Oral-Motor Services in the NICU
By Abigail Scott
The need for speech-language pathologists to provide oral-motor therapy in the neonatal intensive care unit (NICU) is crucial.
"Fifty percent of children in the NICU will later develop communication disorders," stated Amy Urso, a master's-level speech-language path-ology student at Nova Southeastern University in Ft. Lauderdale, FL. She has conducted research on the provision of oral-motor services in the NICU and presented on the topic earlier this year at the annual spring convention of the Florida Association of Speech-Language Pathologists and Audiologists.
Because of the need for services in the NICU, more attention should be given to that setting in speech-language pathology clinical programs, she said. "If there were more exposure, more students would be interested in the area."
Understanding the physiology of the premature infant is paramount for speech-language pathologists who provide oral-motor therapy in the NICU, stated Nancy Fazekas, a master's-level student at Nova Southeastern who cooperated with Urso and fellow students Regina Palek and Denise Zaretski in the research.
"You can't approach a preemie as a full-term infant. You have to know the characteristics of the population so as not to endanger an infant in any way," she said.
Assessing the oral-motor status of a premature infant can only be done when the baby is physiologically stable. The sucking process is based on coordination and neurological maturity, and preemies lack organization in these areas.
At birth premature infants don't have enough fatty tissue in their cheeks to aid in the tightening of cheeks and lips to create the suck-swallow coordination, Fazekas explained. Many are tube-fed because they can't generate the pressure necessary to drink from a bottle.
Clinicians assess the oral-motor status of an infant by evaluating the coordination of the tongue, lips, jaws, cheeks and palate for overall oral-motor function. Other components to be considered include the infant's heart rate, respiratory status and physiological changes that may occur during the feeding process.
Respiratory problems frequently interfere with an in-fant's suck-swallow-breathe pattern. Babies with tracheos-tomies who require ventilators experience hypersensitivity of the mouth, which delays the introduction to oral feeding.
Coordinating oral stimulation and feeding improves oral-motor musculature and physical organization, Fazekas reported. "If infants are not stimulated, they will not know that feeding occurs with the mouth."
To acclimate an infant in the NICU to oral feeding, a clinician should introduce a pacifier to the baby's lips during tube feeding. When the baby begins transferring to a bottle, the clinician could possibly introduce it slowly to give the infant time to coordinate its suck, swallow and breathing pattern.
During feeding, infants can be placed in a sidelying position with their head and trunk slightly elevated on an incline, their arms forward, and their knees and hips flexed. Infants that cannot tolerate physical touch during feeding can be placed in a soft beanbag chair.
Clinicians who provide oral-motor therapy need to closely observe the various stages premature infants go through in responding to their environment.
They typically fluctuate among three stages of neurosocial development: turning in, coming out and reciprocity ("Stages of Behavioral Organization in the High Risk Neonate: Theoretical-Clinical Considerations, Seminars in Perinatology, Vol. 3).
In the first stage the infant focuses all its energy on physical stability, with very little reaction to stimulation. Any stimulation is overwhelming, and there is no reciprocal reaction between the infant and caregiver.
Preemies in the coming out stage begin to gain weight and respond to their environment like full-term newborns do. They also show signs of interaction, such as responding to touch and turning toward caregivers.
During the reciprocity stage, these infants interact with caregivers more and have increased alertness and physical stability.
However, infants in the reciprocity stage don't necessarily remain at that level. Depending on the degree of involvement, a baby could show reciprocity at one point and then regress to another stage a moment later.
Because the NICU is an overwhelming, stressful and scary place for a fragile premature infant, clinicians should be aware of cues in infants when they are experiencing sensory overload, Fazekas said. Simple actions, such as light tapping on an Isolette or gentle rocking, may cause stress reactions that could compromise their health.
Physical cues of overstimulation include crying, gagging, dramatic color changes, yawning, hiccoughing and averted eye gaze.
Babies also may "shut down" by closing their eyes and not responding to being held or movement, she noted.
Clinicians can reposition the infants so they become accustomed to the space around them or swaddle them in blankets to promote flexion and help them self-regulate.
Speech-language pathologists should become familiar with the medical and technological aspects of the NICU, such as the rapid changes in heart rate and respiration monitors, Fazekas said.
Cooperating with other NICU staff--including nurses and respiratory and occupational therapists--is essential, she stated. "You have to be sensitive to them, respect their professions, and integrate what you are doing."
The family's role in oral-motor therapy and the NICU setting is equally important. In working with parents, clinicians must be aware that they may be going through a grieving process as they come to terms with their child's medical complications.
"This is not the baby they had expected," Fazekas said. "Parents may be overwhelmed with grief and wonder why this happened to their baby and their family."
Grieving the loss of a typically developing child, parents may go through a range of emotions, such as anger and denial, and may need support and guidance from professionals.
Speech-language pathologists can help parents understand the implications of their baby having been born prematurely and show them how they can communicate with their infant.
Clinicians should educate parents in the areas of infant development, socialization, and engagement and disengagement cues.
NICU practitioners should work closely with parents to involve them in their infant's care, such as documenting physiological changes. When parents are not able to touch their infant due to medical complications, a speech-language pathologist can give them something else to do. A binding activity such as charting the infant's cues is often used.
During oral-motor therapy, speech-language pathologists can teach parents how to hold and feed their child, how to stroke their baby's cheek or lips during tube feeding, and how to adjust the nipple on the bottle to accommodate the baby's endurance when the infant is ready to be bottle-fed.
An outline of typical speech and language development would assist parents in observing these steps at home, Fazekas said. "They have to be on the look-out more than the average parent. It is their responsibility to alert the speech-language pathologist or other professionals if something is not right."
* For more information, contact Nancy Fazekas, Regina Palek, Amy Urso and Denise Zaretski at the Bernice and Jack LaBonte Institute for Communication Sciences and Disorders, Nova Southeastern University, 3301 College Ave., Ft. Lauderdale, FL 33314.