Problem Solving Your NICU Role with Catherine

Question: I am a NICU therapist in a 57 bed level 4 NICU, we have a very difficult time convincing physicians of the benefit and necessity for speech therapy and OT in the NICU. Chronic babies are ordered as well as babies with a diagnosed syndrome or cleft palate etc. However babies with bleeds, long term intubation and kids with PMA of 24-28 weeks that should have a consult are sometimes overlooked. Prior to my position here I worked in home care / private practice for 17 years and saw NICU graduates with a variety of feeding and swallowing difficulties many of which stemmed from their early feeding difficulties. Is there a standard ordering protocol, an algorithm or other evidence based clinical procedural means to share with the clinical committee to convince practitioners of the value of our work and place in the unit any input would be greatly appreciated.

Answer:
It is always challenging for NICUs and their nurses to see a need for our services when they have “existed” without the benefit of collaborating with rehabilitation therapists regarding feeding readiness and support for optimal feeding outcomes. Lots of dialogue and conversations are needed with NICU staff and leaders to expose them to current research and what value you add. Focusing on those infants most at risk for feeding problems, based on the evidence, is a good place to start. Take a look at these articles on co-morbidities and feeding written by well-respected neonatal researchers. They profile who are the most at risk fragile feeders and therefore guide us as well to those who will benefit from skilled intervention to support the path to PO feeding via oral-sensory-motor readiness. This includes those born at or under 28 weeks GA, at or under BW 1000 grams and with respiratory, airway and GI co-morbidities. Enjoy these articles!

Jadcherla S.R., Peng, J, et al (2012). Impact of personalized feeding program in 100 NICU infants: Pathophysiology-based approach for better outcomes. Journal of Pediatric Gastroenterology & Nutrition 54(1), 62-70.

Jadcherla, S. R., Wang, M., Vijayapal, A. S., & Leuthner, S. R. (2010). Impact of prematurity and co-morbidities on feeding milestones in neonates: a retrospective study. Journal of Perinatology, 30(3), 201-208.

Park, J., Knafl, G., Thoyre, S., & Brandon, D. (2015). Factors Associated With Feeding Progression in Extremely Preterm Infants. Nursing research, 64(3), 159-167.

Also I wrote this manuscript in 2007. In it there is a set of criteria for referrals in the NICU for feeding support. If I were to write it today, I would add to that criteria but it can be a starting point for you to consider and use in conversations. Shaker, C.S. & Woida, A.M. (2007) An evidence-based approach to nipple feeding in a level III NICU: Nurse autonomy, developmental support and teamwork. Neonatal Network, 26:2, 77-83.

Know that creating a role in your NICU is a journey not a destination. It takes many interactions, patient successes and partnering with bedside nurses to make a culture change that embraces the inclusion of therapists when it comes to feeding. And then it needs to be nurtured every day. Be thoughtful, be informed and be a colleague. Share and listen. Build relationships with nurses who become your advocate. Support families in building a relationship with their infant through feeding, and they will sing your praises to the neonatologists!

I hope this is helpful.

Catherine

Seminars in Seattle

What a fabulous time I had teaching in Seattle at Seattle Children’s for 5 days. The west coast weather was fresh and breezy with none of the humidity of Orlando! Therapists from across the US attended, from as far away as Alaska and New York. It’s amazing how the same professional issues, the same clinical challenges and the same love of pediatric patients brings us together and sustains us in tough times. We problem-solved navigating thickening and not thickening, use of the PMV, considerations for feeding on CPAP/HFNC and the latest data, changing the culture of feeding in the NICU, novel ways to approach use of the tools of the trade (bottles/nipples, spoons, cups, straws) and so many interesting cases. I was honored to have Wolf and Glass, both we well-respected and internationally known NICU OTs, join us. It was memorable to discuss both our common and varied perspectives and walk away renewed by clinical questions. The five days was an opportunity for all of us as a group to advance our critical thinking and discuss key issues. As Oliver Wendell Holmes said “Man’s mind stretched to a new idea never goes back to its original dimensions”.

