infants for transfer to a higher level of care. The SLP may provide consultative services to infants in the newborn nursery who are having feeding difficulties but do not require intensive care (i.e., late prematurity, orofacial clefts).

Level II Special Care Nursery

The special care nursery provides postnatal care to infants born at greater than 32 weeks’ gestation, weighing more than 1,500 g or approximately 3 lb (Stark et al., 2023). These infants are usually physiologically immature and/or ill and require respiratory support, thermoregulation, and/or enteral feeding for a short period of time. The interprofessional team may consist of neonatologists, advanced practice providers such as nurse practitioners or physician assistants, neonatal nurses, lactation consultants, and dietitians. Special care nurseries should have access to consultative neonatal therapy services, including one individual skilled in the management of feeding and swallowing disorders, who may be an SLP (Stark et al., 2023).

Level III NICU

The level III neonatal intensive care unit (NICU) provides comprehensive care for all premature and sick infants. Infants in the NICU may be born as early as 22 weeks of gestation, weigh less than 500 g (about 1 lb), and/or have mild to critical illnesses requiring sustained life support (Stark et al., 2023). The NICU can provide hemodynamic support and mechanical ventilation through more invasive or complex interventions such as high-frequency ventilation and therapeutic hypothermia. Infants in a NICU may be hospitalized for weeks or months depending on the complexity of their illness. The interprofessional team is more robust and includes access to pediatric subspecialties such as cardiology, pulmonology, and neurology. The NICU provides on-site neonatal therapy services emphasizing an integrated, preventative model with dedicated time allotted for NICU practice, including access to an SLP with expertise in the management of neonatal feeding and swallowing disorders (Stark et al., 2023). If swallowing studies are not offered on-site at the facility, policies and procedures will be in place to facilitate neonatal transfer to a higher level of care for these necessary procedures (Stark et al., 2023).

Level IV NICU + Regional Services

The level IV NICU provides all the services of a Level III NICU but expands comprehensive care to include provision of surgical services and cardiopulmonary bypass, such as extracorporeal membrane oxygenation (Stark et al., 2023). The Level IV NICU has on-site access to a broad range of pediatric subspecialists, pediatric surgeons, and pediatric anesthesiologists who can provide medical and/or surgical care to infants with complex congenital or acquired conditions. A Level IV facility has access to at least one SLP with neonatal expertise and dedicated time allocated to service the NICU, along with occupational therapists (OTs) and physical therapists (PTs) with neonatal expertise. These qualified neonatal therapists (NTs) can provide on-site consultative services (Stark et al., 2023). Additionally, a Level IV facility has access to instrumental swallowing evaluations—whether videofluoroscopic swallowing study (VFSS) or fiber-optic endoscopic evaluation of swallowing (FEES)—completed by a trained and competent SLP with expertise in the management of neonatal feeding and swallowing disorders.

NICU Follow-Up Clinic

The NICU follow-up clinic provides comprehensive neurodevelopmental care to infants after they are discharged from the hospital. The follow-up clinic addresses the medical, developmental, and psychosocial needs that premature and medically complex infants may have in their home and community environments due to the high-risk nature of their medical history. The interprofessional team evaluates an infant’s medical, nutritional, psychological, and developmental abilities throughout the first 2 years of their life. See the NICU Culture and IPP section for more information.

Generally, infants referred to the follow-up clinic are those born at less than 32 weeks’ gestation and/or weigh less than 1,500 g at birth, but many hospital systems will develop criteria that address specific medical risk factors for altered neurodevelopment. The follow-up clinic typically connects infants and their families with therapy services through their state’s early intervention program or local outpatient facilities. See ASHA’s Practice Portal page on Early Intervention.

Roles and ResponsibilitIes

Roles and Responsibilities of the Audiologist

Audiologists—by virtue of academic degree, clinical training, and license to practice—are qualified to provide guidance, development, implementation, and oversight of newborn hearing screening (NHS) programs. See ASHA’ s Scope of Practice in Audiology (ASHA, 2018).

Hospital-based audiologists are qualified to perform the following roles and responsibilities but need to do so in coordination with their state’s early hearing detection and intervention (EHDI) program:

Supervise NHS Program

• Ensure that the NHS program employs a sufficient number of trained staff and that these staff are scheduled appropriately to complete all daily NHS operations.
• Ensure that the NHS program has sufficient equipment and that this equipment is in good repair and is properly maintained and calibrated regularly.
• Ensure that the NHS staff follow state and hospital NHS protocols and guidelines.
• Provide on-going training for NHS staff.
• Provide quality control for the NHS program to include written policies and procedures for the program, monitoring of key statistics (e.g., refer rate), and in-service training for staff.
• Communicate NHS results to NICU staff and families and provide counseling as necessary.

Provide Audiological Services

• Work closely with the NICU medical care team to determine patient candidacy for diagnostic audiological testing.
• Establish a bedside audiologic evaluation protocol for use with NICU infants.
• Ensure that all equipment to be used in the evaluation of infants is in good repair and is properly maintained and calibrated regularly.
• Perform audiologic evaluation at bedside—this should be inclusive of any and all relevant tests: otoscopy, tympanometry, otoacoustic emissions (OAEs), auditory brainstem response, and so forth.
• Counsel families and NICU personnel regarding test results, prognosis, and audiologic management if any.
• Plan audiologic monitoring or management with the family and NICU care team.
• Make appropriate recommendations and referrals to other health care or developmental professionals.

Coordinate With EHDI and Others

• Follow state guidelines for reporting hearing screening data to EHDI and other local entities (e.g., Department of Health).
• Follow state guidelines for reporting hearing loss data to EHDI and other local entities.

As indicated in the ASHA Code of Ethics (ASHA, 2023), audiologists who work in this capacity should be specifically educated and appropriately trained to do so.

Roles and Responsibilities of SLPs

SLPs are integral to providing holistic, team-based, and family-centered care to infants and their families in the NICU. The professional roles and activities in speech-language pathology include clinical and educational services (diagnosis, assessment, planning, and treatment); prevention and advocacy; and education, administration, and research. See ASHA’s Scope of Practice in Speech-Language Pathology (ASHA, 2016).

The following roles and responsibilities allow SLPs to provide a continuum of services for infants and families in the NICU:

• Identify infants at risk for and with existing developmental communication, cognition, feeding, and swallowing problems.
• Select and conduct developmentally appropriate and culturally responsive clinical assessments. These assessments can be informal or formal and can be standardized or nonstandardized.
• Select and perform a developmentally appropriate assessment of structure and function that includes, but is not limited to, feeding, swallowing, sensory, neurobehavioral, neuromotor, musculoskeletal, communication, or cognition problems. Some examples of these items may include reflexes, postural control, state regulation, interactive abilities, prelinguistic skills, neurobehavioral stability, autonomic stability, prefeeding behaviors, oral feeding patterns and swallowing mechanism, and other oral sensorimotor functions.
• Conduct an instrumental evaluation of the infant for feeding and swallowing problems, which may include VFSSs and/or FEES. Document and communicate findings and recommendations with families, other caregivers, and members of the NICU team in a concise, thorough, and objective manner.
• Provide support and evidence-based intervention for the infant’s sensory, neurobehavioral, and neuromotor and musculoskeletal systems’ communication, cognition, feeding, and swallowing problems.
• Provide neurodevelopmentally supportive and family-centered care (e.g., environmental modulation, appropriate positioning and handling, timing of interventions). See ASHA’ resource on focusing care on individuals and their care partners.
• Identify and describe relevant components of the medical history for both the mother and the infant via medical chart review and interviews with the family and additional health care professionals.
• Recognize the chronic stress and trauma experienced by the infants and families admitted to the NICU; respond to patients and families with a trauma-informed lens to prevent retraumatization.
• Support best practices and evidence-based practice as well as contribute to a positive growth NICU culture (Cardin et al., 2023) by providing education, counseling, and support to families, other caregivers, and staff in the NICU, as it relates to the infant’s sensory, neurobehavioral, and neuromotor and musculoskeletal systems’ communication, cognition, feeding, and swallowing skill development.
• Collaborate and consult with the family and other team members in identifying the need for additional assessments and consultations and regarding management decisions for care of the infant and family. See ASHA’s resource on interprofessional education/interprofessional practice (IPE/IPP).
• Maintain a quality control or risk management program including, but not limited to, identifying and monitoring quality improvement indicators, resolving problems through collaborative team efforts, communicating risk factors with families and team members, and documenting quality improvement goals and processes.
• Provide discharge/transition planning and follow-up care (e.g., document discharge criteria, plan, and follow-up care).
• Educate and supervise SLPs, including Clinical Fellows and students in training. See ASHA’s resource on supervision requirements and ASHA’s Practice Portal page on Clinical Education and Supervision.
• Provide public education and advocacy for serving infants and families in the NICU, including providing testimony to various agencies and helping obtain funding for services.
• Remain informed of research in fetal and neonatal development and function and help advance the knowledge base related to the nature and approaches of neonatal therapy.

As indicated in the ASHA Code of Ethics (ASHA, 2023), SLPs who serve this population should be specifically educated and appropriately trained to do so.

