Neonatology

Explore a Career in Neonatology

Tiny patients. Complex physiology. Critical care. Lifelong impact.

Neonatology is the pediatric subspecialty dedicated to caring for newborn infants who are premature, critically ill, born with congenital abnormalities, or require specialized medical and surgical care after birth.

Neonatologists work primarily in the Neonatal Intensive Care Unit (NICU), where their patients can range from extremely premature infants weighing less than a pound to full-term newborns with serious medical conditions.

What makes the specialty particularly unique is the combination of intensive care and continuity.

A neonatologist may be present at a baby’s delivery, perform life-saving stabilization within the first minutes of life, manage ventilators and complex physiology during critical illness, and then continue caring for that same baby for months—sometimes more than a year—until the day the family finally takes their child home.

Julia S. Spalding, MD

Neonatologist | University of Kentucky

Her path to Neonatology began with a love of science, biology, and working with people. She attended the University of Louisville School of Medicine without knowing exactly which specialty she would ultimately pursue. Pediatrics and OB-GYN both interested her. Then, during her third-year OB-GYN rotation, she was present at a delivery. While the OB team cared for the mother, she found herself wondering: What is happening with the baby? A resident encouraged her to walk over and see what the NICU team was doing. That moment helped solidify her decision to pursue Pediatrics. She subsequently completed Pediatrics residency at the University of Louisville, discovered Neonatology during residency, completed her Neonatology fellowship at Louisville, and then joined the University of Kentucky as faculty.

What Is Neonatology?

Neonatology is a subspecialty of Pediatrics focused on the care of newborn infants who require specialized medical attention. Most neonatologists work in a: NICU — Neonatal Intensive Care Unit Patients may be admitted because they:

The patients are all babies. But the diseases and physiology can be extraordinarily complex.

The NICU Is Not Just for Premature Babies

This is an important misconception to address. When people imagine the NICU, they often immediately think: Prematurity. And that is certainly a major part of Neonatology. But Dr. Spalding explains that at her NICU, approximately half of their babies are full-term. A full-term newborn might require NICU care because of:

Respiratory distress

Infection

Congenital heart disease

Neurologic abnormalities

Gastrointestinal abnormalities

Surgical conditions

Complications surrounding delivery

Other congenital disease

What Conditions Do Neonatologists Treat?

Despite treating patients within a very narrow age range, Neonatology involves an incredibly broad range of pathology.

Respiratory Disease

One of the most common problems in the NICU. Premature babies may require mechanical ventilation, oxygen, or other forms of respiratory support.

Surgical Conditions

Some infants are born with gastrointestinal or other abnormalities requiring surgery.

Infections

Newborns can become severely ill from infection and may require antibiotics and intensive monitoring.

Congenital Heart Disease

Some infants are born with structural abnormalities of the heart.

Congenital Abnormalities

These may involve the brain, limbs, gastrointestinal tract, heart, or other organ systems.

The NICU Is Different From Other ICUs

MANY ADULT ICUS

Critically Ill

↓

Stabilize

↓

Improve

↓

Transfer to the Floor

The ICU team may no longer care for the patient after transfer.

BUT IN THE NICU

Critically Ill Newborn

↓

Stabilize

↓

Intensive Care

↓

Grow

↓

Develop

↓

Feed

↓

Breathe Independently

↓

Prepare the Family

↓

Go Home ❤️

The NICU team may remain involved through that entire journey.

Dr. Spalding describes this as one of her favorite parts of Neonatology: caring for extremely sick babies and then getting to watch them improve, develop, and eventually go home.

From Delivery Room → Home

Birth

Delivery Room Immediate Assessment

Stabilize

Resuscitation Respiratory Support

NICU

Critical Care Complex Physiology

Grow

Nutrition Development Healing

Prepare

Family Education Feeding Home Planning

CRITICAL CARE WITH CONTINUITY

From the Sickest Day to Going Home

This is one of the most powerful parts of Neonatology.

Some families spend: Weeks. Months. Sometimes more than a year. with the NICU team.

That creates relationships very different from many other critical-care specialties.

Dr. Spalding describes becoming very close with families during long hospitalizations. When those babies are finally discharged, the team may miss them—but they’re also thrilled that the family can finally bring their baby into the outside world.

You don’t only see the crisis. You get to see the recovery.

What Does a Typical Day in the NICU Look Like?

A typical day begins with multidisciplinary rounds.

