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Roles of Speech-Language Pathologists in the Neonatal Intensive Care Unit: Technical Report
Ad Hoc Committee on Speech-Language Pathology Practice in the Neonatal Intensive Care Unit (NICU)
Reference this material as: American Speech-Language-Hearing Association. (2004). Roles of SpeechLanguage Pathologists in the Neonatal Intensive Care Unit: Technical Report [Technical Report]. Available from www.asha.org/policy. Index terms: newborns, neonatal intensive care units, early intervention, newborns doi:10.1044/policy.TR2004-00151
Copyright 2004 American Speech-Language-Hearing Association. All rights reserved. Disclaimer: The American Speech-Language-Hearing Association disclaims any liability to any party for the accuracy, completeness, or availability of these documents, or for any damages arising out of the use of the documents and any information they contain.
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About This Document
This technical report was prepared by the American Speech-Language-Hearing Association (ASHA) Ad Hoc Committee on Speech-Language Pathology Practice in the Neonatal Intensive Care Unit (NICU). Members of the committee were Justine J. Sheppard (Chair), Joan C. Arvedson, Alexandra Heinsen-Combs, Lemmietta G. McNeilly, Susan M. Moore, Lisa A. Newman, Meri S. Rosenzweig Ziev, and Diane R. Paul (ex officio). Alex F. Johnson and Celia Hooper served as monitoring officers (vice presidents for speech-language pathology practices, 20002002 and 20032005, respectively). This technical report provides the background and support for the ASHA position statement on the roles of speechlanguage pathologists in the NICU (ASHA, 2004a). ASHA's Executive Board approved this report in October 2003. ****
Executive Summary
Among the immediate medical and behavioral complications confronting infants and their families in the Neonatal Intensive Care Unit (NICU) are feeding, swallowing, and communication issues. In addition, the NICU graduate has been found to be challenged in the long term with deficits in receptive and expressive language skills, related cognitive functions, and increased frequency of dysphagia. Speech-language pathologists (SLPs) have been involved in the assessment and management of pediatric feeding and swallowing disorders since the 1930's. In the 1970's, a clinical literature emerged leading to the expansion of the role of the SLP in research and clinical practice related to pediatric feeding and swallowing. Concurrently, SLPs increased their involvement in clinical management and research related to communication development in infants and toddlers. SLPs' involvement with the birth-to-three population surged with the passing of federal legislation related to early intervention (e.g., Part C of the Individuals with Disabilities Education Act; IDEA 1997). SLPs are providing services in the NICU and are engaging in research in fetal development, and neonatal behavior and management.
Philosophical Perspectives on Care in the NICU

Effective communication and adequate nutrition are fundamental to human functioning. The development of communication and swallowing behaviors begins in utero and continues to mature in the postnatal period. Interruption or disruption of the developmental process has consequences for further maturation of the individual. In recognition of this fact, SLPs have been involved increasingly in the delivery of communication and swallowing services to younger and younger children. SLPs are competent in the assessment of parent and child communication interactions, acquisition of receptive and expressive speech and language skills, and swallowing and feeding functions and behaviors. As a consequence of their expertise, SLPs are particularly suited for therapeutic involvement within the NICU. The purpose of this report is to describe the nature of communication and swallowing development and disorders that are present in neonates and to delineate the role of the SLP in the delivery of services to infants in the NICU.
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SLP roles and responsibilities. SLPs who practice in the NICU provide an array of services that require specialized knowledge (Billeaud, 1993). Services include those provided to and for NICU staff, parents, families of the infants, and to the infants themselves (Rossetti, 1986). Appropriate roles for speech-language pathologists as members of the NICU team, include, but are not limited to: 1. Communication evaluation and intervention, in the context of developmentally supportive and family-focused care. Perform developmentally appropriate assessments of prelinguistic and sociocommunication interactions, including neurodevelopmental assessments. Identify additional disorders that impact communication and make referrals to other professionals as appropriate. Enhance the infant's developmental outcomes and prevent secondary sequelae by providing specific interventions to facilitate social, interactive communication. Intervene to enhance communication directly with infants and indirectly through culturally appropriate family and other caregiver education. 2. Feeding and swallowing evaluation and intervention, to include prefeeding, assessment and promotion of readiness for oral feeding, evaluation of breast and bottle- feeding ability, and completion of videofluoroscopic swallowing evaluations. Perform developmentally appropriate clinical assessments of feeding and swallowing behavior. Perform instrumental assessments that delineate structures and dynamic functions of suckling/swallowing and cardiopulmonary correlates. Diagnose suckling/swallowing disorders and determine the abnormal anatomy and physiology associated with these disorders. Identify additional disorders that impact feeding and swallowing and make referrals to other professionals as appropriate. Enhance the infant's developmental outcomes and prevent secondary sequelae by providing specific interventions to facilitate safe feeding and swallowing. Intervene to facilitate feeding and swallowing skills and adequate skills for safe hydration and nutrition directly with infants, indirectly through culturally appropriate education and counseling for the family and other caregivers. 3. Parent/caregiver education and counseling, staff (team) education, and collaboration, which includes information regarding developmental expectations, communication interaction patterns, and feeding and swallowing behaviors. Contribute to the NICU team's developmental care plan with a focus on communication, cognition, and feeding/swallowing. Contribute to a supportive and nurturing environment in the NICU to enhance development. Provide culturally appropriate educational and counseling opportunities to families, team members, and others involved in care of the infant focusing on communication and feeding/swallowing. 4. Other roles SLPs assume in the NICU include: Quality control/risk management Maintain quality control/risk management program. Discharge/transition planning and follow-up care
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Participate in discharge planning and contribute to a smooth, seamless transition to other levels of care, to home, and to community. Professional education and supervision Educate and supervise SLPs, including clinical fellows and studentsin-training. Public education and advocacy Provide public education and advocacy for serving infants and families in the NICU. Advocate for infants and their families to get services that may assist in reaching neurodevelopmental potential. Research Participate in basic scientific and clinical research to advance the body of knowledge relevant to communication development and feeding and swallowing for infants in the NICU.
Principles of Preferred Practice in the NICU

Principles of preferred practice in the NICU include family-centered and developmentally supportive care, with consideration for multicultural and individual family needs, and for the impact of the NICU experience on the family. Family-centered care and developmentally supportive care. Family-centered care is the compassionate, open, total inclusion of the family in the care and decisionmaking process for their baby (Browne & Smith-Sharp, 1995, p.19). Familycentered care addresses the challenges families may face regarding communication with the hospital staff, environmental and developmental concerns, pain management, ethical decision-making, and follow-up (Harrison, 1993). Parents need information about self-advocacy, child development, their child's condition, financial resources, and service coordination (Billeaud, 1993). Families often require assistance in learning to interpret their infant's nonverbal communication signals (Als, 1982a, b; Billeaud, 1993). Developmentally supportive care is based on the premise that the infant's behavior provides the best information from which to design care (Als, 1982a, b). This type of care involves observation of the infant to determine useful strategies to support the infant's physiological stability, selfregulation, behavioral organization, and developmental progression (Als & Gilkerson, 1995). Multicultural and individual family needs. SLPs who work in the NICU recognize that a family's cultural beliefs, values, language, and practices shape their response to instruction regarding their infant's care and support, and determine access to medical care and intervention for infants in the NICU. SLPs develop culturally appropriate programs that meet the needs of ethnically and linguistically diverse families. Moreover, as team members they do not make assumptions about the needs of families because of their particular cultural, racial, or ethnic group. Rather, they discuss these needs with the families directly. Interpreters are used when appropriate to help linguistically diverse families understand the information. Impact of the NICU experience. The birth of a child prematurely and/or with a complex medical condition is a traumatic event in the life of a family. The family needs to adjust to the additional stress associated with separation from the infant during hospitalization in the NICU (Als & Gilkerson, 1995; Encher & Clark, 1986). When a child is preterm and/or has a critical medical condition, parents often react
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with feelings of shock, anger, disappointment, depression, and/or guilt and may have difficulty maintaining order in their lives (Moses, 1983). Uncertainty about the infant's survival, the unfamiliar environment of the NICU, rapid changes in the infant's condition, and a sense of being out of control, can interfere with and disrupt the family system (Browne & Smith-Sharp, 1995). The family is also mourning the loss of the normal child they did not have. The SLP supports the family members through education that enhances their ability to communicate with and understand their child, to nourish their infant, and to mitigate the effects of the NICU experience on the infant's development. Populations in the NICU. Approximately 12% of the 4.02 million infants born in the United States in 2002 were preterm (i.e., born at less than 37 complete weeks of gestation) and 7.8% were low birth weight (i.e., born at less than 2,500 grams). The number of LBW infants has increased since the mid-1980s and was higher in 2002 than in more than three decades. The rate of VLBW infants (i.e., born at less than 1,500 grams) was 1.45% in 2002 and has remained stable since 1998. The 2002 preterm birth rate increased 20% since 1981 (Hamilton, Martin & Sutton, 2003). Although some preterm infants are healthy, they generally require specialized, comprehensive care in a NICU to support their development. Other preterm infants have compromising medical conditions and a more complex course of care. In addition to preterm infants, term infants also may receive services in a NICU. Among these are term infants with multiple congenital anomalies (MCA). Preterm and term infants with MCA comprise one of the largest and costliest populations (Lindower, Atherton, & Kotagal, 1999). Common etiologies of preterm and term infants with conditions that require NICU placement fall into these broad diagnostic categories: neurologic, gastrointestinal, respiratory, cardiac, and multiple congenital anomalies. Forty percent of preterm infants exhibit feeding difficulties. Neonates with prolonged respiratory support and delayed enteral and oral feeding are most often and most severely affected (Hawdon, Beauregard, Slattery, & Kennedy, 2000). Team participation in the NICU. A team of specialists from varied disciplines follows infants and their families. The team may vary in composition depending upon the level of care required, the specific needs of the infant, and the specific needs of staff and families. Usually, there is a core team and consultant support. The parents, as participants in decision-making for their infant, are included as core team members. Federal legislation regarding intervention in the NICU. Federal legislation related to newborn care provides a framework for assuring appropriate care for the infant in the NICU and after discharge. Pertinent legislation includes the Individuals with Disabilities Education Act (IDEA '97-Part C) and universal infant hearing screening legislation. As mandated by the Newborn and Infant Hearing Screening and Intervention Act of 1999 (H.R. 1193), hearing screening is performed on every infant prior to discharge. Part C of IDEA provides a description of a family-centered, community-based, comprehensive, coordinated, interagency, and
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multidisciplinary system, for infants at risk for disability or developmental delay and their families. In some instances the process of evaluation, family support planning, and intervention is initiated in the NICU.
Infant Development
Prenatal to postnatal continuity and discontinuity. In order to provide developmentally supportive care, SLPs and other members of the NICU team need to be knowledgeable about typical infant development. Development of the neonate and the young infant is continuous with that of the fetus. At birth the infant responds to the extra-uterine environment by adapting behaviors that have been ongoing in utero and by generating new behaviors that will accommodate the new demands. Movement in a gravitational environment, respiration, oral feeding, and adaptation to novel tactile, kinesthetic, and acoustic environments are behaviors that emerge through interactions between genetic expression and extra-uterine, environmental signals (Brauth, Hall, & Dooling, 1991; Emory, 1998). Changes in central nervous system (CNS) structures support the postnatal discontinuation of behaviors that occurred in utero and are no longer needed, and the emergence of the new extra-uterine behaviors (Brauth et al., 1991; Kupfer, 1998; Prechtl, 1984). Emory and Israelian (1998) have proposed a model for prenatal cognitive development. The model describes the third trimester as a period in which sensory motor behaviors emerge. These behaviors are predictable and responsive to the stimulus environment. Learning during this period is seen in the coupling of previously disconnected physiological and behavioral phenomena. In addition, identifiable rest-activity cycles emerge that reflect increasing capabilities for inhibitory control and state regulation (Emory, 1998). Prenatal development during the late second and third trimesters is characterized by emerging behavioral patterns. These are: 1. Spontaneous behaviors that are increasingly regulated by external stimulation (Emory, 1998). 2. Anticipatory action in which adaptive functions, such as grasping, sucking, and breathing movements, habituation, and preference for maternal voice appear in advance as foundations for postnatal adaptations (Fifer & Moon, 1989; Leader & Baillie, 1988; Prechtl, 1984). Prechtl observed that the spontaneous motor patterns of the fetus become responsive to specific stimuli after birth. 3. Neuromotor integration in which isolated movements are seen to merge into coordinated patterns (Emory & Israelian, 1998; Miller, Sonies, & Macedonia, 2003). 4. Behavioral synchrony in which individual physiological events are coupled, such as changes in fetal heart rate during fetal movement (Emory & Noonan, 1984). 5. Inhibitory control and state regulation in which arousal and the ability to inhibit or suppress behavior are manifest as rest and activity cycles (Nijhuis, Martin, & Prechtl, 1984). Neonatal psychology and communication. Patterns of early communication between mothers and young preterm and full-term infants have been described (Brazelton, 1974) and are considered to be the basis for bonding and attachment between parent and infant (Klaus & Kennell, 1976). The infant's contribution to establishing and maintaining this attachment is based on perceptual and reflex
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capacities that include preference for the human face over other visual stimuli, moving in rhythm to human voice (Condon & Sanders, 1974), orienting with eyes, head, and body to animate sound stimuli (Brazelton, 1974), alerting with human holding, quieting with picking up and rocking (Korner & Thoman, 1972), and orienting selectively to smellpreferring the scent of his or her own mother's milk by six days of age (McFarlane, 1975). These capabilities enable the human infant's social interaction from the earliest days of life. Infant anatomy and physiology. The upper aerodigestive tract of the young infant differs in relative and absolute size of oral and pharyngeal structures (Crelin, 1973). In term infants, these structures support nutritive suckling. In general, there is a linear relationship between the growth of oral, lingual, pharyngeal, and laryngeal structures and gestational growth in utero from 15 to 38 weeks. However, rate of growth differs among structures (Miller et al., 2003). Suckling behavior has been shown to mature from 34-week post conceptual age with respect to the number of sucks for each swallow, intensity of suckling pressure, and average time between sucks (Gewolb, Vice, Schweitzer-Kenny, Taciak, & Bosma, 2001; Lau, Alagugurusamy, Schanler, Smith, & Shulman, 2000; Medoff-Cooper, McGrath, & Bilker, 2000). Differences in tongue movements have been observed in preterm infants at 33 to 34 weeks gestational age compared with term infants (Bu'Lock, Woolridge, & Baum, 1990). Cardiorespiratory factors can interfere with progression to full oral feeding. Such factors may include central and obstructive apnea, bradycardia, and respiratory illness (e.g., transient respiratory distress, respiratory distress syndrome, bronchopulmonary dysplasia, pulmonary insufficiency of prematurity) (Mandich, Ritchie, & Mullet, 1996; Morris, MillerLoncar, Landry, Smith, Swank, & Denson, 1999).
Assessment
SLPs in the NICU evaluate communication development and feeding and swallowing function through clinical and instrumental examinations. As members of the NICU team, SLPs also participate in overall developmental assessments, including neurodevelopmental assessments. An SLP's standard pediatric clinical examination consists of history, physical examination including overall developmental assessment, observation of nonnutritive and potentially nutritive suckling and swallowing, and the effectiveness of parent and child interactions for feeding and communication. The SLP considers parental, nursing, and other medical input to determine infant readiness for oral feeding. Cervical auscultation may be used as an adjunct to clinical observations for assessing breath sounds and timing of swallowing. It may be useful as part of a complex of clinical observations to determine readiness of infants to initiate oral feeding and to transition to full oral feeding. However, procedures for its use have not been standardized. The SLP's instrumental methods for evaluating swallowing function include, but are not limited to, video-fluoroscopic swallow study (VFSS), endoscopic assessment, and ultrasonography (ASHA, 2002b). Infants are referred for instrumental examination as an extension of the clinical assessment to answer specific diagnostic questions and guide treatment decisions. SLPs follow a protocol for and interpretation of VFSS that is developmentally appropriate and considers gestational age, positioning, bolus presentation, viscosity of bolus, respiratory rate, and swallowing variability. Fiberoptic nasopharyngolaryngoscopy when used with infants assesses, primarily, the anatomy and
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physiology of the upper aerodigestive tract. However, the swallowing component may be incorporated as needed. Ultrasonography has been used to study sucking and oral transit in breast-fed and bottle-fed infants (Bosma, 1986; Bu'Lock, et al., 1990; Weber, Woolridge, & Braun, 1986; Yang, W. T., Loveday, E. J., Metrewell, C., & Sullivan, 1997). Although ultrasonography provides capabilities for observations of the natural feeding process in a natural environment, it has not been used extensively. Communication and developmental assessment. As part of their overall evaluation of communication and development, SLPs may be the professionals who administer neurodevelopmental assessments. These general developmental assessments, all of which require additional training and certification for their use, include the Naturalistic Observations of the Newborn, Assessment of Preterm Infant Behavior (Als, 1985), and the Neonatal Behavioral Assessment Scale (Als, Lester, Tronick, & Brazelton, 1982; Brazelton & Nugent, 1995), The Neonatal Neurological Examination (Sheridan-Pereira, Ellison, & Helgeson, 1991), and The Neurological Assessment of the Preterm and Full-term Newborn Infant (Dubowitz, Dubowitz, & Mercuri, 1999).
Evidence Related to Outcomes of Treatment

