PEDS2023061957_proof.pdf

Standards for Levels of Neonatal Care:

II, III, and IV

Ann R. Stark, MD, FAAP, DeWayne M. Pursley, MD, MPH, FAAP, Lu-Ann Papile, MD, FAAP, Eric C. Eichenwald, MD, FAAP,

Charles T. Hankins, MD, MBA, FAAP, Rosanne K. Buck, RN, MS, NNP-BC, C-ONQS, Tamara J. Wallace, DNP, APRN, NNP-BC,

Patricia G. Bondurant, DNP, RN, Nicole E. Faster, MSN, RN, RNC-NIC

OVERVIEW

Establishment of risk-appropriate care was first proposed in 1976

when leaders in perinatal health proposed a model system of

regionalized care for obstetrical and neonatal patients, including

definitions of graded levels of hospital car e.

Risk-appropriate care,

in which infants with mild to complex critical illness or physiologic

immaturity are cared for in a facility with the personnel and

resources appropriate for their needs and condition, results in

improved outcomes. This concept is supported by the American

Academy of Pediatrics (AAP) policy statement “Levels of Neonatal

Care,” which provides a review of data supporting a tiered provision

of neonatal care and reaffirms the need for nationally consistent

standards of car e to improve neonatal outcomes.

The work of the AAP NICU Verification Program began in 2013 when

the state of Texas mandated that all Texas facilities caring for

newborns re quire d a ne onata l level of care desig natio n to receiv e

Medicaid payment for neonatal services and an nounced a plan to

engage survey age ncies to verify levels of neonatal care. The AAP

was identified as 1 of 2 Texas-approved survey agencies to pilot the

verification survey process in 2016, and the NICU Verification

Program was officially launched. S ince 2016, the NICU Verification

Program has provided third-party surveys by experienced and

credentialed neonatologists, neonatal n urses, and pediatric surgeons

to assess compliance with state-specific risk-appropriate neonatal

care standards.

Since then, discussions were initiated with the G eorgia Department

of Public Health in 2019 to provide NICU verification surveys in

Georgia. Additionally, the AAP NICU Verification Program is named

as the approved neonatal survey agency for neonatal care services in

Missouri’s code of state regulations for neonatal care designation.

The AAP continues to be approached by additional states and

This document is copyrighted and is property of the American

Academy of Pediatrics and its Board of Directors. All authors have

ﬁled conﬂict of interest statements with the American Academy of

Pediatrics. Any conﬂicts have been resolved through a process

approved by the Board of Directors. The American Academy of

Pediatrics has neither solicited nor accepted any commercial

involvement in the development of the content of this publication.

The content of this publication may be cited in academic

publications, as well as downloaded and printed for individual use

only. These materials may not be distributed, resold, nor used to

create revenue generating content, software, or programs by any

entity other than the American Academy of Pediatrics without the

express written permission of the American Academy of Pediatrics.

DOI: https://doi.org/10.1542/peds.2023-061957

Address correspondence to Ann R. Stark, MD, FAAP. Email: astark@

bidmc.harvard.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

To cite: Stark AR, Pursley DWM, Papile LA, et al. Standards for

Levels of Neonatal Care: II, III, and IV. Pediatrics. 2023; 151(6):

e2023061957

PEDIATRICS Volume 151, number 6, June 2023:e2023061957 FROM THE AMERICAN ACADEMY OF PEDIATRICS

independent facilities for

verification services outside Texas,

Georgia, and Missouri.

Although all states regulate health

care facilities, specifications for

levels of neonatal care and

adhere nce to require ments vary

widely.

3,4

Data indicate that

facilities often assess themselves at

a h ighe r level than an ind epen dent

observer, yet only a few states

require verification by a third-

party surveying agency or health

department official. Recognizing

that a national neonatal

verification program is vital to

high-quality and equitable care, the

AAP NICU Verification Program has

developed the “Standards for Levels of

Neonatal Care: II, III, and IV,” which

have the potential to improve the

quality and consistency of risk-

appropriate neonatal care and is

critical to the future growth of the

AAP NICU Verification Program.

The AAP Standards for Levels of

Neonatal Care are considered a

complementary impleme ntation

tool as they are based on existing

AAP policy; evidence-based

literature; standards of

professional practice from national

neonatal, perinatal, and surgical

organizations; published data; and,

when no data existed, expert

opinion. Developed by the AAP

NICU Veri fication Pr ogram

Leadership Team with the support

of AAP staff, the Standards codify

the minimum components of care

expected for each level of neonatal

care from Special Care Nursery

(Level II), to complex subspecialty

care including surgery (Level IV

NICU). The NICU Verification

Program also convened a virtual

stakeholder meeting in September

2020, which included national

leaders in neonatal intensive care,

neurodevelopmental follow-up

care, pedia tric su rgery , and qualit y

and patient safety. The Section on

Neonatal-Perinatal Medicine

(SONPM) Clinical Leaders Group

(CLG) and Fol low-up Group

provided additional input to the

Standards, and p ublished standards

from nu rsing, pediatric surgery, and

therapist organizations have been

integrated as well.

The lack of standardized or state-

specific risk-appropriate neonatal

carepoliciesisabarriertothe

deliv ery of r egul ate d and hi gh-

quality neonatal care. By

establishing and implementing

risk-appropriate neonatal care

standards, the NICU Verification

Program believes that the AAP will

improve neonatal outcomes by

ensuring that every infant receives

care in a facility with the personnel

and resources appropriate for the

newborn’s needs and condition.

Although the Standards are

identified as minimum

requir emen ts for each le vel of

neonatal care, the AAP NICU

Verification Program encourages

facilities to go beyond the

minimum. The AAP NICU

Verification Program upholds the

AAP Equity Agend a and is

committed to supporting efforts to

improve health outcomes by

encouraging facilities to further

assess the health disparities of

their patients, families, and

community. The AAP values equity,

divers ity, and inc lusi vity and

recognizes that family-centered

care is essential for best outcomes

and encourages facilities to

amplify their focus on family

members and staff to elev ate the

quality of neonatal care and

improve the health outcomes of

the nation’smostvulnerable

population.

3,4

The AAP “Standards for Levels of

Neonatal Care II, III, and IV” (the

“Standards”) were developed

through the cooperative efforts of

the AAP NICU Verification Program

Leadership Team and the

Committee on Fetus and Newborn

(COFN), the SONPM, and the

SONPM C LG. The Standa rds

delineate the components of care

expect ed for each lev el of neon atal

care from Special Care Nursery

(Level II), to c omplex su bspecialty

care including surgery (Level IV

NICU) by setting forth standards

for institutional commitment,

neonatal programing, personnel,

ancillary services, patient and

family care resources, and

equipment required for each level

of neonatal care. Compliance with

the Standards will not guarantee

that a particular neonatal program

is in compliance with applicable

state law or other requirements. In

addition, the Standards are not

designed to be an educational

resource for clinicians related to

treatment decisions or standards

of patient care. Rather, the

Standards set forth the minimum

components to b e included in

any neonatal program desiring

to be recognized as providing

a particular level of neonatal

care.

2 FROM THE AMERICAN ACADEMY OF PEDIATRICS

STANDARD I: INSTITUTIONAL

COMMITMENT

STANDARD II: NEONATAL PROGRAM

DESCRIPTION

(a) The facility’s organized medical staff and institutional governing body must demonstrate an institutional commitment to the neonatal program and will:

1. include a commitment of the facility’s governing body supporting the level-speciﬁc provisions of neonatal services as described in the neonatal program

description;

2. include allocation of sufﬁcient personnel and resources to attain optimal neonatal care;

3. reafﬁrm the neonatal program at least every 3 years; and

4. verify the neonatal program description is current at the time of neonatal veriﬁcation.

(a) The facility will provide a detailed description of the neonatal services provided that includes a comprehensive explanation of the scope of services

available to all neonatal and obstetrical patients that is consistent with accepted professional standards of practice and clinical care; deﬁnes the

neonatal population served; and supports the health, safety, and optimal care of all patients.

1. The comprehensive description of neonatal services will include, at a minimum:

i. identiﬁcation of the resources used to develop the facility’s neonatal policies and procedures for the neonatal services it provides;

ii. description of the review and revision schedule for all neonatal medical practice guidelines, neonatal nursing policies, and ancillary care

team policies that does not exceed 3 years;

iii. written guidelines for consultation, triage, stabilization, and transfer of newborns and/or pregnant or antepartum persons who receive care at

the facility;

iv. provisions to facilitate continuity of care for high-risk neonatal patients from delivery to discharge;

v. delineation of roles, responsibilities, and authority of the medical, nursing, and ancillary patient care directors;

vi. physician, advanced practice nurse, and/or other medical care provider stafﬁng plan for neonatal coverage;

vii. plan for nurse stafﬁng including provisions for ﬂexibility and change in census and acuity;

viii. completion of an annual educational needs assessment to evaluate the ongoing educational needs of all staff participating in the care of

newborns;

ix. annual educational plan for all staff participating in the care of newborns that includes didactic education, simulation, competency, and skills

validation;

x. appropriate allocations for family-centered care including providing parents with reasonable access to their infants and encouraging advocacy,

shared decision-making, and participation in their child’s care;

xi. assurance of equitable care for all neonatal patients and families and provisions for promoting an environment of cultural humility;

xii. capability of neonatal care team members to have the knowledge and skills to provide lactation support;

xiii. a process to assess and establish appropriate on-going care for all newborns after discharge;

xiv. a description of the Neonatal Patient Safety and Quality Improvement Program (NPSQIP); and

xv. established evacuation policies and procedures to guarantee that obstetrical and neonatal patients receive, or are transferred to, the

appropriate level(s) of care.

PEDIATRICS Volume 151, number 6, June 2023 3

STANDARD III: NEONATAL PATIENT

SAFETY AND QUALITY IMPROVEMENT

PROGRAM (NPSQIP)

STANDARD IV: GENERAL PROGRAM

REQUIREMENTS

NPSQIP Core Components:

(a) The facility will have a system for identiﬁcation and review of signiﬁcant events that could indicate threats to patient safety, with a goal of learning

from identiﬁed events and mitigating future risk of recurrence, including:

1. a list of speciﬁc triggers or safety indicators that warrant a record review, with the goal of identifying signiﬁcant safety events such as errors,

adverse events, near misses, complications, and mortalities;

2. a process for systematic multidisciplinary review of selected cases or safety events, using acceptable failure mode and effect analysis tools with

a goal of identifying interventions to improve systems and reduce future safety risks; and

3. a process for monitoring the implementation of identiﬁed interventions.

(b) The facility will have a dashboard or equivalent that is used to summarize and track quality indicators relevant to newborn care, including:

1. a list of selected quality measures relevant to the facility with a process for obtaining data needed for each selected neonatal quality measure;

2. a platform to display performance on the selected quality measures, including a process for updating data with a frequency that allows for

appropriate identiﬁcation of performance concerns;

3. benchmarking of performance, when possible, with internal or external benchmarks; and

4. a multidisciplinary forum for review of the dashboard or equivalent.

(c) The facility will have a structured approach to quality improvement (QI) that seeks to improve care quality and outcomes.

Quality outcomes include

care that is safe, efﬁcient, effective, timely, equitable, and patient centered.

Approaches will include:

1. a clear process for determining current QI initiatives, with a goal that the unit is engaged in at least 1 to 2 such initiatives at any given time;

2. identiﬁcation of a multidisciplinary QI team for each initiative, with a designated team lead;

3. use of structured improvement methods or framework to guide improvement efforts; and

4. a multidisciplinary quality committee that meets regularly to identify and review QI initiatives.

(d) The facility will maximize efforts to standardize and improve care through the use of guidelines and policies that align with research-driven and

evidence-based best practices, including:

1. a process for identifying topics for guideline or policy development;

2. a process for developing guidelines and policies that incorporate evidence-based recommendations;

3. a platform for making guidelines and policies readily available to clinical providers; and

4. a process for periodic review of guidelines and policies to guarantee they remain updated, and evidence based.

(e) The facility will have multidisciplinary involvement in quality and safety activities, including:

1. involvement of all disciplines represented in the neonatal quality and safety activities as appropriate and as described above; and

2. for level IV facilities, involvement of subspecialty services with signiﬁcant presence in the neonatal unit.

(f) The neonatal-speciﬁc unit will coordinate with hospital quality and safety activities, including:

1. structured collaboration with the obstetrics and pediatric surgery departments, if applicable, to identify and implement opportunities for shared quality and

safety efforts;

2. participation in hospital-level quality and safety activities to conﬁrm alignment of neonatal quality goals with hospital priorities;

3. alignment with hospital activities and reporting of quality measures to national organizations; and

4. participation in efforts to guarantee everyday readiness for external assessments by regulatory organizations.

(g) The facility will participate in larger communities of perinatal safety and quality, including:

1. collaboration between transferring and receiving hospitals to examine and improve population-level quality and safety through structured

activities such as transport review and sharing of clinical protocols; and

2. for level III and IV facilities, participation in regional, state, or national databases that allows benchmarking of performance.

NPSQIP Additional Best Practices:

(h) Encourage and support the integration of family into quality improvement and patient safety initiatives.

(i) Explicit efforts to identify inequities and target equity in quality measures.

(j) A process for random chart audits and peer review.

(k) Neonatal team training for safety and Just Culture.

Family-Centered Care Core Components:

(a) The facility will:

1. allow all parents to have reasonable access to their infants at all times;

2. have access to the services, personnel, and equipment needed to provide the appropriate level of care for all infants;

3. support the physiologic, developmental, and psychosocial needs of infants and their families;

4. have a process to screen every family for social determinants, depression, and cultural needs; and

5. refer patients and families to appropriate resources as needed.

Family-Centered Care Additional Best Practices:

(b) Implement the utilization of primary nursing.

4 FROM THE AMERICAN ACADEMY OF PEDIATRICS

(d) Implement and support a family advisory council.

(e) Establish a process to evaluate potential health disparities of the patient population served.

(f) Implement a coordinated process to assess and address the emotional needs of families.

(g) Engage in shared decision-making by involving family in discharge planning, including transport discussions.

(h) Provider and staff training on shared decision-making and how to engage in difﬁcult and inclusive conversations.

(i) Explicit efforts to support lactation and the needs of breastfeeding

individuals.

Lactation and Neonatal Nutrition

(j) The facility will:

1. have personnel with the knowledge and skills to support lactation available at all times;

2. have pumping equipment and secure human milk storage facilities available;

3. have policies and procedures in place to support:

i. the initiation and maintenance of lactation;

ii. early initiation of milk expression;

iii. safety, preparation, storage, and use of human milk and formula;

iv. long-term pumping and transition to breastfeeding; and

v. the utilization of donor human milk, if available.

4. provide annual education to all direct care providers on the importance of, and suppor t of lactation (ie, pumping, mixing, safe storage,

misappropriation, and proper identiﬁcation); and

i. all direct care providers have didactic education, skills veriﬁcation, and competency on the proper mixing of human milk and formula;

5. establish a program for breastfeeding and lactation support, including data collection.

Neonatal Resuscitation

(i) The facility must have written policies and procedures speciﬁc to the resuscitation and stabilization of newborns based on current standards of

professional practice.

1. At least 1 person with the skills to perform a complete neonatal resuscitation including endotracheal intubation, establishment of vascular access,

and administration of medications must be immediately available on-site 24/7.

2. A full range of neonatal resuscitative equipment, supplies, and medications must be immediately available at all times.