Now its time to focus on traveling to Houston mid-August to teach at Texas Children’s Hospital. I’ll be offering my NICU and Pediatric Videoswallow Studies seminars, as well as the Tracheostomy and Swallowing: Pediatrics to Adult seminar taught by Michele Clouse. She is known nationally for her clinical expertise with complex pediatric and adult patients requiring tracheostomy. I am also excited to have the chance to connect with Chantal Lau who is a part of the TCH staff supporting NICU. Her NICU research and writings have informed NICU practice, and her new self-paced bottle, in development, intrigues me. I so look forward to connecting with other therapists who share my passion for feeding and swallowing. In the meantime I’ll keep busy continuing work on a new manuscript for publication reflecting my current interests in neuroprotection and feeding.

As the summer passes all too quickly, I am reminded that the best way to live life is to pay full-throttle attention to our passions, our blessings and to each and every moment. And so it is time now to relax, and appreciate both this beautiful day and my family.

Reflux in the NICU

Reflux is a common issue in the NICU and with many of our pediatric patients. The evidence-base for effective interventions is rapidly emerging but is difficult for each of us to stay on top of! This paper by an NICU nurse published in 2012 is a fabulous resource. It does not just provide strategies but looks at the current evidence base as of its publication, and explains so well the “whys” behind the interventions. It is so easy to join a bandwagon and support the latest idea, but having the rationale and the data to titrate the interventions based on the unique issues and co- morbidities of a specific population, such as the NICU, is essential. I hope you enjoy this article on GER/EER as much as I have.

Click this for more info >>NICU GERD Neonatal Netw 2012 (229-41)

Catherine

Problem-Solving with Catherine

Question:


We had a patient last week that was born at 39 weeks and 4 days-no reported complications with birth history/birth.  He presented with frequent desaturations with feeds- dropping into the 70’s with color changes.  This would also occur with non-nutritive suck on the pacifier. The infant was transferred into the NICU.

Speech was consulted to complete MBSS to r/o aspiration.  This was the first contact speech had with this child. He was 4 days old at the time.  Patient presented with strong rooting reflex, tongue protrusion and non-nutritive suck.  He did present with desaturations into the 80’s with non-nutritive suck.  MBSS was completed using a slow flow nipple. Patient was eager to eat. Patient was able to establish non-nutritive suck without difficulty.  Patient had no aspiration, pooling, residuals during the study. He began to desat after 4-5 sucks-O2 dropped down to 70 and then patient recovered after 2 minutes.  Attempted pacing with patient leaving the nipple in the oral cavity but tilting slightly forward and also by removing the nipple from the mouth.  When nipple was left in the oral cavity patient continued sucking. Patient continued to have desats/color changes with each attempt of pacing- pacing was completed after 3 sucks. Oxygen levels dropped into the low 70’s and upper 60’s with each attempt.  Position change to side lying provided no benefit.

My concern with this patient was the frequency of the desaturations that occurred throughout the feeding.  There was also concern that patient did not receive benefit from the techniques used – slow flow, pacing, side lying position.  The feeling of the physician was that infants desat with feeds in our NICU all the time and we just needed to teach him to coordinate the SSB sequence.  The RN reported that it had taken over an hour to feed the patient using the techniques of pacing and side lying with a slow flow nipple.

My question to the group is how typical is this especially in a term infant? Is there something we can do differently to help this baby?  I am concerned with the level of stress that feeding may be causing him and how do we help to decrease this if the above techniques are not working?

We are waiting on cardiology but the feeling of the physicians is that this is just a coordination problem since it only happens with the nutritive and non-nutritive suck.

Thanks for your thoughts.

Answer:
Desaturations with non-nutritive sucking in an otherwise healthy newborn is not normal. The question is, is he really a healthy newborn? The results you provide from the swallow study and your clinical assessment both suggest that, despite typical interventions (such as positional changes, co-regulated pacing and flow rate regulation), there is something about the aerobic demands of sucking that result in his inability to adequately oxygenate.

The neonatologist’s statement that “infants desat with feeds in our NICU all the time and we just needed to teach him to coordinate the SSB sequence” minimizes a critical component of completing a differential in the NICU — context and co-morbidities matter. Desaturations in and of themselves have limited meaning; the meaning of the desaturations is best understood in the context of each individual infant, his history and co-morbidities. Desaturations with the pacifier is often  for instance observed in a preterm infant with cardio-respiratory co-morbidities who is allowed to suck continuously on a pacifier; co-regulated pacing can often avert that.

