Roles of Speech-Language Pathologists in The Neonatal Intensive Care Unit: Technical

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 Speech-
Language 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
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Roles of Speech-Language Pathologists in the Neonatal Intensive Technical Report
Care Unit: Technical Report
About This This technical report was prepared by the American Speech-Language-Hearing
Document 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,
2000–2002 and 2003–2005, respectively). This technical report provides the
background and support for the ASHA position statement on the roles of speech-
language 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 students-
in-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 decision-
making process for their baby” (Browne & Smith-Sharp, 1995, p.19). Family-
centered 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, self-
regulation, 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
4
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
5
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 smell—preferring 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, Miller-
Loncar, 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 nasopharyngo-
laryngoscopy when used with infants assesses, primarily, the anatomy and
6
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 bottle-
feeding, 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 breast-
feeding 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 parent-
focused 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 23–31 weeks, than in those born at 32–36 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 32–36 weeks performed better in the last two areas than those born
at <32 weeks. Twinning with birth at 28–31 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 cross-
modal 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 nine-
year 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 entry-
level 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.
Technical Report 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
11
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
12
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 family-
professional 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 decision-
making process for their baby” (Browne & Smith-Sharp, 1995, p. 19). Family-
centered 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).
13
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
14
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 1,000–1,499
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.
15
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 “family-
centered, community-based, comprehensive, coordinated, interagency, and multi-
disciplinary 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
16
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,
17
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 smell—preferring 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 system—pattern of respiration (pauses, tachypnea), color changes
(red, pale, dusky, mottled), and visceral signs (e.g., spit up, gag, burp);
b. movement—postural alignment (hyperflexed, extended), muscle tone (flaccid,
hypertonicity), movement patterns in extremities, trunk, head and face, and
level of motor activity;
c. state—the 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. attention—the 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
18
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
19
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 breast-
feeding 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)
20
(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
21
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
22
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 2–3 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 follow-
up, 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.
23
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.
24
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-line—a posture that facilitates swallowing.
25
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, breast-
feeding 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, Anderson-
Shanklin, & 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).
26
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 (Medoff-
Cooper, 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 breast-
feeding than previously thought (Meier, 1988; 1990). Stable 32 week gestation
infants can be put to breast safely for early feeding experiences, while bottle-
feeding 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
27
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.
28
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.
29
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 long-
term 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 parent-
infant 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 32–36 weeks gestational age. Most severely
effected were linguistic areas of auditory discrimination, imitation of articulatory
positions, and imitation of sentences. NIC children born at 32–36 weeks performed
better in the last two areas than those born at <32 weeks. Twinning with birth at
28–31 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 cross-
30
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.
31
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).
32
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 provider—feeding 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 0–10 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 15–20 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 —
1
Sources: Anderson & Anderson, 1990; Batshaw & Perret, 1998; Harrison &
Kositsky, 1983; The Merck Manual of Diagnosis and Therapy, 1999.
33
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 120–160 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 (160–180
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.
34
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.
35
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.
36
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 1,500–2,499 grams, very
low birth weight (VLBW) is 1,000–1,499 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.
37
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.
38
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.
39
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 38–42 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.
References Achenbach, T. M., Howell, C. T., Aoki, M. F., & Rauh, V. A. (1993). Nine-year outcome
of the Vermont intervention program for low birth weight infants. Pediatrics, 91(1), 45–
55.
Acolet, D., Modi, N., Giannakoulopoulos, X., Bond, C., Web, W., Clow, A., & Glover, V.
(1993). Changes in plasma cortisol and catecholamine concentrations in response to
massage in preterm infants. Archives of Disease in Childhood, 68(1 Spec No), 29–31.
Als, H. (1982a). Towards a research instrument for assessment of preterm infant behavior.
In H. E. Fitzgerald, B. M. Lester, & M. W. Youngman (Eds.), Theory and Research in
Behavioral Pediatrics (Vol. 1, pp. 35–53). New York: Plenum Press.