Neonatologist

Supervising attending physician

NICU Fellow

Physician completing subspecialty training

Residents

Physicians completing residency training

Advanced Practice Providers

Nurse practitioners and physician assistants

Bedside Nurse

Provides continuous bedside care

Dietitian

Helps optimize nutrition and growth

Pharmacist

Assists with complex medication management

What Happens Outside of Rounds?

The neonatologist may spend the rest of the day:

Dr. Spalding describes one attending team that also responds to deliveries where NICU assistance may be needed and receives calls regarding babies who may need transfer to the University of Kentucky NICU.

One Baby, One Team

THE NICU RUNS ON TEAMWORK.

Neonatologist

Fellow

Resident

Nurse

APP

Pharmacist

Dietitian

Respiratory Therapy

Surgeons

Therapists

Family

The Delivery Room

Neonatology doesn’t begin after a baby reaches the NICU. Sometimes it begins: THE SECOND THE BABY IS BORN. A neonatologist or NICU team may attend a high-risk delivery when there is concern that the newborn will require immediate assistance. The team may need to rapidly assess and stabilize the infant. This creates an interesting combination within the specialty:

Longitudinal Care

Months-long relationships and development

Acute Care

Immediate stabilization at delivery

Critical Care

Management of life-threatening illness

Dr. Spalding describes that combination as one of the reasons Neonatology offers “the best of all of the worlds.”

How Do You Become a Neonatologist?

The typical pathway is:

4 Years

Medical School

3 Years

Pediatrics Residency

3 Years

Neonatal-Perinatal Medicine Fellowship

Why Choose Neonatology?

Dr. Spalding highlights several features that attracted her to the specialty.

01

The Patients

She enjoys caring for newborn infants.

02

Physiology

Neonatal physiology is complex and constantly changing.

03

Attention to Detail

Small physiologic changes can matter enormously.

04

Critical Care

Neonatologists care for extremely sick patients.

05

Development

They watch infants grow and change over time.

06

Families

They support parents through what was supposed to be one of the happiest moments of their lives but has instead become frightening and uncertain.

What Is Rewarding About Neonatology?

Imagine meeting a baby who: Weighs less than a pound. Cannot breathe independently. Requires intensive medical support.

Then caring for that child for months.

Watching them grow. Watching them breathe. Watching them begin feeding. Watching their parents become more comfortable caring for them.

And eventually: WATCHING THEM GO HOME.

That longitudinal recovery is one of the most distinctive rewards of Neonatology.

Caring for Two Patients: The Baby & the Family

Technically, the neonatologist’s patient is the baby.
In reality, excellent neonatal care also requires caring for the: FAMILY.
Parents may have imagined pregnancy ending with: Delivery → Hold Baby → Go Home
Instead, they suddenly find themselves surrounded by:

Monitors

Ventilators

Feeding tubes

Medications

Specialists

Uncertainty

The neonatologist must explain what is happening while recognizing that this may be one of the most frightening periods of the parents’ lives.

Difficult Conversations in the NICU

Neonatologists regularly have conversations that no family expected to have. These may involve:

Serious diagnoses

Prognosis

Tracheostomy

G-tube placement

Long-term disability

Major changes in expected quality of life

Redirection toward comfort-focused care

I personally see it as an honor to be a person who's trusted enough by a family to have those conversations.

Being a Calm Presence

Sometimes the neonatologist has developed a relationship with the family over months.

Other times: It’s the middle of the night. The baby has just been delivered. The physician has never met the family before. And the news is devastating.

Dr. Spalding describes trying to serve as a calm presence and comfort during those moments.

Communication isn’t separate from the medical care. It is part of the medical care.

Check your own pulse first before you enter one of those situations.

Control yourself first.

Prognosis

Stay calm.

Use your training.

Then help the patient.

Neonatologists sometimes enter emergencies knowing almost nothing about the baby.

They may not know the history. They may not know exactly what happened during delivery. They simply have to arrive and act.

Dr. Spalding recalls advice from one of her mentors.

She emphasizes that a neonatologist must remain calm, cool, and collected when everyone else in the room may be experiencing an extremely stressful event.

What Makes a Good Neonatologist?

Dr. Spalding identifies several important qualities.

Detail-Oriented

Neonatal intensive care involves extraordinary attention to detail.

Organized

Her NICU may have 90+ babies at a time, making organization essential.

Calm Under Pressure

Emergencies require clear thinking despite stress.

Compassionate

Parents may be living through an experience they never imagined.

