Shaker ASHA Sphere Blog: 5 Things You
Need to Know About Working in the
Neonatal Intensive Care Unit
June 2, 2015 by Catherine Shaker, MS/CCC-SLP, BCS-S
If you answered yes to any of the questions in my first post about wanting to work with acute care infants, then read this follow-up!
- The NICU is an intensive care unit: Infants in the NICU are critically ill or were in the recent past. These most fragile patients can become physiologically unstable at any time—and it might happen during your therapy. The emotional roller coaster of NICU leaves families fragile, too.
- It’s not easy to practice in the NICU environment: Quick and constant losses and triumphs cause emotions to run high. An infant’s status can change at any time. Caregivers are highly skilled and passionate, which sometimes leads to strong opinions and respectful disagreements. The SLP needs to thoughtfully collaborate, yet at times take a stand.
- The NICU SLP requires advanced practice skills: It’s not just knowing what to do, but what not to do. We often support feeding/swallowing, so the risk for compromising an infant’s airway is significant. Essential skills include solid critical reflective thinking, the ability to complete a differential, and broad, multi-system knowledge about preterm development and swallowing/feeding. Your preparation should include solid experience with the birth-to-3 patients, as well as continuing education, mentorship and guided participation with many infants in both the newborn nursery and the NICU. The NICU is too demanding to be an initial independent placement after graduate school.
- The NICU evidence base is rapidly evolving: Read, read, read as much professional neonatal literature as possible. Sources are not just within our field but also in medical, nursing and OT/PT journals. Our role is not only to understand the evidence base, but to bring it to the NICU team. Neonatologists and neonatal nurses will ask “why?” and we must be able to discuss the research-based evidence along with our clinical wisdom: For example, if you recommend changing from “volume-driven” to “infant-guided” feeding.
- The NICU is rewarding: After almost 30 years working full time in the NICU, not a day goes by that I don’t learn something, make a difference in an infant’s life or experience the joy of a grateful “thank you!” from a family. The appreciation from nurses and neonatologists when an infant can now feed safely and, therefore, go home, makes your day. With such rewards, however, comes great responsibility. In our hands lies the potential to influence parent-infant relationships through positive neuro-protective feeding experiences that wire the brain toward feeding and build future connections.
If you are thinking about moving into NICU practice, you will find lots of information on my website. Stay tuned for more tips to guide your journey!
Catherine S. Shaker, MS, CCC-SLP, BCS-S, works in acute care/inpatient pediatrics at Florida Hospital for Children in Orlando. She specializes in NICU services and has published in this practice area. She offers seminars on a variety of neonatal/pediatric swallowing/feeding topics across the country. Follow her at http://www.Shaker4SwallowingandFeeding.com or email her at firstname.lastname@example.org.
I am an official blogger for ASHA regarding infant feeding and swallowing and acute care pediatrics. Follow me there too!
Message from Sue Ludwig, OTR, President – NANT
Inaugural Recipients of the Pioneer in Neonatal Therapy Award
Betty Hutchon, Lourdes Garcia Tormos, Kara Ann Waitzman, Lynn Wolf, John Chappel,
Chrysty Sturdivant, Robin Glass, Rosemarie Bigsby, Jane Sweeney, and Cathie Smith.
(Recipients not pictured: Elsie Vergara, Catherine Shaker and Jan Hunter)
The above recipients have worked for decades to advance our presence and purpose in the NICU and have contributed immensely to educating us all. It was past time to honor them.
You may be tempted to believe that they ‘have arrived’, that they are finished learning, that they no longer understand what it’s like to be you, your first year or 10th year in the NICU, trying to wrap your brain around all the knowledge you need to work there.
What you may not know is that these pioneers fully understand how much there is to learn. They stood on that stage at the NANT (National Association of Neonatal Therapists) Conference BECAUSE they never stopped learning and they never once assumed they had arrived. They have elevated the experience for patients and families (and for all of us) for decades. It is only because of their trailblazing efforts that NANT was a conceivable notion for me.
Once they were all present on stage, I turned and saw them smiling broadly ear to ear, truly grateful to be in each other’s presence. Funny thing was, I thought to myself, “Wow, this group is a reflection of the bookshelf in my office.” Articles, notes, books with many dog-eared pages, presentations – they have truly led the way for decades.