3. If the facility provides obstetrical delivery services:

i. Each birth will be attended by at least 1 AAP Neonatal Resuscitation Program (NRP) trained provider whose only responsibility is the

management of the newborn and initiating resuscitation.

ii. In the event of identiﬁed antepartum and intrapartum risk factors, at least 2 NRP trained providers should be present at birth and be

responsible solely for the management and resuscitation of the newborn.

Additional qualiﬁed providers should be available depending on the

anticipated risk, number of newborns, and the obstetrical setting.

iii. If advanced resuscitation measures are anticipated, a fully qualiﬁed neonatal resuscitation team should be present at the time of birth.

Radiology

(j) When obtaining imaging in neonatal and obstetrical patients, radiology services will incorporate the “as low as reasonably achievable” principle.

Policies and Procedures

(k) The facility will have written:

1. neonatal, medical, and ancillary care guidelines, policies, and procedures that are established on evidence-based literature, and best-practice

standards, that are monitored and tracked for adherence, reviewed at least every 3 years, and revised as needed;

2. a policy that mandates the escalation of concern and the urgent presence of a privileged care provider at the bedside, including a method to track

adherence;

3. policies and procedures that deﬁne the criteria for neonatal team presence at a delivery and identify a method to track adherence, if applicable;

4. policies and procedures for the triage, stabilization, and transfer of obstetrical patients to the appropriate level of care, if applicable;

5. policies and procedures for consultation by telehealth and telephone, if applicable;

6. policies and procedures for intrafacility and interfacility neonatal transport;

7. policies and procedures for transfer to a higher level of neonatal care or for services not available at the facility, if applicable;

8. policies and procedures for car seat safety observation before discharge; and

9. policies and procedures for disaster response, including evacuation of obstetrical and neonatal patients to the appropriate level(s) of care.

Staff Privileges

(l) The facility will have:

1. speciﬁed requirements for all privileged care providers participating in the care of neonatal patients, and have a credentialing process for

delineation of privileges;

2. a process to verify that all ancillary care services, clinical staff, and support staff have relevant neonatal training and expertise; and

3. a mechanism in place for medical, nursing, and ancillary care leadership to review and approve these credentials and track adherence.

The word chestfeeding may be used by nonbinary, transgender, and other parents to identify how they feed their infants. It may refer to human milk or human milk substitute

feeding, from a person who lactates or not. Because of this broad and variable deﬁnition, chestfeeding and breastfeeding are not always synonymous, and the words are not in-

terchangeable. Published literature ﬁndings on breastfeeding may not hold the same outcomes for chestfeeding. Throughout this document, the words breastfeeding and human

milk will be used.

PEDIATRICS Volume 151, number 6, June 2023 5

ST ANDARD V: LEVEL II SPECIAL CARE

NURSERY (SCN) REQUIREMENTS

Level II SCN Requirements

(a) The Level II SCN will provide comprehensive care of infants born $32 wk or with birth wt $1500 g who

1. are mild to moderately ill with physiologic immaturity or who have conditions that are expected to resolve quickly

;

2. are not anticipated to require subspecialty services on an urgent basis

;

3. require continuous positive airway pressure (CPAP) or short-term (less than 24 h) conventional mechanical ventilation for a condition expected to

resolve rapidly or until transfer to a higher-level facility is achieved

;or

4. are back transferred from a higher-level facility for convalescent care.

Neonatal Medical Director

(b) The neonatal medical director (NMD) will:

1. be a board eligible or cer tiﬁed neonatologist or a board-certiﬁed pediatrician with sufﬁcient training and expertise to assume responsibility of

care for infants who require level II care, including endotracheal intubation, assisted ventilation, and CPAP management, or equivalent

;

i. if the neonatologist or pediatrician is certiﬁed by The American Board of Pediatrics, they will meet maintenance of certiﬁcation (MOC)

requirements;

2. complete annual continuing medical education (CME) speciﬁc to neonatology; and

3. demonstrate a current status of NRP completion.

Neonatologists

(c) If the NMD and/or on-site provider is not a neonatologist, the privileged care provider must maintain a consultative relationship with a board

certiﬁed or eligible neonatologist at a higher-level neonatal facility; and

1. the facility must have a written policy or guideline that deﬁnes the criteria for neonatologist consultation at a higher-level neonatal facility.

Privileged Care Providers

(d) Privileged care providers with pediatric- or neonatal-speciﬁc training qualiﬁed to manage the care of infants with mild to moderate critical

conditions, including emergencies, will

1. be continuously available on-site, or on-call and available to arrive on-site within an appropriate time frame as deﬁned by the facility’s policies and

procedures;

i. if the on-site or on-call provider is not a physician, a written policy will be in place that deﬁnes the criteria for notiﬁcation and time frame for

on-site physician presence, and a tracking mechanism for compliance is required;

ii. if an infant is maintained on a ventilator, a pediatric- or neonatal-speciﬁc privileged care provider who can manage respiratory emergencies

will be immediately available on-site;

2. demonstrate a current status of NRP completion;

3. complete annual continuing education requirements speciﬁc to neonatology; and

4. have credentials reviewed at least every 2 years by the NMD.

(e) At least 1 person with the skills to perform a complete neonatal resuscitation including endotracheal intubation, establishment of vascular access,

and administration of medications must be immediately available on-site 24/7

; and

1. demonstrate a current status of NRP completion.

(f) The facility will establish a written policy for backup privileged care provider coverage that establishes ﬂexibility for variable census and acuity. This

policy will document the criteria for notiﬁcation and time frame for on-site presence, be based on allocating the appropriate number of competent

medical providers to a care situation, attend to a safe and high-quality work environment, and be operationally reviewed annually for adequacy and

adherence.

Nursing Leadership

(g) The level II SCN nurse leader will:

1. be a registered nurse (RN) with experience and training in perinatal nursing and neonatal conditions, with nursing certiﬁcation preferred

;

2. have at least a Bachelor of Science in Nursing, Master’s preferred;

3. demonstrate a current status of NRP completion;

4. have sufﬁcient experience and expertise to create, and/or support, a program that provides care to infants who require level II SCN care;

5. be responsible for inpatient activities in the level II SCN and, as appropriate, obstetrical, well newborn, and/or pediatric units;

6. coordinate with respective neonatal, pediatric, and obstetric care services, as appropriate;

7. provide oversight of annual neonatal-speciﬁc education, which includes low-volume, high-risk procedures consistent with the care provided in the

level II SCN; and

8. foster collaborative relationships with multidisciplinary team members, facility leadership, and higher-level facilities to create a diverse, equitable,

and inclusive environment focused on the quality of care and patient care outcomes.

Clinical Nurse Stafﬁng

(h) A written nurse stafﬁng plan is in place that establishes ﬂexibility for variable census and acuity. This plan and actual stafﬁng will be based on

allocating the appropriate number of competent RNs to a care situation, attend to a safe and high-quality work environment, and be operationally

reviewed annually for adequacy and adherence.

9,10

Clinical Nurse Staff

(i) Each clinical nurse will:

1. be an RN, with nursing certiﬁcation speciﬁc to the care environment preferred;

2. demonstrate a current status of NRP completion;

3. par ticipate in annual simulation and skills veriﬁcation, which includes low-volume, high-risk procedures consistent with the types of care provided

in the level II SCN; and

6 FROM THE AMERICAN ACADEMY OF PEDIATRICS

4. promote a family-centered approach to care, including but not limited to skin-to-skin care, appropriate developmental positioning based on

gestational age, lactation and breastfeeding support, and engagement of families in their infant’s care.

(j) If the facility utilizes licensed practical nurses (LPNs) or nonlicensed direct care providers to support the clinical nursing staff, the facility must:

1. have written criteria that deﬁne the LPNs’ or nonlicensed direct care providers’ scope of neonatal care;

2. provide annual education speciﬁc to the care of the neonatal population served; and

3. have a written stafﬁng plan that establishes collaborative work assignments in accordance with the facility’s policies and procedures.

Nursing Orientation and Education

(k) Level II SCN nursing orientation will incorporate didactic education, simulation, skills veriﬁcation, and competency and will be tailored to the

individual needs of the nurse based on clinical experience.

(l) The facility will document an annual educational needs assessment to determine the educational needs of the clinical nursing staff and ancillary

team members.

(m) Annual nursing education will address the annual needs assessment and incorporate simulation and skills veriﬁcation of low-volume, high-risk

procedures consistent with the types of care provided in the level II SCN and include education related to serious safety events.

Clinical Nurse Educator

(n) The level II SCN clinical nurse educator or perinatal nurse educator will:

1. be an RN, with nursing certiﬁcation speciﬁc to the care environment preferred;

2. have at least a Bachelor of Science in Nursing, Master’s preferred;

3. demonstrate a current status of NRP completion;

4. cultivate collaborative relationships with the neonatal nurse leader and facility leadership to improve the quality of care and patient care

outcomes

; and

5. have experience and expertise to evaluate the educational needs of the clinical staff, develop didactic and skill-based educational tools, oversee

education and skills veriﬁcation, and evaluate retention of content, critical thinking skills, and competency relevant to level II neonatal care.

(o) The facility will have a dedicated individual with sufﬁcient time allocated to perform the roles and responsibilities of the clinical nurse educator.

Neonatal Transport

(p) The facility will have policies and procedures in place to identify a local neonatal transport program to facilitate neonatal transport to a higher-level

neonatal facility.

Pediatric Medical Subspecialists and Pediatric Surgical Specialists

(q) Policies and procedures will be in place for referral to a higher level of neonatal care when pediatric medical subspecialty or pediatric surgical

specialty consultation and/or intervention is needed.

Laboratory Services

(r) Laboratory services will have:

1. laboratory personnel on-site 24/7;

2. the ability to determine blood type, crossmatch, and perform antibody testing;

3. a blood bank capable of providing blood component therapy and irradiated, leukoreduced or cytomegalovirus (CMV)-negative blood;

4. the ability to perform neonatal blood gas monitoring; and

5. the ability to perform analysis on small volume samples.

(s) Low-volume specialty laboratory services may be provided by an outside laboratory, but the facility will have policies and procedures in place to

verify timely and direct communication of all critical value results.

Pharmacy

(t) The facility will have at least 1 registered pharmacist with experience in neonatal and/or pediatric pharmacology who will:

1. be available for consultation on-site, or by telehealth or telephone, 24/7;

2. complete continuing education requirements speciﬁc to pediatric and neonatal pharmacology; and

3. par ticipate in multidisciplinary care, as needed.

(u) The pharmacy will have policies and procedures in place to address drug shortages and to verify medications are appropriately allocated to the

level II SCN; and

1. have policies and procedures in place to verify neonatal competency for pharmacy staff supporting and preparing medications for neonatal

patients.

Diagnostic Imaging

(v) Radiology services will have:

1. appropriately trained radiology personnel continuously available on-site to meet routine diagnostic imaging needs and to address emergencies;

2. personnel appropriately trained in ultrasonography, including cranial ultrasonography, on-call and/or available on-site to perform advanced imaging

as requested; and

3. the ability to provide timely imaging interpretation by radiologists with pediatric expertise as requested.

Respiratory Therapy

(w) The respiratory care leader will:

1. be a full-time respiratory care practitioner, with neonatal and pediatric respiratory care certiﬁcation preferred;

2. have sufﬁcient time allocated to oversee the respiratory therapists (RTs) who provide care in the level II SCN;

3. provide oversight of annual simulation and skills veriﬁcation, which includes neonatal respiratory care modalities and low-volume, high-risk

neonatal respiratory procedures;

4. develop a written RT stafﬁng plan that establishes ﬂexibility for variable census and acuity. This plan and actual stafﬁng will be based on allocating

the appropriate number of competent RTs to a care situation, attend to a safe and high-quality work environment, and be operationally reviewed

annually for adherence and to verify respiratory therapy stafﬁng is adequate for patient care needs

; and

PEDIATRICS Volume 151, number 6, June 2023 7

5. maintain appropriate stafﬁng ratios for infants receiving supplemental oxygen and positive pressure ventilation.

(x) Respiratory care practitioners assigned to the SCN will:

1. be a respiratory care practitioner with documented experience and training in the respiratory support of newborns and infants, with neonatal or

pediatric respiratory care certiﬁcation preferred;

2. be on-site 24/7 and immediately available when an infant is supported by assisted ventilation or CPAP;

3. be able to attend deliveries and assist with resuscitation as requested;

4. demonstrate a current status of NRP completion;

5. participate in annual simulation and respiratory skills veriﬁcation, which includes low-volume, high-risk procedures consistent with the types of

respiratory care provided in the SCN; and

6. have their credentials reviewed by the respiratory care leader annually for adequacy and adherence.

Dietitian

(y) The facility must have, or have the ability to consult with, at least 1 registered dietitian or nutritionist who has specialized training in neonatal

nutrition, who will

1. collaborate with the medical team to establish feeding protocols, develop patient-speciﬁc feeding plans, and help determine nutritional needs at

discharge;

2. establish policies and procedures to verify proper preparation and storage of human milk and formula; and

3. have policies and procedures for dietary consultation for patients in the SCN.

Neonatal Nutrition

(z) The facility will:

1. provide a specialized area or room, with limited access and away from the bedside, to accommodate mixing of formula or additives to human

milk

;

2. develop standardized feeding protocols for the advancement of feedings based on the availability of, and family preference for human milk, donor

human milk , fortiﬁcation of human milk and formula; and

3. have policies and procedures in place for accurate veriﬁcation and administration of human milk and formula, and to avoid misappropriation.

Lactation and Breastfeeding Support

(aa) The facility will:

1. have personnel with the knowledge and skills to support lactation available at all times;

2. have a certiﬁed lactation counselor (CLC), international board-certiﬁed lactation consultant (IBCLC) preferred, available for on-site consultation

on weekdays and accessible by telehealth or telephone 24/7; and

3. operationally review CLC and/or IBCLC personnel on an annual basis to establish adequately trained lactation coverage based on the speciﬁc need

and volume of the neonatal population served.

Neonatal Therapists

(bb) If the facility does not have in-house access to neonatal therapy expertise, the facility will have a formal process in place for providing on-site

consultative services by quali ﬁed neonatal therapists to address the 6 core practice domains (environment, family or 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. The facility will have on-site access to the following as needed

1. an occupational or physical therapist with neonatal expertise, and neonatal therapy certiﬁcation preferred

; and

2. at least 1 individual skilled in the evaluation and management of neonatal feeding and swallowing concerns, with neonatal therapy certiﬁcation

preferred.

(cc) The facility will operationally review neonatal therapist personnel on an annual basis to maintain adequate multidisciplinary neonatal therapist

coverage based on the speciﬁc need and volume of the neonatal population served.

Social Worker

(dd) The SCN social worker will:

1. be a Master’s prepared medical social worker with perinatal and/or pediatric experience.

(ee) The facility will:

1. provide 1 social worker for every 30 beds providing level II neonatal care and/or specialty and subspecialty perinatal care

;

2. have a written description that clearly identiﬁes the responsibilities and functions of the SCN social worker; and

3. have social services available for each family with an infant in the SCN as needed.

Pastoral Care

(ff) Personnel skilled in pastoral care will be available as needed and by family request, and will represent, or have the ability to consult, multiple

religious afﬁliations representative of the population served.

Retinopathy of Prematurity

(gg) If the facility back transfers infants for convalescent care, the facility must have a process in place to appropriately identify infants at risk for

retinopathy of prematurity to guarantee timely examination and treatment by having

1. documented policies and procedures for the monitoring, treatment, and follow-up of retinopathy of prematurity

5,13

; and

2. the ability to perform on-site retinal examinations, or off-site interpretation of digital photographic retinal images, by a pediatric ophthalmologist

or retinal specialist with expertise in retinopathy of prematurity, if needed.

