Roles and Responsibilities of Speech-Language Pathologists in the Neonatal Intensive Care Unit: Guidelines
Ad Hoc Committee on Speech-Language Pathology Practice in the Neonatal Intensive Care Unit
About this Document
This guideline document is an official statement of the American Speech-Language-Hearing Association (ASHA). The document was prepared by the Ad Hoc Committee on Speech-Language Pathology Practice in the Neonatal Intensive Care Unit (NICU). Members of the committee were: Justine J. Sheppard (Chair), Joan C. Arvedson, Alexandra Heinsen-Combs, Lemmietta G. McNeilly, Susan M. Moore, Meri S. Rosenzweig Ziev, and Diane R. Paul (ex officio). Alex F. Johnson and Celia Hooper served as monitoring officers (vice presidents for speech-language pathology practices, 2000–2002 and 2003–2005, respectively). These guidelines were approved by the Speech-Language Pathology/Speech-Language Science Assembly of ASHA's Legislative Council (LC SLP/SLS 3-2004) on March 27, 2004. The ASHA Scope of Practice (2001) states that the practice of speech-language pathology includes providing services for communication, cognition, feeding, and swallowing problems. The ASHA Preferred Practice Patterns (1997) are statements that define universally applicable characteristics of practice. The guidelines within this document fulfill the need for more specific procedures and protocols for serving infants in the NICU. It is required that individuals who practice independently in the NICU environment and provide services to infants and families hold the Certificate of Clinical Competence in Speech-Language Pathology and abide by the ASHA Code of Ethics (2003), including Principle of Ethics II, Rule B, which states: “Individuals shall engage in only those aspects of the professions that are within the scope of their competence, considering their level of education, training, and experience.”
The ASHA Roles and Responsibilities of Speech-Language Pathologists in the Neonatal Intensive Care Unit (NICU): Guidelines were developed to clarify the roles and responsibilities of speech-language pathologists (SLPs) who provide services in a NICU setting. The guidelines accompany the American Speech-Language-Hearing Association (ASHA) position statement (ASHA, 2004), technical report (ASHA, 2004c), and knowledge and skills statement (ASHA, 2004a), which indicate that SLPs play an important direct role in the NICU setting. A glossary is included at the end of the technical report. Although the documents address specifically the roles and responsibilities of SLPs, they indicate that these roles are implemented in collaboration with others who have expertise in the NICU.
The position statement, technical report, knowledge and skills statement, and the accompanying guidelines were prepared in response to a number of factors, including practical questions from ASHA members about the roles that SLPs play in the NICU. In addition, development of the documents was motivated by the need for: (a) resources for SLPs regarding knowledge and skills to provide communication and feeding/swallowing assessment and intervention for infants in the NICU; (b) strategies to engage in collaborative partnerships among SLPs, families, and other team members to foster communication and feeding/swallowing development and habilitation in infants in the NICU; and (c) information to advocate for an SLP role in the NICU.
The ASHA position regarding an important direct role for SLPs in the NICU is consistent with the ASHA Scope of Practice in Speech-Language Pathology (ASHA, 2001) and Preferred Practice Patterns in Speech-Language Pathology (ASHA, 1997), which include assessment and treatment of communication and feeding/swallowing disorders in persons of all ages. The guidelines and accompanying documents have been written to assist practicing SLPs, academic program faculties, and other educators to add to the existing knowledge and training to support the development and habilitation of communication and feeding/swallowing in the young infant.
The technical report summarizes the literature that establishes the scientific base for the position statement and provides the background for development of the NICU guidelines. The technical report also outlines the professional knowledge base that is needed to prepare SLPs for their unique contributions to the collaborative teams of families and professionals working with infants in the NICU.
Appropriate roles and responsibilities for SLPs are dynamic in relation to the evolving knowledge base and have implications for research, academic, and clinical education. These roles include, but are not limited to:
Communication evaluation and intervention, in the context of developmentally supportive and family-focused care;
Feeding and swallowing evaluation and intervention, to include prefeeding, assessment and promotion of readiness for oral feeding, evaluation of breast and bottle-feeding ability, and completion of instrumental swallowing evaluations;
Parent/caregiver education and counseling; staff (team) education and collaboration, which includes information regarding developmental expectations, communication interaction patterns, and feeding and swallowing behaviors;
Other roles SLPs assume in the NICU including quality control/risk management, discharge/transition planning and follow-up care, professional education and supervision, public education and advocacy, and research.
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These professional practice guidelines are organized into four major sections that encompass the primary roles and responsibilities of speech-language pathologists working in the NICU: (1) communication evaluation and intervention, (2) feeding and swallowing evaluation and intervention, (3) parent/caregiver education and counseling, (4) other roles.
Key principles for performing these roles in the NICU include:
Family-centered care: the “compassionate, open, total inclusion of the family in the care and decision-making process for their baby” (Browne & Smith-Sharp, 1995, p.19). Family-centered care addresses the challenges families may face regarding communication with the hospital staff, environmental and developmental concerns, pain management, ethical decision-making, and follow-up (Harrison, 1993). Parents need information about self-advocacy, child development, their child's condition, financial resources, and service coordination (Billeaud, 1993).