Studies have addressed the broad category of NICU interventions known as developmental care that are designed to minimize the stress placed on the infant and the family by the NICU environment. SLPs, as part of a team of professionals, typically evaluate infants with a primary focus on promoting successful feeding, and caregiver-infant interactions. Furthermore, the SLP facilitates the acquisition of developmentally appropriate communication skills and the underlying competencies that will support further development. Results of 31 studies meeting criteria for randomized trials indicate that a cluster of developmental care interventions benefit preterm infants with respect to improved short-term growth outcomes, decreased respiratory support, decreased length and cost of hospital stay, and improved neurodevelopmental outcomes to 24 months corrected age. Lack of blinding of assessors was a significant methodological flaw in half of the studies. Reviewers concluded that before a clear direction for practice can be supported, evidence demonstrating more consistent effects of developmental care interventions on important short- and long-term clinical outcomes, is needed.
Supplemental Stimulation
Research studies have addressed the effects of vestibular, auditory, and tactile/ kinaesthetic stimulation on state regulation. Vestibular stimulation (VS). Korner (1990) found VS to reduce state level in term and preterm infants. VS reduced the intensity of internal needs (e.g., crying or state disorganization) and permitted the infant to attend to external events through promotion of quiet alertness. Auditory stimulation (AS). Although not studied extensively, AS may enhance environmental adaptation (Korner, 1990). Similarities between auditory and vestibular stimulation may be in rhythmic patterning.
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Tactile/Kinesthetic stimulation (T/KS). Tactile (rubbing/stroking) and kinesthetic (passive flexing and extending limbs) stimulation administered sequentially has been described (White & Labarba, 1976). Limited evidence without formal state analysis shows that benefits obtained from tactile intervention involve heightened alertness and increased activity. T/KS can be administered to preterm infants as young as 23 weeks gestational ages and birth weights as low as 630 g as long as they are clinically stable (Acolet et al., 1993). Weight gain may be enhanced. Massage has been shown to reduce plasma cortisol levels.
Outcomes with Feeding Focused Interventions

Readiness for oral feeding has been the primary outcome considered in studies of feeding focused interventions. Readiness for oral feeding in the preterm infant is associated with the infant's ability to come into and maintain awake states and also to coordinate breathing with sucking and swallowing (McCain, 1997) and the presence of apnea. Apnea is strongly correlated with longer transition time to full oral feeding (Mandich et al., 1996). Introducing breast as opposed to bottlefeeding, the role of kangaroo mother care (KMC), nonnutritive sucking (NNS), and oral stimulation combined with other modalities are interventions that have been considered. Breast versus bottle-feeding. Bier and colleagues (1993) studied readiness for breast versus bottle-feeding. They concluded that (1) VLBW infants can safely breast and bottle-feed at the same postnatal age, (2) VLBW infants are less likely to have oxygen desaturation to less than 90% during breast-feeding than during bottle-feeding, and (3) weight gain is less during breast-feeding. In contrast, Lemons and Lemons (1996) found that the earliest an infant can initiate breastfeeding is at 32 weeks gestation, with bottle-feeding starting at 34 weeks gestation. Considerable variability is found among individual infants. If the assessment indicates that clinical intervention is not indicated, basic nursing, parent preparation of an infant, and watchful waiting for feeding readiness will continue. Kangaroo mother care (KMC). KMC skin-to-skin contact between a mother and her newborn infant, has been found to be an important factor in LBW infants achieving readiness for oral feeding, particularly breast-feeding, and earlier discharge from the hospital. Non-nutritive sucking (NNS). Multiple studies have revealed the usefulness and cost-effectiveness of oral stimulation using NNS via pacifier. Results of studies of the relationship between NNS and nutritive sucking (NS) are not conclusive. Oral stimulation combined with other modalities. Evidence across studies supports the use of auditory, tactile, visual, and vestibular intervention that includes oral and facial stimulation. These combined interventions appear to produce positive effects on improved alertness in the first five minutes of intervention, feeding progression in preterm infants (McCain, Gartside, Breenberg, & Lott, 2001), reduced length of hospital stay (Field 1980, 1988; White-Traut et al., 2002), decreased apnea, more stable organization of state, increased weight gain, decreased abnormal reflexes, and superior sensory and motor performance on behavioral assessments.
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Transition to Breast/Bottle-Feedings
A survey of NICUs in the United States revealed that fewer than 50% of respondents had identified specific criteria and had established a policy for initiation of oral feedings (Siddell & Froman, 1994). Notwithstanding, there was an emerging consensus for using infant behavioral cues, gestational age, and weight criteria to make feeding decisions. To date, no clearly defined profile of neonate behavior predictive of success at oral feeding (either breast or bottle) predominates in clinical practice. Although nasogastric (NG) tube feeding may be a necessary means to compensate for deficient suckling and swallowing, those infants who experience this modality are reported to have some negative responses.
Outcomes With Specific Etiologies

Infants with selected etiologies have been found to have problematic outcomes (Lindower, Atherton, & Kotagal, 1999). The study populations include term newborns admitted to NICU with asphyxia at birth and low Apgar scores (Asakura et al., 2000); infants with newborn encephalopathy (Dixon et al., 2002); and infants with major congenital malformations. Severe respiratory complications (SRC). Infants with SRC experience an increased length of time to reach full enteral feedings and poorer cognitive outcomes at 24 months corrected age (Morris et al., 1999). Preterm infants with bronchopulmonary dysplasia (BPD) and delay in attainment of stable suckle and swallow rhythms are predisposed to subsequent feeding problems and may be neurologically impaired (Gewolb et al., 2001; Hawdon et al., 2000). A parentfocused intervention program (COPE) for infants with SRC improved infant mental development scores at 3 months' corrected age, and resulted in an even wider gap at 6 months' corrected age than control infants (Melnyk et al., 2001). Low birth weight. LBW infants are at an increased risk for language and communication problems, however, causes for language delay early in life are yet to be explored (Lacerda, 2001; Yliherva, Olsen, Maki-Torkko, Koiranen, & Jarvelin, 2001). A cohort of 284 6.5-year-old children who required neonatal intensive care (NIC) were compared for speech and language skills with 40 controls. Scores lower than the 10th percentile were more common in NIC groups who were born at term or at 2331 weeks, than in those born at 3236 weeks gestational age. The linguistic areas of auditory discrimination, imitation of articulatory positions, and imitation of sentences were affected most severely. NIC children born at 3236 weeks performed better in the last two areas than those born at <32 weeks. Twinning with birth at 2831 weeks was associated with increased risk of scoring below the 10th percentile and of scoring below the 10th percentile on more language-related measures (Sedin, 1999). Numerous reports indicate that preterm delivery and VLBW are associated with substantial developmental impairment. Initial difficulties include problems with autonomic control, state organization, and attention regulation (Als, 1986). More long standing problems include auditory and visual deficits and delays in crossmodal transformations (Rose, Gottfried, & Bridger, 1978); abnormal reflexes (Howard, Parmelee, Kopp, & Littman, 1976); inferior grasping and hand use; lower IQ, language, and reading difficulties; academic underachievement (Cohen,
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Parmelee, Beckwith, & Sigman, 1986); and behavioral problems such as hyperactivity and internalizing disorders (Rose, Feldman, Rose, Wallace, & mcCarton, 1992).
Counseling and Support

As noted by Shaker (1999; 2000), the infant's medical status, uncertain outcome, the highly technical environment of the NICU, and the potential maternal complications following labor and delivery of a preterm or medically involved infant may contribute to family stress and crisis. Typical feelings expressed by families as described by Moses (1983) and others suggest families need environments and opportunities for interaction in which they can express their feelings openly in a nonjudgmental arena and discuss plans for managing situations with one or more of the NICU staff (Griffin, 2001; Smith & Hart, 1994). Family Participation. The importance of including the family of the infant in developmentally-based interventions is supported by Parker, Zahr, Cole, & Brecht, (1992). Their findings suggest that teaching assessment and interaction strategies based on infant-initiated cues to mothers resulted in more positive outcomes when compared to a group who did not receive training and education. Results of a nineyear longitudinal study of infants (Achenbach, Howell, Aoki, & Rauh, 1993) whose mothers participated in a NICU and follow-up training program, indicated that the children of these mothers scored higher on measures of mental ability and had advanced more rapidly in school than did children whose mothers did not receive the training. SLPs and other team members facilitate parental involvement in all aspects of the infant's care in the NICU. They assist the families in understanding the etiology of the presenting condition, specific strategies to facilitate growth and development, methods and procedures for feeding and positioning, and handling the infant during feeds. Equipment. Monitoring equipment is an integral element of the NICU, and families require education to use the equipment as a support to their abilities to understand the child's behaviors and responses. Education on how and why the various monitoring devices are used will reduce the parents' fear of harming their medically fragile infants. This also leads to understanding the use and advantages of any adaptive equipment that is needed to optimize the child's feeding, growth, and development following discharge.
SLP Education and Training Needs

