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AAP sets national standards for levels of neonatal care

May 22, 2023

A new AAP document defines the care hospitals provide for newborns by establishing standards for levels of neonatal care, specifying the personnel, equipment and other services needed. The standards codify the minimum components of each level of neonatal care — from special care nursery (Level II) to complex subspecialty care including surgery (Level IV).

The document, Standards for Levels of Neonatal Care: II, III, & IV, is based on AAP policy, evidence-based literature and standards of professional practice. It will be available via a link in the June issue of Pediatrics ( It is a companion to the AAP policy statement Levels of Neonatal Care and the manual Guidelines for Perinatal Care, 8th edition.

The standards also uphold the AAP Equity Agenda by encouraging facilities to assess the health disparities of their patients, families and community, with an emphasis on family-centered care.

Verification program

The publication of the neonatal intensive care unit (NICU) standards also marks the beginning of the AAP NICU Verification Program’s endeavor to expand nationally.

Until this time, the program has served as a surveying body for levels of neonatal care in specific states, while direct oversight has been provided by a state-specific designating authority (i.e., public health department). With publication of the new standards, and when processes are in place, the AAP program will be able to verify a neonatal facility’s compliance and designate that it provides a specific level of neonatal care (II, III or IV).

Hospitals will submit data and undergo a survey of their facility. Those that meet requirements will be able to state that they are AAP-verified at a particular level of neonatal care. The designation then will be transparent to physicians and families deciding where to deliver and/or seek care for their baby.

While all states regulate health care facilities, specifications for levels of neonatal care and adherence to requirements vary widely. Few states require verification by a third-party surveying agency. Facilities that self-assess often rate themselves at a higher level than they actually are.

Therefore, a national neonatal verification program “is vital to high-quality and equitable care,” the document states. Experts note that it is important to have an honest appraisal by an experienced survey team that can evaluate a facility carefully.

Multidisciplinary effort

The standards were developed by a team of neonatal leaders and experienced clinicians with a longstanding interest in risk-appropriate care and education and who comprise the NICU Verification Program Leadership Team. Others who provided input include the AAP Committee on Fetus and Newborn (COFN), Section on Neonatal-Perinatal Medicine and its Clinical Leaders Group, and experts from professional medical and nursing associations.

Boston neonatologist Ann R. Stark, M.D., FAAP, medical director of the AAP NICU Verification Program, heads the team.

She is a former chair of the COFN, was lead author of the initial Levels of Neonatal Care policy statement and is editor of the seventh edition of Guidelines for Perinatal Care.

Her work in this area dates to 2013, when the AAP was identified as one of two Texas-approved survey agencies to pilot the neonatal verification process, and the NICU Verification Program was officially launched. Dr. Stark put together a group of colleagues to do pilot surveys and develop a verification program for facilities in Texas and later in Georgia and Missouri.

“We were concerned that first, babies should be treated in a place with appropriate care and second, that the facility has the people and the equipment that are appropriate for their degree of illness or degree of immaturity,” Dr. Stark said.

Growing need

The NICU Verification Program has performed third-party surveys by experts, including neonatologists, neonatal nurses and pediatric surgeons, assessing whether facilities comply with state standards for neonatal care.

As the need has grown and more facilities have requested surveys, it became clear that the AAP needed to develop national neonatal care standards.

Parents also should understand the level of neonatal care available where they are delivering, Dr. Stark said.

In addition, she said, infants born in rural hospitals should receive the same kind of care as those in big-city academic medical centers, with advanced-level facilities educating lower-level facilities.

Quality and safety are large components of the program, with all facilities tracking their outcomes and making sure all patients are getting optimal care.

“Our whole thesis is to make sure babies get cared for in a place that’s commensurate with their problems, their degree of maturity and so on, so there is equity for babies across the country,” Dr. Stark said.

“We have created these standards with a goal to improve outcomes, increase access to care, improve standardization across all levels of neonatal care and really achieve health equity.”


For information on the AAP NICU Verification Program, visit or email Nicole Faster at

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