Pioneers: we cannot thank you enough for your dedication – fierce and enduring – to the babies and families we serve, and to the thousands of neonatal therapists all over the world for whom you have forged a path. Your immense contributions are deeply appreciated.
*For the sake of disclosure- just know that the Pioneers (both nominated and awarded) were submitted by a global international audience and chosen by NANT members. I nominated no one – the results are due to your input and enthusiasm in submitting your support for each pioneer.
An NICU SLP recently asked about resources for training neonatal nurses on feeding stress cues and stop signs. An SLP I know from Minnesota, Wendy, suggested the SLP take a look at the EFS. I responded to the post and share it with you here since it will let you now what you will hear about at our September 18-19 EFS training seminar in Hollywood, FL this year!
Thank you for your kind comments about The Early Feeding Skills Assessment Tool (EFS). It has evolved over the years as a wonderful guide to cue-based feeding in the NICU. I especially am proud of it because it looks at feeding from the infant’s perspective and is grounded in physiology. It reflects how I conceptualize feeding in the NICU, which I refer to as “infant-guided”, i.e., a dynamic approach based on contingent co-regulation between infant and caregiver. That maybe a parent/family member, a nurse, or a therapist.
A little background for list serve readers. Both working in NICUs at the time, Dr. Suzanne Thoyre and I first collaborated in the early 1980s about infant feeding in the NICU and how to describe infant’s feeding skills. When Dr. Thoyre, as a part of her NICU research, wanted to teach mothers how to describe their infant’s feeding problems during phone follow-up post-NICU discharge, the EFS began to take shape. After using the EFS for years and working with each other to continue to improve it, we published it and began to share it with others in 2005. With multiple revisions, as research and our learning continues, it is now used in several NICUs across the US, both by nurses and SLPs as they assess infant feeding, and as Wendy mentioned, with families to help them understand their infant’s communication and physiology during feeding, using a common language with staff.
The EFS assesses the preterm infant’s ability to maintain physiologic stability during feeding, remain engaged in feeding, organize oral-motor function and coordinate sucking and swallowing with breathing. The EFS, by the nature of its design, considers not just oral-motor skills but rather, the whole infant, from posture, to physiology, to breathing, to state, to coordination, to swallowing, to oral-motor skills as well.
Beyond that, it focuses on the integration of these domains for function, all within a developmental care framework. It is unique in that it recognizes the value of understanding the infant’s adaptive responses to the feeding task, and how they are instructive to the caregiver.
The tool is also based on dynamic systems theory (that multiple systems synergistically affect each other during feeding) and these systems are assessed dynamically throughout an entire feeding, to arrive at a gestalt. Capturing variability across the entire feeding is a critical part of the analysis/integration of information. The items are designed to capture the variability in the infant’s learning of the foundational components of feeding skills, the continuum of that learning, and the emergence of skills; so it assesses whether component skills are not observed, are emerging, or are indeed consistently expressed. It is often used serially to capture developmental progress in feeding over time.
The EFS leads the caregiver, by the nature of how it is designed, to the interventions that naturally flow from the results of the assessment. It profiles interventions to support adaptive function during feeding and swallowing, and therefore interventions for safety.
The EFS is user friendly in that it is not focused on understanding and identifying only isolated oral-motor components but rather making sense of what all caregivers “see” every day when they feed preterm infants–the infant’s communication/cues during feeding. It provides a common language about feeding terminology (such as what do we mean by an infant is “pacing” himself, or what is “coordinated”, for example) to help all team members, including families, get on the same page, so conversations and report have common meaning.
Our original manuscript from 2005 about the EFS is on my website under the Publications tab. We do require training on use of the tool (offered at least yearly) to assure implementation in keeping with its intended purpose and parameters. SLPs typically then go back and teach their own NICU staff with resources provided during the training. I am so glad the EFS has advanced infant-guided feeding in your NICU, Wendy!
I hope this is helpful.
Catherine S. Shaker, MS/CCC-SLP, BCS-S Board Certified Specialist – Swallowing and Swallowing Disorders Florida Hospital for Children Orlando, FL
For many therapists, working with Tracheostomy can sound intimidating. I know, because years again that’s how I felt too☺ When we feel that way, what we need is information, and great mentoring. That’s why I asked Michele Clouse to teach this seminar on Tracheostomy and Swallowing from Pediatrics to Adult!
