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!
Recently, I have seen a number of infants born to diabetic mothers (IDMs) who are LGA, but with an otherwise stable medical status who are persistently poor feeders. I frequently find myself scratching my head and wondering how to address this problem so these babies can be discharged home, but without much success. Do you have any experience, input, or suggestions to help guide our treatment?
Babies who are infants of a diabetic mother often receive the label “LGA” (large for gestational age) but their “greater size” does not mean “greater maturity”, although this may be the presumption of some NICU caregivers. Indeed due to the high fat storage related to being an IDM, their tone is often “doughy” and they are not like “big babies” when it comes to feeding. This unfortunately sets them up to be expected to feed like “big babies” by some NICU caregivers. From the beginning of PO feeding initiation, these expectations are not reasonable, given their medical history.
Besides poor state regulation leading to poor drive to feed, added issues for IDMs can be increased work of breathing, which can lead to respiratory fatigue. Our neonatologists have us follow these infants, and expect significant improvements in feeding over about 2 weeks, once blood sugars are stable. If progress with feeding is not forthcoming, the neonatologists usually do neuroimaging studies such as a CT of the brain to look for brain malformations. Infants of diabetic mothers are at risk for brain malformations due to the altered “fetal environment” secondary to maternal diabetes. Slow flow rate, external pacing to limit bolus size and support coordination, attention to respiratory behaviors during feeding, re-alerting, avoiding passive “prodding” to empty the bottle and judicious interim use of gavage feeds are all useful interventions.
Therapists are essential to the infant’s team, to model patience and infant-driven feeding, to promote careful attention/response to the infant’s cues and behaviors, and to share strategies and rationale with bedside caregivers and families. Too often, “getting the baby home” can overshadow what needs to be a period of recovery and supported learning for the infant.
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!!