The following is an edited transcript of the course, Navigating the NICU Chart Review, presented by Nicole Scafura, M.S., CCC-SLP, CNT.

It is recommended that you download the course handout to supplement this text format.

Learning Outcomes

After this course, participants will be able to:

• Differentiate how feeding skills vary for neonates based on postmenstrual age.
• Analyze common diagnoses in the NICU setting.
• Distinguish between daily factors and their impact on a neonate's feeding performance.

Introduction to Speaker and Topic

Getting into the NICU is not a linear path. My career began in early intervention, then transitioned to an inpatient rehabilitation hospital and, later, acute care. The NICU is considered an advanced area of practice because we work with babies who are premature, medically fragile, and who have complicated intravenous lines and diagnoses. For those who are not yet in the NICU, it is more of a destination than a starting point.

In my current role, I work Monday through Friday, 8 a.m. to 4 p.m. in the NICU. Babies feed every three hours, so I am always in the NICU at 8 a.m., 11 a.m., and 2 p.m. Between those feeding times, I cover the children's hospital, including the pediatric floors, the pediatric cardiac intensive care unit, the pediatric intensive care unit, and outpatient swallow studies. I also regularly mentor graduate students and train full-time speech-language pathologists (SLPs) to cross-cover in the NICU.

The Role of the NICU SLP and Feeding Therapist

As NICU feeding therapists, we work in a setting where lungs, brains, and hearts are developing. Our role involves constantly observing an infant's state, respiration, and feeding readiness. We assess oral motor skills and non-nutritive stimulation before introducing any milk or formula. When the time comes to introduce oral feeding by breast or bottle, we choose the most appropriate delivery system, modify the environment to optimize the infant's performance, and provide supportive strategies such as pacing the bottle, chin support, or cheek support to optimize the chances of safe swallowing.

More specifically, our role includes assessing pre-feeding skills to determine whether a baby is ready for bottle introduction, directing feeding intervention through bottle and nipple selection, positioning, environmental modifications, and techniques such as pacing and burping. We also pursue swallow studies when indicated. Ideally, we prefer a habilitative approach over a rehabilitative one, meaning we aim to be involved with babies before feeding even begins, rather than being consulted only after a problem is identified.

Because we work with infants who cannot follow directions, we are the ones actively implementing all strategies or educating parents to carry them out. We read nonverbal communication and adjust our approach in real time. Parent education and coaching are central to everything we do. We want parents and caregivers to feel confident feeding their baby before discharge, not reliant on the therapy team. Nursing education is equally essential. Nurses care for these babies on 12-hour shifts and may feed them every 3 hours. We need their buy-in to ensure our plan of care is followed consistently, even as nursing staff rotate. We also provide updates to physicians regarding whether a baby is progressing appropriately for their age or diagnosis, and whether discharge with or without a feeding tube is a realistic expectation.

The Importance of a Thorough Chart Review

Before ever going bedside, the chart review is where we gather all available information about a patient and begin forming our clinical hypothesis. We want to understand why we are being consulted as speech-language pathologists, identify factors that may currently be impacting feeding performance, and determine which materials and supplies to bring to the bedside. A thorough chart review allows us to anticipate what we will see before we even meet the baby, the nurse, and the caregivers.

Expectations Based on Age

The Womb Versus the NICU

To appreciate why premature infants struggle with feeding, it helps to contrast the womb environment with the NICU environment. In the womb, a fetus is in a dark, fluid-filled space with muffled sounds, consistent containment in a flexed posture, and temperature regulated entirely by the mother. When a baby arrives early and is placed in the NICU, they encounter bright lights, loud environmental sounds from machines and voices, painful procedures for even routine care such as temperature-taking and diaper changes, and an unsupported posture that contrasts sharply with the contained flexion of the womb. These babies are now expected to regulate their own temperature, begin learning to orally feed, and maintain appropriate posture. These are demands we would never have placed on them had they remained in utero.

Prematurity Definitions

It is helpful to categorize prematurity using the March of Dimes definitions. Extremely preterm refers to infants born before 25 weeks. Very preterm covers 26 to 32 weeks. Moderately preterm spans 32 to 34 weeks. Late preterm includes 34 to 36 weeks. The term is 37 weeks or above. Understanding where a baby falls in this spectrum helps us set appropriate expectations for feeding and development.