Educating and training staff for the NICU environment. The SLP in the NICU brings to the team a wealth of knowledge regarding the nature of infant communication interactions and oral-pharyngeal motor competencies; development of feeding, swallowing, and vocal behaviors; prenatal to postnatal continuities in audition, cognition, swallowing, and regulatory functions; and other aspects of infant development. In addition, SLPs provide interventions for facilitating development of these behaviors and mitigating the effects of pathology and of the NICU experience on the infants and their families. These contributions require that SLPs receive specialized training for team collaboration and for direct patient care. It is assumed that preparation for this advanced practice role for the SLP, as for other disciplines represented on the NICU team, must go beyond entrylevel disciplinary practice (Browne, Vandenberg, Ross, & Elmore, 1999).
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Comprehensive education is needed for accessing the rapidly expanding knowledge base and for meeting the demands of, and responding to, the complex needs of infants and family members. Clearly, more courses and internship experiences with this population are needed at the preservice and in-service levels. In addition, specialized training is needed in the areas of theory development (Als, 1982a), neonatal neuroanatomy, anatomy, physiology, brain development, fetal neuromotor and reflex development, and developmental acquisition of infant motor behaviors, including the influence of muscle tone, oral sensory and motor experiences, and sensory processing. Extensive experience with infants and families is needed in addition to training in infant-family bonding, infant care-giving relationships, and the psychology of illness and its impact on the family experience. The SLP must be educated in the various aspects of the NICU milieu, including personnel, team process, equipment, and infection control. Finally, the SLP should be trained for implementation of intake, discharge, and follow-up. Management-specific knowledge and skills include assessment and intervention methods that are specific to the populations served in the domains of communication, vocal behaviors, feeding and swallowing behaviors, cognition, and other oral sensory-motor behaviors (ASHA, 2004a, b, c). Knowledge and skills for the SLP include instrumental evaluation of infant swallowing and clinical evaluations that examine underlying competencies in reflexive and voluntary movements, respiratory control, and integrity of structures as well as functional competencies (ASHA, 2002a).
Research Needs
Additional evidence that supports SLP practice in the NICU is needed. Basic and applied research needs to be developed in those domains for which the SLP is arguably the most qualified provider. These are feeding and swallowing, communication, cognition, oral sensory-motor function, vocal behavior and prevention and correction of feeding, swallowing, speech production, and receptive and expressive language deficiencies. Additional intervention studies could provide a level of evidence that is adequate for unequivocal support of individual interventions and intervention programs. Research needs are apparent in all areas of concern for practices in the NICU.
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Among the immediate medical and behavioral complications confronting infants and their families in the NICU are feeding, swallowing, and communication issues. In addition, the NICU graduate is challenged in the long term with respect to receptive and expressive language skills, related cognitive functions, and increased frequency of dysphagia. Speech-language pathologists (SLPs) have been involved in the assessment and management of pediatric feeding and swallowing disorders since the 1930's. In the 1970's, a clinical literature emerged leading to the expansion of the role of the SLP in research and clinical practice related to pediatric feeding and swallowing. Concurrently, SLPs also became increasingly involved in clinical management and research related to communication development in the infant and toddler population. Neonatology, a medical subspecialty of pediatrics, emerged in the 1960's. Separate NICUs evolved over the next decade. SLPs' involvement with the birth to three population surged with the passing of federal legislation related to early
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intervention (e.g., Part C of the Individuals with Disabilities Education Act; IDEA 1997). Currently, SLPs are providing services in the NICU and are engaging in research in fetal development, and neonatal behavior and management.
Philosophical Perspectives on Care in the NICU

Effective communication and adequate nutrition are fundamental to all aspects of human functioning. The development of communication skills and swallowing behaviors begins in utero and continues to mature in the postnatal period. Any interruption or disruption of the developmental process has consequences for further maturation of the individual. In recognition of this fact, SLPs have been involved increasingly in the delivery of communication and swallowing services to younger and younger children. SLPs are competent in the assessment of parent and child communication interactions, acquisition of receptive and expressive communication skills, and swallowing and feeding functions and behaviors. As a consequence of their expertise, SLPs are particularly suited for therapeutic involvement within the NICU. The purpose of this report is to describe? the nature of communication and swallowing development and disorders that are presented in neonates and to delineate the role of the SLP in the delivery of services in the NICU. This report will address patient populations, principles of preferred practice in the NICU, the NICU environment, infant development, assessment and intervention, pre-service and in-service education and training, and research needs. In addition, appendices will include terminology and resources. SLP roles and responsibilities. SLPs who practice in the NICU provide an array of services that require specialized knowledge (Billeaud, 1993). As communication, feeding, and swallowing specialists, SLPs provide the early intervention in the NICU. Services include those provided to and for NICU staff, parents, and families of the infants and direct services to neonates (Rossetti, 1986). SLPs' roles and responsibilities in the NICU encompass three primary areas (ASHA, 2004a): 1. Communication evaluation and intervention, in the context of developmentally supportive and family-focused care. 2. Feeding and swallowing evaluation and intervention, to include prefeeding assessment and promotion of readiness for oral feeding, evaluation of breast and bottle-feeding ability, and completion of instrumental swallowing evaluations. 3. Parent/caregiver and staff (team) education, which includes information regarding developmental expectations, communication interaction patterns, and feeding and swallowing behaviors. An SLP's communication evaluation of an infant involves observation and interpretation of, and response to, communication behaviors including those expressed by physiologic, motoric, and state changes. SLPs provide intervention to facilitate effective communication between parents/caregivers and infants. The SLP may guide parents, other family members, and other caregivers in understanding and responding to behavioral cues. Responding to infant communication includes adjusting the manner in which care is provided and altering the infant's environment. SLPs also consult with NICU staff and other team members to help them recognize an infant's behavior as a form of meaningful
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communication. Other roles SLPs assume in the NICU include: quality control/ risk management; discharge/transition planning and follow-up care; professional education and supervision; public education and advocacy; and research. Swallowing and feeding evaluation includes assessment of an infant's readiness and ability to feed and instrumental swallowing studies. Intervention services focus on general oral, sensory-motor development, and transition to oral feeding. SLPs are responsible for providing specific education to families regarding developmental expectations for communication, feeding, and swallowing, and other developmental domains. In addition, the SLP provides information specific to the infant's existing impairments and related disabilities in communication, feeding, and swallowing. Thus, SLPs are integral members of a team in the NICU formed to address the comprehensive and complex needs of infants and families receiving services and supports.
Principles of Preferred Practice in the NICU