Als, H. (1982b). Towards a synactive theory of development: Promise for assessment of
infant individuality. Infant Mental Health Journal, 3(4), 229–243.
Als, H. (1985). Manual for the Naturalistic Observation of Newborn Behavior (preterm and
full term). Boston: The Children's Hospital.
40
Als, H. (1986). A synactive model of neonatal behavioral development in the premature

infant and for support of infants and parents in the neonatal intensive care environment.
Physical and Occupational Therapy in Pediatrics, 6, 3–54.
Als, H., & Gilkerson, L. (1995). Developmentally supportive care in the neonatal intensive
care unit. Zero to Three, 15, 2–10.
Als, H., Lawhon, G., Brown, E., Gibes, R., Duffy, F., McAnulty, G., & Blickman, J. (1986).
Individualized behavioral and environmental care for the very low birth weight preterm
infant at high risk for bronchopulmonary dysplasia: Neonatal intensive care unit and
developmental outcome. Pediatrics, 78(6), 1123–1132.
Als, H., Lester, B., Tronick, E. Z., & Brazelton, B. (1982). Manual for the Assessment of
Preterm Infants' Behavior (APIB). In H. E. Fitzgerald, B. M. Lester, & M. W. Youngman
(Eds.), Theory and Research in Behavioral Pediatrics (Vol. 1, pp. 35–53). New York:
Plenum Press.
American Speech-Language-Hearing Association. (1990). Infant-toddler project. An
interdisciplinary trainer-of-trainers program: Source book and trainer's guide.
Rockville, MD: Author.
American Speech-Language-Hearing Association. (2001). Scope of practice in speech-
language pathology. Rockville, MD: Author.
American Speech-Language-Hearing Association. (2002a). Knowledge and skills needed
by speech-language pathologists providing services to individuals with swallowing and/
or feeding disorders. ASHA Leader, 7(Suppl. 22), 81–87.
American Speech-Language-Hearing Association. (2002b). Roles of speech-language
pathologists in swallowing and feeding disorders: Position statement. ASHA Leader, 7
(Suppl. 22), 73.
American Speech-Language-Hearing Association. (2002c). Roles of speech-language
pathologists in swallowing and feeding disorders: Technical report. In Rockville, MD:
Author.
American Speech-Language-Hearing Association. (2003). Code of ethics. Rockville, MD:
Author.
American Speech-Language-Hearing Association. (2004a). Roles of speech-language
pathologists in the neonatal intensive care unit: Position statement. Rockville, MD:
Author.
American Speech-Language-Hearing Association. (2004b). Knowledge and skills needed
by speech-language pathologists providing services to infants and families in the NICU
environment. Rockville, MD: Author.
Anderson, K., & Anderson, L. (1990). Mosby's pocket dictionary of medicine, nursing, and
allied health. St. Louis, MO: C.V. Mosby.
Ardran, G., & Kemp, F. (1970). Some important factors in the assessment of oropharyngeal
function. Developmental and Medical Child Neurology, 12, 158–166.
Ardran, G. M., Kemp, F. H., & Lind, J. (1958). A cineradiographic study of bottle feeding.
British Journal of Radiology, 31, 11–22.
Asakura, H., Ichikawa, H., Nakabayashi, M., Ando, K., Kaneko, K., Kawabata, M., Tani,
A., Satoh, M., Takahashi, K., & Sakamoto, S. (2000). Perinatal risk factors related to
neurologic outcomes of term newborns with asphyxia at birth: A prospective study.
Journal of Obstetric and Gynaecology Research, 26(5), 313–324.
Association of Women's Health, Obstetric, and Neonatal Nurses. (1990). Systematic
Assessment of the Infant at Breast (SAIB).
Auerbach, K., & Riordan, J. (1999). Breastfeeding and human lactation (pp.287-288,
427-432). Sudbury, MA: Jones and Bartlett.
Batshaw, M., & Perret, Y. (1998). Children with disabilities: A medical primer. Baltimore,
MD: Brookes.