Her practical experience with trachs spans across more than 20 years and provides a rich foundation for problem-solving. From the understanding the components of assessment to the complexities of interventions unique to trachs and vents, she’ll help you touch and feel trach tubes, handle them so you feel comfortable, and understand their effect on swallowing. As a Passy Muir Clinical Specialist, Michele brings added expertise. She will show you how to assess for use of the valve, problem-solve its effectiveness and guide you through learning how to work with the team. You’ll leave this seminar with a new found confidence and, if you have experience with trachs, you will gain a stronger ability to problem-solve this population.
If you see infants in the NICU with Trachs, check out the webinar I did with a colleague for Passy Muir on use of the Passy-Muir valve in the NICU for feeding/swallowing. You will find it with the other outstanding webinars provided free on Passy-Muir.com It is a great resource and includes a video of an NICU baby trialing his PMV ☺ and guidelines that so many therapists have found helpful.
Michele and I hope to see you in Houston in August!
I am excited to bring back my seminar on Pediatric Swallow Studies: From Physiology to Analysis this year! I get so many requests for information about not only how to interpret what we see during the swallow studies but also the hot topics that are unique to pediatrics, such as thickening, nipples, frames per second, patient compliance ☺
I am so amazed at the comments at the end of this seminar, from both adult therapists new to Pediatric video swallow studies, and from seasoned pediatric therapists☺
I think the variety of videos that we watch really helps. Luckily I have captured over the years some great examples of more rare etiologies such as TEF, but also great demonstrations of the evolution of the pediatric swallow. The videos of preterms, then infants then toddlers then young children, help you to see the progression of the swallow. That is so fundamental to understanding what you see radiographically, what it means in the context of the developmental process, and then problem-solving what to recommend.
You’ll have the chance to learn from those attending as well. I often learn something new or gain new insights from the discussions we have as a group, especially with the many case studies with their videos that we problem-solve.
Hope to see you this year in Indy, Boston, Seattle, Houston, Dallas or Hollywood FL!
Today was time to stop and rest. Relaxing has a way of letting your mind wander and mine did.
The start of my 2015 teaching is around the corner and this weekend I took time to just sit and read again the many feedback forms completed by all of you after attending my seminars last year. I like to do this at the start of each seminar season for many reasons. It reminds me to always keep my thinking fresh, well-grounded in the lasts research and re-ignites my focus on bringing you the best learning opportunities I can.
You may have noticed that my 2015 brochure now features the theme “discover, teach, inspire” which has always been my guiding force. And this year that is my continued goal. Whether I meet you at my seminars, through NANT, through Feeding Matters, through ASHA’s List Serve or maybe through YouTube in the future, I am committed to inspire you to be your best and to be the force of change for the children and families whose lives you touch. Whether I inspire you to move toward more infant-guided feeding in the NICU, to better support an NICU graduate in your community clinic, to establish more joy in feeding for the trached infant/toddler with a PMV, to help wean the 5 year old off a GTube, to work even more collaboratively with the school nurse or pulmonologist, or support more positive feedings for both family and child with sensory-motor differences, thank you for the opportunity to be part of the valuable work you do every day. The examples of the good work you do are endless, as are the opportunities for me to inspire my colleagues in this year ahead.
I decided to start a Testimonials TAB on my website to share the gratitude and inspiration. Stay in touch for more feedback and send me yours if I have touched your professional life in ways that matter. I’d love to share it.
Looking forward to seeing you in 2015!
What a fast year this is! I cannot believe it is already almost May. It is a balmy 90 degrees here today. Staying inside in the air conditioning seems the best to me, though my German Shepherd, Heartbreaker, still seems to have the energy to play ball and enjoy the sunny blue skies☺
I am looking forward to my newest seminar The Advanced Clinician in Pediatric Dysphagia: Taking it to the Next Level coming up soon in the Boston area and Seattle. So many of you have contacted me about finally having access to a seminar like this. We’ve designed it to “feed your mind”, get you thinking and sharpen those problem-solving skills. What makes an advanced clinician “advanced”? It’s not just having information. How you use the information you have, what sense you make of it in light of the big picture, and how you apply it dynamically to each pediatric patient is the key. Correlating co-morbidities, clinical data and the infant/child’s behaviors is at the heart of completing a good differential. We’ll look at case studies, including those you bring on DVD or a flash drive to share with the group and problem-solve
And we’ll discuss lots of current hot topics including:
- Everyday challenges “in the trenches”
- Critical thinking about HFNC (high flow nasal cannulae) and feeding
- Cortical learning underlying feeding/swallowing, neuroprotection
- Use of NMES in pediatrics :Contraindications, risks, benefits, cautions
- “Post-Traumatic” feeding disorders
- Thickening: What do we know? What to do?