Development of the Swallow In Utero

Swallowing begins in utero at approximately 11 weeks of gestation. Sucking of amniotic fluid begins around 15 weeks. The suck-swallow-breathe pattern begins to coordinate between 32 and 34 weeks, which is why most NICUs begin initiating oral feeding during that window. However, it is critical to understand that the coordination of suck, swallow, and breathe continues to develop through term and even through the baby's due date. Premature babies who begin oral feeding at 32 to 34 weeks will continue to need support from the feeding team, nursing, and parents through 37 weeks or longer.

33 to 34 Weeks Post Menstrual Age

At 33 to 34 weeks post menstrual age (PMA), a baby likely will not wake with each set of cares, which occur every three hours and include temperature-taking and diaper change. There may be a brief arousal, but the infant typically returns to sleep or drowsiness afterward. If the baby does stay awake and shows hunger cues, the suck pattern will be immature, meaning approximately 3 to 5 sucks per burst. The suck-swallow-breathe pattern is just beginning to emerge. These infants may require strict pacing and may experience bradycardia and desaturation during feeding. The primary barriers to oral intake at this age are inconsistent waking, discoordinated suck-swallow-breathe, and rapid fatigue. If feeding at this stage, a slower nipple, such as a Dr. Brown Ultra Preemie or Preemie nipple, is appropriate.

35 to 36 Weeks Post Menstrual Age

At 35 to 36 weeks PMA, infants should be waking with cares more consistently, though occasional feeds may still be missed. The suck pattern transitions to 5 to 10 sucks per burst. Suck-swallow-breathe coordination is emerging, and infants may still need pacing, either strict counting-based pacing or co-regulated pacing in which the provider pauses with the baby during natural breathing breaks. Apnea, bradycardia, and desaturation events may still occur, particularly at the beginning of a feed when the baby is eagerly hungry or at the end when fatigue sets in. Barriers to oral intake remain inconsistent waking, discoordinated suck-swallow-breathe, and stamina limitations. If this is a new patient, this infant has likely begun feeding with nursing before the SLP was involved. Reviewing the chart for feeding history, volume intake, and bottles used so far is an important first step.

36 to 37 Weeks Post Menstrual Age

By 36 to 37 weeks PMA, infants should be waking before or with care, showing consistent hunger cues such as rooting and hands-to-mouth movement. The suck pattern transitions to maturity, with bursts of 10 or more sucks. If pacing is still needed, it is more likely to be co-regulated rather than strict. Bradycardia and desaturation events become less likely, though they can still occur. The primary remaining barriers are the ongoing emergence of suck-swallow-breathe coordination and reduced stamina for sustaining full feed volumes consistently every three hours. A new patient at this stage is almost term, so the clinical questions shift to the current feeding challenges, whether feeding has progressed since admission, and the current feeding plan.

38 to 40 Weeks Post Menstrual Age

At 38 to 40 weeks PMA, the infant should be waking before every care time with consistent hunger cues. The suck pattern should be mature, with 10 or more sucks per burst. Suck-swallow-breathe coordination should be largely in place, with only occasional pauses needed. Vitals should be stable with feeds. Bradycardia and desaturation events would not be age-appropriate at this point. If a full-term infant is being seen in the NICU, the key chart review questions are why they were admitted, whether their current reason for admission would impact feeding, and whether they have a diagnosis associated with poor feeding outcomes.

Gathering Information per Bodily System

Beyond age, a thorough chart review considers each body system's contribution to feeding performance. Below are the key systems and what to examine in the chart.

The Brain and Nervous System

For neurological status, I review any relevant imaging, such as head ultrasounds and MRIs. I also consider reflex status as documented by physicians or neurologists, and I keep age in mind to contextualize brain development. Neurological diagnoses that raise clinical concern include intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), hydrocephalus, and hypoxic-ischemic encephalopathy (HIE).

