Q & A Time: Swallowing and feeding

Question: Recently I have accepted a new and exciting position at a specialty hospital where I am one of 2 SLPs working solely in the NICU. The rest of the NICU therapy team is composed of OTs. Both OT and Speech provide feeding and swallowing assessment and treatment. Speech interprets the MBSs while OT provides the feeding during these studies, which works great! The potential challenge we see is how do both therapies provide services to an infant and her caregivers without creating a duplication of service when both disciplines treat feeding and swallowing? Does Speech take certain diagnoses, such as all clefts, craniofacial anomalies, etc. and OT the “feeders and growers?” Or do we divide the new orders in half? Has anyone else dealt with, or are you dealing with this? What solutions have you found?

Answer: Actually, all staff in the NICU either support or do not optimally support feeding/swallowing in the NICU, from the first day of life. To the extent that self-regulation is supported during all activities and interactions, the infant wires his brain and entrains the sensory motor system optimally. This then supports the integration of subsystems that underlie safe and effective feeding. Through co-regulation with the infant, i.e., contingent responsiveness by the feeder to the infant’s continuous feedback during feeding, the infant’s self-regulation and therefore physiologic stability, and safe swallowing, can be optimized.

Swallowing and feeding are viewed and supported within the context of the whole infant, the entire team, including the family, and the medical complexities/co-morbidities. A focus on infant-guided versus volume-driven feeding is essential to minimizing stress during feeding. Recent studies have shown that stress in preterms is associated with changes in the structure of the brain. So all of us in the NICU have the potential to either support or constrain the infant’s development, through feeding, both in the short-term in the NICU and in the long-term.

The science and evidence-base regarding neonatal swallowing, its relationship to physiologic stability and postural control, the influence of flow rate on airway protection, the relationship of sucking rate, bolus size and respiratory pattern to safe swallowing must be well understood. Recognizing the uniqueness of the preterm’s anatomy and swallowing physiology, his signs of engagement and disengagement that signal stability versus disruption of the swallow-breathe sequence, awareness of adaptive/compensatory behaviors during feeding, and what are supportive versus non-supportive interventions, are all essential.

Those who support feeding/swallowing in the NICU have the responsibility to bring this level of information-base to the infant and his family, in order to guide the entire team toward infant-guided co-regulatory feeding.

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