The behavior this term infant presents gathers meaning, and directs the next steps in a differential, only in context: history/co-morbidities, what other behaviors co-occur with the desaturation events, as well as the important clinical data that the interventions you trialed during the swallow study did not avert the decompensation. This, then, is a very different picture than what the neo considered. The impression is one of pathology. While the infant did not aspirate or apparently mis-direct the bolus during the VFSS, the integrity of his feeding/swallowing is impaired. Competing the differential of “why “will require cardio-respiratory work up. I have seen many infants for whom impaired feeding is the impetus for a cardiology consult and often that is the unsuspected co-morbidity. Let us know what cardiology finds.

Sad that the staff fed the infant for hour. Someone was not listening to the infant’s communication, which likely showed disengagement long before. We don’t know the caregiver’s perception of her role in feeding NICU infants, but I suspect it is to get the volume in. The caregiver actions adds one more factor in a feeding/swallowing differential.

In the thread there have been mention of a couple possibilities I’d like to touch on. Offering oxygen in some cardiac presentations can actually worsen the infant’s status. Oxygen, one neo told me when I was first starting in the NICU almost 30 years ago, can be toxic. Again the neonatologist’s looking at the possible co-morbidities is essential to guiding management.

Concern that the infant may be “working too hard” using a slow flow nipple  was also mentioned. It is not uncommon for NICU nurses to share that concern as well. Actually research has shown just the opposite,that it is not the work of sucking that fatigues infants, it is the work of trying to breathe in the presence of a flow rate beyond the infant’s capacity. Studies have shown that infants who received a flow rate they can regulate actually take more volume than when offered a free flowing nipple. The concept is that during feeding, fighting the flow to breathe adversely affects ventilation, i.e., the infant breathes less often because he is spending more time swallowing; the less time spent in deep breathing, the more likely saturations are to decrease and stamina suffers. A slow flow rate is also most like the breast flow, which has been shown as well in the literature to be a key factor in maintaining physiologic stability during breastfeeding, even in tiny preterm infants. The literature regarding breast flow is quite instructive for those of us who support bottle feeding in the NICU.

So increasing flow rate for this infant, as you suspected, Ginger, would indeed make the situation worse. The fact that your interventions which are clinically sound did not improve saturations is a key factor that the neo just did not consider. If we increase the flow rate, we would see further physiologic decompensation, as he would breathe less often, perhaps we might even see true bolus mis-direction, as the infant may “open the airway” to catch a much needed breath, and then mis-direct the bolus. The infant’s physiologic stability, his ability to regulate multiple systems and his experience of the feeding would be worsened. In addition, the negative learning that has already unfortunately likely taken place would be exacerbated.

I hope this is helpful.

Catherine

Shaker ASHA Sphere Blog

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

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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!

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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 pediatricseminars@gmail.com

 

I am an official blogger for ASHA regarding infant feeding and swallowing and acute care pediatrics. Follow me there too!
 

Inaugural Recipients of the Pioneer in Neonatal Therapy Award

Message from Sue Ludwig, OTR, President – NANT

Inaugural Recipients of the Pioneer in Neonatal Therapy Award

Pioneer in Neonatal Therapy Award – Inaugural Recipients (left to right)

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.

The Early Feeding Skills Assessment Tool (EFS)

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!

Hi Wendy,

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


Catherine S. Shaker, MS/CCC-SLP, BCS-S
Board Certified Specialist – Swallowing and Swallowing Disorders
Florida Hospital for Children
Orlando, FL

http://www.Shaker4SwallowingandFeeding.com



Learn about Trachs in Pediatrics and Adult!

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!

Catherine

2015 Seminar Updates:

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!

Catherine

Time is so precious…

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!

Catherine

Greetings from Florida!

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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!

Catherine

Want to learn about working in the NICU or enhance your skills as an NICU therapist?

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!
Catherine

Problem-Solving with Catherine

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.
Catherine

Plan to attend Shaker Pediatric Swallowing and Feeding Seminar

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!!

Catherine