Last updated: July 2023
- Babies born early, or born to term with medical difficulties, are at risk of feeding and communication difficulties in the early period as well as in the longer term.
- The number of babies admitted to a neonatal unit has seen an increasing trend due to advances in health care expertise and technology.
- The neonatal unit is a stressful environment which can impact babies’ development.
Role of speech and language therapy in neonatal care
Babies admitted to neonatal units are at risk of feeding and early communication difficulties. This is due to being born early or having complex medical conditions that affect their neurology and development, and/or functioning of the structures required for sucking and swallowing.
The speech and language therapist (SLT) has a role in identifying babies at risk of feeding or communication difficulties and in helping babies and their families to establish safe and positive oral feeding, and support their language development.
The SLT also has a role in education and implementation of developmental care on the neonatal unit as part of the wider team to support babies’ optimal neurodevelopment.
- Speech and language therapy staffing recommendations for neonatal units (PDF) – 2023
- Neonatal unit speech and language therapy staffing calculator – 2023
- RCSLT neonatal competency framework (Word) – 2018
For more in-depth information on the SLT role, log in to view our neonatal care clinical guidance.
Babies may spend time on a neonatal unit if they are born prematurely, unwell, with brain trauma, or require other medical intervention.
The definition of a premature baby is when they are born before 37 weeks gestation.
Premature babies are grouped according to their gestational age:
- Extremely preterm (born <28 weeks)
- Very preterm (born 28-32 weeks)
- Moderate to late preterm (born 32-37 weeks)
Babies may also spend time on a neonatal unit if they are born at a low birth weight. Low birth weight can be caused by prematurity, or being small for gestational age.
Definitions of low birth weight (Tucker and McGuire, 2004):
- Low birth weight: <2500g
- Very low birth weight: <1500g
- Extremely low birth weight: <1000g
Different levels of neonatal care
Level 1 Special Care Baby Unit (SCBU): Babies who need monitoring of their breathing or heart rate, need oxygen support or additional tube feeding, or are undergoing treatment for neonatal jaundice, may spend time on a SCBU.
Level 2 Local Neonatal Unit (LNU): Babies who need intensive care support short term, including receiving respiratory support, such as continuous positive airway pressure (CPAP), or high flow nasal cannula oxygen, as well as babies receiving parenteral nutrition, such as through an IV line, may need this level of care.
Level 3 Neonatal Intensive Care Unit (NICU): Babies who are born before 28 weeks gestation or weigh less than 1000g, babies with brain trauma, and those needing ventilation or a high level of CPAP may spend time in a NICU. Babies who have severe breathing or gut disease or those requiring surgery may also need this level of care.
Babies that spend time on a NICU may receive the following:
- Intensive care: This is the level of care provided for the most unwell or unstable babies that have the greatest needs in terms of staff-to-patient ratio.
- High dependency care: This level of care is for babies who still have high needs and require access to highly-skilled staff, but do not require intensive care.
- Special care: This is the level of care provided for babies who require additional care delivered by the neonatal service but do not require either intensive or high dependency care.
- Transitional care: This is for when babies are almost ready to go home. Mothers may be residents with their babies in transitional care and providing care. A baby may move to transitional care after spending time on a high level unit, or may only spend time in transitional care (such as babies having phototherapy).
Descriptions of levels of neonatal care can be found in the British Association of Perinatal Medicine Categories of Care guidance.
Vulnerability and risks
There are many reasons why a baby may be born prematurely or become unwell during pregnancy, birth, or shortly after birth. In particular, there are certain risk factors that predispose a pregnant person to go into premature labour, as well as known causes (Institute of Medicine, 2007).
The risk of health complications occurring is higher:
- The earlier the baby is born
- The lower the weight in relation to gestational birth age
- The more unwell the baby is
Babies born prematurely or unwell are vulnerable to complications including:
- Feeding difficulties
- Breathing difficulties
- Heart problems
- Neurological injury
- Gut problems
- Structural problems
- Developmental difficulties, including speech, language and communication difficulties
Premature babies are also at risk of having problems with:
- Temperature regulation
- Hearing and vision
- Sensory processing difficulties
- Chronic health problems
Wider impacts include:
- Educational outcomes
- Psychosocial issues
- Impact on families
Feeding is a complex skill for all babies. Babies born early are developing oral feeding skills at a time of significant growth and brain development. Feeding is impacted by immaturity of motor pathways for sucking, swallowing and breathing; development of the gut, developing physiological and state regulation and development of motor and sensory pathways in the brain (Gewolb et al, 1999; Jadcherla, 2016).