The following discussion will focus on principles of preferred practice. These include family-centered and developmentally supportive care, multicultural, and individual family needs, and consideration of the impact of the NICU experience on the family. Contemporary care practices in the NICU encourage familyprofessional alliances that support the family's participation and preparation for ongoing care of their infant (Als & Gilkerson, 1995). This approach is developmentally supportive to the infant and is sensitive to the particular cultural perspectives and individual needs of the infant's family members as they cope with their NICU experience. Family-centered care and developmentally supportive care. Family-centered care is the compassionate, open, total inclusion of the family in the care and decisionmaking process for their baby (Browne & Smith-Sharp, 1995, p. 19). Familycentered care addresses the challenges families may face regarding communication with the hospital staff, environmental and developmental concerns, pain management, ethical decision-making, and follow-up (Harrison, 1993). Parents need information about self-advocacy, child development, their child's condition, financial resources, and service coordination (Billeaud, 1993). Families often require assistance in learning to interpret their infant's nonverbal communication signals (Als, 1982a, b; Billeaud, 1993). As an integral member of the team, SLPs support families by acknowledging and affirming their positive, instinctive attempts to foster communication development with their infant. Developmentally supportive care is based on the premise that the infant's behavior provides the best information from which to design care (Als, 1982a, b). This type of care involves observation of the infant to determine useful strategies to support the infant's physiological stability, self-regulation, behavioral organization, and developmental progression (Als & Gilkerson, 1995). Sharing this information with the caregiving teams and the family is a key component of this approach. SLPs develop their expertise for implementing developmentally supportive care as part of the NICU team through participation in appropriate specialized training (Vandenberg, 1993).
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Multicultural and individual family needs. SLPs who work in the NICU recognize that a family's cultural beliefs, values, language, and practices shape their response to instruction regarding their infant's care and support. SLPs develop culturally appropriate programs that meet the needs of ethnically and linguistically diverse families. Cultural values, beliefs, language, and practices impact access to medical care and intervention for infants in the NICU. This is particularly so for infants with serious medical/surgical conditions. Families who have a limited knowledge of English may not be able to understand complex medical information without an interpreter. Moreover, team members should not make assumptions about the needs of families because of their particular cultural, racial, or ethnic group. Team members should discuss these needs with the families directly. Linguistically diverse families may require an interpreter to understand the information that team members provide. Impact of the NICU experience. The birth of a child prematurely and/or with a complex medical condition is a traumatic event in the life of a family. The family needs to adjust to the additional stress associated with separation from the infant during hospitalization in the NICU (Als & Gilkerson, 1995; Encher & Clark, 1986). When a child's preterm and/or has a critical medical condition, parents often react with feelings of shock, anger, disappointment, depression, and/or guilt and may have difficulty maintaining order in their lives (Moses, 1983). Uncertainty about the infant's survival, the unfamiliar environment of the NICU, rapid changes in the infant's condition, and a sense of being out of control, can interfere with and disrupt the family system (Browne & Smith-Sharp, 1995). Parents have an expectation of what their infant will be like at birth. The premature birth of a child with a congenital defect or medical condition is incompatible with that dream expectation, and the family begins to grieve the loss of their dream (Moses, 1983). The SLP supports the family members through education that enhances their ability to communicate with and understand their child, to nourish their infant, and mitigate the effects of the NICU experience on the infant's development. Populations in the NICU. More than 4 million babies were born in the United States in 2002. Twelve percent of these infants were born prematurely (i.e., less than 37 weeks gestation) (Hamilton et al., 2003). The incidence of preterm births has risen over the past 15 years (Goldenberg & Rouse, 1998; Hamilton et al., 2003). Rates of prematurity vary among population groups. For example, the rate of preterm births is disproportionately high among African American women (18% of all live births are preterm) who account for 31% of all preterm deaths (Emory, Hatch, Blackmore, & Strock, 1993). Although some preterm infants are healthy, they generally require specialized, comprehensive care in a NICU to support their development. Other preterm infants have compromising medical conditions and a more complex course of care. The etiology of prematurity is not fully understood. Primary etiologies of prematurity appear related to multiple factors including fetal abnormalities, maternal age and health, parity, and multiple births. Other factors that may be related include poor prenatal care, cigarette smoking, psychosocial stress, low education, and socioeconomic status of the mother (Wittenberg, 1990). Medical and technological advances have resulted in increased survival of infants. The number of very low birth weight neonates continues to increase. Forty percent of
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preterm infants exhibit feeding difficulties. Neonates with prolonged respiratory support and delayed enteral and oral feeding are most affected and most severely affected (Hawdon et al., 2000). In addition to preterm infants, term infants may also receive services in a NICU. Common etiologies of preterm or term infants with conditions that require NICU placement tend to fall into several broad categories: neurologic, gastrointestinal, respiratory, cardiac, and multiple congenital anomalies. Preterm and term infants with multiple congenital anomalies comprise one of the largest and costliest groups hospitalized in a NICU (Lindower et al., 1999). NICU classifications. NICUs are classified on the basis of level of care. The classifications, which vary by state and region, relate to the complexity of the infant's needs, gestational age at delivery, and birth weight. Preterm infants of LBW (birth weight 1,500 to 2,499 grams), VLBW (birth weight 1,0001,499 grams) and ELBW (birth weight <1,000 grams) are cared for in NICUs (see Hamilton et al., 2003). From most to least intensive, levels typically include III, II, and step down or transitional units. Not all infants admitted to the NICU will require the most intensive level of care. Level III NICU care provides for infants with the most complex needs and is only available in certain hospitals. Infants are followed through a medical progression among these levels of care, as well as through their developmental progression. Team participation in the NICU. A team of specialists from varied disciplines follows infants and their families. The team may vary in composition of specialists depending upon the level of care required, the specific needs of the infant, and the specific needs of staff and families. NICU teams are staffed with representatives from several disciplines which usually include a core team and consultant support. The team may include: 1. Family members as core team participants in the care of their newborn infants with medical and developmental needs 2. Neonatologists 3. Nurses 4. Developmental pediatricians 5. SLPs 6. Audiologists 7. Other rehabilitation specialists (e.g., occupational and physical therapists) 8. Nutritionists/dietitians. 9. Lactation consultants 10. Respiratory therapists 11. Pediatric neurologists, gastroenterologists, pulmonologists, otolaryngologists, radiologists, and other medical specialists, and 12. Social workers NICUs may also offer parent resource consultants and access to parent-to-parent networks that provide information and support. In addition to NICU care, services may include the facilitation of transitions to community resources and follow-up after hospitalization.
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The NICU is increasingly configured to better address the medical, developmental, educational, and emotional needs of infants, families, and staff. The Committee to Establish Recommended Standards for Newborn ICU Design (Martin, 2003) has provided architectural guidelines for the NICU that are sensitive to family needs. Spaces immediately adjacent to or in the NICU that are recommended for the family usage may include a family lounge area, consultation room, feeding area, and family education area. The education facilities may include publications, audio-visual resources, and Internet access for obtaining information about health conditions, child development, and parenting issues, and for parent-to-parent support. This area may facilitate the practice of caregiving techniques and methods (e.g., breast-feeding, rooming-in) and afford privacy to the families. The use of parent resource consultants and cultural mediators, who are of similar background and may speak the language of the family, are a growing resource to families in need of these supports. Federal legislation regarding intervention in the NICU. Federal legislation related to newborn care provides a framework for assuring appropriate care in the NICU and after discharge. Pertinent legislation includes the Individuals with Disabilities Education Act (IDEA '97-Part C), and universal infant hearing screening legislation. As mandated by the Newborn and Infant Hearing Screening and Intervention Act of 1999 (H.R. 1193), hearing screening is performed on every infant prior to discharge from the NICU. Part C of IDEA provides a description of a familycentered, community-based, comprehensive, coordinated, interagency, and multidisciplinary system, for infants at risk for disability or developmental delay and their families. In some instances the process of evaluation, family support planning, and intervention is initiated in the NICU.
Infant Development
Prenatal to postnatal continuity and discontinuity. In order to provide developmentally supportive care, SLPs and other members of the NICU team need to be conversant in typical infant development. Development of the neonate and the young infant is continuous with that of the fetus. At birth, the infant responds to the extra-uterine environment by adapting existing behaviors that have been ongoing in utero and by generating new behaviors that will accommodate the new demands. Movement in a gravitational environment, respiration, enteral nutrition, and adaptation to novel tactile, kinesthetic, and acoustic environments are behaviors that emerge through interactions between genetic expression and environmental signals (Brauth et al., 1991; Duffy & Als, 1998; Emory, 1998). Changes in central nervous system (CNS) structures support the postnatal discontinuation of behaviors that occurred in utero and are no longer needed, and the emergence of new behaviors (Brauth et al., 1991; Kupfer, 1998; Prechtl, 1984). CNS and Behavioral Plasticity. The effects of the interaction of genetic predisposition and environment on brain development and behavior has been studied in the animal model. Of particular interest in this paper are studies of brain plasticity for cortical development (reviewed by Rakic, 1991) and studies of brain plasticity with reference to vocal behaviors of birds (Marler, 1991). Studies of
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feeding and drinking behaviors in perinatal animals indicate that taste, nutrient content, environmental temperature (Phifer, 1991), and interaction with the mother (Brake, 1991) affect motivation of the infant to feed. Animal studies indicate that capabilities observed in the fetus may not be apparent in the neonate because of the inability of the infant to cope with the changed environment. Smotherman and Robinson (1990) studied aversive responses to sour taste in the rat fetus and neonatal pup. Their studies provided evidence that the failure of the neonate to engage in the discriminative behaviors seen in the fetus was not due to immaturity of the neural substrates or to lack of prenatal to postnatal continuity. They concluded that the failure to express the behavior was due to environmental constraints presented by surfaces and gravitational forces. Studies of the human infant have examined prenatal to postnatal continuity in the development of movement behaviors. Prenatal swallowing and associated hand to mouth movements (Macedonia, Miller, & Sonies, 2002; Miller et al., 2003), breathing (deVries, Visser, & Prechtl, 1984), primitive oral reflexes (Hooker 1952; Touwen 1984), and hand to face movements (deVries et al., 1984; Miller et al., 2003) continue in the neonate as movement components of swallowing, feeding, and vocal behaviors. These movements become increasingly complex and increasingly responsive to stimulus conditions as the fetus develops (Emory, 1998; Emory & Israelian 1998; Miller et al., 2003). Studies by Hooker (1952), Humphrey (1969; 1970), and Prechtl (1984) describe postnatal continuities in primitive oral reflexes that are present at term. These reflexes are observed to function in early nutritive suckling. Miller et al. (2003) in their study of human fetuses in vivo, found significant differences between normal and atypically developing fetuses in range, extent, pattern, and vigor of oral, pharyngeal, and laryngeal movements. Similar anomalies were seen in the infants following their birth. Lecanuet, Granier-Deferre, Jacquet, Capponi, and Ledru, (1993) in their studies of human fetal responses to the human voice in the third trimester, provided evidence of prenatal auditory learning. DeCasper and Fifer (1980) and Fifer and Moon (1995) documented recognition memory in the full-term neonate for prenatal auditory experience. The fetus can hear during pregnancy (Hepper & Shahidullah, 1992) habituates to extrauterine sounds. After birth, the infant shows preference for sounds heard in utero (Fifer & Moon, 1995). Emory and Israelian (1998) have proposed a model for prenatal cognitive development. The model describes the third trimester as a period in which sensory motor behaviors emerge. These behaviors are predictable and responsive to the stimulus environment. Learning during this period is seen in the coupling of previously disconnected physiological and behavioral phenomena. During the third trimester identifiable rest-activity cycles emerge that reflect increasing capabilities for inhibitory control and state regulation (Emory, 1998). Prenatal development during the late second and third trimesters is characterized by the following emerging behavioral patterns. These are: 1. Spontaneous behaviors that are increasingly regulated by external stimulation (Emory, 1998). 2. Anticipatory action in which adaptive functions, such as grasping, sucking, and breathing movements, habituation, and preference for maternal voice appear in advance as foundations for postnatal adaptations (Fifer & Moon,
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1989; Leader & Baillie, 1988; Prechtl, 1984). Prechtl observes that the spontaneous motor patterns of the fetus become responsive to specific stimuli after birth. 3. Neuromotor integration in which isolated movements are seen to merge into coordinated patterns (Emory & Israelian, 1998; Miller et al., 2003). 4. Behavioral synchrony in which individual physiological events are coupled, such as changes in fetal heart rate during fetal movement (Emory & Noonan 1984). 5. Inhibitory control and state regulation in which arousal and the ability to inhibit or suppress behavior are manifest as rest and activity cycles (Nijhuis et al., 1984). Neonatal psychology and communication. Patterns of early communication between mothers and young preterm and full-term infants have been described (Brazelton, 1974) and are considered to be the basis for bonding and attachment early in life (Klaus & Kennell, 1976). The infant's contribution to establishing and maintaining this attachment is based on perceptual and reflex capacities that include preference for the human face over other visual stimuli, moving in rhythm to human voice (Condon & Sanders, 1974), orienting with eyes, head, and body to animate sound stimuli (Brazelton, 1974), alerting with human holding, quieting with picking up and rocking (Korner & Thoman, 1972), and orienting selectively to smellpreferring the scent of his or her own mother's milk by six days of age (McFarlane, 1975). These capabilities enable the human infant's social interaction from the earliest days of life. Neonates give cues to caregivers as to their well-being or stress while at rest, as well as during activities such as interaction and feeding. Developmentally supportive care provides excellent context within which to conceptualize feeding (Als et al., 1986; Gorski, Davison, & Brazelton, 1979). These signals may indicate either disorganized (stressed) or smooth (well modulated or well balanced) functioning (stable). Behavior in the infant is expressed by changes in: a. autonomic systempattern of respiration (pauses, tachypnea), color changes (red, pale, dusky, mottled), and visceral signs (e.g., spit up, gag, burp); b. movementpostural alignment (hyperflexed, extended), muscle tone (flaccid, hypertonicity), movement patterns in extremities, trunk, head and face, and level of motor activity; c. statethe range of available states of consciousness (i.e., deep sleep, quiet alert, and crying), the smoothness of transition between them, and the clarity of their expression; and d. attentionthe infant's ability to orient and focus on environmental stimuli, such as face, sounds, or objects. Self-regulation is the infant's ability to maintain physiological homeostasis in autonomic reactions, movement, state, and attention. Self-regulatory control is indicative of the infants' ability to cope with stress. Infant anatomy and physiology. The upper aerodigestive tract of the young infant differs from the adult in relative and absolute size of oral and pharyngeal structures (Crelin, 1973). In term infants these structures support nutritive suckling. In general, there is a linear relationship between the growth of oral, lingual, pharyngeal, and laryngeal structures and gestational growth in utero from 15 to 38
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weeks. However, the rate of growth differs among structures (Miller et al., 2003). The buccal pads are not fully developed in the preterm infant. These pads are thought to provide stability during the act of sucking. (Bosma, 1986; Crelin, 1973). Neurophysiology of the infant swallow. Knowledge of the neurophysiology of the pharyngeal stage of swallowing in the infant derives mainly from the animal model. Although the swallow is present at a prenatal stage and developed at birth, the maturation of the control of swallowing continues in the postnatal period (Miller, 1982). Relationships between swallowing, apnea, and bradycardia have been examined in the animal model (Harding, Johnson, Johnston, McClelland, & Wilkinson, 1976, Miller & Dunmire, 1976; Sasaki, Suzuki, & Horiuchi, 1977). Preterm infants may experience episodes of apnea and bradycardia while feeding orally. These studies demonstrate interdependence among swallowing and respiratory and cardiac function in the very young animal. Similar results were obtained in studies of human preterm and term infants. Thach (2001) identified a cluster of reflexes, including startle, rapid swallowing, apnea, laryngeal constriction, hypertension, and bradycardia, that were associated with an immature laryngeal chemoreflex. An increase in cough and arousal responses and reduction of other features occurred with maturation. In other studies by Davies, Koenig & Thach (1988) and Pickens, Schefft, and Thach (1989), water infused into the pharynx of sleeping, preterm infants elicited similar responses marked by repeated swallowing, apnea, airway closure, and resulting obstructed inspiration. These responses were less frequent and less prolonged in the full-term infant. Infant suckling and swallowing. Suckling is the means by which infants feed orally whether by breast or other nipples (Ardran, Kemp, & Lind, 1958). Ingestion of fluid from the nipple results from the combination of intraoral suction and external pressure on the nipple (Logan & Bosma, 1967). The sensory-motor synergies of the primitive oral reflexes are apparent in locating and latching onto the nipple (Prechtl, 1984). Expression of the nipple occurs as the tongue and jaw moves upward and backward (Ardran et al., 1958). Suction is generated as the infant lowers the floor of the mouth and tongue dorsum while maintaining an anterior seal on the nipple (Miller, 1999). The term infant can adapt quickly to changes in the dynamics of the nipple by increasing or decreasing suction and expression (Sameroff, 1968; Sameroff, 1973). When infants suckle more than once per swallow, they hold the material between the tongue and palate, between posterior tongue and palate or in the valleculae until they initiate the swallow (Kramer, 1985; Logan & Bosma, 1967; Newman, Cleveland, Blickman, Hillman, & Jaramillo, 1991). The bolus is then carried into the pharynx by a roller-like motion of the tongue approximating the palate in a front to back sequence (Logan & Bosma, 1967). Ultrasound and fluoroscopic observations of suckling in newborns revealed the piston-like squeezing or stripping action of the tongue in the bottle-feeding infants. In breast-feeding infants there was a rolling or peristaltic motion (Newman et al., 1991; Weber et al., 1986). The pharyngeal swallow occurs with greater speed in infants than in adults (Kramer, 1985; Newman et al., 1991). The airway of the infants lies at a comparatively higher level than in adults, requiring less laryngeal excursion for airway protection. A small amount of residue may remain in the valleculae in the
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normal infant swallow (Ardran & Kemp, 1970; Newman et al., 1991). The mechanics of hyoid and laryngeal motion and upper esophageal opening have not been fully examined in infants. Suckling behavior has been shown to mature from 34-week post-conceptual age with respect to the number of sucks for each swallow, intensity of suckling pressure, and average time between sucks (Gewolb et al., 2001; Lau et al., 2000; Medoff-Cooper et al., 2000). Differences in tongue movements have been observed in preterm infants at 33 to 34 weeks gestational age compared with term infants (Bu'Lock et al., 1990). Cardiorespiratory factors can interfere with progression to full oral feeding. Such factors may include central and obstructive apnea and bradycardia, and respiratory illness (e.g., transient respiratory distress, respiratory distress syndrome, bronchopulmonary dysplasia, pulmonary insufficiency of prematurity) (Mandich et al., 1996; Morris et al., 1999). Several studies have established an association between oral feeding and the occurrence of simultaneous apnea and bradycardia in preterm infants (Bu'Lock et al., 1990; Koenig, Davies, & Thach, 1990; Menon, 1984). Persistent apnea or bradycardia has been identified in infants with poorly coordinated swallowing, retained barium in the hypopharynx, and nasopharyngeal reflux (Itani, Nishimura, Nii, Su, & Oono, 1988; Kohda, Hisazumi, & Hiramatsu, 1994; Plaxico & Loughlin, 1981). Additional signs associated with nasopharyngeal reflux include choking, duskiness during or after feeding, and pneumonia. Infants with laryngeal aspiration and penetration, as documented on fluoroscopy, have an increased risk of pneumonia (Taniguchi & Moyer, 1994). Features of swallowing in suckling infants that have been associated with laryngeal penetration and aspiration include cricopharyngeal dysfunction, absence of laryngeal excursion, pharyngeal dysfunction, lingual dysfunction, slow laryngeal closure, delayed pharyngeal swallowing response, and spillover of material into the pyriform sinuses prior to initiation of the swallow (Kohda et al., 1994; Newman et al., 2001). In these studies, when infants experienced laryngeal penetration without aspiration, all were able to clear the airway during laryngeal closure as the arytenoids approached the base of the epiglottis. When infants aspirated, most did not cough or clear their airway (Newman et al., 2001).
Physical Assessment and Treatment

