Problem-Solving with Catherine: Proactive versus Reactive NICU Consults

NICU Nurse Decal by AdriansVinyl on Etsy

Question Our institution is currently in the midst of updating the process for order consults in our NICU. We are moving forward with a more proactive approach and proposing automatic/standing orders for all three rehabilitative disciplines (SLP, OT, PT), but at differing times. While there is a lot in the literature suggesting a more “proactive” vs “reactive” approach is optimal for this population, some staff have asked about what specific organizations across the US are doing utilizing this approach, and what the findings have been. I have found it challenging to find specific information within the research to respond to these questions, so thought this would be a great place to get some additional information. I have a few questions and would greatly appreciate any feedback or additional information that you would be willing to share! This will greatly help as we look to expand our program and improve feeding outcomes for our neonatal patients.

Does your institution have automatic orders/standing orders? If so, what level is your NICU?  Also, are orders placed at time of admission for SLP, or is it based on specific gestational age or any other specific parameters?


Catherine’s Answer: Having a solid working relationship with your NICU team seems to be the key. I think that underpins their willingness to develop policies that reflect the value they believe that you —and SLPs–add to the developmentally supportive care they are committed to.

As I travel across the US teaching about NICU practice related to feeding, I often ask this question of SLPs in both Level III and Level IV NICUs. My informal data set suggests that about 50% of the SLPs report being in an NICU with standing orders, they most often occur at 31-32 weeks PMA. I suspect that is because there is literature correlating younger GA with increased risk for feeding problems. About 10 % of the SLPs, sadly, have stated there is no criteria and that it is “hit or miss” or consult is received at the “eleventh hour” or when the infant has had persistently poor feeding, now has aversions or only if the infant has “death defying events.”

The others don’t have standing orders. Approximately 40% have co-morbidity-based criteria, similar to Amber’s. The co-morbidity-based approach has increasing evidence-base in the literature, including for example, younger GA at birth, protracted need for ventilation, CHD, CLD, NEC, need for PDA, HIE, NAS.NOW, laryngomalacia, EA/TEF, reflux. For those neonatologists who truly value an evidence-based approach, the co-morbidity-based criteria often just makes sense, and they readily embrace it. They are often the colleagues for whom their clinical wisdom matters, i.e., they are quite in tune about those medical diagnoses for infants whose LOS is often prolonged related to poor PO feeding and seek SLP input to support improved feeding outcomes.

We have come so far in our data about the most fragile infants in the NICU cohort, known to be at heightened risk for enduring feeding problems. That, combined with the AAP’s recent guidelines, has opened new doors. The new neonatal care standards from the American Academy of Pediatrics recognizes the expertise of SLPs for supporting feeding, swallowing and neurodevelopment, as part of an interdisciplinary NICU team alongside OT and PT. Minimum standards for Level II, III, and IV are specified, with a goal to “improve neonatal outcomes by ensuring that every infant receives care in a facility with the personnel and resources appropriate for the newborn’s needs and condition.”

Both Level III and Level IV NICU Requirements support consistent presence of SLPs in the NICU and ensure that NICU patients and their families receive the services they need to thrive in the NICU and after discharge. This includes onsite access to an SLP with neonatal expertise, who is skilled in the evaluation and management of neonatal feeding and swallowing concerns.

Going forward, we hope that cross-fertilization of knowledge continues amongst all NICU team members, so that our expertise as SLPs for fragile infants learning to PO feed in the NICU continues to gain recognition.

I hope this is helpful. Keep up the good work on behalf of our tiny humans.


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