Developmental care: is defined as a broad category of interventions designed to minimize the stress placed on the infant and the family by the NICU environment. As part of a team of parents and professionals, SLPs typically evaluate infants with a focus on promoting successful feeding and caregiver-infant interactions. The SLP facilitates the acquisition of developmentally appropriate communication skills and the underlying competencies that will support its further development. Developmentally supportive care is based on the premise that the infant's behavior provides the best information from which to design care plans (Als, 1982 a, b). This type of care involves observation of the infant to determine useful strategies to support the infant's physiological stability, self-regulation, behavioral organization, and developmental progressions (Als & Gilkerson, 1995). Sharing this information with the caregiving teams and the family is a key component of this approach. In order to provide developmentally supportive care, SLPs and other members of the NICU team need to be conversant in typical infant development.
Culturally appropriate care: SLPs who work in the NICU recognize care that is sensitive to a family's cultural beliefs, values, language, and practices. These cultural factors shape a family's response to information and instruction regarding their infant's care and support, and influence access to medical care and intervention for infants in the NICU. SLPs develop culturally appropriate programs that meet the needs of ethnically and linguistically diverse families. Moreover, as team members SLPs do not make assumptions about the needs of families based on a particular cultural, racial, or ethnic group. Rather, they discuss these needs with the families directly. Interpreters are used when needed to ensure that linguistically diverse families understand the information.
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Speech-language pathologists play important direct and indirect roles in facilitating communication development for infants in the NICU. These SLP roles include:
Communication evaluation and intervention, in the context of developmentally supportive, family-centered, and culturally appropriate care.
Performing developmentally appropriate assessments of prelinguistic and socio-communication interactions, including behavioral neurodevelopmental assessments.
Identifying additional disorders that affect communication and make referrals to other professionals as appropriate.
The first step in a developmental assessment by the SLP is a chart review of history and prior evaluations. The SLP in the NICU uses results of prior events and evaluations to compare with clinical observations and identify patterns of performance and disorders. Developmental expectations for the infant are based on gestation or adjusted age, not chronologic age.
The SLP, as part of the overall evaluation of communication and development, may administer behavioral neurodevelopmental assessments. Administration of these developmental assessments requires additional training and certification. Examples include Naturalistic Observation of Newborn Behavior (Preterm and Fullterm) (Als, 1985), Assessment of Preterm Infant Behavior (Als, Lester, Tronick, & Brazelton, 1982), Neonatal Behavioral Assessment Scale (Brazelton & Nugent, 1995), The Neonatal Neurological Examination (Sheridan-Pereira, Ellison, & Helgeson, 1991), and The Neurological Assessment of the Preterm and Full-Term Newborn Infant (Dubowitz, Dubowitz, & Mercuri, 1999).
Enhancing the infant's developmental outcomes and preventing secondary sequelae by providing specific interventions to facilitate social, interactive communication.
Intervening to enhance communication directly with infants and indirectly through culturally appropriate family and other caregiver education.
In the past 2–3 years, the Cochrane Database Systems Review process has provided literature searches for all potentially relevant titles and abstracts of studies that measured clinically relevant outcomes. Symington and Pinelli (2001) reviewed the literature for randomized trials in which elements of developmental care are compared to routine nursery care for infants. Because of the inclusion of multiple interventions in most studies, the determination of the effect of any single intervention is difficult. Although there is evidence of some overall benefit of developmental care interventions, and no major harmful effects reported, a large number of outcomes had no or conflicting effects demonstrated. The single trials that did show a significant effect of an intervention on a major clinical outcome were based on small subject populations, and the findings were often not supported in other small trials.
Multiple-intervention approaches may include, but are not limited to: (1) vestibular, auditory, visual, and/or tactile intervention; (2) clustering of care activities to provide more prolonged periods for sleep; (3) positioning or swaddling for the preterm infant; and (4) nipple feeding.
Results of 31 studies meeting criteria for randomized trials indicate that a cluster of developmental care interventions demonstrate some benefit to preterm infants with respect to improved short-term growth outcomes, decreased respiratory support, decreased length and cost of hospital stay, and improved neurodevelopmental outcomes to 24 months corrected age. Lack of blinding of assessors was a significant methodological flaw in half of the studies. Reviewers concluded that before a clear direction for practice can be supported, evidence demonstrating more consistent effects of developmental care interventions on important short- and long-term clinical outcomes, is needed. In long-term follow-up, developmental care did not alter sleep or neurodevelopmental outcome for preterm infants up to 2 years of age. Developmental care practices with infants need to be examined carefully to determine what goals may be realistic for parents who will be following through upon discharge from the hospital.
Supplemental Stimulation. The seminal work of Gottlieb (1971) proposes a sequential development of sensory systems essentially invariant across mammalian and avian species: cutaneous/tactile, vestibular, auditory, and visual. Unvas-Moberg, Widstrom, Marchini, and Windberg (1987) hypothesized that sucking enhances gastrointestinal (GI) functioning through activation of sensory nerves in the oral mucosa that stimulate the vagal nerves. Tactile stimulation is thought to affect vagal mediation via the direct stimulation of peripheral nerves such as the sciatic.
Research studies have addressed the effects of vestibular, auditory, and tactile/kinesthetic stimulation on state regulation:
Vestibular stimulation (VS). Korner (1990) found VS to reduce state level in term and preterm infants. VS reduced the intensity of internal needs (e.g., crying or state disorganization) and permitted the infant to attend to external events through promotion of quiet alertness.