Collaborative

Caring for critically ill infants requires listening to nurses, specialists, advanced-practice providers, therapists, families, and other members of the team.

Comfortable With Complex Physiology

Tiny changes can matter enormously in premature and critically ill infants.

The Parents Are Part of the Team

One particularly complex aspect of Neonatology is decision-making.

The newborn cannot make their own medical decisions. Parents or guardians generally make decisions on their behalf.

Dr. Spalding discusses this through the ethical principle of autonomy, noting that in Neonatology the parents exercise decision-making authority for their child.

That means good neonatal care isn’t simply: Physician decides → Family follows.

Instead, it requires: COLLABORATIVE DECISION-MAKING.

"We're on the Same Team."

When disagreements or uncertainty arise, communication becomes essential. The NICU may organize a care conference bringing together:

Family

Neonatologist

Nurses

Specialists

Nurse practitioners

Physician assistants

Therapists

Other members of the care team

We're on the same team.

Ethics in Neonatology

Few specialties confront the intersection of medicine, ethics, uncertainty, and family decision-making as directly as Neonatology. Questions can involve:

Extreme prematurity

Prognosis

Long-term disability

Life-sustaining treatment

Resuscitation

Comfort-focused care

Parental decision-making

Quality of life

Medical uncertainty

Dr. Spalding explains that ethics teams can become involved when the medical team believes there may be serious disagreement about what is appropriate for the infant, though she notes that this is relatively rare in her experience.

Taking the NICU Home With You

Neonatology can be emotionally difficult. Physicians may care for families for months. They may witness:

Critical illness

Death

Unexpected diagnoses

Complications

Difficult resuscitations

Grieving parents

And sometimes those experiences follow them home.

Dr. Spalding describes learning over time how to better separate work and home while acknowledging that there are still patients she thinks about or even returns to check on when she isn’t working.

Physicians Need Support Too

Dr. Spalding discusses several ways physicians can process difficult experiences:

She emphasizes the importance of creating a “village” around yourself.

That is a valuable message for pre-medical students long before they ever enter a NICU.

Medicine & Family Life

Dr. Spalding also addresses a question many students quietly worry about: Can I have a family and still pursue a demanding specialty? She had a son during her third year of Neonatology fellowship. She describes relying on:

Her husband

Family

Co-fellows

A supportive community

to allow her to continue being both a mother and a neonatologist. Her broader point is important: Family considerations may influence specialty choice. But having a family and pursuing medicine are not mutually exclusive. She notes that she has colleagues throughout medicine who are mothers and fathers and make it work with appropriate support.

Teaching in the NICU

Academic Neonatology also involves teaching.

Dr. Spalding describes herself as someone who naturally likes to be hands-on and know everything happening with the patient.

As an attending, however, part of her responsibility is allowing trainees to take increasing ownership. She gets to watch fellows progress from being:

Timid and Uncertain

Developing Procedural Skills

More Independent

while remaining available as backup when needed. That’s another reward of academic medicine: Your impact extends beyond your own patients.

The Future of Neonatology

Neonatology is a relatively young specialty.

Dr. Spalding notes that the field developed substantially beginning around the 1960s, meaning enormous advances have occurred within only a few generations of physicians.

One of the clearest examples is: THE EDGE OF VIABILITY.

How Early Can a Baby Survive?

Dr. Spalding explains that Neonatology has progressively pushed the limits of how early extremely premature infants may be resuscitated. In her discussion:

24 wks

~20 years ago

23 wks

~10 years ago

22 wks

Today at her center

Artificial Intelligence in Neonatology

Unlike several of the other interviews, this physician specifically discusses AI. Potential applications being explored include predictive models related to:

Extremely Premature Infant Outcomes

Helping inform complex counseling and decision-making.

Sepsis

Identifying babies at increased risk.

Chronic Lung Disease

Predicting outcomes such as bronchopulmonary dysplasia.

Other Clinical Outcomes

Using data to better understand risk and prognosis.

Dr. Spalding describes AI as still developing within Neonatology but believes there will likely be a role for it in the future.

Will AI Replace Neonatologists?

Dr. Spalding doesn’t think so.

And her reasoning illustrates something important about Neonatology.

There isn’t always a randomized controlled trial telling the physician exactly what to do for an extremely premature infant weighing less than a pound. Evidence matters enormously. But so do:

Clinical judgment

Experience

Nuance

Family goals

Communication

Ethics

Uncertainty

She describes this as the continued: ART + SCIENCE OF MEDICINE.