5,13

8 FROM THE AMERICAN ACADEMY OF PEDIATRICS

STANDARD VI: LEVEL III NICU

REQUIREMENTS

Discharge and Follow-up

(hh) Systems will be in place to establish preparation for SCN discharge, including postdischarge follow-up by general and subspecialty pediatric care

providers, home care arrangements and community service resources, and enrollment in a developmental follow-up program as needed.

1. The facility will:

i. have written medical, neurodevelopmental, and psychosocial criteria that automatically warrant high-risk neonatal follow-up with appropriat e

developmental follow-up services; and

ii. have a written referral agreement with a developmental follow-up clinic or practice, when possible, to provide neurodevelopmental services for

the neonatal population served.

Level III NICU Requirements

(a) The Level III neonatal facility will:

1. provide comprehensive care for infants born at all gestational ages and birth weights, with mild to complex critical conditions or medical

problems requiring sustained life support, hemodynamic support, and/or conventional mechanical ventilation

;

2. have the ability to provide high-frequency ventilation, inhaled nitric oxide (iNO) delivery, and/or therapeutic hypothermia or have policies and

procedures in place to facilitate neonatal transfer to a higher level of care

;

3. provide care for infants who are back transferred for convalescent care

; and

4. have sufﬁcient experience based on patient volume and a systematic process to assess the quality of care provided to each very low birth weight

infant, including a method to track speciﬁc quality indicators including obstetrical and neonatal transfers, review aggregate data using accepted

methodology, and develop action plans as needed to improve patient outcomes.

2,14

Neonatal Medical Director

(b) The NMD will:

1. be a board eligible or certiﬁed neonatologist or equivalent;

i. if the neonatologist is certiﬁed by The American Board of Pediatrics, they will meet MOC requirements in neonatal-perinatal medicine;

2. complete annual continuing CME speciﬁc to neonatology; and

3. demonstrate a current status of NRP completion.

Neonatologists

1. be a board eligible or certiﬁed neonatologist or equivalent;

i. if the neonatologist is certiﬁed by The American Board of Pediatrics, they will meet MOC requirements in neonatal-perinatal medicine;

2. complete annual CME speciﬁc to neonatology;

3. demonstrate a current status of NRP completion;

4. have credentials that are reviewed by the NMD at least every 2 years; and

5. preferably be on-site and immediately available 24/7 or on-call and available to arrive on-site within an appropriate time frame, as deﬁned by the

facility’s policies and procedures.

i. If a neonatologist is not on-site 24/7, a written policy will be in place that deﬁnes the criteria for notiﬁcation and time frame for on-site

presence, and a tracking mechanism for compliance is required.

Privileged Care Providers

(d) Privileged care providers with neonatal-speciﬁc training qualiﬁed to manage the care of infants with mild to complex critical conditions, including

emergencies, will be on-site 24/7 and

1. demonstrate a current status of NRP completion;

2. complete annual continuing education requirements speciﬁc to neonatology; and

3. have their credentials reviewed at least every 2 years by the NMD.

(e) At least 1 person with the skills to perform a complete neonatal resuscitation, including endotracheal intubation, establishment of vascular access,

and administration of medications must be immediately available on-site 24/7

; and

1. demonstrate a current status of NRP completion.

(f) The facility will establish a written policy for backup privileged care provider coverage that establishes ﬂexibility for variable census and acuity . This policy will

document the criteria for notiﬁcation and time frame for on-site presence, be based on allocating the appropriate number of competent medical providers to

a care situation, attend to a safe and high-quality work environment, and be operationally reviewed annually for adequacy and adherence.

Nursing Leadership

(g) The level III NICU nurse leader will:

1. be an RN with experience and training in neonatal nursing and conditions, with nursing certiﬁcation preferred

;

2. have at least a Bachelor of Science in Nursing, Master’s preferred;

3. demonstrate a current status of NRP completion;

4. have sufﬁcient experience and expertise to create, and/or support, a program that provides care to infants who require level III NICU care;

5. be responsible for inpatient activities in the NICU(s) and, as appropriate, obstetrical, well newborn, and/or pediatric units;

6. coordinate with respective neonatal, pediatric, and obstetric care services, as appropriate;

PEDIATRICS Volume 151, number 6, June 2023 9

7. provide oversight of annual neonatal-speciﬁc education which includes low-volume, high-risk procedures consistent with the care provided in the

level III NICU; and

8. foster collaborative relationships with multidisciplinary team members, facility leadership, and higher-level facilities to create a diverse, equitable,

and inclusive environment to improve the quality of care and patient care outcomes.

Clinical Nurse Stafﬁng

(h) A written nurse stafﬁng plan is in place that establishes ﬂexibility for variable census and acuity. This plan and actual stafﬁng will be based on

allocating the appropriate number of competent RNs to a care situation, attend to a safe and high-quality work environment, and be operationally

reviewed annually for adequacy and adherence.

9,10

Clinical Nurse Staff

(i) Each clinical nurse will:

1. be an RN, with nursing certiﬁcation speciﬁc to the care environment preferred;

2. demonstrate a current status of NRP completion;

3. par ticipate in annual simulation and skills veriﬁcation, which includes low-volume, high-risk procedures consistent with the types of care provided

in the level III NICU; and

4. promote a family-centered approach to care, including but not limited to skin-to-skin care, appropriate developmental positioning based on

gestational age, lactation and breastfeeding support, and engagement of families in their infant’s care.

(j) If the facility utilizes LPNs or nonlicensed direct care providers to support the clinical nursing staff, the facility must:

1. have written criteria that deﬁne the LPNs’ or nonlicensed direct care providers’ scope of neonatal care;

2. provide annual education speciﬁc to the care of the neonatal population served; and

3. have a written stafﬁng plan that establishes collaborative work assignments in accordance with the facility’s policies and procedures.

Nursing Orientation and Education

(k) Level III NICU nursing orientation will incorporate didactic education, simulation, skills veriﬁcation, and competency and will be tailored to the

individual needs of the nurse based on clinical experience.

(l) The facility will document an annual educational needs assessment to determine the educational needs of the clinical nursing staff and ancillary

team members.

(m) Annual nursing education will address the annual needs assessment and incorporate simulation and skill veriﬁcation of low-volume, high-risk

procedures consistent with the types of care provided in the level III NICU and include education related to serious safety events.

Clinical Nurse Specialist

(n) The clinical nurse specialist will:

1. be an RN, with neonatal nursing certiﬁcation and clinical nurse specialist certiﬁcation preferred

;

2. have at least a Bachelor of Science in Nursing, Master’s or Doctorate preferred

;

3. demonstrate a current status of NRP completion

;

4. foster continuous quality improvement in nursing care

;

5. develop and educate staff to provide evidence-based nursing care

;

6. be responsible for mentoring new staff and developing team building skills

;

7. provide leadership to multidisciplinary teams

;

8. facilitate case management of high-risk neonatal patients

; and

9. cultivate collaborative relationships with multidisciplinary team members and facility leadership to improve the quality of care and patient care

outcomes.

(o) The roles and responsibilities of the NICU clinical nurse specialist can be allocated to multiple individuals to perform this role.

Clinical Nurse Educator

(p) The NICU clinical nurse educator will:

1. be an RN, with nursing certiﬁcation speciﬁc to the care environment preferred;

2. have at least a Bachelor of Science in Nursing, Master’s preferred;

3. demonstrate a current status of NRP completion;

4. cultivate collaborative relationships with the neonatal nurse leader and facility leadership to improve the quality of care and patient care

outcomes

; and

5. have experience and expertise to evaluate the educational needs of the clinical staff, develop didactic and skill-based educational tools, oversee

education and skills veriﬁcation, and evaluate retention of content, critical thinking skills, and competency relevant to level III neonatal care.

(q) The facility will have a dedicated individual with sufﬁcient time allocated to perform the roles and responsibilities of the NICU clinical nurse

educator.

Neonatal Transport

(r) If the facility has a neonatal critical care transport program, it will have an identiﬁed director of neonatal transport services.

The director of

neonatal transport services can be the neonatal medical director or another physician who is a pediatrician, board eligible or certiﬁed

neonatologist, pediatric hospitalist, or pediatric medical subspecialist with expertise and experience in neonatal and infant transport.

1. If the facility does not have its own transport program, the facility must have policies and procedures in place to identify a local neonatal

transport program to facilitate transport.

(s) Responsibilities of the director of neonatal transport services include the following:

1. train and supervise staff

;

2. provide appropriate review of all transport records

;

10 FROM THE AMERICAN ACADEMY OF PEDIATRICS

3. develop and implement policies and procedures for patient care during transport

;

4. develop guidelines for determining transport team composition and medical control and establish a mechanism to track adherence

;

5. establish policies and procedures to provide transport updates and outreach education

;

6. establish a program for evaluating performance by tracking data, identifying trends, and implementing quality improvement initiatives to address

transport performance in a coordinated systematic approach within a culture of safety, equity, and prevention

; and

7. report neonatal transport data and neonatal-speciﬁc reviews back to the NPSQIP.

8. The director of neonatal transport services may delegate speciﬁc requirements to other person(s) or group(s) but retains the responsibility of

certifying that these functions are addressed appropriately.

(t) The facility will:

1. establish minimum education, experience, and training requirements for all transport team members

;

2. select transport team members based on their experience and competence in the care of neonates and the transport team must collectively have

the ability to provide a level of care that is similar to that of the admitting unit

; and

3. provide annual transport education to all transpor t team members that incorporates equipment training, didactic education, simulation, and skills

veriﬁcation of low-volume, high-risk procedures consistent with the types of care provided during neonatal transport.

Neonatal Outreach

(u) The level III facility will provide multidisciplinary outreach education to referring facilities by assessing educational needs and evaluating clinical care

and outcomes, including transport data, as part of collaboration with lower-level neonatal facilities, if applicable.

Pediatric Medical Subspecialists

(v) The facility must have the ability to obtain pediatric medical subspecialist advice or formal consultation either on-site or by prearranged consultative

agreement using telehealth technology and/or telephone consultation from a distant location from a broad range of pediatric medical subspecialists

including, but not limited to

1. cardiology, pulmonology, infectious disease, neurology, ophthalmology, endocrinology, hematology, gastroenterology, nephrology, and genetics or

metabolism.

(w) If the pediatric medical subspecialist is available for on-site consultation, they will:

1. have credentials to consult at the facility including documented training, certiﬁcation, competencies, and CME speciﬁc to their subspecialty; and

2. document consultations in the medical record within an appropriate time frame and as deﬁned by the facility’s policies and procedures.

Neonatal Surgical Program – Optional for Level III

Pediatric Surgeons

(x) Pediatric surgeons and pediatric surgical specialists will be available on-site or at another closely related NICU facility.

1. If pediatric surgery is not offered on-site at the facility, policies and procedures will be in place with a facility that provides surgical care to

facilitate transfer of an infant when needed.

i. Infants requiring cardiovascular surgery or extracorporeal membrane oxygenation (ECMO) will be transferred to a facility that provides these

services.

2. If pediatric surgery is accessible on-site, the surgeons will:

i. be available at the bedside within 1 hour of request or identiﬁed need

;

ii. have credentials to provide care at the facility, including documented training, certiﬁcation, competencies, and continuing education speciﬁcto

their pediatric surgery specialty

;

iii. establish a program for evaluating surgical performance by accurately tracking data, identifying trends, and implementing quality improvement

initiatives to address surgical performance in a coordinated systematic approach within a culture of safety, equity, and prevention

; and

iv. report neonatal surgical and anesthesia care back to the NPSQIP.

Anesthesiologists

(y) If pediatric surgery is performed on-site, anesthesia providers with pediatric expertise must

1. be on the medical staff and promptly available 24/7 to respond to the bedside within 1 hour of request or identiﬁed need

;

2. serve as the primary responsible anesthesia provider for all infants <24 mo of age and should serve as the primary anesthesiologist for children

#5 y of age based on the American Society of Anesthesiologists (ASA) physical status classiﬁcation

; and

3. be physically present for all neonatal surgical procedures for which they serve as the primary responsible anesthesia provider.

Laboratory Services

(z) Laboratory services will have:

1. laboratory personnel on-site 24/7;

2. the ability to determine blood type, crossmatch, and perform antibody testing;

3. a blood bank capable of providing blood component therapy and irradiated, leukoreduced or CMV-negative blood;

i. policies and procedures will be in place to facilitate emergent access to blood and blood component therapy so that the NICU can provide

hematologic interventions, if applicable;

4. the ability to perform neonatal blood gas monitoring;

5. the ability to perform analysis on small volume samples; and

6. access to perinatal pathology services, if applicable.

(aa) Low-volume specialty laboratory services may be provided by an outside laboratory, but the facility will have policies and procedures in place to

maintain timely and direct communication of all critical value results.

Pharmacy

(bb) The facility will have at least 1 registered pharmacist with experience in neonatal and/or pediatric pharmacology who will:

1. be available for consultation on-site, or by telehealth or telephone, 24/7;

2. complete continuing education requirements speciﬁc to pediatric and neonatal pharmacology; and

PEDIATRICS Volume 151, number 6, June 2023 11

3. par ticipate in multidisciplinary care, including participation in patient care rounds.

(cc) The facility will have neonatal appropriate total parenteral nutrition (TPN) available 24/7, and:

1. the facility will have a written policy and procedure for the proper preparation and delivery of TPN.

(dd) The pharmacy will have policies and procedures in place to address drug shortages and to verify medications are appropriately allocated to the

level III NICU, and:

1. have policies and procedures in place to verify neonatal competency for pharmacy staff supporting and preparing medications for neonatal

patients.

Diagnostic Imaging

(ee) Radiology services will have:

1. appropriately trained radiology personnel continuously available on-site to meet routine diagnostic imaging needs and to address emergencies;

2. ﬂuoroscopy available on-call 24/7;

i. if ﬂuoroscopy is not offered on-site at the facility, policies and procedures will be in place to facilitate transfer of an infant to a higher level of

care;

3. personnel appropriately trained in the following techniques will be on-call and/or available on-site to perform advanced imaging as requested:

i. ultrasonography, including cranial ultrasonography;

ii. computed tomography (CT); and

iii. magnetic resonance imaging (MRI); and

4. the ability to provide timely imaging interpretation by radiologists with pediatric expertise as requested.

(ff) The facility will provide pediatric echocardiography and have the ability to consult with a pediatric cardiologist for timely echocardiography

interpretation as requested.

Respiratory Therapy

(gg) The respiratory care leader will:

1. be a full-time respiratory care practitioner, with neonatal and pediatric respiratory care certiﬁcation preferred;

2. have sufﬁcient time allocated to oversee the RTs who provide care in the level III NICU;

3. provide oversight of annual simulation and skills veriﬁcation which includes neonatal respiratory care modalities and low-volume, high-risk

neonatal respiratory procedures;

4. develop a written RT stafﬁng plan that establishes ﬂexibility for variable census and acuity. This plan and actual stafﬁng will be based on

allocating the appropriate number of competent RTs to a care situation, attend to a safe and high-quality work environment, and be operationally

reviewed annually for adherence and to verify respiratory therapy stafﬁng is adequate for patient care needs

; and

5. maintain appropriate stafﬁng ratios for infants receiving supplemental oxygen and positive pressure ventilation.