Auditory stimulation (AS). Although not studied extensively, AS may enhance environmental adaptation (Korner, 1990). Similarities between auditory and vestibular stimulation may be in rhythmic patterning.
Tactile/Kinesthetic stimulation (T/KS). Tactile (rubbing/stroking) and kinesthetic (passive flexing and extending limbs) stimulation administered sequentially has been described (White & Labarba, 1976). Limited evidence without formal state analysis shows that benefits obtained from tactile intervention involve heightened alertness and increased activity. T/KS can be administered to preterm infants as young as 23 weeks gestational ages and birth weights as low as 630g as long as they are clinically stable (Acolet et al., 1993). Weight gain may be enhanced. Massage has been shown to reduce plasma cortisol levels.
Prescription for stimulation of preterm infants. Dieter and Emory (1997) describe a sequential, multimodal stimulation approach that is not contingent on the infant having reached a clinically stable state. The suggested goals include:
Promoting state regulation
Facilitating interface with environment
Enhancing general neurobehavioral development.
The early stages of treatment are aimed at assisting infants to achieve these goals. Once the infants tolerate increased alertness, T/KS can be initiated to promote weight gain. The inherent therapeutic quality of touch may be a factor. Dieter and Emory are continuing their research to compare vestibular and tactile/kinesthetic stimulation on preterm infants.
There appears to be little current agreement among investigators pertaining to the value of general sensory stimulation using these modalities. Horowitz (1990) suggests that the type of stimulation may be less important than whether it promotes state regulation. Unimodality approaches have been recommended to avoid overstimulation because preterm infants lack multimodality contingencies (Lester & Tronick, 1990). Korner (1990) argues that the best approach may be one that avoids over-stimulation of visual and auditory systems and focuses instead upon more mature systems, such as tactile and vestibular.
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Evidence-based studies of general outcomes for NICU graduates have examined the effects of the NICU experience with regard to satisfaction of sleep needs, pain, noise, lighting, infant massage, parental coping, and early language acquisition:
Measures of sleep maturation and neuro-developmental outcome in infants up to two years of age did not differ between groups of infants who experienced Newborn Individualized Developmental Care and Assessment Program (NIDCAP) intervention with less disruption of sleep patterns compared to those that experienced routine infant care.
Stevens and colleagues (1999) studied the effectiveness of developmentally sensitive interventions and sucrose for relieving procedural pain in very low birth weight (VLBW) neonates. The pacifier with sucrose and pacifier with sterile water were more effective for reducing pain from single painful events (Stevens et al., 1999). Prone positioning did not decrease pain.
Levels of pain experienced by preterm and term infants are of concern since pain causes stress in infants which may in turn adversely affect long-term neurodevelopmental outcomes (Whitfield & Grunau, 2000). However, there are no good measures of pain in infants that can be used clinically. Whitfield and Grunau (2000), who reviewed a number of studies, do not believe that long-term negative outcomes will result from repeated procedure-based pain. However, prolonged and repeated untreated pain in the newborn period may produce a relatively permanent shift in basal autonomic arousal related to prior NICU pain experience. This shift may have long-term sequelae. The most significant effect may be on later attention, learning, and behavior problems in these vulnerable children.
Low Birth Weight (LBW) infants are at increased risk for language and communication problems. However, there have been a limited number of studies of the causes for language delay this early in life (Lacerda, 2001; Yliherva, Olsen, Maki-Torkko, Koiranen, & Jarvelin, 2001). A cohort of 284, 6.5-year-old children who required neonatal intensive care (NIC) were compared for speech and language skills with 40 controls. Scores lower than the 10th percentile were more common in NIC groups who were born at term or at 23–31 weeks, than in those born at 32–36 weeks gestational age. Most severely affected were linguistic areas of auditory discrimination, imitation of articulatory positions, and imitation of sentences. NIC children born at 32–36 weeks performed better in the last two areas than those born at <32 weeks. Twinning with birth at 28–31 weeks was associated with increased risk of scoring below the 10th percentile and of scoring below the 10th percentile on more language-related measures (Sedin, 1999).
Numerous reports indicate that preterm delivery and VLBW are associated with substantial developmental impairment. Initial difficulties include problems with autonomic control, state organization, and attention regulation (Als, 1986). More long standing problems include auditory and visual deficits and delays in cross-modal transformations (Rose, Gottfried, & Bridger, 1978); abnormal reflexes (Howard, Parmelee, Kopp, & Littman, 1976); inferior grasping and hand use; lower IQ, language and reading difficulties, academic underachievement (Cohen, Parmelee, Beckwith, & Sigman, 1986); and behavioral problems such as hyperactivity and internalizing disorders (Rose, Feldman, Rose, Wallace, & McCarton, 1992).
In summary, SLPs need to be aware of the evidence base for practice in the NICU. Treatment and outcome studies provide the foundation for research and clinical practice with infants, caregivers, and other professionals.
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2. Feeding and swallowing evaluation and intervention, to include prefeeding, assessment and promotion of readiness for oral feeding, evaluation of breast and bottle feeding ability, and completion of instrumental swallowing evaluations.
Performing developmentally appropriate clinical assessments of feeding and swallowing behavior.
Diagnosing suckling/swallowing disorders and determining the abnormal anatomy and physiology associated with these disorders.
Identifying additional disorders that impact feeding and swallowing and making refer rals to other professionals as appropriate.