The implications of these diagnoses can affect arousability, state regulation, and reflexes, including rooting and sucking reflexes. A baby with a significant neurological diagnosis may be hyperreflexive, with constant rooting but no ability to develop a suck, or hyporeflexive, with no rooting or sucking at all. These findings inform expectations for feeding progress and raise the possibility of silent aspiration, meaning liquid entering the trachea without a cough response. Babies with neurological diagnoses warrant close observation and consideration of an instrumental swallow study when they are developmentally able to participate.

The Cardiac System

For cardiac status, the echocardiogram is the key imaging to review. Relevant diagnoses include atrial septal defect (ASD), ventricular septal defect (VSD), and tetralogy of Fallot (ToF). When a cardiac anomaly is identified, I want to know whether it was diagnosed prenatally or postnatally, whether the baby is currently on medication to manage it, and whether surgical repair is planned.

The clinical implications are significant. Before repair, these babies typically have reduced stamina and endurance for feeding. After surgical repair, there is a higher concern for silent aspiration due to the proximity of the recurrent laryngeal nerve to the aortic arch. Intubation required during surgery may also affect swallowing function. Understanding the cardiac diagnosis, the management plan, and the surgical timeline shapes my expectations for how and when feeding will progress.

The Respiratory System

Respiratory status is among the most important factors in NICU feeding. I review any relevant imaging, such as chest X-rays or lung ultrasounds. In the room, I observe respiratory rate and oxygen levels both at rest and during activities, including cares and non-nutritive sucking. I review the history of intubation and the level of current respiratory support. Respiratory diagnoses that affect feeding include respiratory distress syndrome (RDS), bronchopulmonary dysplasia (BPD), chronic lung disease (CLD), bronchomalacia, and tracheomalacia.

Feeding requires the ability to pause breathing with each swallow. A baby who cannot sustain their own breathing at rest is being asked to layer that swallowing pause on top of already compromised respiratory work during every bottle feed. Many NICUs do not permit oral feeding for babies on 2 liters or more of high-flow nasal cannula, given research indicating a higher aspiration risk at that support level. Infants on higher levels of respiratory support may exhibit a disorganized suck-swallow-breathe pattern and be at heightened risk for aspiration.

The GI and Digestive System

For GI status, I review the current diet order, including the type of formula or breast milk, the volume, and whether feeds are being administered by bolus or continuous infusion. Bolus feeding means a set volume every few hours; continuous feeding means a small amount running through the tube every hour. A baby on continuous feeds does not experience hunger cues in the typical way, which affects readiness to engage in oral feeding. I also note how long tube feeds are being run, since extended run times often indicate GI tolerance challenges, such as emesis.

For oral feeding history, I look at whether the baby has been fed by mouth before the SLP was consulted, the current percentage of feeds taken by mouth, and the bottle and nipple system in use. Any reflux concerns, including frequent emesis and bradycardia or desaturation events after feeds, are also relevant. Relevant GI diagnoses include gastroesophageal reflux disease (GERD), inguinal hernia, feeding intolerance, necrotizing enterocolitis (NEC), and pyloric stenosis. Relevant imaging includes a fluoroscopic esophagram, abdominal ultrasound, and upper GI series.

Other Notable Diagnoses

Several additional diagnostic categories merit attention during the chart review. Size-related diagnoses include intrauterine growth restriction (IUGR), fetal growth restriction (FGR), and small-for-gestational-age (SGA). Babies in these categories may act more developmentally immature than their post-menstrual age would suggest, because their growth in utero was restricted. Conversely, large for gestational age (LGA) babies may appear to have an advantage, but in my experience, they are often sleepier than peers, tire easily, and may have reduced tone.

For babies undergoing genetic workup or with metabolic conditions, I recommend searching the specific diagnosis paired with oral feeding to understand whether it is associated with feeding difficulties and whether those difficulties are expected to improve or progress over time. Airway diagnoses include tracheoesophageal fistula (TEF), laryngomalacia, and subglottic stenosis. Craniofacial diagnoses such as cleft lip, cleft palate, and Pierre Robin sequence affect the anatomical structures required for feeding and require specific adaptive equipment and management pathways.

