The Neonatal Intensive Care Unit (NICU) is a specific area in the hospital that cares for medically fragile and critically ill neonates after birth. These newborns may be born prematurely or born full term, who require further hospitalization for medical management prior to discharge.

There are various levels of NICU, varying from levels 1 to 4.

The level of the NICU indicates how equipped the unit is to manage the neonate’s medical needs. A level 1 NICU is dedicated for full term infants without special needs and level 4 being equipped with the expertise for the most critically ill neonate. In order to ensure that every infant’s needs are being met appropriately for his or her condition, the American Academy of Pediatrics (AAP) recently put forth Standard for Levels of Neonatal Care for Levels 2-4 to improve neonatal outcomes and improve the health outcomes for the nation’s most vulnerable population (Stark et al. 2023).

Occupational Therapists (OT), Physical Therapists (PT) and Speech-Language Pathologists (SLP) are essential members and neonatal therapists for assessing and treating NICU patients.

Neonatal therapy is recognized as a specialty area only for those clinicians with a deep understanding and competency to work with neonates and premature infants. Prior to speech-language pathologist’s working in the NICU, nursing staff were the primary staff who were feeding infants and navigating feeding difficulties in this setting. However, as of 2004, the American Speech-Language Hearing Association (ASHA) has identified that speech-language pathologists have the expertise in interpreting infants’ cues and in managing/treating swallowing disorders.

As the role of the speech-language pathologist in the NICU continues to be defined and recognized, there have been several advances in the literature toward stressing the importance of specialized training in this population prior to working in the NICU setting. For example, ASHA has listed on their website that, “Experience in adult swallowing disorders does not qualify an individual to provide swallowing assessment and intervention for children.”

Additionally, ASHA developed a position statement and technical report in 2004 to define the knowledge and skills that highlight essential areas of competent practice in the NICU. Furthermore, the AAP calls for, “Onsite consultative services by qualified neonatal therapists to address the six core practice domains (environment, family and psychosocial support, sensory system, neurobehavioral system, neuromotor and musculoskeletal systems, and oral feeding and swallowing) and to provide the appropriate care for the neonatal population served” (Stark et al. 2023).

Lastly, approximately 20% of NICU graduates will continue to have feeding difficulties into their toddlerhood (Hoogewerf et al. 2017). This stresses the importance for promoting early intervention of SLP services in the NICU to provide neurodevelopmental care and positive relationships with feeding to prevent negative associations with feeding and aversion post discharge.

Although there is increased advocacy and standardization being developed to establish the presence of speech-language pathologists in the NICU, there are multifactorial barriers that prevent this from becoming a reality. First, there needs to be more foundational knowledge regarding pediatric feeding and swallowing disorders/dysphagia at the graduate level. In 2023, courses from 272 accredited programs were analyzed and approximately less than 1% were categorized as pediatric feeding/swallowing courses (Knollhoff, 2023). Second, without clinical exposure to pediatric dysphagia cases in graduate externship settings, students may not know if they would be interested in this population or not. This relates to there being fewer speech-language pathologists who specialize in pediatric dysphagia compared to clinicians who work with adults with dysphagia.

Aside from the gaps in education for infant feeding/swallowing, there are also limitations in the work setting as there may not always be consistent SLP coverage in an existing NICU. In a study conducted in 2017 at a level 4 NICU, only 51% received SLP services compared to 100% receiving OT and PT (Ross et al. 2017). Lastly, job postings that are advertised for NICU positions typically seek clinicians with prior NICU experience or at the minimum years of prior acute care experience. This is a reasonable expectation given the nature of the NICU being an intensive care unit and the niche knowledge required for managing these patients. However, due to the barriers addressed above, how are clinicians going to get their foot in the door if they begin in the school or home care setting without hospitals considering them for open positions? How can we learn from each other aside from continuing education courses? How can we provide these opportunities in an ethical way without compromising the safety of these infants?

Overall, if ASHA and the AAP are raising their expectations regarding the presence of SLP in the NICU and their importance on the NICU multidisciplinary team, the same standards should be set in place for the programs providing education to new clinicians and seasoned clinicians in other settings. Our work is too important to these neonates and their caregivers to be limiting our services in this setting.


  • American Speech-Language-Hearing Association. (2004). Knowledge and skills needed by speech-language pathologists providing services to infants and families in the nicu environment [Knowledge and Skills]. Available from
  • Hoogewerf, M., Ter Horst, H. J., Groen, H., Nieuwenhuis, T., Bos, A. F., & van Dijk, M. W. G. (2017). The prevalence of feeding problems in children formerly treated in a neonatal intensive care unit. Journal of perinatology : official journal of the California Perinatal Association37(5), 578–584.
  • Knollhoff S. M. (2023). Pediatric Dysphagia: A Look Into the Training Received During Graduate Speech-Language Pathology Programs to Support This Population. Language, speech, and hearing services in schools54(2), 425–435.
  • Ross, K., Heiny, E., Conner, S., Spener, P., & Pineda, R. (2017). Occupational therapy, physical therapy and speech-language pathology in the neonatal intensive care unit: Patterns of therapy usage in a level IV NICU. Research in developmental disabilities64, 108–117.
  • Stark, A. R., Pursley, D. M., Papile, L. A., Eichenwald, E. C., Hankins, C. T., Buck, R. K., Wallace, T. J., Bondurant, P. G., & Faster, N. E. (2023). Standards for Levels of Neonatal Care: II, III, and IV. Pediatrics151(6), e2023061957.

About the Author: Nicole Scafura

Author: Nicole Scafura, M.S., CCC-SLP, Trauma Informed Professional
I am a speech-language pathologist with 5 years experience working with pediatrics in a variety of settings including home care, rehabilitation and acute care. My career focus has centered around working with patients who have feeding difficulties and dysphagia. I am passionate in helping patients and their families to achieve their goals. Please connect with me if you are interested in building your network. I am always looking for opportunities to connect and learn from others.

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