(hh) Respiratory care practitioners assigned to the NICU will:

1. be a respiratory care practitioner with documented experience and training in the respiratory support of newborns and infants, with neonatal

and pediatric respiratory care certiﬁcation preferred;

2. be on-site 24/7 and immediately available to supervise assisted ventilation, assist in resuscitation, and attend deliveries;

3. demonstrate a current status of NRP completion;

4. par ticipate in annual simulation and respiratory skills veriﬁcation, which includes low-volume, high-risk procedures consistent with the types of

respiratory care provided in the NICU; and

5. have their credentials reviewed by the respiratory care leader annually for adequacy and adherence.

Dietitian

(ii) At least 1 registered dietitian or nutritionist who has specialized training in neonatal nutrition will have dedicated time allotted to serve the NICU

and will

1. collaborate with the medical team to establish feeding protocols, develop patient-speciﬁc feeding plans, and help determine nutritional needs at

discharge;

2. establish policies and procedures to verify proper preparation and storage of human milk and formula;

3. par ticipate in multidisciplinary care, including participation in patient care rounds; and

4. have policies and procedures for dietary consultation for infants in the NICU.

Neonatal Nutrition

(jj) The facility will:

1. provide a specialized area or room, with limited access and away from the bedside, to accommodate mixing of formula or additives to human

milk

;

2. develop standardized feeding protocols for the advancement of feedings based on the availability of, and family preference for human milk, donor

human milk , fortiﬁcation of human milk and formula; and

3. have policies and procedures in place for accurate veriﬁcation and administration of human milk and formula, and to avoid misappropriation.

Lactation and Breastfeeding Support

(kk) The facility will:

1. have personnel with the knowledge and skills to support lactation available at all times;

2. have an IBCLC available for on-site consultation on weekdays and accessible by telehealth or telephone 24/7; and

3. operationally review IBCLC personnel on an annual basis to establish adequately trained lactation coverage based on the speci ﬁc need and

volume of the neonatal population served.

12 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Neonatal Therapists

(ll) The facility will provide on-site consultative services by qualiﬁed neonatal therapists to address the 6 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.

(mm) The facility will have on-site access to the following neonatal therapists who have dedicated time allocated to serve the NICU:

1. an occupational and/or physical therapist with neonatal expertise, and neonatal therapy certiﬁcation preferred

; and

2. a speech language pathologist with neonatal expertise, skilled in the evaluation and management of neonatal feeding and swallowing concerns,

and neonatal therapy certiﬁcation preferred.

i. If swallow 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.

(nn) The facility will operationally review neonatal therapist personnel on an annual basis to maintain adequate multidisciplinary neonatal therapist

coverage based on the speciﬁc need and volume of the neonatal population served.

Social Worker

(oo) The NICU social worker will:

1. be a Master’s prepared medical social worker with perinatal and/or pediatric experience.

(pp) The facility will:

1. provide 1 social worker for every 30 beds providing level III neonatal care and/or specialty and subspecialty perinatal care

;

2. have a written description that clearly identiﬁes the responsibilities and functions of the NICU social worker; and

3. have social services available for each family with an infant in the NICU as needed.

Pastoral Care

(qq) Personnel skilled in pastoral care will be available as needed and by family request, and will represent, or have the ability to consult, multiple

religious afﬁliations representative of the population served.

Retinopathy of Prematurity

(rr) The facility must have a process in place to appropriately identify infants at risk for retinopathy of prematurity to guarantee timely examination and

treatment by having

1. documented policies and procedures for the monitoring, treatment, and follow-up of retinopathy of prematurity

5,13

; and

2. the ability to perform on-site retinal examinations, or off-site interpretation of digital photographic retinal images, by a pediatric ophthalmologist

or retinal specialist with expertise in retinopathy of prematurity.

5,13

Discharge and Follow-up

(ss) Systems will be in place to establish preparation for NICU discharge, including postdischarge follow-up by general and subspecialty pediatric care

providers, home care arrangements and community service resources, and enrollment in a developmental follow-up program as needed.

1. The facility will:

i. have written medical, neurodevelopmental, and psychosocial criteria that automatically warrant high-risk neonatal follow-up with appropriate

developmental follow-up services; and

ii. provide developmental follow-up services or have a written referral agreement with a developmental follow-up clinic or practice, when possible,

to provide neurodevelopmental services for the neonatal population served.

PEDIATRICS Volume 151, number 6, June 2023 13

STANDARD VII: LEVEL IV NICU

REQUIREMENTS

Level IV NICU Requirements

(a) The level IV neonatal facility will:

1. provide comprehensive care for infants born at all gestational ages and birth weights, with mild to complex critical conditions or medical

problems requiring sustained life support, hemodynamic support, conventional and high frequency mechanical ventilation, iNO delivery, and/or

therapeutic hypothermia

;

2. have the capability to provide surgical repair of complex congenital or acquired conditions

;

3. have the ability to provide ECMO or policies and procedures in place to facilitate neonatal transfer to another unit or facility that provides ECMO

;

4. maintain a broad range of pediatric medical subspecialists, pediatric surgical specialists, and pediatric anesthesiologists

;

5. facilitate transport and provide outreach education to lower-level facilities

;and

6. have sufﬁcient experience based on patient volume and a systematic process to assess the quality of care provided, including a method to track

speciﬁc quality indicators and clinical diagnoses, review aggregate data using accepted methodology, and develop action plans as needed to improve

patient outcomes.

2,14

Neonatal Medical Director

(b) The NMD will:

1. be a board-certiﬁed neonatologist or equivalent;

i. if the neonatologist is certiﬁed by The American Board of Pediatrics, they will meet MOC requirements in neonatal-perinatal medicine;

2. complete annual CME speciﬁc to neonatology; and

3. demonstrate a current status of NRP completion.

Neonatologists

1. be a board eligible or certiﬁed neonatologist or equivalent;

i. if the neonatologist is certiﬁed The American Board of Pediatrics, they will meet MOC requirements in neonatal-perinatal medicine;

2. complete annual CME speciﬁc to neonatology;

3. demonstrate a current status of NRP completion;

4. have credentials that are reviewed by the NMD at least every 2 years; and

5. preferably be on-site and immediately available 24/7, or on-call and available to arrive on-site within an appropriate time frame, as deﬁned by the

facility’s policies and procedures.

i. If a neonatologist is not on-site 24/7, a written policy will be in place that deﬁnes the criteria for notiﬁcation and time frame for on-site

presence, and a tracking mechanism for compliance is required.

Privileged Care Providers

(d) Privileged care providers with neonatal-speciﬁc training qualiﬁed to manage the care of infants with mild to complex critical conditions, including

emergencies, will be on-site 24/7 and

1. demonstrate a current status of NRP completion;

2. complete annual continuing education requirements speciﬁc to neonatology; and

3. have their credentials reviewed at least every 2 years by the NMD.

(e) At least 1 person with the skills to perform a complete neonatal resuscitation, including endotracheal intubation, establishment of vascular access,

and administration of medications must be immediately available on-site 24/7

; and

1. demonstrate a current status of NRP completion.

(f) The facility will establish a written policy for backup privileged care provider coverage that establishes ﬂexibility for variable census and acuity.

This policy will document the criteria for notiﬁcation and time frame for on-site presence, be based on allocating the appropriate number of

competent medical providers to a care situation, attend to a safe and high-quality work environment, and be operationally reviewed annually for

adequacy and adherence.

Nursing Leadership

(g) The level IV NICU nurse leader will:

1. be an RN with experience and training in neonatal nursing and conditions, with nursing certiﬁcation preferred

;

2. have at least a Bachelor of Science in Nursing, Master’s preferred;

3. demonstrate a current status of NRP completion;

4. have sufﬁcient experience and expertise to create, and/or support, a program that provides care to infants who require level IV NICU care;

5. be responsible for inpatient activities in the NICU(s) and, as appropriate, obstetrical, well newborn, and/or pediatric units;

6. coordinate with respective neonatal, pediatric, and obstetric care services, as appropriate;

7. provide oversight of annual neonatal-speciﬁc education, which includes low-volume, high-risk procedures consistent with the care provided in the

level IV NICU; and

8. foster collaborative relationships with multidisciplinary team members and facility leadership to create a diverse, equitable, and inclusive

environment to improve the quality of care and patient care outcomes.

Clinical Nurse Stafﬁng

(h) A written nurse stafﬁng plan is in place that establishes ﬂexibility for variable census and acuity. This plan and actual stafﬁng will be based on

allocating the appropriate number of competent RNs to a care situation, attend to a safe and high-quality work environment, and be operationally

reviewed annually for adequacy and adherence.

9,10

14 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Clinical Nurse Staff

(i) Each clinical nurse will:

1. be an RN, with nursing certiﬁcation speciﬁc to the care environment preferred;

2. demonstrate a current status of NRP completion;

3. par ticipate in annual simulation and skills veriﬁcation, which includes low-volume, high-risk procedures consistent with the types of care provided

in the level IV NICU; and

4. promote a family-centered approach to care, including but not limited to skin-to-skin care, appropriate developmental positioning based on

gestational age, lactation and breastfeeding support, and engagement of families in their infant’s care.

(j) If the facility utilizes LPNs or nonlicensed direct care providers to support the clinical nursing staff, the facility must:

1. have written criteria that deﬁne the LPNs’ or nonlicensed direct care providers’ scope of neonatal care;

2. provide annual education speciﬁc to the care of the neonatal population served; and

3. have a written stafﬁng plan that establishes collaborative work assignments in accordance with the facility’s policies and procedures.

Nursing Orientation and Education

(k) Level IV NICU nursing orientation will incorporate didactic education, simulation, skills veriﬁcation, and competency and will be tailored to the

individual needs of the nurse based on clinical experience.

(l) The facility will document an annual educational needs assessment to determine the educational needs of the clinical nursing staff and ancillary

team members.

(m) Annual nursing education will address the annual needs assessment and incorporate simulation and skill veriﬁcation of low-volume, high-risk

procedures consistent with the types of care provided in the level IV NICU and include education related to serious safety events.

Clinical Nurse Specialist

(n) The clinical nurse specialist will:

1. be an RN, with neonatal nursing certiﬁcation and clinical nurse specialist certiﬁcation preferred

;

2. have at least a Master of Science in Nursing, Doctorate preferred

;

3. demonstrate a current status of NRP completion

;

4. foster continuous quality improvement in nursing care

;

5. develop and educate staff to provide evidence-based nursing care

;

6. be responsible for mentoring new staff and developing team building skills

;

7. provide leadership to multidisciplinary teams

;

8. facilitate case management of high-risk neonatal patients

; and

9. cultivate collaborative relationships with multidisciplinary team members and facility leadership to improve the quality of care and patient care

outcomes.

(o) The facility will have a dedicated full-time equivalent (FTE) allocated to perform the roles and responsibilities of the NICU clinical nurse specialist.

Clinical Nurse Educator

(p) The NICU clinical nurse educator will:

1. be an RN, with nursing certiﬁcation speciﬁc to the care environment preferred;

2. have at least a Bachelor of Science in Nursing, Master’s preferred;

3. demonstrate a current status of NRP completion;

4. cultivate collaborative relationships with the neonatal nurse leader and facility leadership to improve the quality of care and patient care

outcomes

; and

5. have experience and expertise to evaluate the educational needs of the clinical staff, develop didactic and skill-based educational tools, oversee

education and skills veriﬁcation, and evaluate retention of content, critical thinking skills, and competency relevant to level IV neonatal care.

(q) The facility will have at least 1 dedicated FTE allocated to perform the roles and responsibilities of the NICU clinical nurse educator.

Additional Neonatal Support Personnel

(r) The facility will foster collaborative and consultative relationships with additional neonatal support personnel to facilitate comprehensive

multidisciplinary care consistent with the types of care provided in the level IV NICU.

Neonatal Transport

(s) If the facility has a neonatal critical care transport program, it will have an identiﬁed director of neonatal transport services.

The director of

neonatal transport services can be the neonatal medical director or another physician who is a pediatrician, board eligible or certiﬁed

neonatologist, pediatric hospitalist, or pediatric medical subspecialist with expertise and experience in neonatal and infant transport.

1. If the facility does not have its own transport program, the facility must have policies and procedures in place to identify a local neonatal

transport program to facilitate transport.

(t) Responsibilities of the director of neonatal transport services include the following:

1. train and supervise staff

;

2. provide appropriate review of all transport records

;

3. develop and implement policies and procedures for patient care during transport

;

4. develop guidelines for determining transport team composition and medical control and establish a mechanism to track adherence

;

5. establish policies and procedures to provide transport updates and outreach education

;

6. establish a program for evaluating performance by tracking data, identifying trends, and implementing quality improvement initiatives to address

transport performance in a coordinated systematic approach within a culture of safety, equity, and prevention

; and

7. report neonatal transport data and neonatal-speciﬁc reviews back to the NPSQIP.

8. The director of neonatal transport services may delegate speciﬁc requirements to other person(s) or group(s) but retains the responsibility of

certifying that these functions are addressed appropriately.

PEDIATRICS Volume 151, number 6, June 2023 15

(u) The facility will:

1. establish minimum education, experience, and training requirements for all transport team members

;

2. select transport team members based on their experience and competence in the care of neonates and the transport team must collectively have

the ability to provide a level of care that is similar to that of the admitting unit

; and

3. provide annual transport education to all transpor t team members that incorporates equipment training, didactic education, simulation, and skills

veriﬁcation of low-volume, high-risk procedures consistent with the types of care provided during neonatal transport.

Neonatal Outreach

(v) The level IV facility will provide multidisciplinary outreach education to referring facilities by assessing educational needs and evaluating clinical

care and outcomes, including transport data, as part of collaboration with lower-level neonatal facilities.

Pediatric Medical Subspecialists

(w) The facility must have on-site access to a broad range of pediatric medical subspecialties including, but not limited to

1. cardiology, pulmonology, infectious disease, neurology, ophthalmology, endocrinology, hematology, gastroenterology, nephrology, and genetics or

metabolism; and

2. the pediatric medical subspecialists must:

i. be readily accessible for in-person consultation;

ii. have credentials to consult at the facility, including documented training, certiﬁcation, competencies, and continuing education speciﬁc to their

subspeciality; and

iii. document consultations in the medical record within an appropriate time frame and as deﬁned by the facility’s policies and procedures.

Neonatal Surgical Program – Required for Level IV

Pediatric Surgeons

(x) Pediatric surgeons and pediatric surgical specialists will:

1. be available at the bedside within 1 hour of request or identiﬁed need and be capable of performing major pediatric surgery, including surgery

for complex conditions

;

i. if transplant or cardiac surgery is not offered on-site at the facility, policies and procedures will be in place to facilitate neonatal transport toa

facility that provides appropriate surgical care;

2. provide consultation to a broad range of pediatric surgical specialists including, but not limited to

5,16

i. general pediatric surgery, neurosurgery, urology, ophthalmology, otolaryngology, orthopedics, and plastic surgery;

3. have credentials to provide care at the facility, including documented training, certiﬁcation, competencies, and continuing education speciﬁcto

their pediatric surgery specialty

;

4. establish a program for evaluating surgical performance by accurately tracking data, identifying trends, and implementing quality improvement

initiatives to address surgical performance in a coordinated systematic approach within a culture of safety, equity, and prevention

; and

5. report neonatal surgical and anesthesia care back to the NPSQIP.

Anesthesiologists

(y) Pediatric anesthesiologists must:

1. be on the medical staff and promptly available 24/7 to respond to the bedside within 1 hour of request or identiﬁed need

;

2. serve as the primary responsible anesthesia provider for all infants <24 mo of age and should serve as the primary anesthesiologist for children

#5 y of age or based on the ASA physical status classiﬁcation

; and

3. be physically present for all neonatal surgical procedures for which they serve as the primary responsible anesthesia provider.