Ethics

ASHA does not require or oversee additional training or certifications beyond the Certificate of Clinical Competence; however, individuals should have the necessary knowledge to practice in the NICU setting. The ASHA Code of Ethics states the following (ASHA, 2023):

• Principle of Ethics I: Individuals shall honor their responsibility to hold paramount the welfare of persons they serve professionally or who are participants in research and scholarly activities.
  • Rule A. Individuals shall provide all clinical services and scientific activities competently.
• Principle of Ethics II: Individuals shall provide all clinical services and scientific activities competently.
  • Rule A. Individuals who hold the Certificate of Clinical Competence shall engage in only those aspects of the professions that are within the scope of their professional practice and competence, considering their certification status, education, training, and experience.
  • Rule C. Individuals shall enhance and refine their professional competence and expertise through engagement in lifelong learning applicable to their professional activities and skills.

Acquiring neonatal therapy expertise and provision of neonatal therapy services require specialized training, continuing education, and mentorship. Per the Neonatal Therapy Core Scope of Practice, the NT must have knowledge of medical interventions occurring in tandem with therapeutic interventions and must be skilled in appropriate timing and intensity of interventions within the NICU environment (NANT, 2022). Neonatal therapy promotes optimal long-term developmental outcomes. Neonatal therapy nurtures infant–parent relationships by addressing the synergistic neurodevelopmental systems foundational to the development of functional skills, including the neurobehavioral, neuromotor, neuroendocrine, musculoskeletal, sensory, and psychosocial domains (Craig & Smith, 2020). Individual scopes of practice will differ among PTs, OTs, and SLPs, but any therapist working in the NICU possesses the foundational cross-discipline knowledge underlying neonatal therapy assessment and treatment.

Neonatal therapy expertise can be demonstrated through neonatal therapy certification with the Neonatal Therapy Certification Board. ASHA does not endorse any specific training or certification programs.

Theoretical Framework and Developmental Care Models

SLPs working in the NICU are considered neonatal therapists (NTs). NTs are focused on providing holistic care because the NICU is a stressful environment for infants and their caregivers. The theoretical frameworks and developmental care models in this section are integral to the well-being of infants and their caregivers in the NICU.

Dynamic Systems Theory

Dynamic systems theory states that an infant’s subsystems and their neuromuscular, musculoskeletal, cardiovascular, and integumentary systems are constantly interacting with each other and with the environment to produce functional, meaningful behavior (Thompson et al., 2023). A change in one system may enhance or diminish function in another. For example, an infant struggling to coordinate sucking, swallowing, and breathing while being fed in an upright position may demonstrate more fluid coordination and smoother respiration when repositioned into an elevated side-lying position (Shaker, 2013).

Per the dynamic systems theory, periods of learning are periods of transition for the infant, and it is during these periods that the infant is most responsive to change and primed for motor learning (Sweeney et al., 2010). Examples of dynamic systems theories include the synactive theory of development and the theory of neuronal group selection.

Synactive Theory of Development

The synactive theory of development (Als, 1982) is a framework for understanding preterm infant behavior. It is based on the understanding that preterm infants, and all living organisms, are in constant communication with their environment, and we can understand their needs if we can learn and understand their method of communication. The infant’s behaviors are grouped into five subsystems:

1. Autonomic: the basic physiologic functioning of the nervous system, including heart rate, oxygen saturation, and breathing, and the foundation for all the subsystems.
2. Motor: the infant’s muscle tone, muscle strength, and posture.
3. State: the infant’s level of arousal, usually categorized by sleeping, drowsy, awake, alert, and fussing/crying.
4. Attention/interaction: the infant’s ability to maintain an alert state and interact with their environment, such as making eye contact with a parent.
5. Self-regulation: the infant’s ability to achieve homeostasis and maintain stability within the other subsystems, usually seen through behaviors such as suckling on fingers or a pacifier.

Each subsystem interacts with and is dependent upon the other subsystems and the infant’s environment. These subsystems function smoothly in full-term infants but are not yet fully developed in preterm infants or infants with significant medical morbidities. The framework focuses on understanding an infant’s threshold for stress and disorganization. The infant will demonstrate subsystem instability and signs of stress when exposed to stimuli that are inappropriate in timing, complexity, or intensity. For example, if an infant is exposed to light that is too bright, they may respond with a change in state (e.g., transitioning to sleep) or a change in autonomic stability (e.g., decreased heart rate or oxygen saturation).

Conversely, being exposed to stimuli that are appropriate in timing, complexity, or intensity allows the infant to move toward the stimuli while maintaining balance within the subsystems. For example, infants will suckle on their fingers while contained within a flexed, midline position. See the Behavioral Cues section for more information about signs of stress in an infant.

Theory of Neuronal Group Selection

The theory of neuronal group selection describes how the nervous system becomes organized, stores information, and creates new behavioral patterns (Edelman, 1987). It states that the brain operates as a selective system and is a highly dynamic organ that is capable of structural and functional organization and reorganization based on internal and external signals from the body and the environment throughout development. This is known as neural plasticity—it is how the brain encodes experiences and learns new behaviors.

Newly learned behaviors likely require repeated practice to induce lasting neural changes, and it is hypothesized that behaviors acquired through repeated practice are less resistant to decay (Sweeney et al., 2010). Early sensorimotor experiences, with a central nervous system that is underdeveloped due to prematurity, are likely to permanently alter the architecture of the brain (Hadders-Algra, 2018). For instance, an infant who is orally fed under stressful physiologic conditions may disengage when offered a breast or bottle as a defensive protective response.

Attachment Theory

Attachment theory hypothesizes that there is a fundamental human need to form close relationships with each other. Attachment refers to the connection between a parent and an infant from the infant’s perspective. Although bonding is described as the parent’s feelings and connection to the infant, researchers have used attachment and bonding interchangeably (A. R. Kim & Kim, 2020; S.-Y. Kim & Kim, 2022).

The infant’s attachment to parents is fundamental to growth and brain development in the first few years of life (Feldman, 2015). The environment and interpersonal relationships influence this complex biological process. Different styles of attachment are associated with how the parent responds to an infant (Junewicz & Billick, 2018).

Attachment can significantly impact a child throughout their life, affecting future relationships, brain development, and mental health (Bourne et al., 2022). Impaired attachment and bonding can happen in the NICU due to stress related to alteration in parental role, posttraumatic stress and shock, and separation of the infant and parent. NICU staff can encourage skin-to-skin contact, also known as “kangaroo care,” to help parent–infant attachment (Cho et al., 2016). Skin-to-skin contact involves placing the infant, only wearing a diaper, on the parent’s bare chest and a blanket to facilitate neonatal physiological stability and support bonding (Gupta et al., 2021).

Co-Occupation Theory

Co-occupation occurs when a parent and a NICU infant perform an occupation in a mutually responsive, physical, and emotional interconnected manner. For example, during oral feeding in the NICU, the parent’s occupation is feeding their infant, while the infant’s occupation is eating. Co-occupation is an opportunity for parental bonding and attachment, which influences brain development, as well as for the infant’s communication to be understood and respected (Cardin, 2020). Viewing care activities, such as feedings, diaper changes, and bath time, as occupations and moments for meaningful communication allows the parental role to be fulfilled and for the infant to participate in a functional, developmentally supportive task. This strengthens the bond between the parent and the infant. The infant feels safe and secure, which decreases their physiologic stress, while the parent may feel they are protecting their infant from harm or stress.

Newborn Individualized Developmental Care and Assessment Program

The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) is a comprehensive approach to care that is developmentally supportive and individualized to the infant’s goals and level of stability (Als & McAnulty, 2011). NIDCAP aims to prevent the negative consequences of intensive care and to maintain the connection between the parent and the infant by avoiding overstimulation, stress, pain, and isolation while supporting self-regulation, competence, and goal orientation.

The holistic approach of NIDCAP involves the interprofessional team, who learns to observe infant behavior to guide interactions with the infant. This individualized approach encourages the infant to be an active participant in the experience. The infant’s caregivers and care team partner together to support the infant’s strengths and challenges using a plan of care based on the observations of the infant’s behaviors.

NIDCAP requires an extensive training and certification process. For more information, go to Training and Certification – NIDCAP.

Neonatal Integrative Developmental Care Model

The Neonatal Integrative Developmental Care Model, which outlines seven core measures for neuroprotective, family-centered developmental care of premature infants, is a framework that guides clinical practice in the NICU (Altimier & Phillips, 2016). Neuroprotection strategies aim to prevent neuronal cell death and support the developing brain in creating new neural pathways. The earlier in gestation an infant is born, the more vulnerable and fragile their brain is. It becomes increasingly critical to provide effective and consistent neuroprotective care from birth to protect and support optimal brain development.

The Neonatal Integrative Developmental Care Model uses neuroprotective interventions as strategies to support neural connections; promote normal neurological, physical, and emotional development; and prevent disabilities. The seven core neuroprotective measures are as follows:

1. The healing environment: the physical environment of the NICU (e.g., privacy and safety, sensory environment) as well as people (families and staff) and their interactions.
2. Partnering with families: the effective partnership between families and professionals. The family are the primary caregiver during the infant’s stay. Professionals use a trauma-informed approach to coaching and supporting families, with the goal of protecting the infant from toxic stress. See the Trauma-Informed Care in the NICU section for more information about toxic stress.
3. Positioning and handling: supports the premature infant’s body as closely as possible to the position the baby would have been in the womb, which is essential for optimal musculoskeletal development. See the Neuromotor and Musculoskeletal Development section for more information.
4. Safeguarding sleep: supports sleep preservation, which is essential for the normal neurodevelopment and adequate growth and healing of NICU infants. See the Safe Sleep section below for additional information.
5. Minimizing stress and pain: the influence of toxic stress on the developing brain, resulting in changes that negatively impact the creation of neural connections. See the Developmental Positioning, Handling, and Equipment section and the Trauma-Informed Care in the NICU section below for more information about reducing stress and pain.
6. Protecting skin: protects the underdeveloped skin barrier of the preterm infant, which puts the infant at risk for water loss, electrolyte imbalance, thermal instability, and infection. This measure outlines bathing protocols, emollient usage, humidity practices, and adhesive usage for infants at each stage of development.
7. Optimizing nutrition: the protective benefits of human milk feeding; protecting breastfeeding/chestfeeding; and supporting infant-driven oral feedings that are safe, functional, nurturing, and individually and developmentally appropriate.