AI may help. But Neonatology still requires physicians capable of applying evidence to deeply individual human circumstances.

What Are Common Misconceptions About Neonatology?

"The NICU is only for premature babies."

False. Dr. Spalding notes that approximately half of the babies in her NICU are full-term.

"Neonatologists only take care of babies immediately after birth."

No. Some babies remain under NICU care for months or even more than a year.

"Once the baby gets better, another team takes over."

Not necessarily. Unlike many adult ICUs, NICU teams may continue caring for infants until discharge home.

"It's basically just Pediatrics with smaller patients."

Neonatology combines Pediatrics with intensive care, complex physiology, resuscitation, developmental medicine, ethics, and family-centered decision-making.

"NICU care is mostly the doctor."

Far from it. NICU care is intensely multidisciplinary.

"Critical care means you don't develop long-term relationships."

The NICU can involve some of the longest relationships in critical care because families may remain with the team for months.

Who Is a Good Fit for Neonatology?

Frequently Asked Questions About Neonatology

What does a neonatologist do?

A neonatologist specializes in caring for newborn infants who require intensive or specialized medical care.

Is Neonatology part of Pediatrics?

Yes. Neonatology is a pediatric subspecialty.

Where do neonatologists work?

Primarily in NICUs, though their work may also involve delivery rooms, transport, consultation, follow-up, research, and academic medicine.

Are all NICU babies premature?

No. Dr. Spalding states that approximately half of the infants in her NICU are full-term.

How premature can NICU babies be?

Dr. Spalding discusses caring for infants born as early as 22 weeks at her institution. Practices vary, so this should not be interpreted as a universal threshold.

Do neonatologists attend deliveries?

Yes. NICU teams may attend deliveries where specialized neonatal support is expected or becomes necessary.

Do neonatologists care for babies after they leave intensive care?

In many NICUs, the neonatal team continues caring for the infant throughout the hospitalization until discharge.

Is Neonatology procedural?

It can involve acute stabilization and procedures as part of intensive care, although the transcript does not provide a detailed procedural list.

Is Neonatology emotionally difficult?

It can be. The interview discusses serious diagnoses, comfort-care conversations, critically ill infants, and the importance of physician support systems.

Is Neonatology good for someone who likes physiology?

Dr. Spalding specifically identifies neonatal physiology as one of the things she enjoys about the specialty.

Is Neonatology good for someone who likes critical care but wants continuity?

Potentially, yes. That combination is one of the specialty’s most distinctive features.

Advice for Future Neonatologists

Dr. Spalding’s biggest recommendation is simple:

GO SEE THE NICU.

Shadow

Ask questions

Watch a delivery

See rounds

Meet neonatologists

Observe how the team cares for babies and families

Even if you eventually decide Neonatology isn’t right for you, exposure can help clarify what is right for you.

She also offers advice that fits perfectly with The Long Haul.

When you’re a pre-medical student, the finish line can feel impossibly far away.

There is always another: Exam. Class. Application. Interview. Rotation.

Sometimes spending time with physicians and seeing the career you’re working toward provides enough motivation to keep pushing through.

She describes shadowing as something that can refresh you and give you more stamina when the process becomes difficult.

The Babies You're Caring for Today Are the Future

The interview ends with an unusual question: What song describes being a neonatologist? Her answer: “Waiting on the World to Change” — John Mayer. Her reasoning is what matters. She thinks about the babies she cares for growing up and becoming future:

Engineers

Doctors

Lawyers

Teachers

Parents

Members of their communities

And even if they become none of those things, they are still someone’s son or daughter, deeply loved by their family. Her goal is to give them the opportunity to have the best life possible. And, as she puts it:

I want them to have the best life they can possibly have. And that starts in the NICU.

Hear It From a Neonatologist

Neonatology is much more than caring for premature babies.

It combines: Pediatrics + Intensive Care + Physiology + Development + Resuscitation + Ethics + Communication + Family-Centered Medicine

A neonatologist may meet a baby during the first seconds of life, stabilize them in the delivery room, manage critical illness for months, guide parents through some of the hardest decisions imaginable, and eventually stand beside the family as they finally take their baby home.

Hear directly from a University of Kentucky neonatologist about NICU medicine, training, critical care, family communication, ethics, work-life balance, extreme prematurity, artificial intelligence, and why she believes Neonatology offers “the best of all of the worlds.”