Laboratory Services

(z) Laboratory services will have:

1. laboratory personnel on-site 24/7;

2. the ability to determine blood type, crossmatch, and perform antibody testing;

3. a blood bank capable of providing blood component therapy and irradiated, leukoreduced or CMV-negative blood;

i. policies and procedures will be in place to facilitate emergent access to blood and blood component therapy so that the NICU can provide a full

range of hematologic interventions;

4. the ability to perform neonatal blood gas monitoring;

5. the ability to perform analysis on small volume samples;

6. the capability to process biopsies and perform autopsies; and

7. access to perinatal pathology services, if applicable.

(aa) Low-volume specialty laboratory services may be provided by an outside laboratory, but the facility will have policies and procedures in place to

maintain timely and direct communication of all critical value results.

Pharmacy

(bb) The facility will have at least 1 registered pharmacist with experience in neonatal and/or pediatric pharmacology who will:

1. be available for consultation on-site, or by telehealth or telephone, 24/7;

2. complete continuing education requirements speciﬁc to pediatric and neonatal pharmacology; and

3. par ticipate in multidisciplinary care, including participation in patient care rounds.

(cc) The facility will have neonatal appropriate TPN available 24/7; and

1. the facility will have a written policy and procedure for the proper preparation and delivery of TPN.

(dd) The pharmacy will have policies and procedures in place to address drug shortages and to verify medications are appropriately allocated to the

level IV NICU; and

1. have policies and procedures in place to verify neonatal competency for pharmacy staff supporting and preparing medications for neonatal

patients.

16 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Diagnostic Imaging

(ee) Radiology services will have:

1. appropriately trained radiology personnel continuously available on-site to meet routine diagnostic imaging needs and to address emergencies;

2. ﬂuoroscopy available on-call 24/7;

3. personnel appropriately trained in the following techniques will be on-call and/or available on-site to perform advanced imaging as requested:

i. ultrasonography, including cranial ultrasonography;

ii. CT;

iii. MRI; and

4. the ability to provide timely imaging interpretation by radiologists with pediatric expertise as requested.

(ff) The facility will provide pediatric echocardiography and have the ability to consult with a pediatric cardiologist for timely echocardiography

interpretation as requested.

Respiratory Therapy

(gg) The respiratory care leader will:

1. be a full-time respiratory care practitioner, with neonatal and pediatric respiratory care certiﬁcation preferred;

2. have sufﬁcient time allocated to oversee the RTs who provide care in the level IV NICU;

3. provide oversight of annual simulation and skills veriﬁcation, including neonatal respiratory care modalities and low-volume, high-risk neonatal

respiratory procedures;

4. develop a written RT stafﬁng plan that establishes ﬂexibility for variable census and acuity. This plan and actual stafﬁng will be based on

allocating the appropriate number of competent RTs to a care situation, attend to a safe and high-quality work environment, and be operationally

reviewed annually for adherence and to verify respiratory therapy stafﬁng is adequate for patient care needs

; and

5. maintain appropriate stafﬁng ratios for infants receiving supplemental oxygen and positive pressure ventilation.

(hh) Respiratory care practitioners assigned to the NICU will:

1. be a respiratory care practitioner with documented experience and training in the respiratory support of newborns and infants, with neonatal

and pediatric respiratory care certiﬁcation preferred;

2. be on-site 24/7 and immediately available to supervise assisted ventilation, assist in resuscitation, and attend deliveries, if applicable;

3. demonstrate a current status of NRP completion;

4. par ticipate in annual simulation and respiratory skills veriﬁcation, which includes low-volume, high-risk procedures consistent with the types of

respiratory care provided in the NICU; and

5. have their credentials reviewed by the respiratory care leader annually for adequacy and adherence.

Dietitian

(ii) The NICU will have at least 1 full-time NICU-dedicated registered dietitian or nutritionist available on-site who has specialized training in neonatal

nutrition and will

1. collaborate with the medical team to establish feeding protocols, develop patient-speciﬁc feeding plans, and help determine nutritional needs at

discharge;

2. establish policies and procedures to verify proper preparation and storage of human milk and formula;

3. par ticipate in multidisciplinary care, including participation in patient care rounds; and

4. have policies and procedures for dietary consultation for infants in the NICU.

Neonatal Nutrition

(jj) The facility will:

1. provide a specialized area or room, with limited access and away from the bedside, to accommodate mixing of formula or additives to human

milk

;

2. develop standardized feeding protocols for the advancement of feedings based on the availability of, and family preference for human milk, donor

human milk , fortiﬁcation of human milk and formula; and

3. have policies and procedures in place for accurate veriﬁcation and administration of human milk and formula, and to avoid misappropriation.

Lactation and Breastfeeding Support

(kk) The facility will:

1. have personnel with the knowledge and skills to support lactation available at all times;

2. have an IBCLC available for on-site consultation on weekdays and accessible by telehealth or telephone 24/7; and

3. operationally review IBCLC personnel on an annual basis to establish adequately trained lactation coverage based on the speci ﬁc need and

volume of the neonatal population served.

Neonatal Therapists

(ll) The facility will provide on-site consultative services by qualiﬁed neonatal therapists to address the 6 core practice domains (environment, family or

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.

(mm) The facility will have on-site access to the following neonatal therapists who have dedicated time allocated to serve the NICU:

1. an occupational and/or physical therapist with suf ﬁcient neonatal expertise, and neonatal therapy certiﬁcation preferred

; and

2. a speech language pathologist with neonatal expertise, skilled in the evaluation and management of neonatal feeding and swallowing concerns,

and neonatal therapy certiﬁcation preferred.

(nn) The facility will operationally review neonatal therapist personnel on an annual basis to maintain adequate multidisciplinary neonatal therapist

coverage based on the speciﬁc need and volume of the neonatal population served.

PEDIATRICS Volume 151, number 6, June 2023 17

APPENDIX: NEONATAL LEVELS OF CARE

COMPARISON: LEVEL (II, III, AND IV)

REQUIREMENTS

Child Life Services

(oo) Child life services, or the equivalent, will be available for on-site consultation to support patient- and family-centered care by establishing and

maintaining therapeutic relationships between patients, family members, multidisciplinary team members, and community resources.

Social Worker

(pp) The NICU social worker will:

1. be a Master’s prepared medical social worker with perinatal and/or pediatric experience.

(qq) The facility will:

1. provide at least 1 social worker for every 30 beds providing level IV neonatal care and/or specialty and subspecialty perinatal care, if applicable

;

2. have a written description that clearly identiﬁes the responsibilities and functions of the NICU social worker; and

3. have social services available for each family with an infant in the NICU as needed.

Pastoral Care

(rr) Personnel skilled in pastoral care will be available as needed and by family request, and will represent, or have the ability to consult, multiple

religious afﬁliations representative of the population served.

Retinopathy of Prematurity

(ss) The facility must have a process in place to appropriately identify infants at risk for retinopathy of prematurity to guarantee timely examination

and treatment by having

1. documented policies and procedures for the monitoring, treatment, and follow-up of retinopathy of prematurity

5,13

; and

2. the ability to perform on-site retinal examinations, or off-site interpretation of digital photographic retinal images, by a pediatric ophthalmologist

or retinal specialist with expertise in retinopathy of prematurity.

5,13

Discharge and Follow-up

(tt) Systems will be in place to establish preparation for NICU discharge including postdischarge follow-up by general and subspecialty pediatric care

providers, home care arrangements and community service resources, and enrollment in a developmental follow-up program as needed.

1. The facility will:

i. have written medical, neurodevelopmental, and psychosocial criteria that automatically warrant high-risk neonatal follow-up with appropriate

developmental follow-up services; and

ii. provide developmental follow-up services or have a written referral agreement with a developmental follow-up clinic or practice, when

possible, to provide neurodevelopmental services for the neonatal population served.

Level II Level III Level IV

Level of Neonatal Care Requirements

(a) The Level II SCN will provide comprehensive

care of infants born $32 wk or with birth

wt $1500 g who

1. are mild to moderately ill with physiologic

immaturity or who have conditions that

are expected to resolve quickly

;

2. are not anticipated to require

subspecialty services on an urgent basis

;

3. require CPAP or short term (less than 24 h)

conventional mechanical ventilation for a

condition expected to resolve rapidly or until

transfer to a higher-level facility is achieved

;or

4. are back transferred from a higher-level facility

for convalescent care.

(a) The Level III neonatal facility will:

1. provide comprehensive care for infants

born at all gestational ages and birth

weights, with mild to complex critical

conditions or medical problems requiring

sustained life support, hemodynamic

support, and/or conventional mechanical

ventilation

;

2. have the ability to provide high-frequency

ventilation, iNO delivery, and/or therape utic

hypothermia or have policies and procedures

in place to facilitate neonatal transfer to

another unit or facility that provides

these services

;

3. provi de care for infants who are back

tra nsferred for convalescent care

;and

4. have sufﬁcient experience based on patient

volume and a systemat ic process to assess the

quality of care provided to each very low birth

weight infant, including a method to track

speciﬁc quality indicators including obstetrical

and neonatal trans fers, review aggregate data

using accepted methodology , and develop

(a) The Level IV neonatal facility will:

1. provide comprehensive care for infants born

at all gestational ages and birth weights,

with mild to complex critical conditions or

medical problems requiring sustained life

support, hemodynamic support, conventional

and high frequency mechanical ventilation,

iNO delivery, and/or therapeutic

hypothermia

;

2. have the capability to provide surgical repair

of complex congenital or acquired conditions

;

3. have the ability to provide ECMO or have policies

and procedures in place to facilitate neonatal

transfer to another unit or facility that provides

ECMO

;

4. maintain a broad range of pediatric medical

subspecialists, pediatric surgical specialists, and

pediatric anesthesiologists

;

5. facilitate tr ansport and provide outreach

education to lower-level facilities

;and

6. have sufﬁcient experience based on patient

volume and a systematic process to assess the

quality of care provided, including a method

18 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Continued

Level II Level III Level IV

action plans as needed to improve patient

outcomes.

2,14

to tra ck speciﬁc quality indicators

and clinical diagnoses, review aggregate data

using accepted methodology , and develop

action plans as needed to improve patient

outcomes.

2,14

Neonatal Medical Director

(b) The NMD will:

1. be a physician who is a board-eligible or

-certiﬁed neonatologist or a board-certiﬁed

pediatrician with sufﬁcient training and

expertise to assume responsibility of care

for infants who require level II care,

including endotracheal intubation, assisted

ventilation, and CP AP management, or

equivalent

;

i. if the neonatologist or pediatrician is

certiﬁed by The American Board of

Pediatrics, they will meet MOC

requirements;

2. complete annual CME speciﬁc to neonatology ;

and

3. demonstrate a current status of NRP

completi on.

(b) The NMD will:

1. be a board-eligible or -certiﬁed

neonatologist or equivalent;

i. if the neonatologist is certiﬁed by The

American Board of Pediatrics, they will meet

MOC requirements in neonatal-perinatal

medicine;

2. complete annual CME speciﬁc to neonatology;

and

3. demonstr ate a current status of NRP

completion.

(b) The NMD will:

1. be a board-certiﬁed neonatologist or

equivalent;

i. if the neonatologist is certiﬁed by The

American Board of Pediatrics, they will meet

MOC requirements in neonatal-perinatal

medicine;

2. complete annual CME speciﬁctoneonatology;

and

3. demonstrate a current status of NRP completion.

Neonatologists

neonatologist, the privileged care provider

must maintain a consultative relationship

with a board-certiﬁed or -eligible

neonatologist at a higher-level neonatal

facility; and

1. the facility must have a written policy or

guideline that deﬁnes the criteria for

neonatologist consultation at a higher-

level neonatal facility.

1. be a board-eligible or -certiﬁed

neonatologist or equivalent;

i. if the neonatologist is certiﬁed by The

American Board of Pediatrics, they will

meet MOC requirements in neonatal-

perinatal medicine;

2. complete annual CME speciﬁcto

neonatology;

3. demonstrate a current status of NRP

completion;

4. have credentials that are reviewed by the

NMD at least every 2 years; and

5. preferably be on-site and immediately

available 24/7, or on-call and available to

arrive on-site within an appropriate time

frame, as deﬁned by the facility’s policies

and procedures.

i. If a neonatologist is not on-site 24/7, a

written policy will be in place that

deﬁnes the criteria for notiﬁcation and

time frame for on-site presence, and a

tracking mechanism for compliance is

required.

1. be a board-eligible or -certiﬁed neonatologist

or equivalent;

i. if the neonatologist is certiﬁed by The

American Board of Pediatrics, they will meet

MOC requirements in neonatal-perinatal

medicine;

2. complete annual CME speciﬁctoneonatology;

3. demonstrate a current status of NRP

completion;

4. have credentials that are reviewed by the

NMD at least every 2 years; and

5. preferably be on-site and immediat ely

available 24/7, or on-call and available to

arrive on-site within an appropriate time

frame as deﬁned by the facility’spoliciesand

procedures.

i. If a neonatologist is not on-site 24/7, a

written policy will be in place that deﬁnes

the criteria for notiﬁcation and time frame

for on-site presence, and a tracking

mechanism for compliance is required.

Privileged Care Providers

(d) Privileged care providers with pediatric- or

neonatal-speciﬁc training qualiﬁed to

manage the care of infants with mild to

moderate critical conditions, including

emergencies will

1. be continuously available on-site, or on-

call and available to arrive on-site within

an appropriate time frame, as deﬁned by

the facility’s policies and procedures;

i. if the on-site or on-call provider is not

a physician, a written policy will be in

(d) Privileged care providers with neonatal-

speciﬁc training qualiﬁed to manage the care

of infants with mild to complex critical

conditions, including emergencies, will be on-

site 24/7 and

1. demonstrate a current status of NRP

completion;

2. complete annual continuing education

requirements speciﬁc to neonatology; and

3. have their credentials reviewed at least

every 2 years by the NMD.

(d) Privileged care providers with neonatal-speciﬁc

training qualiﬁed to manage the care of infants

with mild to complex critical conditions,

including emergencies, will be on-site 24/7

and

1. demonstrate a current status of NRP

completion;

2. complete annual continuing education

requirements speciﬁc to neonatology; and

3. have their credentials reviewed at least every

2yearsbytheNMD.

PEDIATRICS Volume 151, number 6, June 2023 19

Continued

Level II Level III Level IV

place that deﬁnes the criteria for

notiﬁcation and time frame for on-site

physician presence, and a tracking

mechanism for compliance is required;

ii. if an infant is maintained on a

ventilator, a pediatric- or neonatal-

speciﬁc privileged care provider who

can manage respiratory emergencies

will be immediately available on-site;

2. demonstrate a current status of NRP

completion;

3. complete annual continuing education

requirements speciﬁc to neonatology; and

4. have their credentials reviewed at least

every 2 years by the NMD.

(e) At least 1 person with the skills to perform

a complete neonatal resuscitation including

endotracheal intubation, establishment of

vascular access, and administration of

medications must be immediately available on-

site 24/7

;and

1. demonstr ate a curren t status of NRP

completion.

(f) The facility will establish a written policy for

backup medical care provider coverage that

establis hes ﬂexibility for variable census and

acuity . This policy will document the criteria

for notiﬁcation and time frame for on-site

presence, be based on allocating the

appropriate number of competent privileged

care providers to a care situation, attend to a

safe and high-quality work environment, and

be operati onally reviewed annually for

adequacy and adherence.