An SLP's standard pediatric clinical examination consists of history, physical examination including developmental assessment, and observation of nonnutritive and nutritive sucking and swallowing as developmentally and functionally appropriate. The SLP considers parental, nursing, and other medical team input to determine infant readiness for oral feeding.
Breast-feeding: There are few standardized assessments available for evaluating potential breast-feeding in the NICU. These assessments include Systematic Assessment of the Infant at Breast (SAIB) (Association of Women's Health, Obstetric, and Neonatal Nurses, 1990), and Preterm Infant Breast-feeding Behavior Scale (PIBBS) (Nyqvist, Rubertsson, Ewald, & Sjoden, 1996). SLPs collaborate with mothers, nurses, and lactation consultants for differential diagnosis of maternal and infant issues and parent preferences for feeding modalities.
The SAIB incorporates specific observations in the categories of alignment, areolar grasp, areolar compression, and audible swallowing. The PIBBS form is formatted as a diary to be kept by the mother. Notation categories include rooting, amount of breast in the infant's mouth, latching, sucking, sucking bursts, swallowing, state, letdown, and time at the breast. Inter-rater reliability between mothers and nurses for this assessment is an area requiring further development.
For the full-term infant in the NICU, the Breastfeeding Evaluation (Tobin, 1996) may be used as a guide. This tool contains a list of expectations for feedings including infant's position, latch, suck, intake, and weight gain. In addition, maternal flow rate and output are considered. The purpose of the Breastfeeding Evaluations is to determine when a mother would benefit from lactation support.
Bottle-Feeding: The SLP may use the Neonatal Oral Motor Assessment Scale (NOMAS; Palmer, Crawley, & Blanco, 1993) to assess bottle-feeding of the preterm infant. The NOMAS describes suckling behaviors in categories of normal, disorganized, and dysfunctional tongue and jaw movement. The Feeding Flow Sheet (Vandenberg, 1990a) is used to document feeding observations for state, respiratory rate, heart rate, nipple type, form of nutrition, infant position, suck/swallow/breathe coordination, support strategies, quantity of intake, and duration changes over time. The Infant Feeding Evaluation (Swigert, 1998) offers a means of documenting a variety of observations, including infant response to attempted interventions. This evaluation was devised for use from birth to 4 months, without specifying components for the preterm or ill infant. This tool is not standardized.
Initiation of oral feeding: There is little consistency across or within most facilities regarding an infant's readiness for the first feeding. In some NICUs, when an infant is determined to be ready for a trial oral feeding the infant is put to the mother's breast. In other NICUs, the infant must demonstrate the ability to bottle-feed safely before being allowed to breast-feed. In NICUs that allow breast-feeding initially, the infant is weighed before and after the feeding with a gram-sensitive scale to measure intake.
Research using the PIBBS supports observations of a developmental progression of sucking patterns and state control in the preterm population (Nyqvist et al., 1996). Feeding performance improves as infants' sucking skills mature. Sucking scales may be used to assess the developmental stages of sucking in preterm infants, and in turn, facilitate the management of oral feeding in these infants (Lau, Alagugurusamy, Schanler, Smith, & Shulman, 2000). Levels of maturation of sucking patterns may be described using the NOMAS (immature, transitional, and mature) (Palmer, Crawley, & Blanco, 1993) and the five developmental stages of sucking per Lau and colleagues (2000).
Instrumental methods for evaluating swallowing function include, but are not limited to, videofluroscopic swallow study (VFSS), endoscopic assessment of swallowing function, and ultrasonography (US) (ASHA, 2002a,b,c). The instrumental examination should answer specific diagnostic questions and guide management decisions. Instrumental assessments performed by other professionals will aid in formulating the SLP's recommendations. These assessments that include scintigraphy/radionuclide milk scanning differentiate aspiration that results from swallowing as opposed to gastroesophageal reflux. In addition, scintigraphy yields an estimate of gastric emptying time (Latini et al., 1999; McVeagh, Howman-Giles, & Kemp, 1987; Tolia, Kuhns, & Kauffman, 1993).
Protocols for performing and interpreting VFSS, endoscopic assessments, and US need to be developmentally appropriate and should consider homeostasis and respiratory status of the infant, gestational age, positioning, bolus presentation, viscosity of bolus, and swallowing variability. VFSS allows for simultaneous visualization of oral, pharyngeal, and upper esophageal swallowing. Fiberoptic nasopharyngolaryngoscopy, frequently used with infants to examine the anatomy and physiology of the upper aerodigestive tract, may incorporate a swallowing component via Fiberoptic Endoscopic Evaluation of Swallowing (FEES) and may include sensory testing (Hartnick, Hartley, Miller, & Willging, 2000). US has been used to study suckling and oral transit in breastfed and bottle-fed infants (Bosma, 1986; Bu'Lock, Woolridge, & Baum, 1990; Weber, Woolridge, & Baum, 1986; Yang, Loveday, Metrewell, & Sullivan, 1997). US provides capabilities for observations of the natural feeding process in a natural environment. Infants are examined by instrumental assessment when they are physiologically stable and when the clinical findings or history and when aspects of swallowing physiology, that cannot be determined by clinical observation, need to be defined in order to guide management decisions.