- Oral motor treatment in pediatrics: Not just exercise !
- Breastfeeding: What the SLP needs to know
- The “steps” to eating
- FEES in pediatrics
- Enhancing respiratory function for swallowing/feeding
- And more!
……….Come ready to take it to the next level! ……………….
Hope to see you in Boston or Seattle!
My teaching will be starting again in May of this year and I am thrilled to have the opportunity to meet many of you who share my passion for the babies in the NICU.
I’ll be teaching my seminar NICU Swallowing and Feeding: In the Nursery and After Discharge in Indianapolis, the Boston area, Houston and Dallas.
I’ll bring you the latest evidence-base about feeding/swallowing in healthy preterms, late preterms, chronically ill preterms and sick newborns—we’ll look at what makes each unique, how to do a differential to sort the most critical factors affecting that infant’s skill.
We discuss a global, whole-baby approach to assessment and interventions that you can individualize based on the infant’s emerging skills during feeding. You’ll love the videos I show of infants feeding as they help you see their cues, what to look for and how to help then be successful feeders both in the NICU and after discharge. There will time to discuss your challenging patients as well.
We’ll discuss infant-guided care to support the best feeding outcomes, and how to share your feeding expertise with the caregivers you work with, both families and staff
Also, you’ll find my recently published manuscripts on the NICU on my website, http://www.Shaker4SwallowingandFeeding.com . They have helped many NICU therapists to better serve this unique population. I hope it helps you too!
Hope to see you in 2015!
QUESTION: I work in a special education setting with preschoolers and kindergarten age students. I have a 6 year old student who choked on a hot dog at age 2. He suffered anoxia and was being revived for nearly an hour. He suffers from seizures and is on heavy seizure meds. He is quadriplegic and tube fed. He has a PM valve and last year he would produce vocalizations at times when he was awake and alert. I was doing orofacial sensory stimulation to encourage movement of his articulators. He tolerated it well and I did observe increased movements of his jaw tongue and lips. Since last year his ability to remain awake and alert and to respond during school hours has really decreased. He has been less and less available for any kind of speech therapy. He has a private nurse during school hours. His mother does not communicate well with the school. During this past winter he was absent for a few weeks. I discovered through his teacher that he had been hospitalized for pneumonia. One of his private nurses shared that it was aspiration pneumonia and that he aspirated his saliva. Since then I have been very wary about doing oral-facial sensory stimulation that stimulates salivation. We have an IEP meeting approaching soon and I plan to ask his mother about this and to get more information from her. I am not sure what to do about providing oral sensory stimulation if what the nurse relayed is indeed accurate. Any feedback from the group about this would be greatly appreciated.
ANSWER: With the clinical picture and co-morbidities you describe, his anoxic event likely caused a significant neurological insult. It is not uncommon that one of the sequelae with such children is swallowing impairment, such that the child does not have the postural/neuromotor, oral-pharyngeal-sensory-motor prerequisites that provide the essential underpinnings to swallow his saliva. He likely immuno-compromised which can increase risk for aspiration pneumonia. It is very possible he is aspirating his saliva at rest, as he may lack the ability to gain the needed mouth closure and tongue control to then drive the saliva bolus intraorally and pharyngeal, which causes accumulated saliva to then often take the path of least resistance toward the airway; he likely lacks then the sensory awareness to perceive saliva is approaching/entering his airway and perhaps the neuromotor skills to generate an effective cough. Good oral cares and oral hygiene will be essential to reduce the potential for bacteria-laden saliva to be aspirated.