(e) At least 1 person with the skills to perform a

complete neonatal resuscitation, including

endotracheal intubation, establishment of

vascular access, and administration of

medications must be immediately on-site

24/7

; and

1. demonstrate a current status of NRP

completion.

(f) The facility will establish a written policy for

backup medical care provider coverage that

establishes ﬂexibility for variable census and

acuity. This policy will document the criteria

for notiﬁcation and time frame for on-site

presence, be based on allocating the

appropriate number of competent privileged

care providers to a care situation, attend to a

safe and high-quality work environment, and

be operationally reviewed annually for

adequacy and adherence.

(e) At least 1 person with the skills to perform a

complete neonatal resuscitation, including

endotracheal intubation, establishment of vascular

access, and administration of medications must be

immediately available on-site 24/7

;and

1. demonstrate a current status of NRP

completion.

(f) The facility will establish a written policy for

backup medical care provider coverage that

establishes ﬂexibility for variable census and acuity .

This policy will document the crite ria for

notiﬁcation and time frame for on-site presence, be

based on allocating the appropriate number of

competent privileged care providers to a care

situation, attend to a safe and high-quality work

environment, and be operationally reviewed

annually for adequacy and adherence.

Nursing Leadership

(g) The level II SCN nurse leader will:

1. be an RN with experience and training in

perinatal nursing and neonatal conditions,

with nursing certiﬁcation preferred

;

2. have at least a Bachelor of Science in

Nursing, Master’s preferred;

3. demonstrate a current status of NRP

completion;

4. have sufﬁcient experience and expertise to

create, and/or support, a program that

provides care to infants who require

level II SCN care;

5. be responsible for inpatient activities in the

level II SCN and, as appr opriate, obstetrical,

well newborn, and/or pediatric units;

6. coordinate with respective neonatal,

pediatric, and obstetric care services,

as appropriate;

7. provide oversight of annual neonatal-

speciﬁc education, which includes low-

volume, high-risk procedures consistent

with the care provided in the level II SCN;

and

(g) The level III NICU nurse leader will:

1. be an RN with experience and training in

neonatal nursing and conditions, with

nursing certiﬁcation preferred

;

2. have at least a Bachelor of Science in

Nursing, Master ’s preferred;

3. demonstrate a current status of NRP

completion;

4. have sufﬁcient experience and expertise to

create, and/or support, a program that

provides care to infants who require

level III NICU care;

5. be responsible for inpatient activities in the

NICU(s) and, as appropriate, obstetrical,

well newborn, and/or pediatric units;

6. coordinate with respective neonatal,

pediatric, and obstetric care services, as

appropriate;

7. provide oversight of annual neonatal-

speciﬁc education, which includes low-

volume, high-risk procedures consistent

with the care provided in the level III NICU;

and

(g) The level IV NICU nurse leader will:

1. be an RN with experience and training in

neonatal nursing and conditions, with

nursing certiﬁcation preferred

;

2. have at least a Bachelor of Science in

Nursing, Master ’s preferred;

3. demonstrate a current status of NRP

completion;

4. have sufﬁcient experience and expertise to

create, and/or support, a program that

provides care to infants who require level IV

NICU care;

5. be responsible for inpatient activities in the

NICU(s) and, as appropriate, obstetrical, well

newborn, and/or pediatric units;

6. coordinate with respective neonatal,

pediatric, and obstetric care services, as

appropriate;

7. provide oversight of annual neonatal-

speciﬁc education, which includes

low-volume, high-risk procedures

consistent with the care provided in the

level IV NICU; and

20 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Continued

Level II Level III Level IV

8. foster collaborative relationships with

multidisciplinary team members, facility

leadership , and higher-level facilities to

create a diverse, equitable, and inclusive

environment focused on the quality of care

and patient care outcomes.

8. foster collaborative relationships with

multidisciplinary team members, facility

leadership, and higher-level facilities to

create a diverse, equitable, and inclusive

environment to improve the quality of care

and patient care outcomes.

8. foster collaborative relationships with

multidisciplinary team members and facility

leadership to create a diverse, equitable,

and inclusive environment to improve the

quality of care and patient care outcomes.

Clinical Nurse Stafﬁng

(h) A written nurse stafﬁng plan is in place that

establishes ﬂexibility for variable census and

acuity. This plan and actual stafﬁng will be

based on allocating the appropriate number

of competent RNs to a care situation, attend

to a safe and high-quality work environment,

and be operationally reviewed annually for

adequacy and adherence.

9,10

(h) A written nurse stafﬁng plan is in place that

establishes ﬂexibility for variable census and

acuity. This plan and actual stafﬁng will be

based on allocating the appropriate number

of competent RNs to a care situation, attend

to a safe and high-quality work environment,

and be operationally reviewed annually for

adequacy and adherence.

9,10

(h) A written nurse stafﬁng plan is in place that

establishes ﬂexibility for variable census and

acuity. This plan and actual stafﬁng will be

based on allocating the appropriate number of

competent RNs to a care situation, attend to a

safe and high-quality work environment, and be

operationally reviewed annually for adequacy

and adherence.

9,10

Clinical Nurse Staff

(i) Each clinical nurse will:

1. be an RN, with nursing certiﬁcation

speciﬁc

to the care environment preferred;

2. demonstrate a current status of NRP

completion;

3. par ticipate in annual simulation and skills

veriﬁcation, which includes low-volume,

high-risk procedures consistent with the

types of care provided in the level II SCN;

and

4. promote a family-centered approach to

care, including but not limited to

skin-to-skin care, appropriate

developmental positioning based on

gestational age, lactation and

breastfeeding support, and engagement of

families in their infant’s care.

(j) If the facility utilizes LPNs or nonlicensed

direct care providers to support the clinical

nursing staff, the facility must:

1. have written criteria that deﬁne the LPNs’

or nonlicensed direct care providers’

scope of neonatal care;

2. provide annual education speciﬁc to the

care of the neonatal population served;

and

3. have a written stafﬁng plan that

establishes collaborative work

assignments in accordance with the

facility’s policies and procedures.

(i) Each clinical nurse will:

1. be an RN, with nursing certiﬁcation speciﬁc

to the care environment preferred;

2. demonstrate a current status of NRP

completion;

3. par ticipate in annual simulation and skills

veriﬁcation, which includes low-volume,

high-risk procedures consistent with the

types of care provided in the level III NICU; and

4. promote a family-centered approach to care,

including but not limited to skin-to-skin care,

appropriate developmental positioning based

on gestational age, lactation and breastfeeding

support, and engagement of families in their

infant’scare.

(j) If the facility utilizes LPNs or nonlicensed direct

care providers to support the clinical nursing

staff, the facility must:

1. have written criteria that deﬁne the LPNs’ or

nonlicensed direct care providers’ scope of

neonatal care;

2. provide annual education speciﬁctothecare

of the neonatal population served; and

3. have a written stafﬁng plan that establishes

collaborative work assignments in accordance

with the facility’s policies and procedures.

(i) Each clinical nurse will:

1. be an RN, with nursing certiﬁcation speciﬁc

to the care environment preferred;

2. demonstrate a current status of NRP

completion;

3. par ticipate in annual simulation and skills

veriﬁcation, which includes low-volume, high-

risk procedures consistent with the types of

care provided in the level IV NICU; and

4. promote a family-centered approach to care,

including but not limited to skin-to-skin care,

appropriate developmental positioning based

on gestational age, lactation and

breastfeeding support, and engagement of

families in their infant’s care.

(j) If the facility utilizes LPNs or nonlicensed direct

care providers to support the clinical nursing

staff, the facility must:

1. have written criteria that deﬁne the

LPNs’ or nonlicensed direct care

providers’ scope of neonatal care;

2. provide annual education speciﬁc to the

care of the neonatal population served;

and

3. have a written stafﬁng plan that

establishes collaborative work

assignments in accordance with the

facility’s policies and procedures.

Nursing Orientation and Education

(k) Level II SCN nursing orientation will

incorporate didactic education, simulation,

skills veriﬁcation, and competency and will

be tailored to the individual needs of the

nurse based on clinical experience.

(l) The facility will document an annual

educational needs assessment to determine

the educational needs of the clinical nursing

staff and ancillary team members.

(m) Annual nursing education will address the

annual needs assessment and incorporate

simulation and skills veriﬁcation of low-

(k) Level III NICU nursing orientation will

incorporate didactic education, simulation,

skills veriﬁcation, and competency and will be

tailored to the individual needs of the nurse

based on clinical experience.

(l) The facility will document an annual

educational needs assessment to determine

the educational needs of the clinical nursing

staff and ancillary team members.

(m) Annual nursing education will address the

annual needs assessment and incorporate

simulation and skill veriﬁcation of low-volume,

(k) Level IV NICU nursing orientation will

incorporate didactic education, simulation,

skills veriﬁcation, and competency and will be

tailored to the individual needs of the nurse

based on clinical experience.

(l) The facility will document an annual

educational needs assessment to determine the

educational needs of the clinical nursing staff

and ancillary team members.

(m) Annual nursing education will address the

annual needs assessment and incorporate

simulation and skill veriﬁcation of low-volume,

PEDIATRICS Volume 151, number 6, June 2023 21

Continued

Level II Level III Level IV

volume, high-risk procedures consistent with

the types of care provided in the level II SCN

and include education related to serious

safety events.

high-risk procedures consistent with the

types of care provided in the level III NICU and

include education related to serious safety

events.

high-risk procedures consistent with the types

of care provided in the level IV NICU and

include education related to serious safety

events.

Clinical Nurse Specialist

(n) The clinical nurse specialist will:

1. be an RN, with neonatal nursing

certiﬁcation and clinical nurse specialist

certiﬁcation preferred

;

2. have at least a Bachelor of Science in

Nursing; Master’s or Doctorate preferred

;

3. demonstrate a current status of NRP

completion

;

4. foster continuous quality improvement in

nursing care

;

5. develop and educate staff to provide

evidence-based nursing care

;

6. be responsible for mentoring new staff and

developing team building skills

;

7. provide leadership to multidisciplinary

teams

;

8. facilitate case management of high-risk

neonatal patients

; and

9. cultivate collaborative relationships with

multidisciplinary team members and

facility leadership to improve the quality of

care and patient care outcomes.

(o) The roles and responsibilities of the NICU

clinical nurse specialist can be allocated to

multiple individuals to perform this role.

(n) The clinical nurse specialist will:

1. be an RN, with neonatal nursing certiﬁcation

and clinical nurse specialist certiﬁcation

preferred

;

2. have at least a Master of Science in Nursing;

Doctorate preferred

;

3. demonstrate a current status of NRP

completion

;

4. foster continuous quality improvement in

nursing care

;

5. develop and educate staff to provide

evidence-based nursing care

;

6. be responsible for mentoring new staff and

developing team building skills

;

7. provide leadership to multidisciplinary teams

;

8. facilitate case management of high-risk neonatal

patients

;and

9. cultivate collaborative relationships with

multidisciplinary team members and facility

leadership to improve the quality of care and

patient care outcomes.

(o) The facility will have a dedicated FTE allocated to

perform the roles and responsibi lities of the NICU

clinical nurse specialist.

Clinical Nurse Educator

(n) The level II SCN clinical nurse educator or

perinatal nurse educator will:

1. be an RN, with nursing certiﬁcation

speciﬁc to the care environment

preferred;

2. have at least a Bachelor of Science in

Nursing; Master’s preferred;

3. demonstrate a current status of NRP

completion;

4. cultivate collaborative relationships with

the neonatal nurse leader and facility

leadership to improve the quality of care

and patient care outcomes

; and

5. have experience and expertise to evaluate

the educational needs of the clinical staff,

develop didactic and skill-based

educational tools, oversee education and

skills veriﬁcation, and evaluate retention

of content, critical thinking skills, and

competency relevant to level II neonatal

care.

(o) The facility will have a dedicated individual

with sufﬁcient time allocated to perform the

roles and responsibilities of the clinical

nurse educator.

(p) The NICU clinical nurse educator will:

1. be an RN, with nursing certiﬁcation speciﬁc

to the care environment preferred;

2. have at least a Bachelor of Science in

Nursing; Master’s preferred;

3. demonstrate a current status of NRP

completion;

4. cultivate collaborative relationships with

the neonatal nurse leader and facility

leadership to improve the quality of care

and patient care outcomes

; and

5. have experience and expertise to evaluate

the educational needs of the clinical staff,

develop didactic and skill-based

educational tools, oversee education and

skills veriﬁcation, and evaluate retention

of content, critical thinking skills, and

competency relevant to level III neonatal

care.

(q) The facility will have a dedicated individual

with sufﬁcient time allocated to perform the

roles and responsibilities of the NICU clinical

nurse educator.

(p) The NICU clinical nurse educator will:

1. be an RN, with nursing certiﬁcation speciﬁcto

the care environment preferred;

2. have at least a Bachelor of Science in

Nursing; Master’spreferred;

3. demonstrate a current status of NRP

completion;

4. cultivate collaborative relationships with the

neonatal nurse leader and facility leadership

to improve the quality of care and patient

care outcomes

;and

5. have experience and expertise to evaluate

the educational needs of the clinical staff,

develop didactic and skill-based educational

tools, oversee education and skills

veriﬁcatio n, and evaluate retention of

content, critical thinking skills, and

competency relevant to level IV neonatal

care.

(q) The facilit y will have at least 1 dedicated FTE

allocated to perform the roles and responsibilities

of the NICU clinical nurse educator.

22 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Continued

Level II Level III Level IV

Additional Neonatal Support Personnel

(r) The facility will foster collaborative and

consultative relationships with additional

neonatal support personnel to facilitate

comprehensive multidisciplinary care consistent

with the types of care provided in the level IV

NICU.

Neonatal Transport

(p) The facility will have policies and

procedures in place to identify a local

neonatal transport program to facilitate

neonatal transport to a higher-level neonatal

facility.

(r) If the facility has a neonatal critical care

transport program, it will have an identiﬁed

director of neonatal transport services.

The

director of neonatal transport services can be

the neonatal medical director or another

physician who is a pediatrician, board-eligible

or -certiﬁed neonatologist, pediatric

hospitalist, or pediatric medical subspecialist

with expertise and experience in neonatal and

infant transport.

1. If the facility does not have its own

transport program, the facility must have

policies and procedures in place to identify

a local neonatal transport program to

facilitate transport.

(s) Responsibilities of the director of neonatal

transport services include the following:

1. train and supervise staff

;

2. provide appropriate review of all transport

records

;

3. develop and implement policies and

procedures for patient care during

transport

;

4. develop guidelines for determining

transport team composition and medical

control, and establish a mechanism to

track adherence

;

5. establish policies and procedures to

provide transport updates and outreach

education

;

6. establish a program for evaluating

performance by tracking data, identifying

trends, and implementing quality

improvement initiatives to address

transport performance in a coordinated

systematic approach within a culture of

safety, equity, and prevention

; and

7. report neonatal transport data and

neonatal-speciﬁc reviews back to the

NPSQIP.

8. The director of neonatal transport services

may delegate speciﬁc requirements to

other person(s) or group(s) but retains

the responsibility of certifying that these

functions are addressed appropriately.

(t) The facility will:

1. establish minimum education, experience,

and training requirements for all transport

team members

;

2. select transport team members based on

their experience and competence in the

care of neonates and the transport team

must collectively have the ability to provide

(s) If the facility has a neonatal critical care

transport program, it will have an identiﬁed

director of neonatal transport services.

