7/7/2011

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Pediatric Medical Speech Pathology - NICU, the New Frontier

Presenter:Kay Thurston, M.S., CCC-SLP

Moderated by:

Amy Hansen, M.A., CCC-SLP, Managing Editor, SpeechPathology.com

Live Expert eSeminar

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7/7/2011

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Peer Review Process

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7/7/2011

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More than just talkMore than just talk

July 11, 2011

Kay Thurston, MS,CCC/SLP, CLC

Objectives Review traditional areas of practice for pediatric medical speech pathology Role of Speech Language Pathologist Skills/knowledge baseg

Discuss the new frontier – Neonatal Intensive Care Role of Speech Language Pathologist Skills/knowledge base

Review of prerequisite knowledge base Swallowing Development Feeding Development Term Infant/Preterm Infant Potential barriers to feeding development

Review educational resources 

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Pediatric Medical Speech Pathology ‐Traditional Venues

Pediatric Intensive Care Unit – PICU

Pediatric Unit – PEDS

Pediatric Medical Speech Pathology Pediatric Intensive Care Unit

Non accidental trauma

Accidental Trauma  Accidental Trauma –

Closed head injuries

Motor vehicle accidents

Acute Illness Respiratory SyncytialVirus

Meningitis

Guillain‐Barre

Pediatric Medical Speech Pathology – PICU Feeding/swallowing

Language Assessment

Developmental Therapy

Medical technology Medical technology Monitors

Ventilators

Supplemental oxygen

IV’s

Shunts

Medications

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Pediatric Medical Speech Pathology Pediatric Unit

Failure to Thrive Feeding Evaluation

Swallow Evaluation

Dysphagia

Acute Illness Feeding/swallowing

Communication 

Chronic Illness Feeding/swallowing

Communication

Pediatric Medical Speech Pathology ‐ PEDS Communication evaluation

Feeding evaluation

Swallow evaluation Swallow evaluation

Clinical Bedside 

Modified Barium Swallow

Medical technology

Supplemental oxygen

Monitor 

Supplemental feedings

Pediatric Medical Speech Pathology – New Frontier

Neonatal Intensive Care Unit

H lth   t   Healthy premature infants

Medically fragile premature infants

Term Infants requiring intensive care

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Pediatric Medical SpeechPathology ‐ NICU Feeding/swallowing

Communication

Developmental Therapy

Medical Technologygy Monitors

Ventilators

Supplemental oxygen

IV’s

Shunts

Splints/braces

Medications

NICU – Roles of the Speech Pathologist ASHA Guidelines1. Communication evaluation and intervention

2. Feeding and swallowing evaluation and intervention

3. Parent/caregiver education and counseling, staff ( )  d i   d  ll b i(team) education and collaboration

4. Other duties including quality control/risk management, discharge/transition planning and professional education and research

Key Principles ‐Family Centered Care Patient family‐centered care is an approach to health care that focuses on the family as a child’s primary source of strength  primary source of strength, support and well being. The word "family" refers to two or more people who are related in any way—biologically, legally, or emotionally. Patients and families define their own families.

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Key Principles ‐Developmental Care Based on work by Als

Synactive Theory of Development

Last twenty years Last twenty years

Considers environmental influence on premature infant development

Macro level – unit

Micro level – immediate surroundings

Key Principles –Culturally Appropriate Care Everyone has culture

Individual

Sensitive to i /f il   lpatient/family culture

Adjust interaction/goals as appropriate

Communication Evaluation and Intervention Infants communicate their 

strengths and challenges from the first day of life

The Speech Pathologist must be fluent in the language of the premature/medically fragile premature/medically fragile infant

Teach parents the language their infant is using

Teach the parents how to respond to their infant Developmentally supportive Contingent and reciprocal

Enable the parents to become the expert on their infant 

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Feeding/Swallow Evaluation and Intervention Preparation for oral feeding begins 

on the first day of life Promote and advocate for 

pleasurable oral experiences for the infant

Educate family regarding oral f di  d lfeeding development

Strategies to support emerging interest in oral feeding

Assess infant for readiness to initiate oral feeds

Strategies to improve coordination, support emerging skill

Aware of potential roadblocks to  oral feeding

Specialized bottle/nipples Swallowing Assessment

Parent/Caregiver Education Education/support for family at the bedside

Education/support for caregivers bedside Problem  Problem solving/collaboration

Participation in multidisciplinary rounds

Formal education for staff  Feeding development Swallowing development Neurodevelopmentaloutcomes