Beauchamp, T., & Childress, J. (1994). Principles of biomedical ethics (4th ed.). New York:
Oxford University.
41
Bell, E. H., Geyer, J., & Jones, L. (1995). A structured intervention improves breastfeeding
success for ill or preterm infants. The American Journal of Maternal Child Nursing,
20, 309–314.
Bernbaum, J. C., Pereira, G. R., Watkins, J. B., & Peckham, G. J. (1983). Nonnutritive
sucking during gavage feeding enhances growth and maturation in premature infants.
Pediatrics, 71, 41–45.
Bier, J. B., Ferguson, A., Anderson, L., Solomon, E., Voltas, C., Oh, W., & Vohr, B. R.
(1993). Breast-feeding of very low birth weight infants. Journal of Pediatrics, 123, 773–
778.
Billeaud, F. P. (1993). Communication disorders in infants and toddlers: Assessment and
intervention. Stoneham, MA: Butterworth-Heinemann.
Bosma, J. F. (1986). Development of feeding. Clinical Nutrition, 5, 210–218.
Brake, S. C. (1991). New information about early feeding and motivation: Techniques for
recording sucking in infant rats. In H. N. Shair, G. A. Barr, & M. A. Hofer (Eds.),
Developmental Psychobiology: New methods and changing concepts (pp. 32–46). New
York: Oxford University Press.
Brauth, S. E., Hall, W. S., & Dooling, R. J. (Eds.). (1991). Plasticity of development.
Cambridge, MA: The MIT Press.
Brazelton, T. B. (1974). Does the neonate shape his environment? Birth Defects Orig Artic
Ser, 10(2), 131–140.
Brazelton, T. B., & Nugent, J. K. (1995). Neonatal Behavioral Assessment Scale (Clinics
in Developmental Medicine No. 137) (3rd Ed.). London: Mac Keith Press.
Browne, J., & Smith-Sharp, S. (1995). The Colorado consortium of intensive care nurseries:
Spinning a web of support for Colorado infants and Families. Zero to Three, 15(6), 18–
23.
Browne, J.V., Vandenberg, K., Ross, E.S., & Elmore, A. M. (1999). The newborn
developmental specialist: Definition, qualifications, and preparation for an emerging
role in the neonatal intensive care unit. Infants and Young Children, 11(4), 53–64.
Bu'Lock, F., Woolridge, M. W., & Baum, J. D. (1990). Development of co-ordination of
sucking, swallowing and breathing: Ultrasound study of term and preterm infants.
Developmental and Medical Child Neurology, 32, 669–678.
Burroughs, A. K., Asonye, U. O., Anderson-Shanklin, G. C., & Vidyasager, D. (1978). The
effect of nonnutritive sucking on transcutaneous oxygen tension in noncrying, preterm
neonates. Research in Nursing Health, 1, 69–75.
Butt, M. L., & Kisilevsky, B. S. (2000). Music modulates behaviour of premature infants
following heel lance. Canadian Journal of Nursing Research, 31, 17–39.
Clum, D., & Primomo, J. (1996). Use of a silicone nipple shield with premature infants.
Journal of Human Lactation, 12, 287–290.
Cohen, S. E., Parmelee, A. H., Beckwith, L., & Sigman, M. (1986). Cognitive development
in preterm infants: Birth to 8 years. Developmental and Behavioral Pediatrics, 7, 102–
110.
Conde-Agudelo, A., Diaz-Rossello, J. L., & Belizan, J. M. (2000). Kangaroo mother care
to reduce morbidity and mortality in low birth weight infants. Cochrane Database of
Systematic Reviews, 4, CD002771.
Condon, W. S., & Sanders, L. W. (1974). Synchrony demonstrated between movements of
the neonate and adult speech. Child Development, 45(2), 456–462.
Crelin, E. (1973). Functional anatomy of the newborn. New Haven, CT: Yale University
Press.
Crook, C. K., & Lipsitt, L. P. (1976). Neonatal nutritive sucking: Effects of taste stimulation
upon sucking rhythm and heart rate. Child Development, 47, 518–522.