Infants in the NICU are often on cardiac, respiratory, and oxygen saturation monitors throughout their NICU stay. During instrumental assessment of swallowing, these monitors along with observations of the infant aid in determining physiologic and behavioral condition. Observations include color changes, nasal flaring, and suckling/swallowing/breathing patterns. Cervical auscultation may be used as an adjunct to behavioral observations that may assist in noting breath sounds and estimating the timing of swallowing. It may be useful as part of a complex of clinical observations to determine readiness of infants to initiate oral feeding and to transition to full oral feeding. However, procedures for its use have not been standardized.
This section will cover (1) outcomes with feeding-focused interventions, (2) effects of nasogastric tubes in VLBW infants, and (3) examples of outcomes with specific etiologies.
Outcomes with feeding-focused interventions. Bier and colleagues (1993) studied readiness for breast- versus bottle-feeding. They concluded that (1) VLBW infants can safely breast- and bottle-feed at the same postnatal age, (2) VLBW infants are less likely to have oxygen desaturation to less than 90% during breastfeeding than during bottle-feeding, and (3) weight gain is less during breast-feeding. They hypothesized that reduced weight gain was associated with lower intake, and concluded that breast-feeding may require more lactation counseling or supplementation of the feeding. In contrast, Lemons and Lemons (1996) found that the earliest an infant can initiate breast-feeding is at 32 weeks gestation, with bottle-feeding starting at 34 weeks gestation. Considerable variability is found among individual infants. It is likely that the readiness relates only in part to postnatal age, with other factors, such as airway, GI tract, neurologic status, and environmental variables, being more prominent. These multiple factors are likely to determine when the developmental feeding assessment is done, and whether intervention by the SLP is needed. If the assessment indicates that clinical intervention is not indicated, basic nursing, parent preparation of an infant, and watchful waiting for feeding readiness will continue.
Readiness. Readiness for oral feeding in the preterm infant is associated with the infant's ability to achieve and maintain awake states, to coordinate breathing with sucking and swallowing (McCain, 1997) and the presence of apnea (Mandich, Ritchie, & Mullett, 1996). Apnea is strongly correlated with longer transition time to full oral feeding. Discussions of readiness for oral feeding may include the role of kangaroo mother care (KMC) (i.e., skin-to-skin contact between a mother and her newborn infant) and nonnutritive sucking (NNS).
Kangaroo mother care (KMC). KMC has been found to be an important factor in LBW infants achieving readiness for oral feeding, particularly breast-feeding, and earlier discharge from the hospital. A randomized controlled trial on 488 infants (246 in the KMC group, 242 in traditional care [TC]) supported the hypothesis that skin-to-skin contact elicited a positive perception in the mothers and readiness to detect and respond to infant cues (Tessier et al., 1998). The authors recommended that KMC should be initiated as soon as possible during the intensive care period up to 40 weeks gestational age. KMC was well tolerated by 20 sick, “very preterm” infants (median gestational age 28 weeks, birth weight 1,238 g), in the first week of life (Tornhage, Stuge, Lindberg, & Serenius, 1999). On the other hand, Conde-Agudelo and colleagues (2000) reviewed multiple studies and concluded that there is insufficient evidence to recommend the routine use of KMC in LBW infants, even though it appears to reduce severe infant morbidity and has no serious deleterious effects.
Nonnutritive sucking (NNS) facilitation. The ability to nipple feed is preceded by rhythmic NNS accompanied by even respirations and swallowing of secretions (Lemons & Lemons, 1996). These capabilities are observed when the infant is roused to an alert state and positioned with head in mid-line—a posture that facilitate swallowing. Multiple studies have revealed the usefulness and cost-effectiveness of oral stimulation using NNS via a pacifier. Findings that support NNS in preterm infants include, but are not limited to:
NNS at the empty breast promotes infant state control, weight gain, breast-feeding ability, and milk production in the mother (Narayanan, Mehta, Choudhury, & Jain, 1991).
Oxygen saturation during nutritive suckling was higher with prefeeding NNS than without prefeeding NNS. Significant differences were found in oxygen saturation and behavioral state after NNS and at the start of oral feeding. With prefeeding NNS, the initiation of the first nutritive suck burst was more rapid and of longer duration. No significant differences were found in total feeding time or percent of formula taken by bottle (Pickler, Frankel, Walsh, & Thompson, 1996).
Increased restfulness and decreased activity were associated with NNS (e.g., Field et al., 1982).
Significant changes in heart rate, vagal tone, respiration, and gustatory functioning were seen (Crook & Lipsitt, 1976; Lipsitt, Reilly, Butcher, & Greenwood, 1976; Porges & Lipsitt, 1993).
There were shorter transitions from tube to full oral feeding (Gaebler & Hanzlik, 1996; Measel & Anderson, 1979).
There was more rapid maturation of the suckle reflex (Bernbaum, Pereira, Watkins, & Peckham, 1983).
There was increased oxygenation saturation (Burroughs, Asonye, Anderson-Shanklin, & Vidyasager, 1978).
There was more rapid weight gain (Field et al., 1982).
There was a soothing effect of NNS on preterm infants during invasive procedures (Field & Goldson, 1984) as with music (Butt & Kisilevsky, 2000).
NNS improved state regulation (Gill, Behnke, Conlon, McNeely, & Anderson, 1988) or resulted in fewer behavioral state changes (McCain, 1995).