Babies with complex needs are at risk of persistent feeding difficulties and potentially the need for longer term alternative feeding methods (Harding et al, 2015; Hawdon et al, 2000).
Risk factors associated with poorer feeding outcomes of ex-premature babies:
- Extreme prematurity
- Extremely low birth weight
- Delayed/disordered oral motor skills at term age
- Breathing problems needing breathing support for longer
- History of necrotising enterocolitis (NEC) (where the tissue in the gut becomes inflamed and starts to die)
- Longer time transitioning from tube to oral feeds
- Medical conditions impacting on feeding eg neurological, heart, sensory, or gut issues
Ex-premature or unwell babies are at risk of longer-term feeding difficulties that include:
- Difficulties using oral motor skills effectively for adequate intake of nutrition
- Fussy eating or refusal
- Swallowing difficulties
- Increased vomiting
- Difficulties with transitioning to solid foods
- Increased stress on families and parent-baby relationships in the longer-term
- Longer term tube use, which can lead to long term eating problems; reduced parent-child interaction opportunities; missed critical periods for taste and texture; impaired feelings of satiation; oral aversive behaviours, and potential impact on oral motor development
Premature babies may have difficulties breathing after birth, due to an underdeveloped respiratory system. The lungs of a premature baby at birth may lack ‘surfactant’, which is a substance produced by the body to allow the lungs to expand and contract.
Term babies with traumatic birth are also at risk of developing breathing difficulties called ‘respiratory distress syndrome’ needing some form of support such as mechanical ventilation, continuous positive airway pressure (CPAP), or oxygen delivered via nasal prongs. Further information is available via the RCSLT feeding and non-invasive respiratory support position paper.
In the majority of cases, respiratory distress syndrome can be effectively treated; however, some babies may also develop longer-term breathing problems called ‘chronic lung disease’.
Breathing difficulties may have an impact on the development of oral feeding for babies, including:
- Delayed introduction of oral feeding due to high levels of support needed.
- Difficulties coordinating sucking, swallowing and breathing during feeding.
- Reduced endurance, with increased effort needed for oral feeding.
- Risk of negative experiences around the face and mouth due to breathing support (Wood et al, 2003; Jadcherla et al, 2010, Ferrara, L et al, 2017).
Congenital heart disease in babies may exist in isolation, or alongside a chromosomal change or a syndrome (Jadcherla, 2016). Infants born prematurely, especially those born extremely preterm have higher blood pressure than term infants. Babies with chronic lung disease are at higher risk of heart problems.
The most common congenital heart diseases in premature babies include ‘patent ductus arteriosus’ (PDA) (a persistent opening between the two major blood vessels leading from the heart), ‘ventricular septal defect’ (VSD) (a hole in the wall that separates the two lower chambers of the heart) and ‘atrial septal defect’ (ASD) (a hole in the wall that separates the two upper chambers of the heart). All heart conditions will impact how effectively the heart is able to pump blood around the body. If untreated, they may cause the baby to go into heart failure.
Congenital heart disease may have an impact on the development of oral feeding for babies, including:
- Delayed introduction of oral feeding due to instability or medical interventions.
- Reduced tolerance of feeds due to poor gut perfusion.
- Poor growth and nutrition due to increased nutritional requirements.
- Increased stress associated with feeding which may impact longer term relationships with eating/drinking.
- Post-surgery or intubation complications impacting the upper airway and swallow.
- Associated problems that may occur alongside congenital heart disease and have an impact on the baby’s oral feeding skills.
The brain of an unborn baby develops rapidly in utero. A baby that is born prematurely is at risk of neurological injury after birth. Neurological injury may include intraventricular haemorrhage (IVH) (bleeding in the brain) or periventricular leukomalacia (PVL) (softening of white brain tissue).
There is increased risk of developmental delay as the severity of injury increases. There is an increased risk of speech, language and communication problems, specifically for babies with PVL grade III/IV and IVH, including moderate-severe language disorders.
Hypoxic ischemic encephalopathy (HIE) is a condition that affects how a baby’s brain functions. It is caused by a reduction in supply of oxygen and blood to the brain and other organs during the time of birth. Lack of oxygen to the brain can lead to brain injury, which may be categorised as mild, moderate or severe.
Babies with moderate to severe HIE in the neonatal period may present with difficulties in muscle control, state and alertness, and sucking and swallowing coordination. The longer-term impact of HIE may include developmental delay, cognitive and neurodevelopmental delays, epilepsy, and motor delay (Shankaran 2014).