Daily Changes and Their Impact on the Plan of Care

Even when a baby is progressing well, day-to-day factors can significantly affect feeding performance. Understanding what has changed in the chart since the last session is essential for interpreting a baby's current presentation. Factors that can affect performance on any given day include a change in bedding from an isolette to an open crib, which demands that the baby regulate its own temperature; an increase or decrease in oxygen support; routine vaccinations, which can cause fatigue and fever; eye exams for retinopathy of prematurity, which are a noxious and painful procedure; weaning from medications or sedation; low red blood cell count, which can lead to more events and lower feeding volumes; increases in total feed volume; removal of the feeding tube, which places the full demand on the infant to take all volumes orally; and changes in the bottle or nipple flow rate.

Bottle and Nipple Consistency

Not all bottles and nipples are the same. Flow rates vary dramatically across products, and switching a baby to a different nipple changes the amount of milk delivered per minute, directly affecting the suck-swallow-breathe demand. When babies are learning to feed, a skill that is inherently challenging, it is important to use a bottle and nipple system that best supports that learning process. Frequent switches make feeding unpredictable for the infant.

The clinical principle here is that flow rate is based on skill level, not on age. Once the infant establishes coordination and endurance, volume intake will follow. Babies do not need to use a specific nipple flow rate to be discharged home.

Based on what I find in the chart regarding prior oral feeding experience, I may bring a bottle and nipple that is one flow rate slower or faster than what the baby is currently using. I may keep the baby on their current setup to observe what is happening. I may choose not to offer a bottle at all and instead focus on non-nutritive stimulation or drops of milk. I also consider whether it is appropriate for a parent to offer the feed as a bonding and coaching experience, or whether it is more appropriate for the SLP to feed first, given safety considerations.

Practice Case

The following case demonstrates how to integrate chart review information into clinical preparation before going bedside.

Patient Information

Baby girl was born at 28 weeks and one day due to spontaneous placental abruption requiring emergency cesarean section. She emerged with poor tone and poor respiratory support, requiring CPAP. Her birth weight was 2 pounds and 8 ounces. She was admitted to the NICU for prematurity and respiratory management. Primary diagnoses include RDS, prematurity, feeding intolerance, IUGR, and left grade I IVH.

Gathering Data from the Chart

Her gestational age at birth was 28 weeks and one day. Her post-menstrual age at the time of the speech consult was 35 weeks.

Respiratory history: She was on CPAP from day of life one through 34 weeks PMA, at which point she was weaned to 2 liters of high-flow nasal cannula at 21% FiO2. Current respiratory status at the time of the speech consult is 1 liter of low-flow nasal cannula, which she has been on for two days.

Neurological history: Initial head ultrasound identified a left grade I IVH. Updated imaging shows that the grade I-IVH is resolving.

GI history: She had difficulty transitioning from continuous tube feeds to bolus feeds due to emesis. Current diet order is 40 mL of fortified expressed breast milk every three hours. An NG tube is in place, and enteral feeds are being run for one hour due to the history of emesis.

Oral feeding history: Nursing began oral feeding attempts when the baby transitioned to 2 liters of high-flow nasal cannula. They offered a Dr. Brown Preemie nipple prior to tube feeds. At that time, her total volume was 30 mL, and she was typically taking 15 to 20 mL per feed. Nursing reported occasional oxygen dips while feeding and intermittent tachypnea. Now that the infant is on a low-flow nasal cannula, the staff switched her to a Similac Slow Flow nipple. Nursing reports no oxygen dips or tachypnea, but the infant appears disinterested in oral feeds and is taking approximately 5 mL per feed.

Integrating the Information

Age: She is 35 weeks PMA, but due to her prematurity and IUGR history, she may present as developmentally younger than her corrected age suggests.

Neurological: She has a unilateral grade I IVH that is resolving on imaging. This is reassuring and is not expected to have a significant impact on her current feeding presentation.

Respiratory: She has a history of high-flow nasal cannula use and is now on low-flow nasal cannula, which is a positive trend. However, she has been on low-flow for only two days and has a history of tachypnea and oxygen dips during feeds. Those events may have been related to demands on her respiratory system, the specific bottle or nipple used, or both. This requires investigation. A discoordinated suck-swallow-breathe pattern is anticipated.

GI: She has a history of emesis and feeding intolerance, and she is still working on tolerating bolus tube feeds. This context is important in understanding her current oral feeding engagement.