Hospital stay was shortened for infants engaging in NNS (Gaebler & Hanzlik, 1996).
Similar NNS and nutritive sucking (NS) patterns in bottle-feeding have been observed (Lau & Hurst, 1999). However, no information is available on whether development of NNS parallels that of NS (Lau & Kusnierczyk, 2001), and use of NNS as a potential indicator of readiness to feed orally is questionable (Lau & Schanler, 1996). Additional research is needed.
Oral stimulation combined with other modalities. Evidence across studies supports the use of auditory, tactile, visual, and vestibular intervention that includes oral and facial stimulation. These combined interventions appear to produce positive effects on improved alertness in the first five minutes of intervention, feeding progression in preterm infants (McCain, Gartside, Breenberg, & Lott, 2001), reduced length of hospital stay (Field 1980, 1988; White-Traut et al., 2002), decreased apnea, more stable organization of state, increased weight gain, decreased abnormal reflexes, and superior sensory and motor performance on behavioral assessments.
Transition to breast/bottle feedings. A survey of NICUs in the United States revealed that fewer than 50% of respondents had identified specific criteria and had established a policy for initiation of oral feedings (Siddell & Froman, 1994). Notwithstanding, there was an emerging consensus for using infant behavioral cues, gestational age, and weight criteria to make feeding decisions. To date, no clearly defined profile of neonate behavior predictive of success at oral feeding (either breast or bottle) predominates in clinical practice.
A review of literature by Lemons and Lemons (1996) resulted in practical guidelines for facilitating the transition from gavage (tube) feeding to breast- or bottle-feeding. These guidelines were based on the studies of neurobehavioral development in preterm infants (Als, 1986). The guidelines suggest that 32 weeks gestation is the earliest an infant would be expected to have some limited ability to suckle and swallow for oral feeding. Infants who are gavage fed and who show little or no reaction to placement of an orogastric (OG) or nasogastric (NG) tube are not current candidates for nipple feedings (Medoff-Cooper, 1991). Infants less that 2 kg generally tolerate OG tube placement better than NG tube placement. The preterm infant has limited ability to integrate the suckle-swallow-breathe cycle during feeding which may impede their ability to protect the airway adequately. Preterm infants generally have limited ability to change suckling pressures in response to flow rate through the nipple unit. This may lead to nasopharyngeal reflux.
Some evidence suggests preterm infants may be better adapted to early breast-feeding than previously thought (Meier, 1988; 1990). Stable 32-week gestation infants can be put to the breast safely for early feeding experiences, while they may not be ready for bottle-feeding until about 34 weeks gestation. Many difficulties in the transition relate to limited ability to control the flow rate (Mathew, 1991). Feeding strategies have been developed to minimize the work of suckling in the erroneous belief that preterm infants have a weak suckle and need high flow rate delivery systems (Mathew, 1991). Suckling pressures in general are not reliable predictors of the ability to feed orally (Bu'Lock et al., 1990). It is important to avoid fast flow nipples (e.g., “preemie” nipples and “orthodontic” nipples) (Vandenberg, 1990b). Considerable variation in flow rates has been noted among the same nipple types from the same manufacturer. Some authors recommend avoiding fast flow nipples, or at least using caution during weaning from OG or NG tube feedings to nipple feedings. Close attention needs to be paid to the infant's behavioral cues and physiologic signs when testing infants for the appropriate nipples or other nursing equipment. If a nipple is such that flow is initiated without active suckling, the infant is unprepared for timely initiation of swallowing (Lemons & Lemons, 1996).
Alternatively, Schrank and colleagues (1998) found that the free-flow of formula from the nipple is an effective stimulus for feeding activity in both preterm and term infants and is not associated with increased apnea or other adverse behaviors. They found that preterm infants could divert excess formula flow by drooling as an efficient airway protective behavior. They hypothesized that reduced maximum suckle and swallow frequency may be a primary basis for slow feeding in preterm infants.
Another technique that has been found to mitigate difficulties with nipple feeding is cheek and jaw support. This technique enhances suckling efficiency in preterm infants (Einarrson-Backes, Deitz, Price, Glass, & Hays, 1994), fosters return of infants' prefeeding oxygen saturation values, and does not interfere with cardiopulmonary function during feeding (Hill, Kurkowski, & Garcia, 2000). Further research is needed to determine whether there is a cumulative beneficial effect of oral support and whether it influences state behavior.
Breast-feeding preterm infants. The logistics are complex for transitioning preterm infants in the NICU to breast-feeding as the mother is not present for all feedings. Use of various alternatives to the breast when the mother is not present has been studied with mixed results: (a) use of cup instead of bottle nipple reduced “nipple confusion,” and allowed successful breastfeeding (Gupta, Khanna, & Chattree, 1999); (b) cup-feeding had questionable efficacy and efficiency and there was considerable spillage (Dowling, Meier, DiFiore, Blatz, & Martin, 2002); (c) NG tube supplements were more likely to result in breast-feeding at discharge and for the first 6 months than bottle supplements (Kliethermes, Cross, Lanese, Johnson, & Simon, 1999); (d) an orthodontic nipple may be appropriate for supplementing breast-feeding for some preterm infants, although there is limited evidence and lack of long-term outcomes (Dowling, 1999); and (e) nipple shield was found to be a useful means to facilitate breastfeeding in preterm infants (Clum & Primomo, 1996; Meier et al., 2000) while others have noted drawbacks (e.g., Auerbach & Riordan, 1999). Bell and colleagues (1995) described a structured intervention to improve breast-feeding success in ill or preterm infants.