Neurological injury in babies may lead to longer term neurodevelopmental impairments. Data from EPICure studies show that the prevalence of neurodevelopmental impairment was associated with the gestation of premature babies, with greater prevalence of impairment the shorter the gestation (45% at 22-23 weeks, 30% at 24 weeks, 25% at 25 weeks and 20% at 26 weeks) (Moore et al, 2012).
Neurological injury may have an impact on oral feeding and communication development for premature babies, including:
- Impaired motor and sensory control of the muscles required for coordination of sucking, swallowing and breathing during feeding.
- Increased risk of aspiration of fluid to the lungs.
Longer term neurodevelopmental and neurological impairments in premature babies may also impact their:
- Speech, language and communication development
- Motor skill development
- Learning abilities
- Sensory processing
- Attention and behaviour
Premature babies may experience gastro-oesophageal reflux (GORD). Reflux occurs when partially-digested milk passes from the stomach back into the oesophagus and sometimes into the mouth. The acid from the stomach may make this uncomfortable and painful for babies.
Premature babies are also more likely to have an immature gut, putting them at risk of complications such as necrotising enterocolitis (NEC). NEC is the most common gut problem in the premature population. The risk of NEC is related to the gestational age and weight of a baby. The younger the gestation and smaller the weight at birth, the higher the risk of NEC (Thompson and Bizzaro, 2008).
NEC can be associated with other long term conditions, such as ‘short gut syndrome’ (lack of a functional small intestine), which can also affect term babies. In extreme cases, NEC can cause multi-system failure and death in babies.
Gut problems may impact oral feeding development for babies, including:
- Delayed or interrupted introduction of feeds
- Pain and discomfort with feeding
- Negative associations with feeding leading to refusal or reduced acceptance
- Swallowing difficulties
Anatomical differences in the structures of the head and neck, which could happen either in utero or after birth, may affect an infant’s ability to suck, swallow and breathe safely and effectively. This increases the risk of aspiration (fluid entering the airway or lungs) and poor growth.
Abnormalities of the head and neck anatomy present at birth occur during certain stages of development in utero. Some are identified during routine pregnancy scans, others are not evident until the infant is examined after birth. These abnormalities include:
- Choanal atresia (narrowing of the nasal passages)
- Cleft lip and/or palate
- Micrognathia (small jaw) which may be isolated or associated with a syndrome
- Laryngomalacia (floppy upper airway)
- Laryngeal cleft (abnormal opening between the voice box and oesophagus)
- Upper airway obstruction or subglottic stenosis (narrowing of the airway)
- Vocal fold paralysis
- Tracheoesophageal fistula (opening between the airway and the oesophagus)
- Oesophageal atresia (the upper part of the oesophagus is not connected to the stomach)
- Abnormalities in blood vessels
- Presence of a tracheostomy (an opening created at the front of the neck to help the baby breathe)
Structural difficulties caused by trauma occur mostly after surgery or intubation. It may at times involve bruising or damage to a nerve. The most commonly seen are airway swelling post extubation, subglottic stenosis and vocal fold paralysis.
Anatomical abnormalities may have an impact on the development of oral feeding for babies, including:
- Poor suction during sucking leading to slow or inefficient feeding.
- Increased risk of aspiration of fluid into the airway due to ineffective protection.
- Poor coordination of the suck, swallow, breathe sequence due to an interruption in airflow.
Developmental and speech, language and communication difficulties
Babies born prematurely are at risk of experiencing developmental delays, including language and communication. This risk increases with lower gestational age and lower birth weight of the baby (Kerstjens et al, 2013; Guellec et al, 2001).
The neonatal unit environment can also be stressful and babies in hospital have reduced exposure to language and developmental stimulation. Communication difficulties could also be associated with brain damage that the baby may experience at birth (Limperopoulos et al, 2007).
Developmental and communication difficulties experienced by the premature baby, or those with neurological damage may include:
- Movement difficulties
- Delay in reaching milestones
- Attention difficulties
- Cognitive difficulties
- Sensory processing difficulties
- Difficulties with understanding language
- Expressive language difficulties
- Social interaction difficulties
Educational outcomes, psychosocial issues and impact on families
The EPICure studies have shown that extreme preterm children have persistent communication and cognition difficulties that have an impact on their access to the national curriculum into school age.
A study looking at the educational outcomes of the extreme preterm population at age 11 found that these children had poorer performance than their classmates across all national curriculum subjects, with the most prominent difficulties in maths, and around age 2/3 had some degree of special educational needs (Johnson et al, 2009).
The neonatal unit is a stressful environment for vulnerable preterm and medically fragile infants. Preterm and sick infants are exposed to multiple potential stressors in the neonatal environment, including the daily routines that are necessary for the infant’s medical care.