SLPs in the NICU evaluate communication development and feeding and swallowing function through clinical and instrumental examinations. As members of the NICU team, SLPs also participate in overall developmental assessments, including neurodevelopmental assessments. Clinical feeding and swallowing assessment. An SLP's standard pediatric clinical examination consists of history, physical examination including overall developmental assessment, observation of nonnutritive and potentially nutritive suckling, and swallowing. The SLP considers parental input, nursing another medical input from the medical team to determine infant readiness for oral feeding. There are few standardized assessments available for evaluating potential breastfeeding in the NICU. These assessments include Systematic Assessment of the Infant at Breast (SAIB) (Association of Women's Health, Obstetric, and Neonatal Nurses, 1990, and Preterm Infant Breast-feeding Behavior Scale (PIBBS)
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(Nyqvist, Rubertsson, Ewald, & Sjoden, 1996). SLPs collaborate with mothers, nurses, and lactation consultants for differential diagnosis of issues related to infant feeding ability and those related to the mother. The SAIB incorporates specific observations in the categories of alignment, areolar grasp, areolar compression, and audible swallowing. The PIBBS form is formatted as a diary to be kept by the mother. Notation categories include rooting, amount of breast in the mouth, latching, sucking, sucking bursts, swallowing, state, letdown, and time. Interrater reliability between mothers and nurses for this assessment is an area requiring further development. For the full-term infant in the NICU, the Breastfeeding Evaluation (Tobin, 1996) may be used as a guide. This tool contains a list of expectations for feedings including position, latch, suck, milk flow, intake, output, and weight gain. Its purpose is to identify when a mother would benefit from lactation support. The SLP would focus on infant behaviors related to suckling and swallowing. To assess bottle-feeding of the preterm infant, the SLP may use the Neonatal Oral Motor Assessment Scale (NOMAS; Palmer, Crawley, & Blanco, 1993). The NOMAS contains checklists of behaviors in categories of normal, disorganized, and dysfunctional tongue and jaw movement. The Feeding Flow Sheet (Vandenberg, 1990a) documents feeding observations for state, respiratory rate, heart rate, nipple, form of nutrition, position, coordination, support, quantity, and duration changes over time. The Infant Feeding Evaluation (Swigert, 1998) is not a standardized evaluation, but offers a means of documenting a variety of observations, including infant response to attempted interventions. This evaluation was devised for use from birth to 4 months, without specifying components for the preterm or ill infant. SLPs may assess sucking patterns, such as immature, transitional, and mature (Palmer, Crawley, & Blanco, 1993) or the five developmental stages of sucking (Lau et al., 2000). There is little consistency across or within most facilities regarding first feedings when a mother chooses to breast-feed. In some hospitals, as soon as the baby is ready to attempt oral feeding, even when a full oral feeding is not anticipated, the baby is put to breast. In other medical centers, infants must demonstrate the ability to safely bottle-feed before being allowed to breast-feed. In facilities that allow breast-feeding initially, weighing the infant before and after the feeding, with a gram-sensitive scale, is used to assess the quantity of intake. Research using the PIBBS supports observations of a developmental progression of sucking patterns and state control in the preterm population (Nyqvist et al., 1996). Feeding performance improves as infants' sucking skills mature. Sucking scales may be used to assess the developmental stages of sucking in preterm infants, and in turn, facilitate the management of oral feeding in these infants (Lau et al., 2000).
Instrumental Assessment
The SLP's instrumental methods for evaluating swallowing function include, but are not limited to, videofluoroscopic swallow study (VFSS), endoscopic assessment, and ultrasonography (ASHA, 2002a,b,c). Completion of every instrumental examination should answer specific diagnostic questions and guide therapeutic decisions. There are other instrumental assessments not completed by
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the SLP, the results of which will influence an SLP's recommendations. These include scintigraphy or radionuclide milk scanning, which are used to identify aspiration from swallowing or gastroesophageal reflux and to examine gastric emptying time (Latini et al., 1999; McVeagh, Howman-Giles, & Kemp, 1987; Tolia, Kuhns, & Kauffman, 1993). SLPs follow a protocol for radiographic examination of swallowing. Protocols for and interpretation of VFSS need to be developmentally appropriate and should consider the thermal status of the infant, gestational age, positioning, bolus presentation, viscosity of bolus, respiratory rate, and swallowing variability. Fiberoptic nasopharyngolaryngoscopy when used with infants is primarily for assessment of the anatomy and physiology of the upper aerodigestive tract. However, the swallowing component may be incorporated as needed. A modification of this procedure, called Flexible Endoscopic Examination of Swallowing (FEES), includes swallowing and may include sensory testing (Hartnick, Hartley, Miller, & Willging, 2000). Ultrasonography has been used to study sucking and oral transit in breast-fed and bottle-fed infants (Bosma, 1986; Bu'Lock et al., 1990; Weber et al., 1986; Yang, Loveday, Metrewell, & Sullivan, 1997). Although ultrasonography provides capabilities for observations of the natural feeding process in a natural environment, it has not been used extensively. In general, infants are referred for instrumental assessment when they are physiologically stable and when the clinical findings or history indicate possible swallowing or related abnormalities that will impact decision-making regarding oral feeding. Instrumental assessments of swallowing may be combined with information from measures of respiratory/cardiac function. Infants requiring intensive care are usually kept on cardiac, respiratory, and oxygen saturation monitors, until they are discharged from the hospital. During assessment, these monitors and observations of the infant aid in determining physiologic and behavioral correlates, such as color changes, nasal flaring, sucking-burst/breathing-pause patterns, and rate of breathing. Cervical auscultation may be used as an adjunct to behavioral observations for appreciating breath sounds and timing of swallowing. It has been found to be useful for assessing readiness to initiate nursing and transition to full nursing. However, procedures for its use have not been standardized.
Communication and Developmental Assessment

The first step in a developmental assessment by the SLP is a chart review of history and prior evaluations. The SLP in the NICU uses results of prior evaluations to compare with behavioral observations and identify delays or disorders. Developmental expectations for an infant are based on estimated gestational or adjusted age, not chronologic age. The SLP, as part of their overall evaluation of communication and development, may be the professional who administers neurodevelopmental assessments. These general developmental assessments require additional training and certification for their use. Examples include the Naturalistic Observations of the Newborn, Assessment of Preterm Infant Behavior (Als, 1985), and the Neonatal Behavioral Assessment Scale (Als et al., 1982; Brazelton & Nugent, 1995), The Neonatal
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Neurological Examination (Sheridan-Pereira, Ellison, & Helgeson, 1991), and The Neurological Assessment of the Preterm and Full-term Newborn Infant (Dubowitz, Dubowitz, & Mercuri, 1999).
Evidence Related to Outcomes of Treatment

General medical and physiologic issues - developmental care. Developmental care is defined as a broad category of interventions designed to minimize the stress placed on the infant and the family by the NICU environment. As part of a team of professionals, SLPs typically evaluate infants with a primary focus on promoting successful feeding, and caregiver-infant interactions. Furthermore, the SLP facilitates the acquisition of developmentally appropriate communication skills and the underlying competencies that will support further development. This section of the report is targeted toward evidence, albeit limited, for specific interventions related to promotion of developmental care of preterm infants, especially for feeding. In the past 23 years, the Cochrane Database Systems Review process has provided literature searches for all potentially relevant titles and abstracts of studies that measured clinically relevant outcomes. Symington and Pinelli (2001) reviewed the literature for randomized trials in which elements of developmental care are compared to routine nursery care for infants. Because of the inclusion of multiple interventions in most studies, the determination of the effect of any single intervention is difficult. Although there is evidence of some benefit of developmental care interventions overall, and no major harmful effects reported, a large number of outcomes demonstrated no or conflicting effects. The single trials that did show a significant effect of an intervention on a major clinical outcome were based on small subject populations, and the findings were often not supported in other small trials. Multiple-intervention approaches may include, but are not limited to: (1) vestibular, auditory, visual, and/or tactile intervention; (2) clustering of care activities to provide more prolonged periods for sleep; (3) positioning or swaddling for the preterm infant; and (4) nipple feeding. Results of 31 studies meeting criteria for randomized trials indicate that a cluster of developmental care interventions demonstrate some benefit to preterm infants with respect to improved short-term growth outcomes, decreased respiratory support, decreased length and cost of hospital stay, and improved neurodevelopmental outcomes to 24 months corrected age. Lack of blinding of assessors was a significant methodological flaw in half of the studies. Reviewers concluded that before a clear direction for practice can be supported, evidence demonstrating more consistent effects of developmental care interventions on important short- and long-term clinical outcomes, is needed. In long-term followup, developmental care did not alter sleep or neurodevelopmental outcome for preterm infants up to 2 years of age. Developmental care practices with infants need to be examined carefully to determine what goals may be realistic for parents who will be following through upon discharge from the hospital.
Broad Considerations for Intervention

Supplemental Stimulation. The seminal work of Gottlieb (1971) proposes a sequential development of sensory systems essentially invariant across mammalian and avian species: cutaneous/tactile, vestibular, auditory, and visual.
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Unvnas-Moberg, Widstrom, Marchini, & Windberg, 1987) hypothesized that sucking enhances GI functioning through activation of sensory nerves in the oral mucosa that stimulate the vagal nerves. Tactile stimulation is thought to promote vagal mediation via the direct stimulation of peripheral nerves such as the sciatica. Research studies have addressed the effects of vestibular, auditory, and tactile/ kinesthetic stimulation on state regulation. Vestibular stimulation (VS). Korner (1990) found VS to reduce state level in term and preterm infants. VS reduced the intensity of internal needs (e.g., crying or state disorganization) and permitted the infant to attend to external events through promotion of quiet alertness. Auditory stimulation (AS). Although not studied extensively, AS may enhance environmental adaptation (Korner, 1990). Similarities between auditory and vestibular stimulation may be in rhythmic patterning. Tactile/Kinesthetic stimulation (T/KS). Tactile (rubbing/stroking) and kinesthetic (passive flexing and extending limbs) stimulation administered sequentially has been described (White & Labarba, 1976). Limited evidence without formal state analysis shows that benefits obtained from tactile intervention involve heightened alertness and increased activity. T/KS can be administered to preterm infants as young as 23 weeks gestational ages and birth weights as low as 630g as long as they are clinically stable (Acolet et al., 1993). Weight gain may be enhanced. Massage has been shown to reduce plasma cortisol levels. Prescription for stimulation of preterm infants. Dieter and Emory (1997) describe a sequential, multimodal stimulation approach that is not contingent on the infant having reached a clinically stable state. The suggested goals include: Promoting state regulation Facilitating interface with environment Enhancing general neurobehavioral development. The early stages of treatment are aimed at assisting infants to achieve these goals. Once the infants tolerate increased alertness, T/KS can be initiated to promote weight gain. The inherent therapeutic quality of touch may be a factor. Dieter and Emory are continuing their research to compare vestibular and tactile/kinesthetic stimulation on preterm infants.
Guidelines for Intervention