A structured intervention was devised at the University of Iowa Hospital, for assessing readiness and progress toward breast-feeding all feedings, using the SAIB (Bell, Geyer, & Jones, 1995). After one year of implementation, successful breast-feeding of NICU infants at discharge was doubled, from 40% of mothers who were interested, to 80% (Bell, Geyer, & Jones, 1995).
Overall, mothers of preterm infants find that the rewards of breast-feeding outweigh the efforts (Kavanaugh, Meier, Zimmermann, & Mead, 1997). Benefits of breast-feeding include, but are not limited to, protection against a variety of bacterial and viral infections (e.g., May, 1984), reduced incidence of necrotizing enterocolitis (e.g., Lucas & Cole, 1990), and reduced incidence of otitis media in the first year of life (e.g., Duffy, Faden, Wasielewski, Wolf, & Drystofik, 1997).
Effects of nasogastric tubes in VLBW infants. Although NG tube feeding may be a necessary means to compensate for deficient suckling and swallowing, those infants who experience this modality are reported to have some negative responses.
There is a longer transition period from tube feedings to oral feedings (Shiao, Brooker, & DiFiore, 1996).
During oral feeding there is increased duration of desaturation by an average of 8 seconds, with less forceful sucking and less formula consumed (Shiao, Youngblut, Anderson, DiFiore, & Martin, 1995).
Oxygen saturation before, during, and after feedings is significantly lower than in infants managed with OG tubes (Daga, Lunkad, Daga, & Ahuja, 1999).
Decreased nasal airflow, increased airway resistance, and abnormal airflow distribution is seen in infants with NG tubes in place (Symington, Ballantyne, Pinelli, & Stevens, 1995).
Management with intermittent NG tube insertion is problematic. Insertion stimulates the larynx. Laryngospasm, apnea, and bradycardia are more likely; pharyngeal and esophageal trauma are possible (Symington et al., 1995).
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Problematic outcomes have been reported for infants with certain etiologies (Lindower, Atherton, & Kotagal, 1999). The study populations include term newborns admitted to NICU with asphyxia at birth and low Apgar scores (Asakura et al., 2000), infants with newborn encephalopathy (Dixon et al., 2002), and infants with major congenital malformations (one of the largest and costliest groups referred to the NICU).
Infants with severe respiratory complications experience an increased length of time to reach full enteral feedings and poorer cognitive outcomes at 24 months corrected age (Morris et al., 1999). Preterm infants with bronchopulmonary dysplasia (BPD) and delay in attainment of stable suckle and swallow rhythms are predisposed to subsequent feeding problems and may be neurologically impaired (Gewolb, Bosma, Taciak, & Vice, 2001; Hawdon, Beauregard, Slattery, & Kennedy, 2000).
Evidence-based oral feeding focused intervention. Knowledge of the normal ontogeny of the rhythms of suck and swallow may enable us to differentiate immature (but normal) feeding patterns in preterm infants from abnormal patterns (Gewolb, Vice, Schwietzer-Kenney, Taciak, & Bosma, 2001). This differentiation would aid in selecting appropriate intervention measures. Quantitative assessments of the stability of suckle and swallow rhythms in preterm infants might predict subsequent feeding dysfunction as well as neurologic impairment.
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3. Parent/caregiver education and counseling, staff (team) education and collaboration, which includes information regarding developmental expectations, communication interaction patterns, and feeding and swallowing behaviors.
Contributing to the NICU team's developmental care plan with a focus on communication and feeding/swallowing.
Contributing to a supportive and nurturing environment in the NICU to enhance development and prevent sequelae.
The team of specialists that follows infants and their families and provides information and education includes medical specialists, SLPs, and other allied health professionals. A parent-focused intervention program (COPE) has been shown to be effective in improved infant mental development scores at 3 months' corrected age, and an even wider gap at 6 months' corrected age than with comparison infants (Melnyk et al., 2001). Other strategies have been found to be effective. These include early discharge that supports formation of parent-infant attachment (Schmidt & Levine, 1990); use of massage as complementary therapy in the NICU resulting in short-term improvement in the transition from touch aversion to touch acceptance (Lindrea & Stainton, 2000).
NICUs also may offer parent resource consultants and access to parent-to-parent networks that provide information and support. These networks often are organized by NICU staff, who in turn help to facilitate contacts with other parents when appropriate.
Families often experience limited opportunities or delayed access to interact and communicate with their infants in the NICU because of medical conditions, geographical locations (e.g., infant in regional center and family at home), family obligations to other children, work patterns, and/or family crisis. In implementing the principles of family-centered, culturally appropriate care, SLPs and other NICU team members work with families of infants to provide parent education for feeding and care protocols, to inform parents regarding their infant's gestural and vocal communication patterns, and to demonstrate developmentally supportive practices that support infant self-regulation and the ongoing development of communication skills. They also may assist in preparing families for the transition out of the NICU.
Counseling and support. Moses (1983) and others suggest that families need environments and opportunities for interaction in which they can express their feelings openly in a nonjudgmental arena and discuss plans for managing situations with one or more of the NICU staff (Griffin, 2001; Smith & Hart, 1994). These services are most effective when provided in a manner that is sensitive to the individual cultural and personal perspectives of the family.