Current research is now paying closer attention to the impact of adverse childhood experiences on an individual’s emotional and psychosocial development. Studies show that prolonged activation of stress hormones (toxic stress) in infancy can reduce neural connections at a point where new pathways should be forming, therefore altering brain structure and function (Smith et al, 2011). The practice of ‘developmental care’ focuses on reducing exposure to this stressful environment, by providing neonatal care that is nurturing, stable, and engaging.
Impact on families
Having an infant that is born early or unwell and needing to spend time on a neonatal unit is difficult for families and can cause high levels of anxiety and stress (Agaard et al, 2008).
The experience of having a preterm or sick infant can impact on a parent’s ability to take on their parenting role (Flacking et al, 2006) and has an impact on their interactions with their infants, not only on the neonatal unit, but also when discharged home (Forcada-Gues et al, 2006).
Family-centred/family-integrated care places parents at the centre of their babies’ care, and has been shown to have a positive impact on families as it:
- Reduces babies’ stress levels
- Promotes better health and reduces length of stay in hospital
- Helps parents to bond with their baby
- Improves outcomes, both on the unit, and after discharge
More information about family-integrated care (FiCare).
SLTs in Neonatal Care CEN
This is the RCSLT Clinical Excellence Network (CEN) of SLTs specialising in neonatal care.
Aims of the CEN
- To advise the RCSLT about clinical developments and evidence relevant to the speciality of neonatal speech and language therapy, including developing competencies, outcome measures and staffing recommendations.
- To provide a professional support network and discussion forum for SLTs working in neonatal care to facilitate and encourage the development of specialist knowledge and research.
- To coordinate and provide evidence-based educational opportunities, including an annual CEN conference for SLTs in neonatal care, and participation with other AHPs to plan and participate in the annual Neonatal Therapy conference.
- To inform national policies and standards relevant to neonatal care in collaboration with other neonatal organisations, eg National Institute for Health and Care Excellence (NICE) guidelines, British Association of Perinatal Medicine (BANP), etc.
- To support joint collaborative audits, research and quality/service improvements in neonatal feeding and communication within a developmental care framework.
- To provide a forum for discussion of current issues within the field of neonatal feeding and communication and provide position statements as required.
- To work alongside other neonatal AHPs and develop links with other professional groups working in neonatology.
Contact information and to join the network
- Education and training
- Outcome measures
- Event planning
- Communications and social media
Find more information on Clinical Excellence Networks (CENs).
If you would like to speak to an adviser in this area, please contact us.
Neonatal networks in the UK
Organisations and resources
- Bliss – UK charity working to provide the best possible care and support for all premature and sick babies and their families.
- British Association of Perinatal Medicine (BAPM) – Professional association and registered charity, which aims to improve standards of perinatal care by supporting all those involved in perinatal care to optimise their skills and knowledge, promote high quality, safe and innovative practice, encourage research, and speak out for the needs of babies and their families.
- Paediatric Neonatal Specialist Dietitians Sub-Group (NDiG) – Subgroup of the Paediatric Group of the British Dietetic Association, providing a formal network for neonatal dietitians from the UK and Ireland.
- National Association of Neonatal Therapists (NANT) – US-based organisation created specifically for neonatal occupational therapists, physical therapists, and speech-language pathologists aiming to improve neurodevelopmental outcomes for premature and sick infants.
- National Perinatal Association (NPA) – US-based organisation bringing together people who are interested in perinatal care including healthcare providers, parents and caregivers, educators, and service providers – all driven by their desire to support and advocate for babies and families at risk and positively impact perinatal care.
- The Association of Paediatric Chartered Physiotherapists: Neonatal Committee – The Neonatal Committee focuses on work with neonates and ex-preterm infants and supports the role of physiotherapists working in neonatal units or in-reaching from the community.
- UNICEF works in over 190 countries and territories to save children’s lives, to defend their rights, and to help them fulfil their potential, from early childhood through adolescence. Programmes include maternal and newborn health, The Baby Friendly Initiative, and Every Newborn Action Plan with the World Health Organization.
Resources for families
- Tommy’s Information on Premature Birth – series of information about prematurity produced by Tommy’s registered charity for families.
- Information for families: NICORE, Northern Ireland (PDF) – a leaflet for parents explaining the work of NICORE.
- Small Wonders DVD – series of 12 films by Best Beginnings, following 14 families on their journey from birth to first contact with their baby, to one year on.
