SLPs in the NICU
SLPs in the NICU
Prenatal risk factors impact development
Prenatal development refers to the time from conception to nine months, or approximately 40 weeks, which is the average amount of time necessary for a baby to come to full-term development. During that time, the baby's development can be endangered by a variety of factors, which may have lasting effects on the child after birth. Many of the problems that may arise during the gestation phase may have an impact on future development of speech, language and feeding skills. Speech-language pathologists may be involved moments after the birth of an infant that is at risk to treat problems with regard to feeding or to train parents in ways to stimulate the infant's speech and language.
Some infants are at risk due to neurological problems associated with negative maternal behaviors during pregnancy, while others may be genetically predisposed to certain syndromes that are associated with speech and language deficits.
"If a child is likely to have a neurological abnormality, the first 10 weeks of pregnancy are when they are at greatest risk," Cheri S. Carrico, PhD, CCC-SLP, director of the Speech-Language-Hearing Clinic at Elmhurst College in Illinois, told ADVANCE. "That's when the neurological substrates, biochemical substrates and anatomical substrates of future development are all beginning to occur."
Within the first 10 weeks of development, the brain and organs start to form, the heart starts to beat, and fingers and toes start to take shape. During the latter part of the first trimester, sex organs develop, muscles contract and relax, bones begin to harden, and the baby begins to breathe amniotic fluid.
The second trimester is devoted to maturation of the organs developed during the first trimester, and the third trimester is a period of rapid growth. If something happens during the third trimester, the fetus may be at risk for impaired growth, said Dr. Carrico.
Some maternal behaviors can negatively affect fetal development, resulting in problems. The use of drugs or alcohol, smoking, poor nutrition, and the lack of prenatal care or vitamins can put the baby at risk for developmental problems. In addition, high blood pressure, metabolic diseases, sexually transmitted diseases, and infections like rubella can pose serious risks to a baby's health.
External factors also can have an effect on development. Toxic agents like paint and radiation can cause developmental problems.
Finally, mothers over the age of 35 and teen mothers face a higher risk of problems.
"Babies born to teens are twice as likely to die compared to babies born to moms over 20," Dr. Carrico said. "The increased risks are associated with a lack of prenatal care, poor diet and a smaller pelvis."
The lack of proper nutrition is a major concern for fetal development because babies need an appropriate number of calories and vitamins for growth. A lack of oxygen is another big risk factor.
"If a mom takes certain drugs that minimize the oxygen supply or is exposed to anything that can minimize that supply to the fetus, it could be disruptive to development," the clinician explained. "If the mother is in a car accident and either she is out of oxygen for awhile or the umbilical cord gets clamped, the oxygen supply to the fetus could be reduced and be associated with developmental problems in the baby."
Babies born prematurely also may have problems breathing because their blood vessels are very thin and they're not ready to breathe air, which may put them at risk for a cerebral hemorrhage. Doctors can now supply premature infants with artificial surfactant. This substance lines the lungs, helping them to expand and contract, and minimizes the risk of bleeding in the brain.
In addition, "artificial surfactant is thought to be associated with the reduction of brain hemorrhages in premature infants," Dr. Carrico stated. "An infant that has a brain hemorrhage is at risk for cerebral palsy."
Speech-language pathologists may need to become involved with infants in the neonatal intensive care unit (NICU) if they are considered to be at risk due to prematurity or negative maternal behaviors. Infants born with certain syndromes also require their expertise.
At least 105 syndromes have been identified that involve speech and language deficits, according to Dr. Carrico. Some of the more common ones are Down syndrome, Fragile X, Prader Willi, Cornelia de Lange, Möbius, fetal alcohol syndrome, and familial dysautonomia, also called Riley-Day syndrome. [See ADVANCE, 11 (13): 19.]
"We know that babbling typically doesn't occur until about 4 to 6 months of age and most children don't start talking until they're 1 year old," she said. Therefore, if a child has Down syndrome, the speech-language pathologist can give the parents some ideas for things they can do to stimulate language.
Speech-language pathologists also become involved early on with infants who have feeding problems. If babies are medically ready, clinicians can teach them how to feed orally by helping them to develop good sucking and swallowing skills. A speech-language pathologist also should be involved if a baby has a feeding tube.
When working with newborns that are at risk, clinicians must take every precaution to ensure they remain calm and free of stress. When working with this population, speech-language pathologists must be aware of signs that a baby is in distress. In the event this occurs, clinicians work to reduce stimulation and calm the infant.
Signs to look for are finger-splaying, crying, gaze aversion, fussiness, frowning, grunting, or extending their arms and arching their back, Dr. Carrico said. These signs indicate the baby is in distress and is not ready to interact with the clinician.
Once a baby is in distress, clinicians must take steps to reduce the overall stimulation in the environment. This may include dimming the lights or turning off unnecessary public address systems. Nestling a child against the body, swaddling infants, tucking their hands under their chin, or giving them their fingers or hands to suck on are calming techniques.
Signs that indicate the baby is ready for interaction are cooing, making eye contact, relaxing their arms and legs, sucking on their hands or fingers, and trying to smile.
"If you're dealing with an infant that is medically fragile, you need to be very aware of the monitors and making sure that your baby is medically safe and not distressed by the procedures you're engaging them in," Dr. Carrico said. "You want to be careful about not stressing the baby out more when you're providing a service to them."
This precaution especially applies to preemies, she said. "They're not ready to be here until they're close to 40 weeks gestational age; so if they're born at 32 weeks, they're not really ready for people to be talking to them, interacting with them, or holding them. Clinicians need to watch what they're doing and be very careful."
Dr. Carrico suggests that clinicians work with infants frequently for short periods, as opposed to regular half-hour or 45-minute therapy sessions. She also suggests going at an appropriate pace and not trying to do too much too soon.
In addition, she advises training parents and staff on appropriate ways to work with the baby. Clinicians need to be very aware of feedback from both parents and hospital staff.
For more information contact:
Cheri S. Carrico, PhD, Speech-Language-Hearing Clinic, Elmhurst College, 190 Prospect Ave, Elmhurst, IL 60126; (630) 617-3196; e-mail: firstname.lastname@example.org
Nicole Klimas is assistant editor of ADVANCE.