Infant- and Family-Centered Developmental Care Standards

The Infant- and Family-Centered Developmental Care (IFCDC) standards are recommendations for best practices that describe the competencies needed for interprofessional practice (IPP) and for parents to provide individualized, environmentally protective, and nurturing care within an organizational culture (Browne et al., 2020). These practices also show the value of integrating the infant and family. The IFCDC recommendations are centered around the infant’s behavioral communication and the nurturing relationship of the parent(s) and family, who are key to managing and delivering care. The concept model focuses on individualized care, neuroprotection, environmental protection, and infant mental health, viewing the infant as a competent communicator and interactor. The IFCDC recommendations are as follows:

• Best Practices in Systems Thinking
• Best Practices for Positioning and Touch
• Best Practices to Support Sleep and Arousal
• Recommendations for Skin-to-Skin Contact with Intimate Family Members
• Best Practices for Reducing & Managing Pain and Stress in Newborns and Families
• Best Practices for Feeding, Eating and Nutrition Delivery

EHDI Programs

The Joint Committee on Infant Hearing (JCIH) recommends that all infants undergo a hearing screening prior to discharge from the hospital and no later than 1 month of age (JCIH, 2019). The JCIH recognizes that some medically fragile infants in the NICU (e.g., those on ventilators) may need to wait to undergo hearing screening until they are more stable. Factors that may affect the feasibility of or results from hearing screenings in the NICU environment are as follows:

• noise and/or electric interference from medical equipment
• maturation of the neurological pathways for premature newborns
• the presence of middle ear effusion in many of these infants

Audiologists must ensure to document the infant’s length of stay in the NICU for accurate state EHDI program data.

When considering what technology to employ for screening this population, the JCIH recommends utilizing automated auditory brainstem response (A-ABR) technology or a combination of A-ABR and OAEs. This is because screening with OAEs only would not detect auditory neuropathy, for which infants in the NICU are at an increased risk (Berg et al., 2005). Infants in the NICU who do not pass their hearing screening should be referred to a pediatric audiologist for rescreening, with A-ABR, and, if indicated, a comprehensive audiologic evaluation including a diagnostic auditory brainstem response. For infants who are in the NICU for a prolonged period of time, a diagnostic audiologic evaluation should be completed prior to discharge. Infants who are in the NICU for greater than 5 days should be considered “at risk” for delayed-onset hearing loss and monitored accordingly (JCIH, 2019).

For more information on risk factors for early childhood hearing loss and hearing screening protocol in the NICU, see ASHA’s Practice Portal page on Newborn Hearing Screening and Year 2019 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs.

NICU Culture and IPP

Neonatal therapy is provided in an integrated collaborative care model. This means that the NT is a member of the interprofessional team, with protected time solely for NICU practice. While each NT (i.e., OT, PT, SLP) has skills that fall specifically within the scope of practice of their profession, there are foundational neonatal therapy service skills included within the NANT’s scope of practice across all three professions of occupational therapy, physical therapy, and speech-language pathology (NANT, 2022).

The increasing medical complexity of infants in the NICU makes it difficult for any individual family or provider to manage all facets of neonatal care independently. Ideal care requires an interprofessional collaborative team working toward the same goals for provision of neurodevelopmentally appropriate care and desired outcomes.

The core interprofessional NICU care teams may include the following:

• medical providers
  • nurses
  • nurse practitioners
  • physicians
• developmental specialists
  • audiologists
  • lactation consultants
  • OTs
  • PTs
  • respiratory therapists
  • SLPs
• ancillary providers
  • dietitians
  • lactation consultants
  • psychologists
  • social workers
• infant and their family

Delivering high-quality care to medically complex infants in the NICU requires a cohesive team of professionals who collaborate and communicate effectively. The team approach is essential for incorporating developmental and therapeutic goals and interventions into nursing and medical care, for example, managing an infant’s pain with positioning or facilitating kangaroo care for a critically ill, mechanically ventilated infant. Professionals must have a mutual understanding of the infant’s conditions and the role sharing and delineation of each team member for the team to function effectively. This collaboration includes screening for social determinants of health and identifying the needs and circumstances of the family that may require support and accommodations. The interprofessional team coordinates how information is gathered, responded to, and shared.

Dynamics of the NICU Care Team

Interdependencies exist between groups in the NICU (i.e., medical team, developmental team, support personnel, families). These interdependencies require that

• all members be engaged and collaborative while working toward a common goal and
• each member interacts with others to influence positive infant and family health outcomes (Barbosa, 2013).

Team members are encouraged to listen with the intent of learning from each other, which helps build trust, gain respect, and form close relationships—especially in a physiologically challenging environment (Barbosa, 2013).

The components of effective teamwork include the following (Masten et al., 2019):

• a shared mission
• communication and management of conflict
• psychological safety
• trust and respect

NICU team members can overcome professional barriers to care by acknowledging conflict among team members and developing processes for addressing it. The following strategies can help mitigate or constructively address conflict when it occurs (Masten et al., 2019):

• questioning hierarchies
• ensuring psychological safety so team members feel free to voice concerns
• providing mechanisms and tools for providing feedback

See ASHA’s resource on interprofessional education/interprofessional practice (IPE/IPP).

Components of Assessment In The NICU

Framework for Assessment

The evaluation and intervention practices of each neonatal therapy discipline (occupational therapy, physical therapy, and speech-language pathology) will vary based on the diagnosis or problem, the scope of practice, and state regulations. The underlying principles regarding assessment and intervention include the following:

• Intervention requires continuous assessment.
• Assessment occurs before, during, and after intervention.
• Assessment can be formal and/or informal and includes observational assessment.
• The development of subsystems is connected to one another.
• Medical status, diagnoses, age, and medications affect assessment and intervention.

Types of Assessment

Standardized Assessment

The NT uses standardized outcome measures to assess neuromotor development, movement patterns, neurobehavior, and feeding. Standardized assessments are usually psychometrically sound and are criterion- or norm-referenced. They require infant handling and following a specific set of instructions to elicit infant neurobehavioral and neuromotor responses, or they may be a parent-reported outcome measure. NTs use standardized assessments to assess developmental delays and feeding skills. Standardized assessments can also help NTs identify and predict risk for developmental disorders (e.g., cerebral palsy), plan intervention, and document change over time.

Non-Standardized and Observational Assessment

Non-standardized assessment involves participating in care activities, such as feeding, with handling to assess an infant’s neuromotor, neurobehavioral, neuroendocrine, musculoskeletal, and sensory development. Non-standardized assessment also includes consideration of the infant and family’s psychosocial well-being. These considerations are made in the context of the family’s social determinants of health and cultural and linguistic background. Ethnographic interviewing techniques help clinicians take note of different practices and beliefs surrounding birth, feeding, newborns, and family structure.

During a non-standardized assessment, the NT participates in the infant’s routine care to gain information about the infant’s internal and external responses to stimuli. Using the infant’s communication as a guide, the NT applies interventions as needed to regulate state modulation and support physiologic stability to decrease exposure to toxic stress. The infant’s needs and responses to interventions then inform therapeutic recommendations and a treatment plan, as well as caregiver coaching and interprofessional team education.

See ASHA’s resource on social determinants of health. See ASHA’s Practice Portal page on Cultural Responsiveness for more information on ethnographic interviewing.

Observational assessment involves observations of the infant’s macro- and microenvironment and of infant behavior during daily care. Observation of the macro- and microenvironment helps determine what adaptations are necessary to protect the infant’s neurobehavioral system. Observation of the infant’s behavior during daily care provides an important basis for recommendations in how best to minimize stress and optimize an infant’s development. Observational assessment allows the infant to be an active participant and guides interactions based on their communication. Observational assessment may include participation in care with the family or interprofessional team, with the NT as an observer to the infant’s behavior.

Practice Domains and Interventions

The NICU is a unique setting in which NTs require specialized knowledge and skills. The NT understands the common comorbidities, vulnerabilities, and interconnectedness of the infant.

This section describes the various practice domains that a clinician will encounter as a member of the NICU interprofessional team. The team assesses and makes intervention recommendations based on these practice domains and the infant’s medical status. The NT is aware of how postnatal medications, associated medical/surgical interventions, and the birthing parent’s risk factors and complications (i.e., hypertension, tobacco use) may impact the infant. For example, the NT is aware that medications that manage comorbidities, such as chronic lung disease, may negatively influence growth and neurodevelopment. The clinician continually assesses the infant when providing intervention and adjusts interventions as necessary.

Family Dynamic

The SLP provides psychosocial support to families in the NICU that aligns with their individual cultural and linguistic preferences and needs. The SLP assesses the family’s confidence and competence related to the following (Craig & Smith, 2020):

• attachment and bonding with their infant
• psychosocial support available to the family
• activities of daily living (e.g., feeding, diapering, changing clothes, bathing)
• their cognitive abilities or barriers while facilitating confidence in caregiving interventions and supporting the transition to home

Postpartum practices—as well as child–parent interactions and expectations—vary by culture and may not always align with the beliefs of the clinician or interprofessional team. It is necessary to respect and incorporate the family’s beliefs and practices during interactions and when providing education and recommendations.