Typical NICU PopulationThree general populations ‐ Healthy Preterm Infant

“Feeder Grower” Minimal medical complications Oral feeding skills emerge with maturationOral feeding skills emerge with maturation

Medically Complex Premature Infant – VLBW, ELBW Complications due to prematurity, low birth weight, anatomical abnormalities, medical course/interventions

Oral feedings skills impacted by medical course

Medically Complex Term Infant Medical diagnoses that require intensive care often impact ability to orally feed safely and/or efficiently

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Pediatric Medical Speech Pathology – Skills Required Normal Development

Communication/Articulation Oral Motor/Feeding Swallowing 

Premature Infant Development Assessment Strategies appropriate for premature/medically fragile 

population Intervention Strategies appropriate for premature/medically fragile 

population Technology Ability to coordinate with staff and family

Balancing short term and long term goals Balancing textbook and reality of life in the NICU

Ability to advocate appropriately for patient

Prerequisite Skills Swallow Development

Swallow Assessment

Infant 

P di i Pediatric

Normal Oral Motor/Feeding Development

Feeding Assessment

Infant 

Pediatric

Potential Roadblocks to normal feeding/swallowing

Anatomy and Physiology of Swallowing –Why?

Basic knowledge of normal function and anatomy

Guide thought process  Guide thought process when infant/child anatomy is abnormal

Guides assessment and intervention

Know correct questions

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Swallowing Control Complex and specialized motor act

Normal adult swallows 580 x dayswallows 580 x day

Involves over 29 muscles and five cranial nerves

Shared anatomy with respiratory tract

Swallowing Swallowing –– Four StagesFour Stages

Oral prep

Oral 

Ph l  Pharyngeal 

Esophageal 

Swallowing : Oral Prep

Voluntary

Airway open

Variable length

Biting/Chewing  preparation of bolus for swallow

Limited in liquid feeding

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Swallowing: Oral Stage Voluntary

Airway open

One second duration

Tongue squeezes bolus posterior into pharynx

Ends when liquid passes the faucialpillars

Swallowing : Pharyngeal Stage

Voluntary and involuntary

Shortest and most complexcomplex

Airway closes

Epiglottis inverts

Larynx lifts, true and false cords close

Soft palate elevates

Swallowing : Esophageal Stage

Involuntary

Airway open

Duration 6‐10 seconds

Food enters esophagus Food enters esophagus

Peristaltic wave action of the esophagus propels food to stomach

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Cranial Nerves

12 pairs of nerves

5 of these nerves play a role in oral feeding/swallowing

Motor and sensory components

Cranial Nerves Involved in Swallowing Cranial Nerves Involved in Swallowing Trigeminal V

Motor – muscles for chewing Sensory – oral, nasal cavities, tongue, teeth and face

Facial VII Motor – facial expression muscles, suprahyoid muscles Sensory ‐ taste in anterior 2/3 tongue, soft palate

Glossopharyngeal XI Motor – some muscles of palatal elevation Sensory – tactile sensation posterior tongue, taste posterior 1/3 tongue

Cranial Nerves involved in SwallowingCranial Nerves involved in Swallowing

Vagus X Motor‐muscles of pharyngeal contractionsome muscles velopharyngeal closurei h id l   i h  hcricothyroid muscle ‐ pitch changes

intrinsic laryngeal muscle – vocal fold Sensory – supraglottic sensation subglottic sensation

Hypoglossal XII  Motor – all intrinsic and extrinsic muscles of tongue except one

Sensory – none

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Aspiration ‐What is it? Aspiration occurs when food or fluid enters the airway

Aspiration can be b i   il tobvious or silent.

Obvious signs include coughing during or after feeding, and choking.

Silent Aspiration Silent aspiration occurs without coughing or choking. An infant that aspirates silently may continue to attempt to nipple and even be viewed as enjoying feedingfeeding.

Signs of silent aspiration may include

teary eyes while feeding

sudden loss of tone, state

increased wet vocal quality with feeding

ongoing physiological instability with feeds

sudden refusal to orally feed

More Signs of Aspiration Limited alerting for oral feeding

Refusal to eat orally or take only minimal volumes

Lack of improvement/progress in obtaining all oral f difeeding

Poor growth/weight gain

Increased supplemental oxygen need

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Primary vs Secondary Primary Aspiration

Food or liquid enters the airway

B f  d i     f   Before, during or after swallow is initiated

Prior to food entering the esophagus

.