There appears to be little current agreement across investigators pertaining to the value of general sensory stimulation using these modalities. Horowitz (1990) suggests that the type of stimulation may be less important than whether it promotes state regulation. Unimodal approaches have been recommended to avoid overstimulation because preterm infants lack multimodal contingencies (Lester & Tronick, 1990). Korner (1990) argues that the best approach may be one that avoids over-stimulation of visual and auditory systems and focuses instead upon more mature systems, such as tactile and vestibular.
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Evidence-based oral feeding focused intervention. Knowledge of the normal ontogeny of the rhythms of suck and swallow may enable us to differentiate immature (but normal) feeding patterns in preterm infants from abnormal patterns (Gewolb et al. 2001). This differentiation would aid in selecting appropriate intervention measures. Quantitative assessments of the stability of suck and swallow rhythms in preterm infants might predict subsequent feeding dysfunction as well as neurologic impairment. Nurses commonly report evidence-based interventions directly related to facilitation of oral feeding, with professionals from other disciplines as co-authors in some cases. When outcomes are reported, it is not always clear that the intervention was responsible, because there are likely to be multiple independent variables. The evidence is mixed, and at this time, SLPs in NICUs do not have solid, consistent evidence on which to base their management decisions and interventions. This section will cover (1) outcomes with feeding-focused interventions, (2) effects of nasogastric tubes in VLBW infants, and (3) examples of outcomes with specific etiologies. Outcomes with feeding focused interventions. Bier and colleagues (1993) studied readiness for breast versus bottle-feeding. They concluded that (1) VLBW infants can safely breast and bottle-feed at the same postnatal age, (2) VLBW infants are less likely to have oxygen desaturation to less than 90% during breast-feeding than during bottle-feeding, and (3) weight gain is less during breast-feeding. They hypothesized that reduced weight gain was associated with lower intake, and concluded that breast-feeding may require more lactation counseling or supplementation of the feeding. In contrast, Lemons and Lemons (1996) found that the earliest an infant can initiate breast-feeding is at 32 weeks gestation, with bottle-feeding starting at 34 weeks gestation. Considerable variability is found among individual infants. It is likely that the readiness relates only in part to postnatal age, with other factors, such as airway, GI tract, neurological status, and environmental variables, being more prominent. These multiple factors are likely to determine when the developmental feeding assessment is done, and whether intervention by the SLP is needed. If the assessment indicates that clinical intervention is not indicated, basic nursing, parent preparation of an infant, and watchful waiting for feeding readiness will continue.
Intervention
Readiness. Readiness for oral feeding in the preterm infants is associated with the infant's ability to come into and maintain awake states and also to coordinate breathing with sucking and swallowing (McCain, 1997) and the presence of apnea. Apnea is strongly correlated with longer transition time to full oral feeding (Mandich, Ritchie, & Mullett, 1996). Discussions of readiness for oral feeding may include the role of kangaroo mother care (KMC) (i.e., skin-to-skin contact between a mother and her newborn infant) and nonnutritive sucking (NNS). The ability to nipple feed is preceded by rhythmic, NNS accompanied by even respirations and swallowing of secretions (Lemons & Lemons, 1996). These capabilities are observed when the infant is roused to an alert state and positioned with head in mid-linea posture that facilitates swallowing.
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Kangaroo mother care. KMC has been found to be an important factor in LBW infants achieving readiness for oral feeding, particularly breast-feeding, and earlier discharge from the hospital. Other benefits of KMC include temperature regulation promotion of breast feeding, parental empowerment and bonding, stimulation of lactation, and oral stimulation for the promotion of oral feeding ability. A randomized controlled trial on 488 infants (246 in the KMC group, 242 in traditional care [TC]) supported the hypothesis that skin-to-skin contact built up a positive perception in the mothers and a state of readiness to detect and respond to infant cues (Tessier et al., 1998). The authors recommended that KMC should be initiated as soon as possible during the intensive care period up to 40 weeks gestational age. KMC was well tolerated by 20 sick, very preterm infants (median gestational age 28 weeks, birth weight 1238 g), in the first week of life (Tornhage, Stuge, Lindberg, & Serenius, 1999). On the other hand, Conde-Agudelo and colleagues (2000) reviewed multiple studies and concluded that there is insufficient evidence to recommend the routine use of KMC in LBW infants, even though it appears to reduce severe infant morbidity and has no serious deleterious effects. Nonnutritive sucking (NNS) facilitation. Multiple studies have revealed the usefulness and cost-effectiveness of oral stimulation using NNS via pacifier. Findings that support NNS in preterm infants include, but are not limited to: 1. NNS at the empty breast promotes infant state control, weight gain, breastfeeding ability, and milk production in the mother (Narayanan, Mehta, Choudhury, & Jain, 1991). 2. Oxygen saturation during nutritive sucking was higher with prefeeding NNS than when preterm infants did not receive prefeeding NNS. Significant differences were found in oxygen saturation and behavioral state after NNS behavioral state, and at start of oral feeding. With prefeeding NNS, the initiation of the first nutritive suck burst was more rapid and of longer duration. No significant differences were found in total feeding time or percent of formula taken by bottle (Pickler, Frankel, Walsh, & Thompson, 1996). 3. Increased restfulness and decreased activity was associated with NNS (e.g., Field et al., 1982). 4. Significant changes in heart rate, vagal tone, respiration, and gustatory functioning were seen (Crook & Lipsitt, 1976; Lipsitt, Reilly, Butcher, & Greenwood, 1976; Porges & Lipsitt, 1993). 5. There were shorter transitions from tube to full oral feeding (Gaebler & Hanzlik, 1996; Measel & Anderson, 1979). 6. There was more rapid maturation of the suck reflex (Bernbaum, Pereira, Watkins, & Peckham, 1983). 7. There was increased oxygenation saturation (Burroughs, Asonye, AndersonShanklin, & Vidyasager, 1978). 8. There was more rapid weight gain (Field et al., 1982). 9. There was a soothing effect of NNS on preterm infants during invasive procedures (Field & Goldson, 1984) as with music (Butt & Kisilevsky, 2000). 10. NNS improved state regulation (Gill, Behnke, Conlon, McNeely & Anderson, 1988) or resulted in fewer behavioral state changes (McCain, 1995). 11. Hospital stay was shortened for infants engaging in NNS (Gaebler & Hanzlik, 1996).
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Results of studies of the relationship between NNS and nutritive sucking (NS) are not conclusive. Similar NNS and NS patterns in bottle-feeding have been observed (Lau & Hurst, 1999). No information is available on whether development of NNS parallels that of NS (Lau & Kusnierczyk, 2001). Use of NNS as a potential indicator of readiness to feed orally is questionable (Lau & Schanler, 1996). Clearly, additional research is needed. Oral stimulation combined with other modalities. Evidence across studies supports the use of auditory, tactile, visual, and vestibular intervention that includes oral and facial stimulation. These combined interventions appear to produce positive effects on improved alertness in the first five minutes of intervention, feeding progression in preterm infants (McCain et al., 2001), reduced length of hospital stay (Field, 1980, 1988; White-Traut et al., 2002), decreased apnea, more stable organization of state, increased weight gain, decreased abnormal reflexes, and superior sensory and motor performance on behavioral assessments. Transition to breast/bottle-feedings. A survey of NICUs in the United States revealed that fewer than 50% of respondents had identified specific criteria and had established a policy for initiation of oral feedings (Siddell & Froman, 1994). Notwithstanding, there was an emerging consensus for using infant behavioral cues, gestational age, and weight criteria to make feeding decisions. To date, no clearly defined profile of neonate behavior predictive of success at oral feeding (either breast or bottle) predominates in clinical practice. A review of literature by Lemons and Lemons (1996) resulted in practical guidelines for facilitating the transition from gavage (tube) feeding to nursing. These guidelines were based on the studies of neurobehavioral development in preterm infants described by Als (1986). The guidelines suggest that 32 weeks gestation is the earliest an infant would be expected to have some limited ability to suck and swallow. Infants who are gavage fed and who show little or no reaction to placement of a tube are not current candidates for nipple feedings (MedoffCooper, 1991). Infants less than 2 kg generally tolerate orogastric (OG) tube placement better than nasogastric (NG) tube placement. The preterm infant has a limited ability to integrate the suck-swallow-breathe cycle during feeding which may impede their ability to protect the airway adequately. Preterm infants generally have a limited ability to change suckling pressures in response to flow rate through the nipple unit. This may lead to flooding of the nasopharynx. Some evidence suggests preterm infants may be better adapted to early breastfeeding than previously thought (Meier, 1988; 1990). Stable 32 week gestation infants can be put to breast safely for early feeding experiences, while bottlefeeding should not commence until about 34 weeks gestation. Many difficulties in the transition relate to limited ability to self-regulate milk flow (Mathew, 1991). Feeding strategies have been developed to minimize the work of suckling in the erroneous belief that preterm infants have a weak suck and need high flow rate delivery systems (Mathew, 1991). Sucking pressures in general are not reliable predictors of the ability to feed by mouth (Bu'lock et al., 1990). It is important to avoid high flow nipples, specifically preemie nipples and orthodontic nipples that have the highest flow rate (Vandenberg, 1990b). Considerable variation in flow rate has been noted among the same nipple types from each manufacturer. Some authors recommend avoiding high flow rate nipples, or at least using caution
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during weaning to nipple feedings. Close attention needs to be paid to the infant's behavioral cues and physiologic signs when testing with a variety of nipples. If the nipple is so pliable that the milk flow is initiated without active sucking, the oral phase of swallowing is bypassed and the infant is unprepared for the pharyngeal phases (Lemons & Lemons, 1996). Alternatively, Schrank and colleagues (1998) found that the free-flow of formula from the nipple is an effective stimulus for feeding activity in both preterm and term infants and is not associated with increased apnea or other adverse behaviors. They found that preterm infants could divert excess formula flow by drooling as an efficient airway protective behavior. They hypothesized that reduced maximum suck and swallow frequency may be a primary basis for slow feeding in preterm infants. Another technique that has been found to mitigate difficulties with nippling is cheek and jaw support. This technique enhances sucking efficiency in preterm infants (Einarrson-Backes, Deitz, Price, Glass, & Hays, 1994), fosters return of infants' prefeeding oxygen saturation values, and does not interfere with cardiopulmonary function during feeding (Hill, Kurkowski, & Garcia, 2000). Further research is needed to determine whether there is a cumulative beneficial effect of oral support and whether it influences state behavior. Infants who are fed too quickly may experience autonomic instability in the 30 minutes after the feeding. Breastfed infants who empty both breasts in sequence avoid rapid gastric distention in the first 10 minutes of feeding, because likely no more than half the feed has been taken in that time interval. In contrast, bottle-fed infants take more than 80% of their total volume in the first 10 minutes, which may exacerbate postprandial distress. Breast-feeding preterm infants. The logistics are complex for transitioning preterm infants in the NICU to breast-feeding as the mother is not present for all feedings. Use of various alternatives to the breast when the mother is not present have been studied with mixed results: (a) Use of cup instead of bottle nipple reduced nipple confusion, and allowed successful breast-feeding (Gupta, Khanna, & Chattree, 1999); (b) cup-feeding had questionable efficacy and efficiency and there was considerable spillage (Dowling, Meier, DiFiore, Blatz, & Martin, 2002); (c) NG tube supplements were more likely to result in breast-feeding at discharge and for the first 6 months than bottle supplements (Kliethermes, Cross, Lanese, Johnson, & Simon, 1999); (d) an orthodontic nipple may be appropriate for supplementing breast-feeding for some preterm infants, although there is limited evidence and lack of long-term outcomes (Dowling, 1999); and (e) nipple shield was found to be a useful means to facilitate breast-feeding in preterm infants (Clum & Primomo, 1996; Meier et al., 2000) while others have noted drawbacks (e.g., Auerbach & Riordan, 1999). Bell and colleagues (1995) described a structured intervention to improve breast-feeding success in ill or preterm infants. This protocol appears systematic and helpful, but the article is not evidence-based.
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A structured intervention was devised at the University of Iowa Hospital, for assessing readiness and progress toward breast-feeding all feedings, using the SAIB (Bell, Geyer, & Jones, 1995). After one year of implementation, successful breast-feeding of NICU infants at discharge was doubled, from 40% of mothers who were interested, to 80% (Bell et al., 1995). Overall, mothers of preterm infants find that the rewards of breast-feeding outweigh the efforts (Kavanaugh, Meier, Zimmermann, & Mead, 1997). Benefits of breast-feeding include, but are not limited to, protection against a variety of bacterial and viral infections (e.g., May, 1984), reduced incidence of necrotizing enterocolitis (e.g., Lucas & Cole, 1990), and reduced incidence of otitis media in the first year of life (e.g., Duffy, Faden, Wasielewski, Wolf, & Drystofik, 1997). Effects of nasogastric tubes in very low birth weight (VLBW) infants. Although NG tube feeding may be a necessary means to compensate for deficient suckling and swallowing, those infants who experience this modality are reported to have some negative responses. 1. There is a longer transition period from tube feedings to oral feedings (Shiao, Brooker, & DiFiore, 1996). 2. During oral feeding there is increased duration of desaturation by an average of 8 seconds, with less forceful sucking and less formula consumed (Shiao, Youngblut, Anderson, DiFiore, & Martin, 1995). 3. Oxygen saturation before, during, and after feedings is significantly lower than in infants managed with OG tubes (Daga, Lunkad, Daga, & Ahuja, 1999). 4. Decreased nasal airflow, increased airway resistance, and abnormal airway distribution is seen in infants with NG tubes in place (Symington, Ballantyne, Pinelli, & Stevens, 1995). 5. Management with intermittent NG tube insertion is problematic. Insertion stimulates the larynx. Laryngospasm, apnea, and bradycardia are more likely, and pharyngeal and esophageal trauma are possible (Symington et al., 1995).
Outcomes with Specific Etiologies