Oral feeding: She has had variable experiences with different bottles and nipples and has not had consistently positive feeding encounters. The current decrease in oral intake may reflect fatigue from the demands of feeding every three hours, her prematurity, the recent oxygen wean, or some combination of all three.

Bedside considerations: I will bring a Dr. Brown Preemie nipple and a Dr. Brown Ultra Preemie nipple. If the infant is awake and cueing, I will start with the Similac Slow Flow nipple currently in use to assess whether the disinterest and low volumes are related to the nipple, overall prematurity, or respiratory status. I will provide education on cue-based feeding, quality over quantity, the current barriers the infant is still working through from a respiratory and GI standpoint, and the cumulative changes this infant has experienced since admission that may be contributing to her current presentation.

Questions and Answers

What do the diagnoses IVH, PVL, and HIE mean?

IVH stands for intraventricular hemorrhage. It is graded 1-4 and can be unilateral or bilateral. Grade I or II on one side is considered less severe; grade III or IV, especially bilateral, is more significant. Some cases resolve on their own; others persist. PVL, or periventricular leukomalacia, refers to abnormal white matter in the brain and carries a high correlation with cerebral palsy in later development. HIE, or hypoxic-ischemic encephalopathy, results from a lack of oxygen delivered to the brain, often at birth. Interventions may be available depending on how quickly they are initiated, and the outcomes vary based on the severity of the hypoxic event.

How long did it take for you to feel competent and confident in your clinical skills in the NICU?

Confidence builds with consistent exposure and clinical experience. The more time you spend reviewing charts, seeing patients, and testing and confirming hypotheses, the more confident you become. For me, it took approximately one to two years of consistent practice before I felt genuinely confident in my NICU clinical skills.

Would attaining certification as a lactation consultant be a significant benefit for SLPs working in the NICU?

Lactation certification can be a meaningful supplement, since feeding therapists benefit from understanding both bottle and breastfeeding. However, in many NICUs, lactation consultants are separate employees, often registered nurses with dedicated lactation credentials. Lactation certification alone is unlikely to guarantee a NICU position if you have no prior NICU exposure.

What are some signs of possible silent aspiration beyond oxygen decline?

Babies typically do not develop a cough response until closer to term or their due date, so the absence of coughing is not reassuring. Other signs to watch for include apnea, sudden bradycardia, desaturation, behavioral signs of stress during feeds, throat clearing, congestion or gurgling sounds while feeding, and difficulty weaning from oxygen despite increasing age and strength. If a baby continues to require oxygen support and feeding remains difficult despite developmental progress, aspiration should be considered as a contributing factor.

How do you provide chin and cheek support when feeding?

Chin-and-cheek support involves placing one finger under the chin and one at the cheek to provide external stabilization. However, this intervention is not appropriate for all infants. I use it selectively for babies with low tone associated with a specific diagnosis, such as trisomy 21. For a premature baby who has a weak suck due to prematurity alone, chin and cheek support actually increases the flow rate of milk into the mouth, which is counterproductive for an infant who is not yet ready to manage a faster flow.

What was the training and mentorship process like when you first started working in the NICU?

I came to the NICU with a background in early intervention, inpatient rehabilitation, and acute care, providing foundational experience in hospital-based practice, infant feeding, and swallow studies. When I joined the NICU, I was paired closely with an experienced speech-language pathologist. I did not see any baby independently for approximately six months. That level of supervised practice was entirely appropriate given the differences in how preterm infants present compared to full-term infants.

How do you recommend standing orders for assessment at 32 weeks, and how would you encourage nursing and neonatologists' buy-in for cue-based feeding over volume-first approaches?

Standing orders at 32 weeks create an opportunity to educate before oral feeding even begins. Even if a baby will not start oral feeds until 33 or 34 weeks, that window allows you to assess the infant with a pacifier or gloved finger, evaluate rooting, reflexes, suck quality, and secretion management, and educate parents on what developmental milestones to expect. Teaching parents how to provide care in a supportive and developmentally appropriate way is an active intervention. For nursing and physician buy-in on cue-based feeding, the most effective strategies are consistent presence, education, and relationship-building over time. The more visible and knowledgeable the feeding team is, the more other staff members will align with the cue-based approach.

References

References are provided in the course handout.