The

director of neonatal transport services can be

the neonatal medical director or another

physician who is a pediatrician, board-eligible

or -certiﬁed neonatologist, pediatric hospitalist,

or pediatric medical subspecialist with

expertise and experience in neonatal and infant

transport.

1. If the facility does not have its own transport

program, the facility must have policies and

procedures in place to identify a local

neonatal transport program to facilitate

transport.

(t) Responsibilities of the director of neonatal

transport services include the following:

1. train and supervise staff

;

2. provide appropriate review of all transport

records

;

3. develop and implement policies and

procedures for patient care during tr ansport

;

4. develop guidelines for determining transport

team composition and medical control, and

estab lish a mechanism to track adher enc e

;

5. establish policies and procedures to provide

transport updates and outreach education

;

6. establish a progr am for evaluating performance

by tracking data, identifying trends, and

implementing quality improvement initiatives to

address transpo rt performance in a

coordinated systematic approach within a

culture of safety , equity , and prevention

;and

7. report neonatal transport data and neonatal-

speciﬁc reviews back to the NPSQIP.

8. The director of neonatal transport services may

delegate speciﬁc requirements to other

person(s) or group(s) but retains the

responsibility of certifying that these functions

are addressed appropriately.

(u) The facility will:

1. establish minimum education, experience, and

training requirements for all transport team

members

;

2. select transport team members based on their

experience and competence in the care of

neonates and the transport team must

collective ly have the ability to provide a level of

care that is similar to that of the admitting

unit

;and

3. provide annual transport education to all

tra nsport team members, which incorporates

equipment training, didactic education,

PEDIATRICS Volume 151, number 6, June 2023 23

Continued

Level II Level III Level IV

a level of care that is similar to that of

the admitting unit

; and

3. provide annual transport education to all

transport team members, which

incorporates equipment training, didactic

education, simulation, and skills

veriﬁcation of low-volume, high-risk

procedures consistent with the types of

care provided during neonatal transport.

simulation, and skills veriﬁcation of low-volume,

high-risk procedures consistent with the types of

care provided during neonatal tran sport.

Neonatal Outreach

(u) The level III facility will provide

multidisciplinary outreach education to

referring facilities by assessing education

needs and evaluating clinical care and

outcomes, including transport data, as part of

collaboration with lower-level neonatal

facilities, if applicable.

(v) The level IV facility will provide multidisciplinary

outreach education to referring facilities by

assessing education needs and evaluating

clinical care and outcomes, including transport

data, as part of collaboration with lower-level

neonatal facilities.

Pediatric Medical Subspecialists

(q) Policies and procedures will be in place for

referral to a higher level of neonatal care

when pediatric medical subspecialty or

pediatric surgical specialty consultation and/

or intervention is needed.

(v) The facility must have the ability to obtain

pediatric medical subspecialist advice or

formal consultation either on-site or by

prearranged consultative agreement using

telehealth technology and/or telephone

consultation from a distant location, from a

broad range of pediatric medical

subspecialists including, but not limited to

1. cardiology, pulmonology, infectious disease,

neurology, ophthalmology, endocrinology,

hematology, gastroenterology, nephrology,

and genetics or metabolism.

(w) If the pediatric medical subspecialist is

available for on-site consultation, they will:

1. have credentials to consult at the facility

which includes documented training,

certiﬁcation, competencies, and continuing

education speciﬁc to their subspecialty; and

2. document consultations in the medical

record within an appropriate time frame

and as deﬁned by the facility’s policies and

procedures.

(w) The facility must have on-site access to a

broad range of pediatric medical subspecialties

including, but not limited to

1. cardiology, pulmonology, infectious disease,

neurology, ophthalmology, endocrinology,

hematology, gastroenterology, nephrology, and

genetics or metabolism; and

2. the pediatric medical subspecialists must:

i. be readily accessible for in-person

consultation;

ii. have credentials to consult at the facility,

including documented training, certiﬁcat ion,

competencies, and continuing education

speciﬁc to their subspeciality; and

iii. document consultations in the medical

record within an appropriate time frame and

as deﬁned by the facility’s policies and

procedur es.

Neonatal Surgical Program

Pediatric Surgeons

(Optional for level III, but required for level IV) (x) Pediatric surgeons and pediatric surgical

specialists will be available on-site or at

another closely related NICU facility.

1. If pediatric surgery is not offered on-site at

the facility, policies and procedures will be

in place with a facility that provides

surgical care to facilitate transfer of an

infant when needed.

i. Infants requiring cardiovascular surgery or

ECMO will be transferr ed to a facility that

provides these services.

2. If pediatric surgery is accessible on-site, the

surgeons will:

(x) Pediatric surgeons and pediatric surgical

specialists will:

1. be available at the bedside within 1 hour of

request or identiﬁed need and be capable of

performing major pediatric surgery, including

surgery for complex conditions

;

i. if transplant or cardiac surgery is not

offered on-site at the facility, policies and

procedures will be in place to facilitate

neonatal transport to a facility that

provides appropriate surgical care;

2. provide consultation to a broad range of

pediatric surgical specialists including, but

not limited to

5,16

24 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Continued

Level II Level III Level IV

i. be available at the bedside within 1 hour of

request or identiﬁed need

;

ii. have credentials to provide care at the

facility , including documented training,

certiﬁcation, competencies, and continuing

education speciﬁc to their pediatric surgery

specialty

;

iii. establish a progr am for evaluating surgical

performance by accurately tracking data,

identifying trends, and implementing quality

improvement initiatives to address surgical

performance in a coordinated systematic

approach within a culture of safety , equity,

and prevention

;and

iv . report neonatal surgical and anesthesia

care back to the NPSQIP.

i. general pediatric surgery, neurosurgery,

urology, ophthalmology, otolaryngology,

orthopedics, and plastic surgery;

3. have credentials to provide care at the

facility, including documented training,

certiﬁcation, competencies, and continuing

education speciﬁc to their pediatric

surgery specialty

;

4. establish a program for evaluating surgical

performance by accurately tracking data,

identifying trends, and implementing

quality improvement initiatives to address

surgical performance in a coordinated

systematic approach within a culture of

safety, equity, and prevention

; and

5. report neonatal surgical and anesthesia

care back to the NPSQIP.

Anesthesiologists

(y) If pediatric surgery is performed on-site,

anesthesia providers with pediatric expertise

must

1. be on the medical staff and promptly available

24/7 to respond to the bedside within 1 hour

of request or identiﬁed need

;

2. serve as the primary responsible anesthesia

provider for all infants <24 mo of age and

should serve as the primary anesthesiologist

for children #5 y of age based on the ASA

physical status classiﬁcation

;and

3. be physically present for all neonatal surgical

procedures for which they serve as the

primary responsible anesthesia provider.

(y) Pediatric anesthesiologists must:

1. be on the medical staff and promptly

available 24/7 to respond to the

bedside within 1 hour of request or

identiﬁed need

;

2. serve as the primary responsible anesthesia

provider for all infants <24 mo of age and

should serve as the primary anesthesiologist

for children #5 y of age or based on the

ASA physical status classiﬁcation

; and

3. be physically present for all neonatal

surgical procedures for which they serve

as the primary responsible anesthesia

provider.

Laboratory Services

(r) Laboratory services will have:

1. laboratory personnel on-site 24/7;

2. the ability to determine blood type,

crossmatch, and perform antibody testing;

3. a blood bank capable of providing blood

component therapy and irradiated,

leukoreduced or CMV-negative blood;

4. the ability to perform neonatal blood gas

monitoring; and

5. the ability to perform analysis on small

volume samples.

(s) Low-volume specialty laboratory services

may be provided by an outside laboratory,

but the facility will have policies and

procedures in place to verify timely and

direct communication of all critical value

results.

(z) Laboratory services will have:

1. laboratory personnel on-site 24/7;

2. the ability to determine blood type,

crossmatch, and perform antibody testing;

3. a blood bank capable of providing blood

component therapy and irradiated,

leukoreduced or CMV-negative blood;

i. policies and procedures will be in place

to facilitate emergent access to blood

and blood component therapy so that the

NICU can provide hematologic interventions,

if applicable;

4. the ability to perform neonatal blood gas

monitoring;

5. the ability to perform analysis on small

volume samples; and

6. access to perinatal pathology services, if

applicable.

(aa) Low-volume specialty laboratory services may

be provided by an outside laboratory , but the

facili ty will have polic ies and procedur es in

place to maintain timely and direct

communication of all critical value results.

(z) Laboratory Services will have:

1. laboratory personnel on-site 24/7;

2. the ability to determine blood type,

crossmatch, and perform antibody testing;

3. a blood bank capable of providing blood

component therapy and irradiated,

leukoreduced or CMV negative blood;

i. policies and procedures will be in place to

facilitate emergent access to blood and

blood component therapy so that the NICU

can provide a full range of hematologic

interventions;

4. the ability to perform neonatal blood gas

monitoring;

5. the ability to perform analysis on small

volume samples;

6. the capability to process biopsies and

perform autopsies; and

7. access to perinatal pathology services, if

applicable.

(aa) Low-volume specialty laboratory services may

be provided by an outside laboratory, but the

facility will have policies and procedures in

PEDIATRICS Volume 151, number 6, June 2023 25

Continued

Level II Level III Level IV

place to maintain timely and direct

communication of all critical value results.

Pharmacy

(t) The facility will have at least 1 registered

pharmacist with experience in neonatal and/

or pediatric pharmacology who will:

1. be available for consultation on-site, or by

telehealth or telephone, 24/7;

2. complete continuing education

requirements speciﬁc to pediatric and

neonatal pharmacology; and

3. par ticipate in multidisciplinary care, as

needed.

(u) The pharmacy will have policies and

procedures in place to address drug

shor tages and to verify medications are

appropriately allocated to the level II SCN;

and

1. have policies and procedures in place to

verify neonatal competency for pharmacy

staff supporting and preparing

medications for neonatal patients.

(bb) The facility will have at least 1 registered

pharmacist with experience in neonatal and/

or pediatric pharmacology who will:

1. be available for consultation on-site, or

by telehealth or telephone, 24/7;

2. complete continuing education

requirements speciﬁc to pediatric and

neonatal pharmacology; and

3. participate in multidisciplinary care,

including participation in patient care

rounds.

(cc) The facility will have neonatal appropriate

TPN available 24/7; and

1. the facility will have a written policy and

procedure for the proper prepar ation and

delivery of TPN.

(dd) The pharmacy will have policies and

procedur es in place to address drug

shortages and to verify medications are

appropriately allocated to the level III NICU;

and

1. have policies and procedur es in place to

verify neonatal competency for pharmacy

staff supporting and preparing medications

for neonatal patients.

(bb) The facility will have at least 1 registered

pharmacist with experience in neonatal and/

or pediatric pharmacology who will:

1. be available for consultation on-site, or by

telehealth or telephone, 24/7;

2. complete continuing education requirements

speciﬁc to pediatric and neonatal

pharmacology; and

3. participate in multidisciplinary care, including

participation in patient care rounds.

(cc) The facility will have neonatal appropriate TPN

available 24/7; and

1. the facility will have a written policy and

procedure for the proper prepar ation and

delivery of TPN.

(dd)Thepharmacywillhavepoliciesand

procedures in place to address drug

shortages and to verify medications are

appropriately allocated to the level IV NICU;

and

1. have policies and procedures in place to

verify neonatal competency for pharmacy

staff supporting and preparing medications

for neonatal patients.

Diagnostic Imaging

(v) Radiology services will have:

1. appropriately trained radiology

personable available on-site to meet routine

diagnostic imaging needs and to address

emergen cies;

2. personnel appropriatel y trained in

ultrasonogr aphy, including cranial

ultrasonogr aphy, will be on-call and/or

available on-site to perform advanced

imaging as requested; and

3. the ability to provide timely imaging

interpretation by radiologists with

pediatric expertise as requested.

(ee) Radiology services will have:

1. appropriately trained radiology personnel

available on-site to meet routine

diagnostic imaging needs and to address

emergencies;

2. ﬂuoroscopy available on-call 24/7;

i. if ﬂuor oscopy is not offered on-site at the

facility , policies and procedures will be in

place to facilitate transfer of an infant to a

higher level of care;

3. personnel appropriately trained in the

following techniques will be on-call and/or

available on-site to perform advanced

imaging as requested:

i. ultrasonogr aphy, including cranial

ultrasonogr aphy;

ii. CT;

iii. MRI; and

4. the ability to provide timely imaging

interpretation by radiologists with pediatric

expertise as requested.

(ff) The facility will provide pediatric

echocardiography and have the ability to

consult with a pediatric cardiologist for timely

echocardiography interpretation as requested.

(ee) Radiology services will have:

1. appropriately trained radiology personnel

available on-site to meet routine diagnostic

imaging needs and to address emergencies;

2. ﬂuoroscopy available on-call 24/7;

3. personnel appropriately trained in the

following techniques will be on-call and/or

available on-site to perform advanced

imaging as requested:

i. ultrasonography, including cranial

ultrasonography;

ii. CT;

iii. MRI; and

4. the ability to provide timely imaging

interpretation by radiologists with pediatric

expertise as requested.

(ff) The facility will provide pediatric

echocardiography and have the ability to

consult with a pediatric cardiologist for

timely echocardiography interpretation as

requested.

Respiratory Therapy

(w) The respiratory care leader will:

1. be a full-time respiratory care practitioner,

with neonatal and pediatric respiratory

care certiﬁcation preferred;

2. have sufﬁcient time allocated to oversee

(gg) The respiratory care leader will:

1. be a full-time respiratory care practitioner ,

with neonatal and pediatric respiratory care

certiﬁcation preferred;

2. have sufﬁcient time allocated to oversee the

(gg) The respiratory care leader will:

1. be a full-time respiratory care practitioner,

with neonatal and pediatric respiratory care

certiﬁcation preferred;

2. have sufﬁcient time allocated to oversee the

26 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Continued

Level II Level III Level IV

theRTswhoprovidecareinthelevelIISCN;

3. provide oversight of annual simulation and

skills veriﬁcation, which includes neonatal

respirat ory care modalities and low-volume,

high-risk neonatal respiratory procedures;

4. develop a written RT stafﬁng plan that

establishes ﬂexibility for variable census and

acuity . This plan and actual stafﬁng will be

based on allocating the appropriate number

of competent RTs to a care situation, attend

to a safe and high-qualit y work environment,

and be operational ly reviewed annually

for adherence and to verify respiratory

therapy stafﬁng is adequate for patient

care needs

;and

5. maintain appropriate stafﬁng rati os for

infants receiving supplemental oxygen and

positive pressure ventilation.

(x) Respiratory care practitioners assigned to

the SCN will:

1. be a respiratory care practitioner with

documented experience and training in the

respir atory support of newborns and infants,

with neonatal and pediatric respiratory care

certiﬁcation preferred;

2. be on-site 24/7 and immediately available

when an infant is supported by assisted

ventilation or CP AP;

3. be able to attend deliveries and assist with

resuscitation as requested;

4. demonstrate a current status of NRP

completion;

5. participate in annual simulation and

respiratory skills veriﬁca tion, which includes

low-volume, high-risk procedure s consistent

with the types of respiratory care provided in

the SCN; and

6. have their credentials reviewed by the

respir atory care leader annually for adequacy

and adherence.