Infants with selected etiologies have been found to have problematic outcomes (Lindower et al., 1999). The study populations include term newborns admitted to NICU with asphyxia at birth and low Apgar scores (Asakura et al., 2000); infants with newborn encephalopathy (Dixon et al., 2002); and infants with major congenital malformations (one of the largest and costliest groups referred to the NICU). Infants with severe respiratory complications experience an increased length of time to reach full enteral feedings and poorer cognitive outcomes at 24 months corrected age (Morris et al., 1999). Preterm infants with bronchopulmonary dysplasia (BPD) and delay in attainment of stable suckle and swallow rhythms are predisposed to subsequent feeding problems and may be neurologically impaired (Gewolb et al., 2001; Hawdon et al., 2000).
Evidence From Outcome Studies

Evidence-based studies of general outcomes for NICU graduates have examined the effects of the NICU experience with regard to satisfaction of sleep needs, pain, noise, lighting, infant massage, parental coping, and early language acquisition.
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Measures of sleep maturation and neurodevelopmental outcome in infants up to two years of age did not differ between groups that experienced Newborn Individualized Developmental Care and Assessment Program (NIDCAP) intervention and less disruption of sleep patterns and those that experienced routine infant care. Stevens and colleagues (1999) studied the effectiveness of developmentally sensitive interventions and sucrose for relieving procedural pain in VLBW neonates. The pacifier with sucrose and pacifier with sterile water were most effective for reducing pain from single painful events (Stevens et al., 1999). Prone positioning did not decrease pain. Levels of pain experienced by preterm and term infants are of concern since pain causes stress in infants which may in turn adversely affect long-term neurodevelopmental outcomes (Whitfield & Grunau, 2000). However, there are no good measures that can be used clinically. Whitfield and Grunau (2000), who reviewed a number of studies, do not believe that longterm negative outcomes will result from repeated procedure-based pain. However, prolonged and repeated untreated pain in the newborn period may produce a relatively permanent shift in basal autonomic arousal related to prior NICU pain experience. This shift may have long-term sequelae. The most significant effect may be on later attention, learning, and behavior problems in these vulnerable children. A parent-focused intervention program (COPE) has been shown to be effective in improved infant mental development scores at 3 months' corrected age, and an even wider gap at 6 months' corrected age than with comparison infants (Melnyk et al., 2001). Findings support the need for further testing of early NICU interventions with parents to determine their effectiveness on parental coping and infant developmental outcomes. Early discharge supports formation of parentinfant attachment (Schmidt & Levine, 1990). Use of massage as complementary therapy in the NICU resulted in improved transition from touch aversion to touch acceptance; however, no long-term effects were reported (Lindrea & Stainton, 2000). LBW infants are at increased risk for language and communication problems, however, causes for language delay early in life are yet to be explored (Lacerda, 2001; Yliherva, Olsen, Maki-Torkko, Koiranen, & Jarvelin, 2001). A cohort of 284, 6.5-year-old children who required neonatal intensive care (NIC) were compared for speech and language skills with 40 controls. Scores lower than the 10th percentile were more common in NIC groups who were born at term or at 23 31 weeks, than in those born at 3236 weeks gestational age. Most severely effected were linguistic areas of auditory discrimination, imitation of articulatory positions, and imitation of sentences. NIC children born at 3236 weeks performed better in the last two areas than those born at <32 weeks. Twinning with birth at 2831 weeks was associated with increased risk of scoring below the 10th percentile and of scoring below the 10th percentile on more language- related measures (Sedin, 1999). Numerous reports indicate that preterm delivery and VLBW are associated with substantial developmental impairment. Initial difficulties include problems with autonomic control, state organization, and attention regulation (Als, 1986). More long standing problems include auditory and visual deficits and delays in cross30
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modal transformations (Rose et al., 1978); abnormal reflexes (Howard et al., 1976); inferior grasping and hand use; lower IQ, language and reading difficulties, academic underachievement (Cohen et al., 1986); and behavioral problems such as hyperactivity and internalizing disorders (Rose et al., 1992). In summary, SLPs need to be aware of the evidence base for practice in the NICU. Treatment and outcome studies provide the foundation for research and clinical practice with infants, caregivers, and other professionals.
Ethical Perspectives
Speech-language pathologists, as part of the NICU team, must be knowledgeable about policies and procedures for ethical decision-making within their hospital. There are guides for dealing with the ethical principles (Beauchamp & Childress, 1994; Goodhall, 1997; Wilson, Rubin, & Millard, 1991). ASHA's Code of Ethics (ASHA, 2003) states that SLPs shall hold paramount the welfare of persons they serve professionally. Both ethics and morality are at issue. Typically the term morality refers to widely held beliefs about the norms of right versus wrong conduct (Fletcher, Miller, & Spencer, 1995). An ethical dilemma refers to a state of moral uncertainty or ambiguity, where the question is asked; what should we do in this situation, and would such actions be justified (Fletcher et al., 1995).
Strengths of Family-Centered Care

SLPs, as integral members of the NICU team, share the responsibility for facilitating the infant's development of swallowing/feeding and communication behaviors. Furthermore, SLPs support the infant in coping with and compensating for the interruption in development that has occurred as a consequence of preterm birth or medical-surgical procedures. Families often experience limited opportunities or delayed access to interact and communicate with their infants in the NICU because of medical conditions, geographical locations (e.g., infant in regional center and family at home), family obligations to other children, work patterns, and/or family crisis. In implementing the principles of family-centered care, SLPs and other NICU team members work with families of infants to provide parent education for feeding and care protocols, to inform parents regarding their infant's gestural and vocal communication patterns, and to demonstrate developmentally supportive practices that support infant self-regulation and the ongoing development of communication skills. They may also assist in preparing families for the transition out of the NICU. Counseling and support. As noted by Shaker (1999, 2000), the infant's medical status, uncertain outcome, the highly technical environment of the NICU, and the potential maternal complications following labor and delivery of a preterm or medically involved infant may contribute to family stress and crisis. Moses (1983) and others suggest that families need environments and opportunities for interaction in which they can express their feelings openly in a nonjudgmental arena and discuss plans for managing situations with one or more of the NICU staff (Griffin, 2001; Smith & Hart, 1994). Family participation. The importance of including the family of the infant in developmentally based interventions is emphasized by Parker and colleagues (1992). Their findings suggest that teaching assessment and interaction strategies based on infant-initiated cues to mothers resulted in more positive outcomes when compared to a comparison group who did not receive training and education.
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Results of a nine-year longitudinal study of infants (Achenbach et al., 1993) whose mothers participated in a NICU and follow-up training program, indicated that the children of these mothers scored higher on measures of mental ability and had advanced more rapidly in school than children whose mothers did not receive the training. SLPs and other team members facilitate parental involvement in all aspects of the infant's care in the NICU. They assist the families in understanding the etiology of the presenting condition, acquiring specific strategies to facilitate growth and learning development, methods and procedures for feeding and for positioning, and handling the infant during feedings. Equipment. Monitoring equipment is integral to the NICU environment. Families benefit from education that enhances their ability to use this equipment to assist them in understanding their child's behaviors and responses. Education on how and why the various monitoring devices are used will reduce the parents' fear of harming their medically fragile infants. This also leads to understanding the use and advantages of any adaptive equipment that is needed following discharge to optimize the child's feeding, growth, and development.
SLP Education and Training Needs

