Do you hope to get a coveted pediatric placement during graduate school or for your clinical fellowship experience? Are you interested in an even more specialized subset of pediatrics? Working as a speech-language pathologist in the neonatal intensive care unit (NICU) requires many specific skills. These tiny patients and their families are fragile. The family-centered care we provide as SLPs, in support of neuroprotection, communication and safe feeding, create the foundation for a thriving parent-infant relationship.
Graduate school coursework alone can’t completely prepare students for pediatric placements, much less for the broad, complex information base needed for clinical practice in the NICU. As a NICU-based SLP for more than 32 years, I’d like to share some key points to help speech-language pathology students prepare for such a delicate placement. In future posts, I’ll introduce other concepts for NICU practice, but let’s begin at the beginning.
Below, I list what my decades of experience taught me about neuroprotection—interventions SLPs can perform to promote brain development and prevent onset of iatrogenic neuronal injury in developing premature infants related to stress and/or pain:
- The preemie’s brain, unfortunately, develops largely in the NICU, more so than in mother’s womb. Research shows rapid change occurs in the brain during the last trimester, whether in the womb or in the NICU.
- Dendritic growth, synaptic connections, apoptosis, myelination and finally, pruning, all contribute to creating brain connections.
- During the time preemies learn to feed in the NICU, they also develop motor and sensory neuropathways.
- Every early experience affects the developing brain. Unused pathways typically get pruned, while used pathways—positive and negative—get reinforced.
- Modulated via the amygdala, the onset of fear or stress responses during feeding can activate the fight-or-flight response and cue the adrenal glands to release stress hormones into the bloodstream.
- Repeated stressful feeding experiences in the NICU—ones adversely affecting both physiology and pleasure/pain responses—can alter the architecture of the infant’s brain.
- Repeated stressful experiences during feeding can also establish altered pathways in the developing brain that guide the infant away from feeding, lead to maladaptive behaviors, and adversely affect the ability and desire to feed in the NICU and after discharge home.
- Well-intentioned caregivers who do whatever they need to “get infants to eat” so they can go home might inadvertently generate these adverse experiences.
- This leads to physiologic stress and negative feeding behaviors, as the preemie struggles either to fight the flow to breathe or to be fed despite disengaging.
- Undue stress associated with trying to feed orally can predispose the infant to safety issues and altered sensory-motor pathways in the brain, which may in turn lead to long-term learned feeding refusals. The infant might experience these effects not just in the NICU, but after discharge if parents were taught to focus on emptying the bottle as their goal during feeding.
- Caregivers influence the premature infant’s brain with every interaction. Interventions promoting adaptive neuronal connectivity or “mapping” protect the developing brain and can help prevent the onset of maladaptive behaviors.
- NICU caregivers can protect the developing brain by being in the moment, being present, decreasing stress and supporting coping skills, reducing pain, offering well-graded positive touch, promoting sound sleep and kangaroo care, educating parents to understand and respond to the infant’s communicative cues, and incorporating family-centered care.
- Preterm infants establish their learned experiences with each feeding, and so NICU caregivers need to make every feeding experience as positive as possible.
- One negative stressful feeding experience can change the brain of the developing preterm infant and leave an impression lasting for the rest of the infant’s life.
- Supporting neuroprotection during oral feeding means reducing the stress experienced by the preterm infant while facilitating the infant’s emerging competence. With frequent opportunities to feed in the NICU, SLPs can best support the premature infant’s brain through non-stressful feedings using a co-regulated infant-guided approach.
Stay tuned for “Part Two: Dynamic Systems Theory and Infant-guided Feeding”
Catherine S. Shaker, MS, CCC-SLP, BCS-S, an SLP since 1977, works in acute care/inpatient pediatrics at Florida Hospital for Children in Orlando. She is an affiliate of ASHA Special Interest Group 13, Swallowing and Swallowing Disorders (Dysphagia). Read more of her insights at Shaker4SwallowingandFeeding.com. firstname.lastname@example.org