Aspiration Risks in the Infant Rapid blunting of pharyngeal sensation

Decreases awareness of aspiration

Creation of silent aspirator ‐may never acquire ability to coughg

Bronchiectasis ‐ permanent lung tissue damage

Aspiration Pneumonia

Pairing aversive stimuli with feeding – oral aversion

Refusal to eat sufficient volumes to support growth and development – Failure to Thrive

Poor growth – Failure to thrive

Swallowing DevelopmentSwallowing Development First coordinated motor activity 

In‐utero by 15‐18 weeks A ti   ll i   Active swallowing amniotic fluid Regulate fluid levels Gut maturation Taste

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Suck Swallow DevelopmentMouthing and suckling by 27/28 weeks

Sucking developed before the ability to coordinate swallowing and breathing Breathing not 

 ig

necessary in‐utero Burst/pause pattern seen at 32 weeks

Non‐nutritive suck on pacifier, fingers NNS 2 suck/second NS 1 suck/second

Increasing rhythm emerging at 34 weeks

Swallowing‐ Early Oral Feeding in Premature Infant 34 weeks typical age to initiate oral feeding in NICU

Sucking is typically not   bl  a problem ‐coordination of sucking/swallowing and breathing 

Usually require external pacing

Swallowing‐ Early Oral FeedingInfant progression to full oral feeding is variable 

Medical course and stability

Energy available 

Multiple caregivers

Family availability

Developmental skill

Culture of NICU

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Swallowing ‐Early Oral Feeding ‐ Breast Feeding

Developmental skill

Multiple factors impact infant/mother success

Infant medical status

Infant anatomy

Mother’s anatomy

Mother’s availability

Institution support for breast feeding

Term Infant‐ Efficient Eating Machine‐ Built to Feed

Physiologic flexion

High rib cage, short neck

Buccal sucking pads Buccal sucking pads

Tongue to oral cavity ratio

Position of hyoid bone and larynx

Epiglottis position

Term Infant – Efficient Feeding Machine

Physiological Flexion

Keeps arm/legs tucked and close to bodyy

Hips flexed

Head forward

Provides stability 

Energy available for breathing/eating

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Term Infant – Efficient Eating Machine

Natural Chin tuck

High rib cage and short neckneck

Jaw nearly resting on chest/rib cage

Stability 

Support for jaw and tongue

Swallow protection

Term Infant – Efficient Eating Machine

Buccal sucking pads

Support/stability for mandible

Lateral support for lip seal

Compress intra‐oral space

Direct milk flowing backwards

Term Infant – Efficient Eating Machine

Tongue to Oral cavity

Tongue large in comparison

ll l Fills oral space

Increases efficiency of bolus transfer 

Limits energy required

Cupped tongue directs and controls milk

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Term Infant – Efficient Eating Machine

Hyoid Bone and Larynx Position

High position in neck relative to adult

Closer to base of tongue

Extra layer of protection

Infant feeding rapid consecutive liquid swallows

Term Infant – Efficient Eating Machine

Epiglottis function

Leaf shaped

f l At rest contacts soft palate

Obligate nose breathing

Pulled backward over airway by raising hyoid/larynx

Funnels milk towards esophagus

Reflexes Present at Birth

Rooting‐ 32 wks

Finding food source

Gag‐ 32 wks

ll b Expelling objects

Transverse Tongue‐ 28 wks

Positioning nipple on tongue

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Reflexes Present at Birth  Palmomental

Opening mouth to   palms stimulation

Finding food 

S ki   fl Sucking reflexes

Non‐nutritive ‐ 27wks

Calming

Organizing

Nutritive – 34 wks

Premature vs Term Infant

No sucking pads

Lack of physiological flexion

Lower tone

All systems immature

Limited energy

Limited alerting

Limited socialization or engagement

Feeding Development in the NICU Environment Expectation for normal development in an abnormal environment Medical course Medical complicationsMedical complications

Caregiver driven Hectic/noisy Unpredictable but highly scheduled

Multiple caregivers Absent parents Unit supports or philosophy

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Developmental Approach to Feeding in the NICUSpeech Language Pathologist’s Role

Parent Education and Support pp

Preparing Parent to be the expert

Modeling developmentally supportive caregiving

Staff education/support to facilitate pleasurable oral experiences

Preparation from Day One for the Parent and BabyEducation 

Infant cues of readiness or approach

Infant cues of stress or avoidanceavoidance

Typical progression to full feeding

Promote holding and nuzzling, pleasurable oral experiences 

Feeding Assessment

Preparation ‐ It’s a Family Affair Support Mother’s wishes breast/bottle

Encourage and foster kangaroo care/holding

Encourage and foster li   h  nuzzling when 

appropriate Facilitate parents as primary feeders

Facilitate parents as experts on their baby

Foster contingent/reciprocal relationship

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Feeding SupportsHealthy preterm infants often require less direct intervention during their NICU stay