Educating and training staff for the NICU environment. SLPs require specialized training for team collaboration in the NICU and for direct patient care. Comprehensive education is needed for accessing the rapidly expanding knowledge base and for responding to the complex needs of infants and family members. It is assumed that preparation for this advanced practice role for the SLP, as for other disciplines represented on the NICU team, must go beyond entry-level disciplinary practice (Browne et al., 1999). Clearly, more courses and internship experiences with this population are needed at the preservice and in-service levels. The SLP in the NICU should bring to the team knowledge and skills regarding the nature of normal and abnormal communication interactions, development of feeding, swallowing, and vocal behaviors, prenatal to post-natal continuities in audition, cognitive development, swallowing, and regulatory functions, and other related aspects of infant development. In addition, specialized training is needed in the areas of synactive theory of development (Als, 1982a), neonatal neuroanatomy, anatomy, physiology, brain development, neuromotor and fetal reflex development, and developmental acquisition of infant motor behaviors, including the influence of muscle tone, oral sensory and motor experiences, and sensory processing. Training in infant-family bonding, infant care-giving relationships, and the psychology of illness and its impact on the family experience should be supplemented with extensive experience with infants and families. The SLP must be educated in the various aspects of the NICU milieu, including personnel, team process, equipment, and infection control. Finally, the SLP should be trained for implementation of intake, discharge, and follow-up. Knowledge and skills that are needed for patient management include procedures that are specific to the NICU environment for assessment and intervention in the domains of communication, vocal behaviors, audition, feeding and swallowing behaviors, cognition, and other oral sensory-motor behaviors (ASHA, 2004b). Knowledge and skills for the SLP include instrumental evaluation of infant swallowing and clinical evaluations that examine underlying competencies in reflexive and voluntary movements, respiratory control, and integrity of structures as well as functional competencies for feeding and vocal behaviors (ASHA, 2002a, b, c; ASHA, 2003).
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Given the extensive body of knowledge, the wide-ranging and specialized skills that are needed for SLP practice in the NICU and the rapidly advancing information and practices in this environment, the need for advanced level training and continuing education is clearly apparent. The specific knowledge and skills needed by many SLPs providing developmental care in the NICU has been reported in the literature or presented at ASHA conventions (ASHA, 1990). The recent ASHA Task Force on Dysphagia developed a position statement and technical report and outlined specific knowledge and skills needed in the areas of swallowing and feeding (ASHA, 2002a, b, c). A survey conducted of speech-language pathologists working in NICU environments conducted by Dunn, van Kleeck, and Rossetti (1993) supports the need for formalized education at the preservice and continuing education levels.
Research Needs
An expanded evidence base that supports SLP practice in the NICU is needed. Basic and applied research needs are apparent in those domains for which the SLP is arguably the most qualified providerfeeding and swallowing, communication, audition, cognition, oral sensory-motor function, vocal behavior, and prevention and correction of feeding/swallowing of speech production and receptive and expressive language deficiencies. The needs include normal and abnormal fetal and neonatal development, assessment, intervention, and primary and secondary prevention as well as the family, cultural, and social dynamics that influence acquisition of infant behaviors and skills. It is reasonable to anticipate that additional intervention studies could provide a level of evidence that is adequate for unequivocal support of specific interventions and intervention programs. Research needs are apparent in all areas of concern for practices in the NICU.
Glossary1
Anencephaly: Congenital absence of the cranial vault, with cerebral hemispheres completely missing or reduced to small masses attached to the base of the skull. Anoxia: A lack of sufficient oxygen. Apgar Score: A system for evaluating an infant's physical condition at birth based on a 010 scale. The infant's heart rate, respiration, muscle tone, response to stimuli, and color are rated at one and five minutes after birth. Apnea: A pause in breathing that lasts for 1520 seconds or is accompanied by a slow heart rate (bradycardia) or a change in skin color. Apnea is common among preterm infants, who have immature control of their breathing. Central Apnea is caused by Central Nervous System (CNS) problems and is characterized by an absence of respiratory gas flow and no respiratory effort. Obstructive Apnea
Sources: Anderson & Anderson, 1990; Batshaw & Perret, 1998; Harrison & Kositsky, 1983; The Merck Manual of Diagnosis and Therapy, 1999.
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is caused by an anatomic/physiologic problem and is characterized by continual respiratory effort but no respiratory gas flow. Mixed Apnea is a combination of central and obstructive apnea. Appropriate for gestational age (AGA): An infant whose size, weight, and growth is between the 10th and 90th percentiles for his or her gestational age at birth regardless of whether the infant was born term, preterm, or post-term. Asphyxia: A condition caused by insufficient intake of oxygen. An apgar score at birth of 5 or lower is indicative of asphyxia. Aspiration: Passage of a foreign material such as formula, meconium, or stomach contents into the trachea. Atrial septal defect (ASD): A hole in the wall between the two upper chambers of the heart. At risk: A term indicating that an infant has a greater-than-average chance of having a developmental delay or disorder. The risk can arise from a diagnosed disabling condition or medical, biological, or environmental factors. Federal legislation (IDEA 1997, Part C) allows states to define and include or exclude certain risk groups as eligible for services under provisions of the law; hence, eligibility varies from state to state for members of specific risk groups. Bonding: Refers to the strong psychologic attachments between parents and their newborn that begins before birth and are strengthened in the first hours and days after birth. Bonding is influenced by the parent's own childhood experiences, by their cultural and social attitudes towards child rearing, by their personalities, by their desire to have a child, and by prior psychologic planning for their newborn's arrival. Bonding helps ensure early parental support in the development of the child's personality. Bradycardia (or brady): A slower than normal heart rate (in an infant = below 100 beats/minutes; normal heart rates are 120160 beats/minutes); often occurs with apnea. Bradycardia is relative to each individual infant's normal resting heart rate. For example, preterm infants typically have higher heart rates (160180 beats/minute). During work such as feeding, it is common to see the heart rate increase 10 beats/minute over the baseline value. Brain stem evoked response audiometry (BSER): A way of testing for hearing loss on infants, in which the baby's brainwaves are measured in response to various sounds. Bronchopulmonary dysplasia (BPD): A chronic pulmonary disease process generally seen in neonates after treatment with positive pressure ventilation. The criteria for diagnosis of BPD include: 1) positive pressure ventilation for at least three days during the first weeks of life, 2) clinical signs of abnormal respiratory function that persist beyond 28 days of life, 3) supplemental oxygen required longer than 28 days of life, and 4) diffuse abnormal findings on chest X-ray characteristic of BPD.
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Care plan: Any of several plans designed to provide optimal assistance to a given child or family; examples include the nursing care plan, individualized health care plan, individual family service plan, and individual education plan. Cephalocaudal development: Pertaining to the development of the long axis of the body, in a direction from head to tail. Chorioamnionitis: An infection of the amniotic fluid and sac. CLD: An abbreviation for chronic lung disease, also called bronchopulmonary dysplasia. Congestive heart failure (CHF): Failure of the heart to act and perform efficiently because of circulatory imbalance. Continuous positive airway pressure (CPAP): Pressurized air that is delivered to a baby's lungs to keep them expanded while inhaling and exhaling. The air is sometimes accompanied by extra oxygen. Corrected age or adjusted age: The age a preterm baby would have been if he/ she were born on his/her due date. Example: A baby is 10 months old (according to her birth age) because she was 2 months preterm; her corrected age would be 8 months. Developmental care. A broad category of interventions designed to minimize the stress of the NICU environment on the infant. Developmental delay: A delay in reaching certain developmental milestones, relative to most other children of the same age. In preterm infants, developmental delays may be transient or persistent. Developmental impairment/disabilities: Conditions that are permanent, have a neurodevelopmental basis, and have an effect on functional abilities in the areas of major life activity such as cognition, receptive and expressive language, and mobility. Encephalopathy: A disorder or disease of the brain. Esophageal atresia: A congenital lack of continuity between the esophagus and the stomach, commonly associated with tracheoesophageal fistula and characterized by excessive salivation, gagging, vomiting when fed, cyanosis, and edema. Failure to thrive (FTT): Failure to reach or maintain a weight above the 3rd percentile for typically growing infants.
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Family-centered care: A standard of care practiced in the NICU that addresses the medical, developmental, educational, and emotional needs of infants, families, and staff. The goal is to facilitate the infant's development and compensate for interruptions in development that have occurred as a consequence of preterm birth or medical and surgical procedures. Full term (FT): A term that describes a baby born between the 37th and 42nd weeks of gestation. Gastroesophageal reflux (GER): Retrograde flow of gastric or billiary secretions from the stomach into the esophagus, the upper airway, or the mouth. GER may or may not be associated with emesis. Gavage feeding: Feeding through a tube inserted through the mouth or nose that goes into the stomach. Genetic disorder: Any of several disorders arising from autosomal dominant or autosomal recessive inheritance patterns or genetic mutation. Gestational age: The age of an infant, in weeks, counted from the first day of the mother's last menstrual cycle before conception until the infant is delivered or reaches full term of 40 weeks. High risk: A term referring to people or situations needing special attention and intervention to ward off sickness (or keep it from worsening), damage, or death. Homeostasis: A tendency to stability in the normal body states (internal environment) of the organism. Hyperbilirubinemia: Too much bilirubin in the blood. Hypertonia: Overly tense body tone; can be a diagnostic sign of motor development problem. Hyponatremia: Sodium levels in the blood that are too low. Hypotonia: Floppiness of body tone; can be diagnostic sign of motor or other developmental problem. Intracranial hemorrhage (ICH): Any bleeding that occurs in and around the brain. Intraventricular hemorrhage (IVH): A condition common to preterm infants involving bleeding within the ventricles of the brain. The extent of the bleeding is designated by assignment of a grade: grade I is least extensive, and grade IV is most extensive. Informally referred to as a bleed, the condition may resolve itself with no discernible after-effects. A child with grade III or grade IV IVH is considered to be at risk for communication (and other developmental) problems that can emerge at a later date.
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Intubation: Inserting a tube into the windpipe (trachea) to allow air to get to the lungs. Jaundice: A yellowish tint of the skin and the whites of the eyes that is caused by too much bilirubin. Kangaroo care: A strategy for supporting an infant by holding the naked infant skin-to-skin, against the parent's bare chest, inside the shirt or covered by a blanket, like a baby kangaroo in its mother's pouch. Lactation: The period of the secretion of milk from the mother's breasts. Large for gestational age (LGA): Any infant whose weight is above the 90th percentile for gestational age. Low birth weight (LBW): A term used to describe an infant who weighs less than 2,500 grams. LBW is typically considered to be between 1,5002,499 grams, very low birth weight (VLBW) is 1,0001,499 grams, and extremely low birth weight (ELBW) is under 1,000 grams. Myelomeningocele: Hernial protrusion of the cord and its meninges through a defect in the vertebral canal. Nasogastric tube (NGT): A tube inserted through the nose to the stomach. It may be used for nutrition, hydration, or to empty the stomach of gas. Necrotizing enterocolitis (NEC): A condition of the intestinal tract where (normally) harmless bacteria attacks the intestinal wall. Neonatal intensive care unit (NICU): The unit in the hospital where preterm infants and sick newborns are cared for and monitored. Neonatal seizures: Abnormal electrical discharges from the CNS occurring in newborns, usually manifested by stereotyped muscular activity or autonomic changes (infantile spasms). Neonatal sepsis: Invasive bacterial infection occurring in the first four weeks of life. The incidence is 0.5 to 8.0/1000 live births. The highest rates occur in LBW newborns, those with depressed respiratory function at birth, and those with maternal perinatal risk factors. The risk is greater in males (2:1) and in newborns with congenital malformations, particularly of the GI tract. Neonate: A term used to describe an infant during the first 30 days of life. Neural tube defects (NTDs): A general term inclusive of myelomeningocele, meningocele, spina bifida, and anacephaly. NIDCAP: Abbreviation for the Newborn Individualized Developmental Care and Assessment Program. Nippling: Another term used for bottle-feeding.
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Nipple shield: A thin latex or silicone device that resembles a sombrero. It is placed over the breast nipple and, although flexible, makes the nipple slightly more rigid and sometimes longer, thereby providing greater proprioceptive input to the infant and, thereby, facilitating suckling. Non-nutritive sucking (NNS): A pattern of infant sucking for reasons other than nutrition. May be elicited by a pacifier. NNS occurs in the absence of nutrient flow and may be used to satisfy an infant's basic urge or as a state regulatory mechanism and to facilitate development of nutritive sucking. Nutritive sucking (NS): A pattern of infant sucking on a bottle or breast nipple for ingestion. Oral motor: Oral sensorimotor function. A commonly used phrase to refer to underlying competencies related to behaviors in which oral structures are involved or to the behaviors themselves. These behaviors include oral postural control, saliva/secretion management, eating, and vocalization. In addition, culturally based voluntary tasks are included in older children (e.g. brushing teeth, blowing, and oral imitation). Orogastric tube (OGT): A soft tube inserted through the mouth that goes straight into the stomach. It can be used for feeding or to empty the stomach of gas. Oscillating ventilator: Also called a high frequency ventilator, it works differently than a conventional ventilator. An oscillating ventilator keeps the infant's lungs continuously inflated by providing tiny quantities of air at extremely rapid rates. Oto-acoustic emission (OAE): Used as a part of newborn infant hearing screening. Sounds that are measured in the outer ear canal that are produced by the normal hair cells in the cochlea. The presence of these sounds may indicate normal hearing acuity in the newborn. Oxygen (O2): The gas that is responsible and imperative for supporting life. Oxygen saturation: The amount of oxygen present in the blood and available for exchange at the tissue level, typically measured in capillary blood flow by a pulse oximeter with external sensors. The levels are expressed as a percentage of 100. A normal infant has oxygen saturation above 95% in most conditions. Preterm infants may be considered to have acceptable saturation levels above 90%. Some degree of hypoxia is indicated below 90%. Parenteral nutrition: Nutrition that is given intravenously, rather than through the stomach and the intestines. Parity (para): The condition of a woman with respect to her having borne viable offsprings. Patent ductus arteriosus (PDA): A typical situation in preterm infants where the fetal blood vessel that links the aorta and the pulmonary artery does not close following birth; common problem that may require drug or surgical treatment.
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Periodic breathing: Three or more episodes of apnea lasting 3 seconds or more, occurring within a 20-second period. Periventricular leukomalacia (PVL): Cysts in the white matter of the brain near the ventricles, indicating areas that have been permanently damaged. Post-conceptual age: The number of weeks following conception; approximately two weeks less than gestational age. Determined by taking weeks of gestation and adding the number of weeks of life. Postmature infant: Any infant born after 42 weeks gestation. Premature or preterm infant (preemie): An infant born before 37 weeks of pregnancy. Prone: Lying on the stomach or abdomen. Respiratory distress syndrome (RDS, hyaline membrane disease): A set of symptoms resulting from oxygen deprivation in the perinatal period; often associated with bronchopulmonary dysplasia. Retina: The nerve tissue that lines the back of the eye. Retinopathy of prematurity (ROP): The abnormal growth of blood vessels in the eye, seen in many preterm infants; this happens because the blood vessels are not finished developing at the time of a preterm infant's birth. They have to finish developing outside the protected environment of the womb. ROP can also be caused by excessive or prolonged use of supplementary oxygen in preterm infants during the perinatal period, which adversely affects the infant's retina; associated with reduced visual acuity. Room air: The air, containing 21% oxygen, that we normally breathe. Sepsis: Presence of infection in the blood. Small for gestational age (SGA): A newborn whose weight is lower than expected for gestational age. Spina bifida: A developmental anomaly characterized by defective closure of the bony encasement of the spinalcord, through which the cord and meninges may or may not protrude. State regulation disorder: A condition that, for a variety of reasons, causes some infants to be unable to adjust physiologic functions such as sleep-wake cycles, level of alertness, or maintenance of body temperatures; this difficulty is common in infants suffering from prenatal drug exposure, but can result from other factors.
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Suck: To draw liquid into the mouth by producing a partial vacuum as a result of contracting the muscles of the lips, tongue, and cheeks. Sucking: The act of drawing liquids into the oral cavity through negative pressure created by sealing the lips around the nipple and moving the tongue repeatedly up and down. Used with reference to the nippling pattern of an older infant. Suckling: A form of sucking present in the first few months of life in which forward and backward movements of the tongue help remove liquid from a nipple for feeding. Sudden infant death syndrome (SIDS): The sudden and unexpected death of an apparently healthy infant, typically occurring between the ages of 3 weeks to 5 months, and not explained by careful postmortem studies. Supine: Lying on the back, face upward. Surfactant: The substance made in the lungs or delivered to a sick infant through an endotracheal tube that aids in keeping the tiny air sacs (alveoli) from collapsing and clinging together. Swaddling: A calming technique that provides physical containment to an infant whose movements may be tonic, disorganized, or frequent. When swaddled, the infant is wrapped in a blanket; the arms should be together in the midline and the hips flexed. Blankets can cover the head for additional containment if needed. Tachycardia: An exceptionally fast heart rate. Term infant: An infant born between 3842 weeks gestation. TORCH study: Tests for the following viral infections: toxoplasmosis, rubella, cytomegalovirus, herpes, and others (AIDS, syphilis, hepatitis). Tracheoesophageal fistula (TEF): An abnormal hole between the trachea and esophagus that allows a bolus to enter the trachea causing symptoms similar to aspiration.
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Roles of Speech-Language Pathologists in the Neonatal Intensive Care Unit: Technical Report

About This Document

Philosophical Perspectives on Care in the NICU

Principles of Preferred Practice in the NICU

Evidence Related to Outcomes of Treatment

Outcomes with Feeding Focused Interventions

Outcomes With Specific Etiologies

Counseling and Support

SLP Education and Training Needs

Philosophical Perspectives on Care in the NICU

Principles of Preferred Practice in the NICU

Physical Assessment and Treatment

Communication and Developmental Assessment

Evidence Related to Outcomes of Treatment

Broad Considerations for Intervention

Guidelines for Intervention

Outcomes with Specific Etiologies

Evidence From Outcome Studies

Strengths of Family-Centered Care

SLP Education and Training Needs

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