It has been said that "it takes a village" to raise a child. In their professional lives, speech-language pathologists and audiologists are finding that it takes a team of professionals to serve patients and families. This is the first article in an occasional series that will take readers to various settings as The ASHA Leader explores different clinical partnerships.
Speech-language pathologists are increasingly bringing their ex pertise to teams in caring for the youngest patients as the survival rate of premature infants increases and neonatal intensive care units (NICUs) place a greater emphasis on developmental care and family involvement.
Gone are the days of noisy, bright NICUs with side-by-side isolettes. The focus on developmental care has led to interventions designed to minimize the stress of the NICU environment and promote the development of feeding and interaction with caregivers. Across the country, NICUs are being redesigned with these goals in mind by creating more space around the infant beds so families can be with their newborns 24 hours a day and have more privacy for bonding, early communication, and feeding, said Joan Arvedson, an SLP who works in the NICU at the Children’s Hospital of Wisconsin in Milwaukee.
"The role of the SLP with NICU teams is increasing as more hospitals adopt a focus on developmental outcomes," Arvedson said. "More SLPs will need to be well-trained and have the extraordinary knowledge to help support these infants and families."
SLPs who provide services in the NICU find themselves joining a unique medical culture that functions as an independent community with its own personnel, policies, equipment, and terminology, said Meri Ziev, an SLP in the NICU at Bethesda Memorial Hospital in Boynton Beach, FL. Service delivery in the NICU involves a paradigm shift from direct service delivery to forming a network of clinical partnerships on multiple levels. SLPs collaborate closely with members of the developmental care team that includes audiologists, occupational therapists, physical therapists, and allied professionals.
Some NICUs divide service delivery among the various specialties, while others teams, such as the one at Bethesda Memorial Hospital, provide transdisciplinary services through cross-training. "The rehabilitation team communicates daily regarding the roles and responsibilities for each infant, based on the infant’s schedules and needs," Ziev said. Needs may be related to parent education, developmental assessment and care, feeding plan/intervention, or discharge evaluations for referral to the Early Intervention Program through Part C of the Individuals With Disabilities Education Act (IDEA).
Recommendations from the SLP, which are made in person and in writing, follow further collaboration with neonatologists and other physician specialists who may be involved with the infant, such as the craniofacial surgeon and gastroenterologist.
"Our role is not so much to provide direct intervention, but to assist others in determining the ways that everyone who comes in contact with the infant can help facilitate early prelinguistic communication and feeding," Arvedson said.
"This emphasis on global developmental outcomes can determine how quickly an infant is discharged," she added.
But in order to demonstrate that speech-language pathology interventions in the NICU lead to better outcomes, more evidence-based research is needed. Research on infant feeding and swallowing in the NICU—like the population—is in its infancy, Arvedson said.
"Only a limited number of studies are evidence-based and most of the research is being done by physicians and nurses," Arvedson noted. "SLPs need to seek their own data, so that they can contribute to the research, and realize that there is value to clinical research at all levels of evidence."
While randomized clinical trials are the "gold standard" and yield the greatest level of evidence about the efficacy of an intervention, these studies are difficult to conduct for feeding, swallowing, and communication issues in the NICU. Existing studies may be limited with regard to design, number of subjects, and comprehensiveness, but they can suggest the need for more research and support clinical practice.
More research is needed on sucking, swallowing, and respiratory coordination in the development of normal and abnormal feeding processes, and how this translates into the best and most efficient oral feeding techniques and practices, Arvedson said.
Entering the NICU
Gaining access to the NICU has proved challenging for SLPs. Most SLPs cannot walk into the NICU and conduct research—or even provide services. The NICU requires specialized knowledge of infant development and the development of swallowing and communication, as well as medical conditions associated with low birth weight or prematurity, Arvedson said.
"We have to demonstrate knowledge and experience to help support these infants and families," Arvedson said. To help define the practice of SLPs in the NICU and identify skills needed to work in this environment, an ASHA ad hoc committee, chaired by Justine Joan Sheppard, is developing a position statement and technical report along with practice guidelines, and knowledge and skill statements (see sidebar above).
"SLPs who are interested in joining the NICU may want to contact other SLPs who have teamed in the NICU who can serve as mentors," Ziev suggested.
The journey to the NICU begins with a foundation in early intervention service delivery, a review of the literature, and completion of coursework that will provide cross-training. SLPs should identify the appropriate contacts within their hospital to obtain permission to observe the NICU as an attendee, and through their department or rehabilitation team, determine the training criteria for their facility, and gain supervised experience.
For Ziev, the hurdles in gaining access to the NICU have been worthwhile. "I especially like the necessity of teaming and hope that we can make a difference from the beginning."
Resources for professionals and parents can be found in The ASHA Leader Online.