I am not sure what oral-facial input you are providing, but it did not “cause” the aspiration pneumonia itself, although in some children it may increase saliva production at that moment during therapy. Specific deep sensory input to muscles to support active movement may be provided from a neurodevelopmental treatment (NDT) perspective. An NDT approach in this situation would be like “PT for not only the body but for the mouth” as one mom put it; this muscle based approach combines facilitation and inhibition and works directly on the muscles. I took an 8 week NDT course with PTs and OTs years ago to learn this approach, and it has been invaluable. With such children as you describe, using an NDT approach, I have observed clinical improvements in head/neck control, the driving force of the tongue, ability to use the cheeks/lips, and, as a result, swallowing.
You need more information to make sense of where to go next. Maybe mom would sign a release to allow your team to get more information, and contact his past therapists to better understand his co-morbidities, medical history/status. That may help you understand the changes in mental status you describe (his reduced alertness and awareness); all of this information should be the guide for you about continuing therapy or discontinuing therapy, and what to focus on in therapy, not the fact that he had aspiration PNA.
I hope this is helpful. You are doing a good job asking questions. As you get more information, you can continue problem-solving. He would be a complex and challenging patient for any of us.
Want to enhance your problem-solving and skills with completing a differential for your pediatric feeding/swallowing patients?
Join us for Pediatric Swallowing and Feeding: The Essentials in 2015! I’ll be teaching this seminar in Indianapolis, Seattle, Hollywood FL and Plano, TX this year. My colleague, Theresa Gager, will be there as well to share her thoughtful down to earth approach that has won her the heart of many parents and children☺ you’ll especially enjoy her discussion of Tools of the Trade – the many ways to facilitate feeding that involve the child and caregivers.
We’ll problem-solve tough cases as a group and we’ll bring you the latest evidence and years of practical experience with a variety of diagnoses and give you insights on how to assess, sort out relevant factors, make a treatment plan and then implement it.
Theresa and I absolutely love teaching this seminar together. We have worked together as therapists for over 25 years and continue to learn every day from the children we are fortunate to work with, and their families☺ Join us for a great learning opportunity!
We look forward to sharing our experiences and insights with you at Pediatric Swallowing and Feeding!!
Problem-Solving with Catherine: Video Swallow Studies
Question: Do you find that sippy cups with spouts used during swallow study do not give the results you are looking for. . The swallow you get has a different pattern than open cup drinking and are you seeing a more immature oral phase. If the child is of the age that they should be drinking from an open cup do you find a more immature swallow with poor collecting. How do you report this and do you recommend open cup drinking to improve swallow maturity. If you are looking for aspiration do you think the immature pattern may be affecting this. I am looking more for your experience and information than answering your questions.
Answer: Good questions!
Looking at what the child is currently utilizing is a good place to start so we see a baseline that reflects the everyday feeding environment. A spouted sippy cup does typically promote different oral-motor patterns than an open cup, both for cheek/lip and tongue activity. It may also alter bolus size and flow rate, positively or negatively for that particular child.
Depending on the swallowing physiology observed, a spouted cup may actually promote a safer swallow for that child. The spout may provide more oral stability and/or promote more effective channeling of fluid through the oral cavity for that child. It is true that an open cup promotes more mature oral-motor patterns, but in the study we need to weigh intake, physiology, safety and developmental goals for that child with his history and co-morbidities. So on an interim basis, a sippy cup might be recommended, with the ultimate goal to work in therapy to provide oral-sensory-motor experiences and therapeutic trials with an open cup, if the study suggested that was appropriate and safe.
Delayed development of oral-motor patterns that support the emergence of more mature swallowing patterns can indeed affect physiology. During the swallow study, we are looking at the child’s swallowing physiology within the context of current level of development, his history and co-morbidities. While we may or may not capture aspiration events during the procedure, the nature of the physiology we observe should guide us to objectify potential interventions during the study. From there, the range of interventions useful for mealtime and those for focus in therapy, can be recommended.
I hope this is helpful.