Daga, S. R., Lunkad, N. G., Daga, A. S., & Ahuja, V. K. (1999). Orogastric versus
nasogastric feeding of newborn babies. Tropical Doctor, 29, 242–243.
Davies, A. M., Koenig, J. S., & Thach, B. T. (1988). Upper airway chemoreflex responses
to saline and water in preterm infants. Journal of Applied Physiology, 64, 1412–1420.
42
de Vries, J. P., Visser, G. A., & Prechtl, H. R. (1984). Fetal motility in the first half of
pregnancy. In H. R. Prechtl (Ed.), Continuity of neural functions from prenatal to
postnatal life (pp. 46–64). Philadelphia: J. B. Lippincott.
DeCasper, A. J., & Fifer, W. P. (1980). Of human bonding: Newborns prefer their mothers'
voices. Science, 208, 1174–1176.
Dieter, J. N., & Emory, E. K. (1997). Supplemental stimulation of premature infants: A
treatment model. Journal of Pediatric Psychology, 22(3), 281–295.
Dixon, G., Badawi, N., Kurinczuk, J. J., Keogh, J. M., Silburn, S. R., Zubrick, S. R., &
Stanley, F. J. (2002). Early developmental outcomes after newborn encephalopathy.
Pediatrics, 109, 26.
Dowling, D. A. (1999). Physiological responses of preterm infants to breast-feeding and
bottle-feeding with the orthodontic nipple. Nursing Research, 48, 78–85.
Dowling, D. A., Meier, P. P., DiFiore, J. M., Blatz, M. A., & Martin, R. J. (2002). Cup-
feeding for preterm infants: Mechanics and safety. Journal of Human Lactation, 18, 13–
20.
Dubowitz, L. M. S., Dubowitz, V., & Mercuri, E. (1999). The neurological assessment of
the preterm and full-term newborn infant (Clinics in Developmental Medicine, 148)
(2nd ed.). MacKeith.
Duffy, F. H., & Als, H. (1998). Neural plasticity and the effect of a supportive hospital
environment on premature newborns. In J. F. Kavanagh (Ed.), Understanding mental
retardation: Research accomplishments and new frontiers (pp. 179–206). Baltimore:
Brookes.
Duffy, L. C., Faden, H., Wasielewski, R., Wolf, J., & Drystofik, D. (1997). Exclusive
breastfeeding protects against bacterial colonization and day care exposure to otitis
media. Pediatrics, 100.
Dunn, S., van Kleeck, A., & Rossetti, L. (1993). The role of the speech-language pathologist
in the neonatal intensive care unit. American Journal of Speech-Language Pathology, 2
(2), 52–64.
Einarsson-Backes, L. M., Deitz, J., Price, R., Glass, R., & Hays, R. (1994). The effect of
oral support on sucking efficiency in preterm infants. American Journal of Occupational
Therapy, 48, 490–498.
Emory, E. K. (1998). Biobehavioral development in prenatal life: Basic principles. In D.
M. Hann, L. C. Huffman, I. L. Lederhendler, & D. Meinecke (Eds.), Advancing research
on developmental plasticity: Integrating the behavioral science and neuroscience of
mental health (pp. 51–67). Bethesda, MD: National Institute of Mental Health, National
Institutes of Health.
Emory, E. K., Hatch, M., Blackmore, C., & Strock, B. (1993). Psychophysiological
responses to stress during pregnancy. Atlanta, GA: Centers for Disease Control and
Prevention, Division of Reproductive Health.
Emory, E. K., & Israelian, M. (1998). Prenatal cognitive development. In S.A.M.I. Soraci
& J. William (Eds.), Perspectives in fundamental processes in intellectual functioning
(Vol. 1, pp. 67–90). Stamford, CT: Ablex.
Emory, E. K., & Noonan, J. R. (1984). Fetal cardiac responding: Correlate of birth weight
and newborn behavior. Developmental Psychology, 20, 354–357.