Sensory System

The fetus’s sensory system develops in a precise order within the intrauterine environment, which is rich with positive sensory input and has limited light and noise exposure. Sensory input is primarily provided by the boundaries of the uterine walls, contact with amniotic fluid, birthing parent voice, and filtered sounds from the extrauterine environment.

Sensory development occurs in the following sequential order (Graven & Browne, 2008b):

1. Tactile: The fetus begins reacting to tactile input at 8 weeks’ gestation, though immaturely; tactile sensation is fully developed at 12 weeks’ gestation.
2. Vestibular: This sensory system becomes functional at 10–14 weeks’ gestation.
3. Olfactory and gustatory: These sensory systems develop closely together; the olfactory system develops between 7 and 12 weeks’ gestation, whereas the gustatory system develops between 12 and –13 weeks’ gestation.
4. Auditory: The fetus consistently responds to auditory input at 24–25 weeks’ gestation; orients to sound by 34–35 weeks’ gestation.
5. Visual: The eyelids begin to open at 24 weeks’ gestation; pupillary constriction to light begins at approximately 30 weeks’ gestation but is not mature until 36+ weeks.

Preterm infants have an immature nervous system and are exposed to sensory input that are different from the intrauterine experience. Negative sensory input replaces positive sensory input in the brain and can permanently alter neurological development (Altimier & Phillips, 2016). Sensory interference may occur when immature sensory systems are stimulated out of turn or with inappropriate stimuli. An example of stimulating a sensory system out of turn includes exposing an infant to bright light before their vision is fully developed. An example of stimulating a sensory system with inappropriate stimuli includes exposing an infant to constant loud noise. Sensory interference could contribute to the behavioral, cognitive, and functional deficits, which many premature infants manifest. Facilitating an environment that is appropriate in sensory stimulation duration and frequency is necessary toward supporting optimal neurodevelopment and neurodevelopmental outcomes (Pineda et al., 2023). Programs, such as SENSE (Supporting and Enhancing NICU Sensory Experiences), have recommendations for sensory inputs based on age and stimuli (Pineda & Raney et al., 2019).

Environment

The macroenvironment is the larger sensory environment of the NICU and includes temperature, humidity, light, and sound. The microenvironment is the infant’s immediate bedspace, which could be within an incubator or on a parent’s chest for skin-to-skin contact.

Modifying the infant’s environment reduces sensory interference, promotes stability (e.g., neurobehavioral, neuromotor, state system stability), and protects sleep.

Sound and Noise

In utero, the fetus is exposed to low-frequency sounds, such as the birth parent’s cardiovascular system (heartbeat) and gastrointestinal digestion. The birth parent’s voice and the muffled sounds coming from the extrauterine environment also serve important low-frequency auditory inputs necessary to slowly stimulate the auditory cortex for sensory development.

In contrast, the sound environment of the NICU has high levels of low- and high-frequency sounds, such as alarms, beeps, and respiratory equipment (Byers et al., 2006). Excessive ambient noise—that is, greater than 45 decibels (dB)—may result in physiologic effects on the preterm infant, such as increased heart rate, decreased respiratory rate, and decreased oxygen saturation (Coston & Aune, 2019; Kuhn et al., 2012).

NICU professionals limit excessive sound and noise to protect the infants from sleep disturbances and their immature sensory systems from being stimulated out of turn or with inappropriate stimuli (Coston & Aune, 2019).

Parental/Maternal Voice

Exposure to parental voice while in utero is an important part of a fetus’s hearing and neurological development. Preterm infants lack this experience, to some extent. Environmental obstacles limit physical contact between the parent and the infant, so there are fewer opportunities for parental/maternal voice exposure and attachment (Krueger, 2010).

Exposure to parental voice is beneficial for the preterm infant’s feeding, cognitive, and neurobehavioral development (Provenzi et al., 2018). Parental voice includes (a) live and recorded parental speaking or singing and (b) recorded parental speech combined with biological parental sounds (Williamson & McGrath, 2019). The preterm infant is exposed to sound based on the infant’s gestational age (Pineda et al., 2023). The method of parental voice exposure is based on the infant and family’s unique needs. Opportunities for parental voice exposure are as follows:

• skin-to-skin care
• feeding and caregiving activities
• painful procedures, such as a heel lance
• reading at the bedside

Cycled Lighting

Sight is the last sense to mature. Therefore, a preterm infant’s eyes are very sensitive to stimuli and are often overstimulated by the lack of light–dark cycles in the NICU environment. Light is not necessary for development since the infant is not exposed to light in utero. NTs use cycled lighting to help regulate visual stimuli and promote a biologically appropriate circadian rhythm (Rea & Figueiro, 2016).

Cycled lighting is the exposure of indirect light for 12 hours during the day and then providing a dim or dark environment for 12 hours at night. Examples of cycled lighting include the following (Browne et al., 2020; Morag & Ohlsson, 2016; Rea & Figueiro, 2016):

• Day versus night lighting can be achieved through artificial lighting or uncovering of windows during the day. This allows the infant to be exposed to 200–500 lux of lighting.
• At nighttime, windows can be curtain-covered, and light can be limited to low-intensity night light of < 30 lux.
• Ambient lighting levels in infant care spaces can be adjustable through a range of at least 10 to no more than 600 lux. Eye protection may be used if higher intensity light is needed for procedures or during examination.

Neuromotor and Musculoskeletal Development

Maturation of Posture, Tone, Movement, and Alignment Reflexes

In the uterus, the fetus exists in an antigravity-like environment. When preterm infants are born, the effects of gravity and prolonged periods of static positioning can lead to adverse muscular, postural, and alignment consequences (Sweeney & Gutierrez, 2002; Yang et al., 2023). Appropriate postural alignment and muscle tone is necessary to support the infant’s head and neck for safe and functional movements. Safe and functional movement is needed for the infant’s activities of daily living such as feeding and exploring and learning about their environment.

Muscle tone and posture develops in a caudocephalic (feet-to-head) direction in preterm infants, with the following neuromotor expectations through gestation:

• 28 weeks’ gestation and less: global hypotonia
• 30–32 weeks’ gestation: beginning of flexion in lower extremities
• 34 weeks’ gestation: hip flexion, flexor tone in upper extremities
• 36 weeks’ gestation: flexor tone dominates in trunk and extremities
• 40 weeks’ gestation: flexor and extensor muscles equalize

Preterm infants are typically unable to change their static positions independently. Prolonged periods in one position allow for muscle imbalances to develop (Yang et al., 2023). For example, head, neck, and/or trunk hyperextension can be a consequence of the preterm infant’s muscles being in extended positions for long periods of time. These altered neuromotor movement patterns can result in long-term muscle abnormalities that influence posture, tone, and movement needed for later motor milestones such as sitting, crawling, and reaching (Monterosso et al., 2002; Yang et al., 2023). Alterations in neuromotor patterns and motor milestones directly impact the progression of oral feeding skills.

Primitive and postural reflexes are controlled by the central nervous system and are present to ensure the body remains aligned. These reflexes create the foundations for movement patterns, safety, and proprioception. For example, the head righting reflex is triggered to maintain the head in an upright position with eyes facing forward and level with the ears. Head righting is important for head control that is necessary for all later motor skills.

Some reflexes have “windows” in which they are present to facilitate skill development before integration. For example, the sucking reflex helps establish functional sucking and swallowing skills. When an infant is between 3 and 6 months of age, their involuntary reflex makes way for more mature movement patterns and learning. Absent, excessive, or retained reflexes can negatively impact motor development—and indicate the need for a comprehensive neurological evaluation.

Developmental Positioning, Handling, and Equipment

During gestation, the fetus receives consistent positioning and sensory input from the uterus that facilitates musculoskeletal development and physiologic flexion needed for neuromuscular development and self-regulation. Preterm infants lose the stability of the uterine environment and are exposed to the effects of gravity with immature musculoskeletal and neuromuscular systems (Altimier & Phillips, 2016). NTs support infants through positioning interventions that promote the integrity and organization of the musculoskeletal, postural, and sensorimotor systems.

Uterine crowding, which occurs in the third trimester, supports the development of physiologic flexion. Shoulder flexion, scapular protraction, hip and knee flexion, and posterior pelvic tilt facilitate midline orientation. Absence of these experiences influences neurodevelopmental outcomes, such as oral feeding, musculoskeletal development, and parent–infant attachment and bonding.

Appropriate neurodevelopmental positioning influences functioning in the autonomic, pulmonary, and digestive systems.

The main goals of neurodevelopmental positioning are as follows:

• Optimize musculoskeletal developmental and alignment.
• Provide support for posture and movement.
• Promote calm state and behavioral regulation.
• Provide opportunities to engage with proprioceptive and tactile stimuli.
• Conserve energy and support growth.
• Provide opportunities for protected sleep.