- From Bump to Breastfeeding – breastfeeding videos
- Global Health Media – breastfeeding videos
References and contributors
Agaard H, Hall E (2008) Mother’s Experiences of Having a Preterm Infant in the Neonatal Care Unit: A Meta-Synthesis. Journal of Paediatric Nursing. 23(3).
Behrman, RE, Butler AS (2007) Preterm Birth: Causes, Consequences, and Prevention. Institute of Medicine.
Buss C, Entringer S, Swanson JM, Wadhwa PD (2011) The Role of Stress in Brain Development: The Gestational Environment’s Long-Term Effects on the Brain. Cerebrum. 2012(4).
Ferrara, L, Bidiwala, A, Sher, I, Pirzada, M, Barlev, D, Islam, S and Hanna, N (2017) Effect of nasal continuous positive airway pressure on the pharyngeal swallow in neonates. Journal of Perinatology.
Flacking R, Ewald U, Nyqvist KH, Starrin B (2006) Trustful bonds: A key to ‘becoming a mother’ and to reciprocal breastfeeding. Stories of mothers of very preterm infants at a neonatal unit. Social Science and Medicine. 62, 70-80.
Forcada-Guex M, Pierrehumbert B, Borghini A, Moessinger A and Muller-Nix C (2006) Early dyadic patterns of mother-infant interactions and outcomes of prematurity at 18 months. Pediatrics. 118(1).
Gewolb IH, Vice FL, Schweitzer EL, Taciak VL, Qureshi M, Bosma JF (1999) Developmental Patterns of Rhythmic Suckle and Swallow in Preterm Infants. Pediatric Research. Apr 1;45:199A
Guellec I, Lapillonne A, Renolleau S, Charlaluk ML, Roze JC, Marret S, Vieux R, Monique K and Ancel PY (2011) Neurologic Outcomes at School Age in Very Preterm Infants Born With Severe or Mild Growth Restriction. Pediatrics. 127(4).
Harding C, Frank L, Botting N, Hilari K (2015) Assessment and management of infant feeding. Infant. 1; 11 (3):85-9.
Hawdon, JM, Beauregard, N, Slattery, J, and Kennedy, G (2000) Identification of neonates at risk of developing feeding problems in infancy. Developmental Medicine & Child Neurology. 42(4), 235-239.
Jadcherla, SR (2016) Dysphagia in the high-risk infant: potential factors and mechanisms. The American journal of clinical nutrition. 103(2), 622S-628S
Jadcherla SR, Wang M, Vijayapal AS, Leuther SR (2010) Impact of prematurity and comorbidities on feeding milestones in neonates: a retrospective study. Journal of Perinatology. 30, 201-208.
Johnson S, Hennessy E, Smith R, Trikic R, Wolke D and Marlow N (2009) Academic attainment and special educational needs in extremely preterm children at 11 years of age: the EPICure study. Arch Dis Child Fetal Neonatal Ed. 94(4).
Kerstjens, JM (2013) Development of moderately preterm-born children. Doctor of Philosophy, Groningen.
Limperopoulos C, Bassan H, Gauvreau K, Robertson RL, Sullivan NR, Benson CB, Avery L, Stewart J, Soul JS, Ringer SA, Volpe JJ and duPlessis A (2007) Does cerebellar injury in premature infants contribute to the high prevalence of long-term cognitive, learning, and behavioral disability in survivors? Pediatrics. 120(3), 584-593.
Moore T, Hennessy EM, Myles J, Johnson S, Draper ES, Costeloe K and Marlow N (2012) Neurological and developmental outcome in extremely preterm children born in England in 1995 and 2006: the EPICure studies. BMJ. 345:e7961.
Shankaran (2014) Outcomes of Hypoxic-Ischemic Encephalopathy in Neonates Treated with Hypothermia. Clinics in Perinatology. 41(1), 149-159
Thompson AM and Bizzaro MJ (2008) Necrotising enterocolitis in newborns: pathogenesis, prevention and management. Drugs. 68(9),1227-1238.
Tucker, J, and McGuire, W (2004) Epidemiology of preterm birth. BMJ. 329(7467), 675.
Wood N, Costeloe K, Gibson A, Hennessy E, Marlow N and Wilkinson A (2003) The EPICure study: growth and associated problems in children born at 25 weeks of gestational age or less. Archives of Disease in Childhood, Fetal and Neonatal edition. (88)6, 492-500.
This information was developed by the SLTs in Neonatal Care CEN with specific contributions by:
- Maya Asir
- Louise Bax
- Deborah Carr
- Alexandra Connolly
- Siew-Lian Crossley
- Heather Forster
- Kate Law
- Kristy O’Connor
- Katy Parnell