Catherine S. Shaker, MS/CCC-SLP, BCS-S Board Certified Specialist – Swallowing and Swallowing Disorders
SHAKER SEMINARS 2015
May Indianapolis IN
May 28-29 Pediatric Swallowing and Feeding
May 30 Pediatric Swallow Studies
May 31-June 1 NICU Swallowing and Feeding: In the Nursery and after Discharge
June Boston MA
June 19 Pediatric Swallow Studies
June 20-21 NICU Swallowing and Feeding: In the Nursery and after Discharge
June 22-23 The Advanced Clinician in Pediatric Dysphagia: Taking it to the Next Level
July Seattle WA
July 18 Pediatric Swallow Studies
July 19-20 Pediatric Swallowing and Feeding
July 21-22 The Advanced Clinician in Pediatric Dysphagia: Taking it to the Next Level
August Houston TX
August 13 Pediatric Swallow Studies
August 14-15 NICU Swallowing and Feeding: In the Nursery and after Discharge
August 16-17 Tracheostomy and Swallowing
September Hollywood (near Miami and Ft. Lauderdale) FL
September 17 Pediatric Swallow Studies
September 18-19 The Early Feeding Skills Assessment Tool: A Guide to Cue-based Feeding in the NICU
September 20-21 Pediatric Swallowing and Feeding
October Dallas TX
October 23-24 Pediatric Swallowing and Feeding
Oct 25 Pediatric Swallow Studies
Oct 26-27 NICU Swallowing and Feeding: In the Nursery and after Discharge
As my traveling comes to a close for 2014, I look forward to some relaxation and time to catch my breath! Today in Florida it is breezy sunny and cool — 79 degrees!) My German Shepherds were happy to get out for a long walk in the early morning sunshine and enjoy nature with me. After I finish this update, I am headed outside to relax on the lanai by the pool with my husband and watch the palm trees sway!
The next few months of “R & R” let me recharge and also focus on catching up on things at home and time to write. My teaching schedule will resume in May 2015 and it will be a packed year with lots of opportunities to share my passion and dialogue with you. My schedule should be finalized soon so watch for the announcement on my website. If you are interested in having me bring my seminars to your facility/community, send me an e-mail and let me know some details and why. I enjoy getting across the country and having the opportunity to learn about the work you do. I hope if we have not met, that our paths will cross in 2015!
ASHA is right around the corner. If you are attending this year in Orlando, be sure to stop by to say hello at my presentation on Thursday November 20th on Cue-Based Feeding. It is always rewarding to share my passion with fellow SLPs and have an opportunity to contribute to my colleagues’ practice.
As the holiday season gets closer, enjoy the preparation and be sure to take time to relax.
It’s hard to believe that October is almost here! Fall is approaching and I am already looking forward to the Holidays. It’s been a whirlwind year as I have travelled across the US and met so many therapists, both at national conferences and at my seminars.
I’ve been busy too at Florida Hospital for Children where my fulltime work allows me to touch so many families. I am amazed how much learn from them along the way. I reconnected with the father of one of one of my NICU babies, Carter, who was a 24 weeker, and is thriving at home and growing like a weed. Feeding is fun they tell me, as he plays with food on his high chair tray and eats off his little hands. That’s what I like to hear. Maybe I helped through the early guidance I offered at feedings in the NICU, building trust and supporting positive experiences that wired his brain toward, not away from, feeding. And now his success makes my day.
October is my last teaching series in 2014 and I am headed to Chicago. It is always heartwarming to return to the Midwest, where I spent much of my life until relocating to Orlando 5 years ago. I do hope I miss the snow, though I know from past experience it can snow in October in Illinois!
I’ll start teaching again in May 2015 and you’ll have plenty of advanced notice about where I will be and when. My break from teaching allows me to recharge, to spend some time relaxing, enjoy more Florida sunshine, reconnect with my family, including my German Shepherds, and write a few manuscripts to submit for publication. And I’ll be working on next year’s teaching schedule, too, and staying connected with all of you! If only there were more than 24 hours in a day!
In November, I am excited to be presenting at ASHA in Orlando on Cue-Base Feeding, with a focus on developing and sustaining a cue-based feeding program in the NICU. Like any other program we service, it requires our dedicated care and ongoing nurturing to continue to grow. In the NICU, how we cultivate our partnership with nurses and neonatologists is critically important, for each interaction about, and with, feeding matters. It matters to the infant’s brain and to the infant’s relationship with the family, and to long term feeding outcomes.
The challenges are there for all of us as we continue to problem-solve how to best support infant-guided feeding in the NICU. I especially look forward to meeting SLP colleagues after the session or when we pass in the conventions center and sharing our passion for helping the infants, children and families we are fortunate to support.
Enjoy the season ahead and stay in touch!