Family participation. The importance of including the family of the infant in developmentally based interventions is emphasized by Parker, Zahr, Cole, and Brecht (1992). Their findings suggest that teaching assessment and interaction strategies based on infant-initiated cues to mothers resulted in more positive outcomes when compared to a comparison group who did not receive training and education. Results of a nine year longitudinal study of infants (Achenbach, Howell, Aoki, & Rauh, 1993) whose mothers participated in a NICU and follow-up training program indicated that the children of these mothers scored higher on measures of mental ability and had advanced more rapidly in school than children whose mothers did not receive the training. SLPs and other team members facilitate parental involvement in all aspects of the infant's care in the NICU, thus empowering them in their caregiving role. They assist the families in understanding the etiology of the presenting condition, acquiring specific strategies to facilitate growth and learning development, methods and procedures for feeding and for positioning, handling the infant during feedings, and related family concerns.
Equipment. Monitoring equipment is integral to the NICU environment. Families benefit from education that enhances their ability to use this equipment to assist them in understanding their child's behaviors and responses. Education on how and why the various monitoring devices are used will reduce the parents' fear of harming their medically fragile infants. This also leads to understanding the use and advantages of any adaptive equipment that is needed following discharge to optimize the child's feeding, growth, and development.
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Educating and training staff for the NICU environment. A survey conducted of SLPs working in NICU environments conducted by Dunn, van Kleeck, and Rossetti (1993) supports the need for formalized education at the preservice and continuing education levels.
SLPs require specialized training for team collaboration in the NICU and for direct patient care. Comprehensive education is needed for accessing the rapidly expanding knowledge base and for responding to the complex needs of infants and family members. It is assumed that preparation for this advanced practice role for the SLP, as for other disciplines represented on the NICU team, must go beyond entry-level disciplinary practice (Browne, Vandenberg, Ross, & Elmore, 1999).
The SLP in the NICU should bring to the team knowledge and skills regarding the nature of normal and abnormal communication interactions; development of feeding, swallowing, and vocal behaviors; prenatal to postnatal continuities in audition; cognitive development, swallowing, and regulatory functions; and other related aspects of infant development. Specialized training is needed in the areas of synactive theory of development (Als, 1982b; Als, 1986), neonatal neuroanatomy, anatomy, physiology, brain development, neuromotor and fetal reflex development, and developmental acquisition of infant motor behaviors, including the influence of muscle tone, oral sensory and motor experiences, and sensory processing. Knowledge and skills for the SLP include instrumental evaluation of infant swallowing and clinical evaluations that examine underlying competencies in reflexive and voluntary movements, respiratory control, and integrity of structures as well as functional competencies for feeding and vocal behaviors (ASHA, 2002a, b, c; ASHA, 2003). Knowledge and skills that are needed for patient management include procedures that are specific to the NICU environment for assessment and intervention in the domains of communication, vocal behaviors, audition, feeding and swallowing behaviors, cognition, and other oral sensory-motor behaviors (ASHA, 2004a). Training in infant-family bonding, infant caregiving relationships, and the psychology of illness and its impact on the family experience should be supplemented with clinical experience with infants and families. The SLP must be educated in the various aspects of the NICU milieu, including personnel, team process, equipment, and infection control. Finally, the SLP should be trained for implementation of intake, discharge, and follow-up.
Given the extensive body of knowledge, the wide-ranging and specialized skills that are needed for SLP practice in the NICU and the rapidly advancing information and practices in this environment, the need for advanced level training and continuing education is clearly apparent.
The specific knowledge and skills needed by many SLPs providing developmental care in the NICU has been reported in the literature or presented at ASHA conventions (ASHA, 1990). The recent ASHA Task Force on Dysphagia developed a position statement and technical report and outlined specific knowledge and skills needed in the areas of swallowing and feeding (ASHA, 2002 a, b, c).
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An expanded evidence base that supports SLP practice in the NICU is needed. Basic and applied research needs are apparent in those domains for which the SLP is arguably the most qualified provider—suckling, swallowing, communication, cognition, oral sensory-motor function, vocal behavior, and prevention and correction of suckling, swallowing, prespeech and vocal behaviors, and receptive and expressive language deficiencies. To this end research needs include normal and abnormal fetal and neonatal development, assessment, intervention, primary and secondary prevention, and family, cultural, and social dynamics that influence acquisition of infant behaviors and skills. It is reasonable to anticipate that additional intervention studies may provide an adequate level of evidence to support specific interventions and intervention programs.
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These guidelines assert that SLPs have the necessary expertise and the responsibility to play important roles in the NICU. The roles and responsibilities vary with the characteristics and needs of the infants and families being served and with the experiences of the professionals involved. SLPs have appropriate roles related to all aspects of professional activity, including communication evaluation and intervention; feeding and swallowing evaluation and intervention; parent/caregiver education and counseling; staff (team) education and collaboration; and other roles, including quality control/risk management, discharge/transition planning and follow-up care, professional education and supervision, and public education and advocacy. Responsibilities include using practices that are research-based; family-centered; culturally, linguistically, and developmentally appropriate; and collaborative. Practicing professionals, university professors, and the new generation of practitioners bear responsibility for increasing their own knowledge and disseminating information concerning roles of SLPs in the NICU.
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