Neurodevelopmental positioning enables the following (Sweeney et al., 2010):

• a flexed, midline, and contained position
• head and neck in neutral position and midline
• shoulders rounded to promote hands toward midline
• trunk in a “C” curve to promote hands and legs toward midline
• posterior pelvic tilt
• legs and hips symmetrical, in flexion, and in neutral rotation
• foot support for bracing, allowing for self-regulation

Examples of positioning interventions are as follows (Sweeney et al., 2010; Yang et al., 2023):

• Positioning and handing the infant in flexion and containment during all care activities.
• Providing hand containment or facilitative tucking during care and procedures to reduce stress and exposure to pain.
• Swaddling with arms and legs midline and flexed, with hands facilitated toward face, especially during activities such as bathing, weighing, and blood draws/heel sticks.
• Using positioning aids to form a “nest” within an infant’s bedspace that includes soft boundaries and support for foot bracing to assist with self-regulation, physiologic stability, and decreased energy expenditure.
• Allowing for spontaneous movement in side-lying and prone positions—but also providing secure containment through positioning aids. These aids facilitate the reflex stimulus for extremity extension and subsequent flexion recoil.
• Providing tactile and proprioceptive input through positioning aids, as well as displacing the infant’s body weight when prone to avoid the effects of gravity.

Positioning aids may include the following:

• Buntings and wraps—a support that forms the foundation of a contained “nest,” allows for flexion recoil, and provides support for foot bracing.
• Beanbag positioners—weighted beanbags of various shapes that provide flexible boundaries and proprioceptive input, usually used to assist with head or lower extremity positioning.
• Fluidized positioners—positioners that are molded around the infant and infant medical interfaces (e.g., head gear, IV board). This supports optimal positioning while offsetting pressure and allowing for extremity extension, recoil, flexion, or bracing.
• Prone pads—provides support to the head, neck, and trunk, allowing for flexion in a prone position.
• Foam boundaries—flexible tube boundaries that can be adjusted and shaped to provide circumferential containment in support of flexion maintenance.
• Gel mattresses or pad—gel-filled mattress or pad used to support the infant’s body or head.

Safe Sleep

Protecting sleep is essential to supporting neurodevelopment. Sudden unexplained infant death (SUID) is any sudden and unexpected death, with a known or an unknown cause, occurring during infancy (Moon et al., 2022). Sudden infant death syndrome, also known as SIDS, is a subcategory of SUID and occurs when an infant with intrinsic vulnerability (such as impaired arousal, cardiorespiratory, and/or autonomic responses) undergoes an external trigger event (such as exposure to an unsafe sleeping environment) during a critical developmental period. Preterm infants have an increased risk of SUID (Bandoli et al., 2022; Ostfeld et al., 2017).

It is essential that families are provided with safe-sleep education and modeling throughout their NICU stay to support a smooth transition to a safe-sleep environment at home (Goodstein et al., 2021). The American Academy of Pediatrics (AAP) recommends that preterm infants are kept in a predominantly supine (i.e., lying on their back) position to adjust to supine sleeping from 32 weeks’ gestation onward. However, many preterm infants are not yet developmentally appropriate for supine positioning, and some may still require support from positioning aids that are not used for safe sleep at home (Goodstein et al., 2021; Moon et al., 2022). Families should be educated that positioning aids are for use only in the NICU setting, where the infant is constantly monitored, and that they are not part of a home safe-sleep environment.

Infants with neonatal opioid withdrawal syndrome, or NOWS, have additional considerations as treatment usually includes nonpharmacologic strategies aimed at increasing self-regulation and minimizing stimulation and discomfort (Goodstein et al., 2021). Prone positioning can decrease the severity of NOWS scores during the acute withdrawal phase in the NICU but is discontinued as soon as possible to promote a safe-sleep environment.

The NT is knowledgeable of these recommendations to facilitate a neuroprotective home safe-sleep environment in line with the infant’s developmental abilities.

Neurobehavior

Behavioral Cues

Behavioral cues are the nonverbal communication method that infants use to express their needs. A caregiver’s appropriate interpretation of these behavioral cues is a vital part of developmentally supportive care.

Behavioral cues can be divided into two categories: avoidance cues and approach cues. Avoidance cues are behaviors that indicate the infant is stressed and not able to cope with the interaction occurring. Approach cues are behaviors that indicate the infant is able to manage the interaction and is in a receptive state for learning and communication.

These cues occur across the five behavioral subsystems and are largely communicated subconsciously by the infant.

Examples of avoidance cues include the following:

• Autonomic: apnea, bradycardia, desaturations, gagging, color changes, tremors, visceral stress such as constipation and reflux
• Motor: hypertonia, hypotonia, finger splaying, extension
• State: fluctuating states, fussiness, poor sleep/wake cycles
• Attention/interaction: gaze aversion, staring, eye widening, sudden shutdown in arousal
• Self-regulatory: unable to engage in self-regulating behaviors such as moving their hands to their mouth or sucking

Examples of approach cues include the following:

• Autonomic: stable heart rate, respiratory rate and oxygenation, appropriate color
• Motor: smooth movements, relaxed posture, flexion
• State: smooth state transitions, alert and focused, appropriate sleep/wake cycles
• Attention/interaction: orients to sound, alert and attentive
• Self-regulatory: hands to mouth, sucking, foot bracing

States of Arousal

The duration of and the transition between states of arousal mature as infants age (Foreman et al., 2008). An infant’s arousal state can communicate their readiness for interaction and learning. There are six arousal states:

1. Quiet sleep: deep sleep where the infant can disregard disturbing noise in their environment. This state is important for brain growth and development.
2. Active sleep: also known as “REM sleep.” The infant might show small body movements and may have irregular, shallow breathing and sucking.
3. Drowsy: a transitional state where the infant may have their eyes open but may be fussy or have delayed or slowed reactions. Light stimulation, such as rocking, can help the infant either become alert or transition back to sleep.
4. Quiet alert: This state is ideal for learning. The infant is generally calm and displays visual attention to a caregiver or the environment.
5. Active alert: The infant is physically active and may be communicating needs such as tiredness, wanting to feed, or needing a break from interaction.
6. Crying: The infant is in distress and is communicating the need for comfort and support.

Infants’ sleep–alert behaviors change with age. Active sleep decreases, and quiet sleep, active alert, and quiet alert increase (Holditch-Davis et al., 2004). Environmental factors and co-occurring conditions disrupt the proper sleep–alert development of preterm infants in the NICU (Bennet et al., 2018; Foreman et al., 2008). Preterm infants do not have the same sleep functioning as full-term infants. Preterm infants, who have an immature central nervous system, often lack cycling between sleep states, have shorter sleep periods, and have more transitional sleep states (Ardura et al., 1995).

Pre-Feeding, Oral Feeding, and Swallowing

See the Pediatric Feeding and Swallowing Evidence Map—Preterm/Low Birth Weight for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Oral Reflexes

Much like gross motor reflexes, oral reflexes support the attainment of motor patterns needed for oral feeding and facilitate the foundational skills necessary for later motor movements for chewing, drinking, and so forth. Oral reflexes include the following:

• Rooting: The infant moves toward stimulation when touched on the cheek or lips. This reflex helps the infant locate the breast or bottle for feeding and integrates around 3–4 months of age.
• Sucking: The infant sucks rhythmically on a finger, breast, or bottle using anterior–posterior lingual movement. This reflex is necessary for establishing oral feeding until integration and voluntary sucking at about 3–4 months of age.
• Tongue protrusion: The tongue protrudes when the lips are touched. This reflex supports sucking from a breast or bottle and protects against choking. It integrates between 4 and 7 months of age.
• Phasic bite: This reflex involves opening and closing of the jaw to bite when pressure is applied to the gums and supports later development of chewing skills and integrates between 9 and 12 months of age.
• Lateral tongue: This reflex involves lateral lingual movement when sides of the tongue are stimulated and supports tongue lateralization needed for bolus control and mastication and integrates between 7 and 9 months of age.
• Gag: The tongue moves up and forward to expel an object anteriorly when the posterior tongue is stimulated. This reflex protects against airway invasion.

Lactation

The SLP collaborates with the family, the lactation consultant, and the IPP team to support breastfeeding/chestfeeding of human milk in the NICU. The SLP plays a critical role in educating families on the benefits of breastfeeding/chestfeeding. Various organizations recommend exclusive breastfeeding or the provision of human milk for at least 6 months after birth and until 2 years or beyond, if desired by the child and the parent (Meek et al., 2022; World Health Organization, 2023). Pasteurized donor human milk may be provided if a parent’s milk is not available or is contraindicated (Abrams et al., 2017; Meek et al., 2022).

Human milk has a unique composition that contributes to the infant’s developing immune system, which is superior to the composition of commercial infant formulas. In the NICU, human milk can provide various benefits for very-low-birthweight infants, such as reduction of necrotizing enterocolitis, late-onset sepsis, chronic lung disease, and retinopathy of prematurity as well as improved neurodevelopment (Pados, 2023; Parker et al., 2021). Human milk also reduces the risk of death across vulnerable infant populations in the NICU (Pados, 2023).

Successful provision of human milk begins from birth. Early lactation education can include skin-to-skin care, non-nutritive sucking (NNS), milk expression, and oral immune therapy (OIT) or therapeutic tastes of human milk. Families usually aim to provide frequent skin-to-skin care as soon as possible following birth, as the infant’s medical status allows. Human milk feeding equipment may include a hospital-grade pumping system. There is currently no Food and Drug Administration (FDA) definition of a “hospital-grade pump.” This FDA resource discusses breast pump options.

Although the benefits of human milk are well known and frequently encouraged in the NICU, the SLP also practices cultural responsiveness and keeps the family’s social determinants of health in mind. SLPs, lactation consultants, and the NICU medical team support the family’s decision. All NICU professionals avoid using language that may create stress or guilt. Respecting the choice of the parents is imperative for a trusting and supportive relationship between the health care team and the family.