Family education

D l t l  t f   i   kill Developmental support for emerging skills

Preterm infants/Term infants with complex medical course often require more direct intervention

Family and staff education implications of infant medical course on feeding development

Feeding/Swallowing assessment

Development appropriate feeding plan

Feeding Roadblocks

Diagnoses and experiences that impact/impede normal development 

Term or Preterm Infant

Prerequisite Skills for Oral Feeding

“Intact anatomy and physiology, intact sensory and tactile systems, adequate muscle tone and postural support of the oral, pharyngeal and respiratory systems, stable autonomic nervous system, adequate state regulation and enough energy to support the entire process.” Alexander 1993

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Feeding Roadblocks ‐ Intact Anatomy and Physiology

Changes in structure impact function

Oral

Cardiac

Digestive

Pulmonary 

Feeding Roadblocks – Infant Anatomy and Physiology

Cleft Palate

Down Syndrome

TEF/EA

Gastroschisis

Omphalocele

Diaphragmatic Hernia

Prematurity

Feeding Roadblocks ‐ Infant Physiological Stability

Maintain body temperature

Oxygen saturation

Heart rate 

Tolerate changes in breathing rhythm with oral feeding exertion

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Feeding Roadblocks – InfantPhysiological Stability

Cardiac conditions

Chronic lung disease

PrematurityPrematurity

Neurologic damage from brain injury

During birth

IVH following birth

Feeding Roadblocks‐ InfantSensory Control

Attend to body cues hunger/satiety

Signal hunger/satiety to caregivers

Tolerate position changes Tolerate position changes

Organize body for feeding

Recognize fluid in mouth/pharynx 

Feeding Roadblocks – InfantSensory Control

Drug Withdrawal

Prematurity

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Feeding Roadblocks – Infant State Control

Infant must be able to alert consistently

Recognize  and respond to hunger cues

Communicate hunger to caregiver

Engage with caregiver during feeding

Maintain alert state

Recognize and communicate satiety to caregiver 

Feeding Roadblocks – InfantState Control Drug Withdrawal

Down Syndrome

GER

Prematurityy

Feeding Roadblocks – InfantMuscle Tone

Achieve and maintain softly flexed position 

Protect airway

l Support oral cavity

Support efficient bolus transfer with minimal energy expenditure

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Feeding Roadblocks – InfantMuscle Tone

Down Syndrome

Dysphagiay p g

Prematurity

IVH/Brain damage

Feeding Roadblocks‐ InfantRespiratory Control

Breathing is primary

Infant must be able to maintain adequate oxygenation

S ll i l id f ti h d t Swallowing an overlaid function – shared anatomy

Oral feeding requires infant to suck, stop breathing, swallow, and reinitiate breathing

Maintain coordination for 30 minutes

Repeat every 2 -3 hours

Feeding Roadblocks – InfantRespiratory

Chronic Lung Disease 

Bronchopulmonary Displasia

Tracheomalacia

Laryngomalacia

Dysphagia

Prematurity

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Feeding Roadblocks ‐Digestive

Infant must be able to digest food without pain or discomfort

Di   ilk/f l         h  h Digest milk/formula every two to three hours

Feeding Roadblocks – InfantDigestive

Gastroesophagealreflux  ‐ GER

Short GutShort Gut

Omphalocele

Gastroschisis

Prematurity

Feeding Roadblocks ‐ Family

Medically fragile infant

Premature infant

Steep learning curve

Multiple medical providers

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Feeding Roadblocks ‐ Family

Stress, fear, guilt, grief, depression

Feeling of incompetence/inability to read and respond  i fto infant

Infant’s inconsistent cues

Lack of infant reciprocity

Educational overload

Later ‐ continued perception of infant as fragile, limiting experience

How do I get this training? Pediatric Medical Affiliations

Inpatient Outpatient clinic

Seek out courses, webinars, conferences N ti l A i ti  N t l Th i t National Association Neonatal Therapists

American Speech Language Hearing Association Contemporary Forums ‐Developmental Interventions in Neonatal Care

Journals Read and research from a variety of sources Nursing, Pediatrics, Gastroenterology  Quarterly search by topic 

Medical Pediatric Speech Pathology

An opportunity to meet the needs of a vulnerable population and improve neuro‐developmental poutcomes with our skills and knowledge base

Communication 

Feeding/Swallowing

Family/Staff education