What does it mean to be a Speech and Language Therapist in a Neonatal Unit?

By Naomi Proszynska

Whilst it may not seem obvious, given the title of the role, Speech and Language Therapists (SALTs) are trained in the treatment of eating, drinking, and swallowing difficulties. In fact this makes up a significant proportion of the work they do. Given that supporting clients with communication difficulties or swallowing difficulties requires expertise in the anatomy and physiology of the oral cavity, pharynx and larynx, it makes sense that SALTs use their knowledge to treat both client groups. Moreover communication and swallowing difficulties often co-occur – an example being clients with articulation difficulties and swallowing difficulties (dysphagia) following a stroke.

Siew-Lian Crossley is a highly specialised speech and language therapist in the field of eating, drinking and swallowing. She works on the Neonatal Unit (NNU) at Homerton University Hospital and her role is to assess and support the feeding and early interaction development of premature infants. She tells me that “when working with families, they can be initially surprised to see a speech and language therapist working with their premature infant. However once we explain our role, they are more than happy for us to work together with them”.

premature baby being fed

Siew is part of the developmental care group on the ward, working jointly with nursing staff, breastfeeding specialists, physiotherapists, occupational therapists, and the medical team to ensure a holistic view of the infant’s development. She tells me, “We work closely on a daily basis, supporting feeding with nursing staff and discussing assessment findings with the medical team. Because feeding is one part of development we don’t work in isolation. We are part of a weekly multidisciplinary ward round which reviews babies known to the Multi-Disciplinary Team (MDT) where we can all have input and put together plans to support development for infants on the unit”.

The Level 3 Neonatal Unit NNU cares for premature babies who are born at gestation as young as 23 weeks. At this early stage in development, infants are unable to orally feed (from the mother’s breast or from a bottle), as their ability to co-ordinate the complex suck-swallow-breathe pattern has not yet developed. The sucking reflex only fully develops between 34-36 weeks gestation in utero, and feeding development is impacted by experiences of the Neonatal Unit for babies born prematurely. Infants are therefore first fed intravenously, and then through nasogastric (NG) tubes that send nutrients directly into their stomachs.

NG fed baby

Throughout both pre-oral and oral feeding, SALTs work closely with the occupational therapist and physiotherapist on the unit to advise parents and nurses on how to recognise and respond to “neurobehavioral cues of feeding readiness” during early interactions, such as rooting, licking, smacking lips and non-nutritive sucking (when an infant spontaneously makes rhythmic sucking movements), body position and facial expression. These behavioural cues are the infant’s way of communicating his or her needs. Reading these cues ensures that the infant has safe and psychosocially positive feeding experiences.

The team also encourages, whenever possible, for the baby to be breast-fed. This is because breast milk is specifically designed to meet the needs of the human infant, providing both a provision of nutrients and immune protection. Furthermore during breastfeeding the flow of milk is controlled by the infant’s sucking, which means that the infant only takes milk when ready. Bottle-feeding is less controlled, as the flow from the bottle continues, regardless of whether the infant is ready to feed.

breastfeeding + NG

Unfortunately Siew tells me that it can be extremely challenging for mothers of preterm infants to establish lactation initially and then to establish breastfeeding for their preterm infants in the medical environment of the NNU. Thus an important part of her role as the feeding specialist is to work closely with the breastfeeding specialist nurses to help mothers overcome these barriers. If breastfeeding is not possible, then the team have a crucial role in supporting the parents to feed their infant through alternative methods in the physically and psychologically safest way possible.

In addition to having not yet developed the systems required for safe and effective feeding, preterm infants often have complex medical conditions such as Chronic Lung Disease (CLD), Hypoxic-ischemic Encephalopathy (HIE), and congenital cardiac conditions that may have impacted on their oral feeding development. Siew explains that these infants can be at risk of aspiration of fluid into their lungs, which can lead to serious illness. These babies therefore require careful observation to establish whether oral feeding is safe, and this may involve ongoing support even after the infant is at home.mum being taught how to feed

Siew tells me, that with larger numbers of extremely preterm infants surviving earlier, there is a greater understanding of some of the factors that may be associated with prematurity later on, such as impact on developing cognition, motor development, communication skills, as well as feeding. “This is where is it exciting to be a speech and language therapist with skills in supporting both communication and feeding,” Siew explains. Using her expertise in both areas and through close work with families, she is able to identify infants early who are at risk of feeding or interaction difficulties and put supports in place for them.

Training is an important part of the SALT’s role. At Homerton University Hospital, the Neonatal SALTs are part of both medical and nursing induction so that from the beginning new staff are aware of their role on the unit. In addition, Siew explains, “every interaction that we have with other team members on the unit is an opportunity for informal training and sharing knowledge”. The wider team Grand Round teachings are also a good opportunity to share research and new practices with medical colleagues on the NNU.

NG with tube

Keeping up-to-date on new research is essential for the efficacy of the SALT’s work. Siew explains that it is important that the SALT is able to “bring this evidence back to the wider team on the Neonatal Unit” to promote best practice. As the field is still developing, this is a challenging aspect of the role, Siew tells me, but she also reflects positively on this aspect: “I love that every day on the unit is different and that you are constantly having to think and reflect on practice and refer back to the literature to help guide your practice”.

The Royal College of Speech and Language Therapists (RCSLT) is currently working on ways to support SALTs working in neonatal care, in response to the rapid growth of SALTs working in this field. The neonatal SALT team at the Homerton have been fortunate to be able to work closely with RCSLT in being a part of the national ‘Neonatal Working Party’ that is looking specifically at developing support for SALTs in Neonatal Units nationally. This includes developing a webpage of information for SALTs and other professionals, training and development opportunities for SALTs in Neonatal Units and also collecting data on SALTs working across the UK to share information with providers and commissioners.

Breastfeeding baby

After hearing about the work Siew does, I feel that being a speech and language therapist on a Neonatal Unit can be challenging in the sense that the role is not well known by those external to it, and moreover the field of neonatal care is developing, and so the role itself is currently growing and changing. In this sense it seems that Siew’s determination as a campaigner as well as a professional helps her to succeed.

What also becomes clear after my interview with Siew is that her position as an integrated member of the multidisciplinary team ensures that each infant receives comprehensive care, where feeding is considered carefully and with an understanding of the long-term implications. Her role in supporting infants’ feeding at home ensures that this care is continued. Siew’s own reflection captures this idea, and shows her dedication to people-centred goals: “I think that working with families and a range of staff and with the infants themselves is the most reuniting, and knowing that you are part of a team that can have a lasting and positive impact for these babies later on.”

 

Siew Photo

Siew-Lian Crossley

To learn more about the role of the speech and language therapist in the feeding of premature infants, visit Best Beginnings Charity:

http://www.bestbeginnings.org.uk/small-wonders

To find out more about speech and language therapy, visit the Royal College of Speech and Language Therapists:

http://www.rcslt.org/speech_and_language_therapy/what_is_an_slt 

and Giving Voice Charity:

http://givingvoiceuk.org/key-campaign-messages/

 

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