Even with adequate pumping with quality equipment, many parents of preterm infants are unable to produce enough human milk or maintain their milk supply throughout their infant’s hospital stay. NICUs can offer donor human milk to supplement the parent’s milk, as necessary. However, following discharge, parents must purchase donor human milk at a very high cost if they wish to continue the use of donor human milk in place of infant formula. Additionally, some parents must return to work soon after their infant’s birth. They may not have an opportunity or a location in which to pump while at work. In these cases, the parent might choose to use either

• a combination of own mother’s milk (OMM) and donor human milk or
• OMM and formula.

NICU staff must also understand that there will be times when a human milk diet may not be best for the family—for the following reasons:

1. Stress and anxiety may be aggravated by pumping, resulting in poor mental health.
2. Birthing parents who have experienced physical trauma may not wish to pump or chestfeed.
3. Parents have made an informed decision to use formula.
4. Parents have religious concerns about using donor human milk
5. The birthing parent uses certain required medications that are contraindicated for chestfeeding or pumping for infants.
6. The infant may have a condition in which they cannot tolerate human milk.

Non-Nutritive Sucking

Non-nutritive sucking (NNS) is an important precursor for an infant’s ability to orally feed. NNS involves the coordination of compression bursts of sucking and pause intervals for breathing, in the absence of liquids. Each burst contains six to 12 suck cycles, at a rate of two sucks per second (Barlow et al., 2023). The maturation and coordination of NNS serves as a foundational skill that precedes nutritive sucking skills.

NNS is an important precursor for a preterm infant’s ability to orally feed (Pineda & Dewey et al., 2019). However, preterm infants consistently present with immature sucking for two reasons:

1. Gestational age was found to be a direct predictor of sucking skill and feeding maturation (Amaizu et al., 2008). The lower the gestational ages, the less mature their skill levels.
2. Physiologic stability and neurodevelopmental status are intricately linked to sucking skills. Preterm infants who have poor reactivity to stimulation, poor motor responses, and poor state control were found to have slower suck rates (Silberstein et al., 2009).

SLPs in the NICU offer NNS to reduce feeding intolerance and promote oral feeding (Zhao et al., 2024).

NNS can be offered during skin-to-skin care at an empty breast to provide positive oral feeding experiences and support parent–infant bonding and attachment (Fucile et al., 2021). The parent can pump until their mammary glands are emptied and then can position the infant skin-to-skin so they can suckle at the breast. The parent can provide additional NNS opportunities by offering their infant a pacifier. There is no precise age at which an infant can begin NNS. Timing is based on the infant’s physiologic stability and interest in sucking.

Oral Immune Therapy and Single-Swallow Bolus Intervention

The intrauterine environment is rich with sensory inputs for the fetus, such as the following:

• tastes from the amniotic fluid
• smooth, wet, soft surfaces to rub their face against
• Fingers, toes, and an umbilical cord to suck on

The fetus also practices swallowing throughout fetal development by sucking and swallowing approximately 400–700 ml of amniotic fluid a day. These sensory experiences stimulate the development of neural pathways that connect acts of eating and swallowing with stability and pleasure. Preterm birth limits these positive exposures, which are then replaced with noxious stimulation—which includes endotracheal tube placement, feeding tube placement, tapes on their face to hold these tubes in place, and oral suctioning. Noxious stimulation can negatively impact oral feeding success in the long term.

NTs provide single-swallow bolus interventions. A single-swallow bolus intervention is a neuroprotective intervention that provides positive oral enjoyment while honing oral motor skills by helping the infant work on swallowing to prepare for oral feeding (ORourke et al., 2023). The single-swallow bolus intervention may also be called

• pacifier dip,
• milk drop intervention,
• taste,
• therapeutic trial,
• therapeutic drop/taste, or
• oral enjoyment.

A single-swallow bolus intervention or “milk drop intervention” (ORourke et al., 2023) is a procedure in which the NT gives small, single drops of milk to the infant during NNS. The milk components can stimulate the infant’s oropharyngeal-associated lymphoid tissues, thus providing protective immunomodulatory effects (Gephart & Weller, 2014). The caregiver pays careful attention to the infant’s cues and interest. Milk drops are discontinued with any signs of stress or disengagement.

These interventions can easily be confused with a similar practice that shares many of the same benefits, most often seen as oral immune therapy (OIT). In the literature, it may also be called

• colostrum OIT,
• oral colostrum care,
• oropharyngeal administration of colostrum or mother’s milk,
• oral care,
• mouth care, or
• oral swabbing.

OIT is typically provided by using a sterile cotton swab or sponge tip applicator soaked in a small amount of human milk or colostrum (Gephart & Weller, 2014) or delivered along the buccal mucosa via syringe drops (Maffei et al., 2020). With olfactory stimulation, the sterile cotton swab is held near the infant’s nose. With intraoral stimulation, the swab is placed on the infant’s gums, tongue, and buccal cavities. The caregiver carefully avoids overstimulating or noxiously stimulating the infant.

OIT and single-swallow bolus intervention aim to stimulate both the olfactory and gustatory sensory development pathways, provide positive oral sensory experiences, and protect against the negative sensory inputs associated with necessary medical care in the NICU (Davidson et al., 2019).

Skin-to-Skin Care

Skin-to-skin care can begin from birth or as early as the infant’s medical status allows. Skin-to-skin care may also promote maternal milk production and the likelihood of exclusive breastfeeding (Boundy et al., 2016; Daniels et al., 2023).

Cue-Based Feeding

Cue-based feeding is a broad term used to describe the framework by which families and the IPP team attend to an infant’s communication to promote optimal feeding opportunities. Cue-based feeding is also known as “infant-led feeding” or “infant-driven feeding.” This approach supports the quality of oral feedings rather than the volume (Shaker, 2013). The infant’s feeding skills develop pleasurably and at the infant’s own pace. When the focus of a feeding is led by volume expectations, negative consequences—such as disinterest, oral aversion, and reduced quality of feeding—can occur. These consequences may compromise short- and long-term feeding experiences.

Cue-based feeding depends on co-regulation between the infant and the caregiver. The caregiver observes the infant’s behaviors to guide the frequency, timing, and length of interventions to support physiologic stability (Thoyre et al., 2012). Co-regulation, the foundation for a positive infant-guided feeding approach, includes the following (Shaker, 2013):

• Observing the infant from moment to moment during feeding, all the while noting whether the infant is communicating stress or stability—especially with swallowing, breathing, physiologic stability, postural control, and state regulation.
• Continuously modifying the feeding approach based on the infant’s ongoing communication.

Breastfeeding/Chestfeeding and Bottle-Feeding

Assessment of an infant’s oral feeding abilities may include breastfeeding and bottle-feeding. The SLP collaborates with the family, the bedside nurse, the lactation consultant, and the interprofessional team to support safe, neurodevelopmentally supportive bottle-feeding in the NICU. Breastfeeding and bottle-feeding assessment may include the following (Arvedson, 2008):

• chart review of family, medical, developmental, and feeding history
• physical examination of prefeeding readiness such as infant and parent interactions, arousal, and movement patterns
• oral structure and function assessment
• clinical feeding observation

The oral structure and function assessment includes a thorough examination of oral structures before any liquid is offered to the infant. The assessment includes observations of the following (Arvedson, 2008):

• symmetry or asymmetry of facial features
• lip and jaw position
• palate shape and height
• tongue position in the oral cavity
• tongue movement patterns
• anatomical variations such as cleft palate, cleft lip, and ankyloglossia
• oral reflexes and NNS in young infants
• laryngeal function as noted by voice quality

A clinical feeding observational assessment includes observation of the infant’s neuromotor skills; neurobehavior; sensory tolerance; and infant–family dynamic in the context of the demands of oral feeding, whether by breast, bottle, or both.

Initial oral feeding attempts are from the lactating parent, as infant and parent are able.

Breastfeeding Interventions

Breastfeeding interventions may include the following:

Flow rate: The lactating parent can use a strategy of pumping some milk before latching the infant to minimize the impact of a forceful or fast milk ejection reflex. Positioning can assist with the management of milk flow.

Positioning: Education and support to optimize positioning is important. Infants are placed tummy-to-chest with enough support of the trunk, hips, and neck. Interventions may include changes in position such as a football hold, cradle hold, or cross-cradle hold. Breastfeeding pillows and foot stools may be used to support the dyad or triad in the case of multiple babies such as twins who feed simultaneously.

Nipple shields: Nipple shields are used when the infant needs more sensory input in their mouth. Cases to use nipple shields include prematurity, variations in breast/chest anatomy (e.g., flat, inverted nipples), and variations in oral anatomy (e.g., tone, ankyloglossia, high palates). Nipple shields can increase the volume of milk transfer by compensating for decreased sucking pressures exhibited by preterm infants (Meier et al., 2000). They can be used during early nursing attempts and until the infant is able to fully nurse. Recommendations to use a nipple shield are combined with strategies to support transition to nursing without a nipple shield. Support for transition includes collaboration with a professional with lactation education and credentials.

Milk supply: A person’s milk supply may be impacted by the medical history of the lactating parent, pump and flange styles and sizes, and medication. Collaboration with a board-certified lactation consultant is essential to support milk production and maintenance.

Bottle-Feeding Interventions

Flow rate modifications: Nipple flow rate selection is one of the most important considerations for keeping the airway safe during bottle-feeding. A slower flow rate can help the infant with suck–swallow–breathe coordination (Goldfield et al., 2013). Bottle nipple manufacturing is an unregulated industry. Therefore, there can be high flow rate variability between brands and sometimes between individual nipples. This variability can also be altered by external variables such as infant sucking pressures, pliability, hydrostatic pressure, and thickness modifications (Pados, 2021).