RTs who provide care in the level III NICU;

3. provide oversight of annual simulation and

skills veriﬁcation, which includes neonatal

respiratory care modalities and low-volume,

high-risk neonatal respiratory procedures;

4. develop a written RT stafﬁng plan that

establis hes ﬂexibility for variable census

and acuity . This plan and actual stafﬁng will

be based on allocating the appropriate

number of competent RTs to a care

situation, attend to a safe and high-quality

work environment, and be operationally

reviewed annually for adherence and to

verify respirat ory therapy stafﬁng is

adequate for patient care needs

;and

5. maintain appropriate stafﬁng ratios for

infants receiving supplemental oxygen and

positive pressure ventilation.

(hh) Respiratory care practitioners assigned to the

NICU will:

1. be a respir atory care practition er with

documented experience and training in the

respirat ory support of newborns and

infants, with neonatal and pediatric

respirat ory care certiﬁcation preferred;

2. be on-site 24/7 and immediately available to

supervise assisted ventilation, assist in

resuscitation, and attend deliveries;

3. demonstrate a current status of NRP

completion;

4. participat e in annual simulation and

respir atory skills veriﬁcation, which includes

low-volume, high-risk procedures consistent

with the types of respiratory care provided

in the NICU; and

5. have their credentials reviewed by the

respir atory care leader annually for

adequacy and adherence.

RTs who provide care in the level IV NICU;

3. provide oversight of annual simulation and

skills veriﬁcation, which includes neonatal

respiratory care modalities and low-volume,

high-risk neonatal respiratory procedures;

4. develop a written RT stafﬁng plan that

establishes ﬂexibility for variable census and

acuity . This plan and actual stafﬁng will be

based on allocating the appropriate number

of competent RTs to a care situation, attend

to a safe and high-quality work environment,

and be operationally reviewed annually for

adherence and to verify respiratory therapy

stafﬁng is adequate for patient care needs

;

and

5. maintain appropriate stafﬁng ratios for

infants receiving supplemental oxygen and

positive pressure ventilation.

(hh) Respiratory care practitioners assigned to the

NICU will:

1. be a respiratory care practitioner with

documented experience and training in the

respir atory support of newborns and infants,

with neonatal and pediatric respiratory care

certiﬁcation preferred;

2. be on-site 24/7 and immediately available to

supervise assisted ventilation, assist in

resuscitation, and attend deliveries, if

applicable;

3. demonstrate a current status of NRP

completion;

4. participate in annual simulation and

respir atory skills veriﬁcation, which includes

low-volume, high-risk procedures consistent

with the types of respirat ory care provided in

the NICU; and

5. have their credentials reviewed by the

respir atory care leader annually for adequacy

and adherence.

Dietitian

(y) The facility must have, or have the ability to

consult with, at least 1 registered dietitian

or nutritionist who has specialized training

in neonatal nutrition, who will

1. collaborate with the medical team to

establish feeding protocols, develop

patient-speciﬁc feeding plans, and help

determine nutritional needs at discharge;

2. establish policies and procedures to verify

proper preparation and storage of human

milk and formula; and

3. have policies and procedures for dietary

consultation for infants in the SCN.

(ii) At least 1 registered dietitian or nutritionist

who has specialized training in neonatal

nutrition will have dedicated time allotted to

serve the NICU and will

1. collaborate with the medical team to

establish feeding protocols, develop patient-

speciﬁc feeding plans, and help determine

nutritional needs at discharge;

2. establish policies and procedures to verify

proper preparation and storage of human

milk and formula;

3. par ticipate in multidisciplinary care,

including participation in patient care

rounds; and

(ii) The NICU will have at least 1 full-time NICU-

dedicated registered dietitian or nutritionist

available on-site who has specialized training in

neonatal nutrition and will

1. collaborate with the medical team to

establish feeding protocols, develop patient-

speciﬁc feeding plans, and help determine

nutritional needs at discharge;

2. establish policies and procedures to verify

proper preparation and storage of human

milk and formula;

3. participate in multidisciplinary care, including

participation in patient care rounds; and

4. have policies and procedures for dietary

consultatio n for infants in the NICU .

PEDIATRICS Volume 151, number 6, June 2023 27

Continued

Level II Level III Level IV

4. have policies and procedures for dietary

consultation for infants in the NICU.

Neonatal Nutrition

(z) The facility will:

1. provide a specialized area or room, with

limited access and away from the bedside,

to accommodate mixing of formula or

additives to human milk

;

2. develop standardized feeding protocols for

the advancement of feedings based on the

availability of, and family preference for ,

human milk, donor human milk, fortiﬁcation

of human milk, and formula; and

3. have policies and procedures in place for

accurate veriﬁcation and administration of

human milk and formula and to avoid

misappropriation.

(jj) The facility will:

1. provide a specialized area or room, with

limited access and away from the bedside,

to accommodate mixing of formula or

additives to human milk

;

2. develop standardized feeding protocols for

the advancement of feedings based on the

availability of, and family preference for,

human milk, donor human milk, fortiﬁcation

of human milk, and formula; and

3. have policies and procedures in place for

accurate veriﬁcation and administration of

human milk and formula and to avoid

misappropriation.

(jj) The facility will:

1. provide a specialized area or room, with

limited access and away from the bedside, to

accommodate mixing of formula or additives

to human milk

;

2. develop standardized feeding protocols for

the advancement of feedings based on the

availability of, and family preference for ,

human milk, donor human milk, fortiﬁcation

of human milk, and formula; and

3. have policies and procedures in place for

accurate veriﬁc ation and administration of

human milk and formula and to avoid

misappropriation.

Lactation and Breastfeeding Support

(aa) The facility will:

1. have personnel with the knowledge and

skills to support lactation available at all

times;

2. have a CLC, IBCLC preferred,

available for on-site consultation on

weekda ys and accessible by teleheal th

or telephone 24/7; and

3. operationally review CLC and/or IBCLC

personnel on an annual basis to establish

adequately trai ned lactation coverage

based on the speciﬁcneedandvolumeof

the neonatal population served.

(kk) The facility will:

1. have personnel with the knowledge and

skills to support lactation available at all

times;

2. have an IBCLC available for on-site consultation

on weekdays, and accessible by telehealth or

telephone 24/7; and

3. operationally review IBCLC personnel on an

annual basis to establish adequately trained

lactation coverage based on the speciﬁc need

and volume of the neonatal population

served.

(kk) The facility will:

1. have personnel with the knowledge and skills

to support lactation available at all times;

2. have an IBCLC available for on-site consultation

on weekdays, and accessible by telehealth or

telephone 24/7; and

3. operationally review IBCLC personnel on an

annual basis to establish adequately trained

lactation coverage based on the speciﬁc need

and volume of the neonatal population served.

Neonatal Therapists

(bb) If the facility does not have in-house

access to neonatal therapy expertise, the

facility will have a formal process in place

for providing on-site consultative services

by qualiﬁed neonatal therapists to address

the 6 core practice domains (environment,

family or 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. The facility

will have on-site access to the following

as needed

1. an occupational or physical therapist with

neonatal expertise, and neonatal therapy

certiﬁcation preferred

;and

2. at least 1 individual skilled in the

evaluation and management of neonatal

feeding and swallowing concerns, with

neonatal therap y certiﬁcation preferred.

(cc) The facility will operationally review neonatal

therapis t personnel on an annual basis to

maintain adequate multidisciplinary neonatal

therapist coverage based on the speciﬁcneed

and volume of the neonatal population

served.

(ll) The facility will provide on-site consultative

services by qualiﬁed neonatal therapists to

address the 6 core practice domains

(environment, family or 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.

(mm) The facility will have on-site access to the

following neonatal therapists who have

dedicated time allocated to serve the NICU:

1. an occupational and/or physical therapist

with sufﬁcient neonatal expertise, and

neonatal therap y certiﬁcation preferred

;and

2. a speech language pathologist with

neonatal expertise, skilled in the

evaluation and management of

neonatal feeding and swallowing

concerns, and neonatal therap y

certiﬁcation preferred.

i. If swallow 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.

(nn) The facility will operationally review neonatal

ther apist personnel on an annual basis to

maintain adequate multidisciplina ry neonatal

(ll) The facility will provide on-site consultative

services by qualiﬁed neonatal therapists to

address the 6 core practice domains

(environment, family or 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.

(mm) The facility will have on-site access to the

following neonatal therapists who have

dedicated time allocated to serve the NICU:

1. an occupational and/or physical therapist

with sufﬁcient neonatal expertise, and

neonatal therapy certiﬁcation preferred

; and

2. a speech language pathologist with neonatal

expertise, skilled in the evaluation and

management of neonatal feeding and

swallowing concerns, and neonatal therapy

certiﬁcation preferred.

(nn) The facility will operationally review neonatal

therapist personnel on an annual basis to

maintain adequate multidisciplinary neonatal

therapist coverage based on the speciﬁc need

and volume of the neonatal population

served.

28 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Continued

Level II Level III Level IV

therapist coverage based on the speciﬁc need and

volume of the neonatal population served.

Child Life Services

(oo) Child life services, or equivalent, will be

available for on-site consultation to support

patient- and family-centered care by

establishing and maintaining therapeutic

relationships between patients, family

members, multidisciplinary team members,

and community resources.

Social Worker

(dd) The SCN social worker will:

1. be a Master’s prepared medical social

worker with perinatal and/or pediatric

experience.

(ee) The facility will:

1. provide 1 social worker for every 30 beds

providing level II neonatal care and/or

specialty and subspecialty perinatal care

;

2. have a written description that clearly

identiﬁes the responsibilities and functions

of the SCN social worker; and

3. have social services available for each

family with an infant in the SCN as

needed.

(oo) The NICU social worker will:

1. be a Master’s prepared medical social

worker with perinatal and/or pediatric

experience.

(pp) The facility will:

1. provide 1 social worker for every 30 beds

providing level III neonatal care and/or

specialty and subspecialty perinatal care

;

2. have a written description that clearly

identi ﬁes the responsibilities and functions

of the NICU social worker; and

3. have social services available for each

family with an infant in the NICU as needed.

(pp) The NICU social worker will:

1. be a Master’s prepared medical social worker

with perinatal and/or pediatric experience.

(qq) The facility will:

1. provide at least 1 social worker for every 30

beds providing level IV neonatal care and/or

specialty and subspecialty perinatal care, if

appli cabl e

;

2. have a written description that clearly

identi ﬁes the responsibilities and functions of

the NICU social worker; and

3. have social services available for each family

with an infant in the NICU as needed.

Pastoral Care

(ff) Personnel skilled in pastoral care will be

available as needed and by family request

and will represent, or have the ability to

consult, multiple religious afﬁliations

representative of the population served.

(qq) Personnel skilled in pastoral care will be

available as needed and by family request

and will represent, or have the ability to

consult, multiple religious afﬁliations

representative of the population served.

(rr) Personnel skilled in pastoral care will be

available as needed and by family request and

will represent, or have the ability to consult,

multiple religious afﬁliations representative of

the population served.

Retinopathy of Prematurity

(gg) If the facility back transfers infants for

convalescent care, the facility must have a

process in place to appropriately identify

infants at risk for retinopathy of

prematurity to guarantee timely

examination and treatment by having

1. documented policies and procedures for

the monitoring, treatment, and follow-up of

retinopathy of prematurity

5,13

;

2. the ability to perform on-site retinal

examinations, or off-site interpretation of

digital photographic retinal images, by a

pediatric ophthalmologist or retinal

specialist with expertise in retinopathy

of prematurity , if needed.

5,13

(rr) The facility must have a process in place to

appropriately identify infants at risk for

retinopathy to guarantee timely examination

and treatment by having

1. documented policies and procedures for

the monitoring, treatment, and follow-up

of retinopathy of prematurity

5,13

; and

2. the ability to perform on-site retinal

examinations, or off-site interpretation

of digital photographic retinal images,

by a pediatric ophthalmologist or retinal

specialist with expertise in retinopathy

of prematurity.

5,13

(ss) The facility must have a process in place to

appropriately identify infants at risk for

retinopathy to guarantee timely examination

and treatment by having

1. documented policies and procedures for

the monitoring, treatment, and follow-up

of retinopathy of prematurity

5,13

; and

2. the ability to perform on-site retinal

examinations, or off-site interpretation of

digital photographic retinal images, by a

pediatric ophthalmologist or retinal specialist

with expertise in retinopathy of prematurity .

5,13

Discharge and Follow-up

(hh) Systems will be in place to establish

prepar ation for SCN discharge, including

postdischarge follow-up by general and

subspecialty pediatric care providers , home

care arrangements and community service

resource s, and enrollment in a developmental

follow-up progr am as needed.

1. The facility will:

i. have written medical, neurodevelopmental,

and psychosocial criteria that

automatically warrant high-risk

(ss) Systems will be in place to establish

preparation for NICU discharge, including

postdischarge follow-up by general and

subspecialty pediatric care providers, home

care arrangements and community service

resources, and enrollment in a

developmental follow-up program as needed.

1. The facility will:

i. have written medical, neurodevelopmental,

and psych osocial criteria that automatically

warrant high-risk neonatal follow-up with

(tt) Systems will be in place to establish

preparation for NICU discharge including

postdischarge follow-up by general and

subspecialty pediatric care providers, home

care arrangements and community service

resources, and enrollment in a developmental

follow-up program as needed.

1. The facility will:

i. have written medical, neurodevelopmental,

and psychosocial criteria that automatically

warrant high-risk neonatal follow-up

PEDIATRICS Volume 151, number 6, June 2023 29

AAP NICU VERIFICATION PROGRAM

LEADERSHIP TEAM

Ann R. Stark, MD, FAAP – Medical

Director, NICU Verification Program

DeWayne M. Pursley, MD, MPH, FAAP

Lu-Ann Papile, MD, FAAP

Eric C. Eichenwald, MD, FAAP

Charles T. Hankins, MD, MBA, FAAP

Rosanne K. Buck, RN, MS, NNP-BC,

C-ONQS

Tamara J. Wallace, DNP, APRN, NNP-BC

Patricia G. Bondurant, DNP, RN

AAP NICU VERIFICATION PROGRAM

SUPPORT STAFF

NicoleFaster,MSN,RN,RNC-NIC

Jaime Thomas, MHA

Sunnah Kim, MS, RN

AAP SECTION ON NEONATAL-PERINATAL

MEDICINE CLINICAL LEADERS GROUP

Munish Gupta, MD, MMSc, FAAP

James Barry, MD, FAAP

Jessica Davidson, MD, FAAP

Jeffrey Meyers, MD, FAAP

Michael Posencheg, MD, FAAP

ACKNOWLEDGMENTS

The authors of this paper comprise

the Am erican Academy of Pediat-

rics (AAP) NICU Verificati on Pro-

gram’s Leadership Team. All are

highly experienced clinicians with a

long-standing interest in r isk-ap-

propriate care. The Standa rds for

Levels of Neon atal Care: II, III, and

IV ar e based on the AAP policy

statement “Lev els of Neonatal Care”

and the AAP/ACOG textbook Guide-

lines for Perinatal Care. To compile

the Standards, the NICU Verifica-

tion Program Lead ersh ip Team col-

laborated wit h the AAP Committee

on Fetus and Newborn (COFN), the

Section on Neonatal-Perinatal Medi-

cine (SONPM), the S ONPM Clinical

Leaders Group (CLG), and addi-

tional neonatal stakeholders. We

also ac knowledge importan t guid-

ance from Dr. Keith Oldham and

other membe rs of the American

College of Surgeons Children’sSur-

gery Verification Quality Improve-

ment Prog ram, the Centers for

Disease Control and Preventi on, the

National Association of Neon atal

Nurses, and the National Associa-

tion of Neonatal Therapis ts.

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PEDIATRICS Volume 151, number 6, June 2023 31