Elevated side-lying positioning: Elevated side-lying positioning aims to promote neurodevelopmentally appropriate positioning through midline orientation and can support improved physiologic stability, less work of breathing, and better bolus control (Girgin et al., 2018; Park et al., 2018; Raczyńska et al., 2022). The infant is positioned on their side, with the head, shoulders, and hips neutrally aligned and facing upward and elevated to approximately 45 degrees. Flexion is provided through swaddling.

Co-regulated pacing: Co-regulated pacing provides opportunities for breathing by interpreting an infant’s behaviors and reducing the number of consecutive sucks. The caregiver paces feeding by emptying the nipple or removing the nipple from the infant’s mouth. Pacing aims to facilitate improved physiologic stability (less heart rate and oxygen saturation fluctuations), less behavioral disorganization, and less work of breathing (Thoyre et al., 2012).

Swaddling: Swaddling provides containment, midline positioning, thoracic stability, and flexion. Infants are swaddled with arms midline and their hands to their face. This position promotes positive oral touch and boundaries needed to maintain a calm state during oral feeding (A. P. Smith et al., 2023). Swaddling can also help improve state regulation, pain and stress, and physiologic stability.

Alternative sources of feeding and nutrition: Many NICU infants will require non-oral methods of nutrition to support growth and development when full oral feeding is not a possibility. See ASHA’s resource on alternative nutrition and hydration in dysphagia care.

Instrumental Swallowing Assessments

For information specific to instrumental assessment, see ASHA’s Practice Portal page on Pediatric Feeding and Swallowing and ASHA’s related resources on videofluoroscopic swallow study (VFSS) and flexible endoscopic evaluation of swallowing (FEES). See also the Tutorial on Clinical Practice for Use of the Fiberoptic Endoscopic Evaluation of Swallowing Procedure With Pediatric Populations: Part 2.

Special Considerations for the NICU

VFSS has limitations for the NICU infant. Examples of limitations include

• time constraints to limit radiation exposure;
• the infant’s behavioral disorganization from transporting them from the NICU to radiology; and
• the use of barium, which does not directly replicate viscosities of human milk or formula (Suterwala et al., 2017).

Clinicians also consider the infant’s corrected gestational age and maturation to avoid the need for repeat exams and the cumulative effects of radiation exposure (Ingleby et al., 2023; Martin-Harris et al., 2021). Despite these limitations, VFSS is typically well tolerated by NICU infants. It allows the clinician to view all phases of the swallow and captures how the swallow may change over time (McGrattan et al., 2020). Positioning the infant during a VFSS will vary based on facility dimensions and equipment. When facilities use an elevated side-lying position, the table is flat, and a wedge elevates the infant. Some facilities position the table at an incline, in which case additional positioning aids are not necessary. Families may be able to participate in the VFSS procedure if space and facility policy allows.

FEES also has limitations, which can include poor tolerance to the exam and inability to view oral and esophageal phases of the swallow. FEES allows for better detection of penetration in NICU infants, which is found to be predictive of aspiration, and can be used to assess pharyngeal swallowing during breastfeeding (Armstrong et al., 2019). FEES is typically completed at the bedside, allowing for parent participation with the IPP team, whether breastfeeding/chestfeeding or bottle-feeding. The exam may be completed with human milk or formula instead of barium, mitigating any viscosity and flow rate differences.

Viscosity Modifications

For some infants, thickening may be necessary for dysphagia based on the results of an instrumental assessment. The goals of thickening agents are as follows:

• Establish safe oral feeding that is least disruptive to developing feeding skills.
• Reduce and stop thickener as quickly as possible.

There is limited evidence about the effects of viscosity modifications, or thickening, as an intervention for dysphagia in infants (Gosa et al., 2011). There are several anecdotal data linking some thickened liquids and harmful side effects (Beal et al., 2012; Clarke & Robinson, 2004). The IPP team discusses the risks and benefits of viscosity modifications as well as the infant’s unique comorbidities, health status, and parent preferences (Duncan et al., 2019).

Pain Assessment and Management

Pain can permanently alter the architecture of the brain and have short- and long-term effects that result in higher sensitivity to pain and lower pain tolerance (Cong et al., 2017; Perry et al., 2018). NICU infants experience pain from birth related to medical procedures and equipment, but their pain is not always well assessed or managed (Garcia-Rodriguez et al., 2021).

Infant pain is typically assessed through parameters such as behavioral and physiologic responses, including heart rate, breathing fluctuations, and duration and intensity of crying. NICU nursing staff typically utilize the Neonatal Pain, Agitation and Sedation Scale (N-PASS) to assess infant pain. The following procedures may be painful and/or stressful for the NICU infant (Garcia-Rodriguez et al., 2021):

• needle punctures for blood draws and placement of central lines
• feeding tube placement
• intubation
• mechanical ventilation
• circumcision
• eye examinations
• diaper changes

The NICU team manages pain with medications or through nonpharmacologic strategies. Examples of nonpharmacologic pain management strategies are as follows (Perry et al., 2018; Squillaro et al., 2019):

• breastfeeding/chestfeeding
• kangaroo care
• NNS
• provision of oral sucrose
• swaddling and flexed containment
• facilitated tucking

Service Delivery Models

Direct Service Delivery

Direct service delivery consists of therapeutic time spent directly with the infant and their family, provided one-on-one, in a group setting, or via telehealth.

Indirect Service Delivery

Indirect services are those that contribute to infant neurodevelopmental outcomes, staff support, and psychosocial support of families and are essential to the preventative/habilitative model of care. Indirect services may include staff/family education regarding developmental care, management of environmental factors, participation in unit-wide program development, and preparation of the family for discharge and follow-up services (Craig & Smith, 2020). A minimum of 25% of nonbillable time allows NTs to incorporate quality improvement activities that address NICU infants’ unique and complex issues (Craig & Smith, 2020).

Remote Consultation

Typically used in Level 1 well newborn nurseries, remote consultation includes an established pathway for consultative input via phone or telehealth with an NT from a higher level NICU.

In-Person, Consultative Services

Used in lower acuity special care nurseries, the NT is present to provide direct services to infants in need but does not have dedicated time in the unit and may work in another area of the hospital or at a separate location.

Integrated Neonatal Therapy

Neonatal therapy is an elemental part of the NICU team, and NTs have consistently dedicated time in the NICU (Craig & Smith, 2020). Staffing allotment considers the work within a systematic model of collaborative neuroprotective care based on known risk factors. NTs participate in medical and/or developmental rounds, committees, family meetings, and leadership opportunities within the NICU as appropriate. See Craig and Smith (2020) for recommended staffing ratios and formulas.

Family-Centered and Family-Integrated Care

Family-centered care (FCC) is an approach to the planning, delivery, and evaluation of health care that is based upon a partnership between health care professionals and families of patients (Gooding et al., 2011). See ASHA’s resource on Focusing Care on Individuals and Their Care Partners for more information about the basic concepts of this collaborative approach.

Sometimes, parents feel like they are only a supportive role in the NICU. Family-integrated care (FIC) is a model that directly empowers parents to be the primary caregiver. NICU staff educate, coach, and collaborate with parents during medical rounds and their baby’s care (Waddington et al., 2021).

The Role of Parents in FCC/FIC

Hospitalization of an infant in the NICU and separation from the infant are stressful experiences for the infant and parents. FCC requires that parents have unlimited access to their infants and that they are not excluded from the NICU during rounds, nursing report, admissions, or emergencies.

A parent’s inability to comfort their baby can cause undue stress. Parents are taught how to manage their infant’s discomfort and pain using interventions, such as pacifiers, administration of sucrose or colostrum/human milk, positioning, and swaddling, so they can provide comfort measures during procedures.

Alteration in parent role is a stressor for families as they search for opportunities to parent their infant in ways they never expected. Research shows that parents desire to collaborate with NICU staff, who are in a unique position to support a parent in defining their role and gaining expert knowledge about their infant (Griffin, 2006).

Peer Support and Parent Partnership

In a NICU setting, parent-to-parent partnership or peer support and parent mentoring are provided by volunteer parents who have had a similar experience and who have received training (Hall et al., 2015). Parent partnership programs can be either hospital or community based. Peer support can be provided one-on-one or with support groups (in person or via technological means).

Peer support programs in NICUs can serve to support a feeling of safety and comfort among parents. Parents can share their fears, get validation for their feelings, and gain perspective. Such programs can also serve as a forum for parents’ questions and encourage parents to become advocates for their babies and themselves.

Parents who receive peer support show increased confidence and well-being, exhibit better problem-solving capacity and coping skills, and have improved perceptions of social support, self-esteem, and acceptance of their situation (Hall et al., 2015). Parents feel more empowered and visit their infants more frequently to participate in caregiving, leading to a shorter length of stay for their infants. Parental stress and anxiety, as well as depression, are all reduced.

Caregiver Coaching

Caregiver coaching and early parental sensitivity training teach parents how to recognize signs of infant stress and how to nurture the distressed infant. Early sensitivity training teaches parents to comfort their infant with various nonpharmacologic strategies (Milgrom et al., 2010). See the Pain Assessment and Management section for more information. Early sensitivity training can also help the parent cope with their stress and altered parental role while their infant is in the NICU.

Trauma-Informed Care in the NICU

Trauma-informed care advocates that physical and psychological traumatic events can have adverse effects beyond the event(s) itself (Substance Abuse and Mental Health Services Administration [SAMHSA], 2014).

Trauma-informed care acknowledges the impact of trauma—and that past trauma can influence a person’s response to a current potentially traumatic situation (Sanders & Hall, 2018). It also recognizes the signs and symptoms of trauma in people and the staff caring for them and avoids retraumatization in which a tolerable stress evolves into a toxic stress. Toxic stress occurs when infants are exposed to prolonged activation of the stress response, which can alter brain development and predispose children to stress-related cognitive and health impairments in adulthood (Johnson et al., 2013). Toxic stressors for hospitalized infants include long periods of separation from their parents, inconsistent caregivers, repeated painful procedures without environmental support, and a sensory environment that overwhelms the immature brain (Sanders & Hall, 2018). Parents may experience toxic stress related to the NICU stay where they witness their infant receiving painful procedures or cardiopulmonary resuscitation and experience helplessness and a lack of control.

Sanders and Hall (2018) adapted SAMHSA’s (2014) key principles of trauma-informed care to the NICU setting, as follows:

1. Physical and psychological safety: Privacy and confidentiality are maintained; there is mutual respect; and providers are caring, empathetic, and validate parents’ experiences.
2. Trustworthiness and transparency: Parents are encouraged to participate in rounds, and communication is clear and without medical jargon.
3. Peer support: The NICU offers free peer support as soon as possible in a one-on-one, group, or virtual setting.
4. Collaboration and mutuality: Parents are part of the NICU team, are involved in caregiving as early as possible, and participate in shared decision making.
5. Empowerment, voice, and choice for parents and staff: Parents have emotional and psychosocial support to encourage their resilience. NICU staff encourage and support parents in taking on their roles as parents and caregivers. Administration support staff with appropriate assignments, mentoring, and self-scheduling. Culturally responsive care, including consideration of social determinants of health, can help clinicians determine supports and recommendations that are the most functional and empowering for the family.
6. Cultural, historical, and gender issues: Culturally responsive and competent care is provided to everyone, and all parents are welcome and treated equally. Certain communities are more commonly stigmatized and discriminated against during health care experiences, which may impact trust and buy-in of provider recommendations. It is also important to consider generational trauma resulting from a history of discrimination and health care disparities.

Cultural and Linguistic Considerations

Beliefs about birth, newborns, child-rearing, and feeding vary between cultures and from family to family. The family’s beliefs and practices are incorporated into clinical decision making and recommendations made by the interprofessional team. See ASHA’s Practice Portal page on Cultural Responsiveness for more information.

Practices and beliefs around newborn feeding, including religious practices involving feeding, may impact the family’s preferences and needs with certain clinical decisions. For example, there may be religious restrictions on using donor human milk or formula. Such decisions are made with the approval of the family, allowing for religious consultation and practices that may be necessary when considering those options.

Family structure and dynamics vary greatly from family to family. Discussing each family’s preferences helps create an environment that is most functional to them. These conversations may include what terms and pronouns the family uses. Additionally, the family’s schedule, their transportation access, and other factors can be incorporated to allow for participation in treatment.

Treatment and education should be provided in the language(s) used by the family. See ASHA’s Practice Portal pages on Multilingual Service Delivery in Audiology and Speech-Language Pathology and Collaborating With Interpreters, Transliterators, and Translators for more information.

Counseling/Psychosocial Support for Families

In the NICU environment, parents experience alterations in their parental role because of professionals caring for their infant and because of hospital policies, such as visitation policies, that influence bonding and attachment. Parents may perceive the threat of severe illness or death when they see their infant attached to medical devices and experiencing physiologic instability.

NICU parents can experience aspects of stress- and trauma-related distress, such as anxiety, stress, or posttraumatic stress, because of these experiences that can persist for years after their infant is discharged from the NICU (Roque et al., 2017). Prolonged postnatal distress harms parents’ mental health, with about 27% of NICU parents experiencing posttraumatic stress symptoms even a year after discharge (Malouf et al., 2021). Postnatal distress also disrupts the parent–infant relationship and can influence the infant’s cognitive and social–emotional development.

See ASHA’s Practice Portal page on Counseling in Audiology and Speech-Language Pathology. See also Interdisciplinary Recommendations for the Psychosocial Support of NICU Parents.

When to Make a Mental Health Referral

It is not within the scopes of the audiologist and SLP to diagnose mental health conditions. However, clinicians can make timely referrals to the support and resources that parents need by knowing the signs of mental health conditions that commonly affect NICU parents. Seek immediate medical attention if there is a risk of the parent hurting themselves, their infant, or others.

Clinicians make a referral to a mental health professional when parents show any of the following signs (Cleveland Clinic, 2022a, 2022b, 2023):

• being controlling
• being overly cautious
• delusions or hallucinations
• difficulty concentrating
• disturbed sleep or insomnia
• fatigue
• feeling like they are unable to bond with their infant
• feelings of guilt
• heart palpitations, nausea, and/or shortness of breath
• intense psychological or physical distress when they are reminded of the event
• irritability
• angry outbursts
• manic behavior
• memory loss around a traumatic event
• paranoia
• racing thoughts or obsessing over irrational thoughts
• recurring nightmares and flashbacks

Discharge Considerations

Early Intervention Services

Depending on the state’s eligibility criteria, the discharged infant may be automatically eligible to receive early intervention services under Individuals with Disabilities Education Act (IDEA), Part C. For more information, see ASHA’s resource on the IDEA Part C regulations and ASHA’s Practice Portal page on Early Intervention services.

Discharge and Transition Planning

Following a family and home needs assessment, each family participates in comprehensive and individualized discharge planning to facilitate the transition from the NICU to the home. The NICU team sets clear criteria that each family and infant need to accomplish before being discharged (V. C. Smith et al., 2022). The NICU provides each family with discharge education and anticipatory guidance to prepare the family with what to expect at home with their infant. These discharge recommendations consider social determinants of health, such as access to health care providers, transportation, and food security. Guidance may include the following categories (V. C. Smith et al., 2022):

• home and family life
• infant behavior, including typical and atypical infant behaviors
• coping with a crying infant
• emergency planning
• parental mental health
• paying for a NICU stay

The NICU team educates families on safe-sleep recommendations to reduce the risk of sleep-related infant death. See the AAP’s safe-sleep policy statement and technical report for specific recommendations.

See The ASHA Leader article on the impact of social determinants of health at NICU discharge. See also ASHA’s resource on social determinants of health.

ASHA Resources

• Alternative Nutrition and Hydration in Dysphagia Care
• At NICU Discharge, Considering Social Determinants of Health
• Common Terminology and Diagnoses in the NICU
• Current IDEA Part C Final Regulations (2011)
• Flexible Endoscopic Evaluation of Swallowing (FEES)
• Focusing Care on Individuals and Their Care Partners
• Infant Feeding History and Clinical Assessment Form [PDF]
• Interprofessional Collaboration Makes the Difference to Infants in the NICU
• Interprofessional Education/ Interprofessional Practice (IPE/IPP)
• Social Determinants of Health
• Supervision Requirements for Clinical Educators and Clinical Fellowship Mentors
• The Psychosocial Aspects of Feeding in the Neonatal Intensive Care Unit and Beyond
• Videofluoroscopic Swallow Study (VFSS)

Non-ASHA Resources

This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.

• American Academy of Pediatrics—Safe Sleep
• Family Integrated Care (FiCare)
• FDA What to Know When Buying or Using a Breast Pump
• Developmental Care Standards for Infants in Intensive Care
• Interdisciplinary Recommendations for the Psychosocial Support of NICU Parents
• Joint Committee on Infant Hearing–Year 2019 Position Statement: Principles and Guidelines for Early Hearing Detection and intervention Programs
• March of Dimes—NICU Initiatives
• National Association of Neonatal Nurses (NANN)
• National Association of Neonatal Therapists (NANT)
• National Coalition for Infant Health
• National Perinatal Association (NPA)
• Neonatal Therapy Certification Board (NTCB)
• Newborn Individualized Developmental Care and Assessment Program (NIDCAP)
• Newborn Reflexes
• NICU Helping Hands—Resources
• NICU Parent Network (NPN)
• NICU Resources
• Toxic Stress

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Content for ASHA’s Practice Portal is developed and updated through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Neonatal Intensive Care Unit (NICU) page:

• Tara Carroll, MCD, CCC-A
• Louisa Ferrara Gonzalez, PhD, CCC-SLP, BCS-S, CNT
• Shannon Frey, MBA, MS, CCC-SLP, CNT
• Raquell Garcia, SLP-D, CCC-SLP, CLC, CNT, BCS-S
• Ally Gore, SLP-D, CCC-SLP, CNT, CLC, C-ELBW, NTMTC
• Ramya Kumar, MS, CCC-SLP, BCS-S, CNT, IBCLC, NTMTC
• Anjanette Lee, MS, CCC-SLP, NTMTC
• Andrew P. McGrath, AuD, CCC-A
• Jenny Reynolds, MS, CCC-SLP, BCS-S, CLC, CNT
• Brittany Rush, MS, CCC-SLP

ASHA seeks input from subject matter experts representing differing perspectives and backgrounds. At times a subject matter expert may request to have their name removed from our acknowledgment. We continue to appreciate their work.

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Neonatal intensive care unit (NICU) [Practice portal]. https://www.asha.org/practice-portal/clinical-topics/neonatal-intensive-care-unit/