Encher, G. L., & Clark, D. (1986). Newborns at risk: Medical care and psychoeducational
intervention. In Rockville, MD: Aspen.
Field, T. (1980). Supplemental stimulation of preterm neonates. Early Human Development,
3, 301–314.
Field, T. (1988). Stimulation of preterm infants. Pediatrics in Review, 10, 149–153.
Field, T., & Goldson, E. (1984). Pacifying effects of nonnutritive sucking on term and
preterm neonates during heelsticks. Pediatrics, 74, 1012–1015.
Field, T., Ignatoff, E., Stringer, S., Brennan, J., Greenberg, R., Widmayer, S., & Anderson,
G. C. (1982). Nonnutritive sucking during tube feedings: Effects on preterm neonates
in an intensive care unit. Pediatrics, 70, 381–384.
43
Fifer, W. P., & Moon, C. (1989). Psychobiology of newborn auditory preferences. Seminars
in Perinatology, 13, 430–433.
Fifer, W. P., & Moon, C. M. (1995). The effect of fetal experience with sound. In J. P.
Lacanuet, W. P. Fifer, N. A. Krasnegor, & W. P. Smotherman (Eds.), Fetal development,
A psychobiological perspective (pp. 351–368). Hillsdale, NJ: Lawrence Erlbaum.
Fletcher, J., Miller, F., & Spencer, E. (1995). Clinical ethics: History, content and resources.
In J. C. Fletcher, C. Hite, P. Lombardo, & M. Marshall (Eds.), Introduction to clinical
ethics (pp. 3–17). Frederick, MD: University Publishing Group.
Gaebler, C. P., & Hanzlik, J. R. (1996). The effects of a prefeeding stimulation program on
preterm infants. American Journal of Occupational Therapy, 50, 184–192.
Gewolb, I. H., Vice, F., Schweitzer-Kenny, E., Taciak, V., & Bosma, J. (2001).
Developmental patterns of rhythmic suck and swallow in preterm infants.
Developmental Medicine and Child Neurology, 43(1), 22–27.
Gewolb, I. H., Bosma, J. F., Taciak, V. L., & Vice, F. L. (2001). Abnormal developmental
patterns of suck and swallow rhythms during feeding in preterm infants with
bronchopulmonary dysplasia. Developmental Medicine and Child Neurology, 43, 454–
459.
Gill, N. E., Behnke, M., Conlon, M., McNeely, J. B., & Anderson, G. C. (1988). Effect of
nonnutritive sucking on behavioral state in preterm infants before feeding. Nursing
Research, 37, 347–350.
Goldenberg, R. L., & Rouse, D. J. (1998). Prevention of premature birth. New England
Journal of Medicine, 339, 313–320.
Goodhall, L. (1997). Tube feeding dilemmas: Can artificial nutrition and hydration be
legally or ethically withheld or withdrawn? Journal of Advanced Nursing, 25, 217–222.
Gorski, P. A., Davison, M. F., & Brazelton, T. B. (1979). Stages of behavioral organization
in the high-risk neonate: Theoretical and clinical considerations. Seminars in
Perinatology, 3(1), 61–72.
Gottlieb, G. (1971). Ontogenesis of sensory function in birds and mammals. In E. Tobach,
L R. Aronson, & E. Shaw (Eds.), The biopsychology of development (pp. 67–128). New
York: Academic Press.
Griffin, T. (2001). Parental visits and infant care: Understanding parents' needs. Neonatal
Network, 20(1), 65.
Gupta, A., Khanna, K., & Chattree, S. (1999). Cup feeding: An alternative to bottle feeding
in a neonatal intensive care unit. Journal of Tropical Pediatrics, 45, 108–110.
Hamilton, B. E., Martin, J. A., & Sutton, P. D. (2003). Births: Preliminary data for 2002.
In National Vital Statistics Reports (Vol. 51, Issue 11). Hyattsville, MD: National Center
for Health Statistics.
Harding, R. P., Johnson, P., Johnston, B. E., McClelland, M. F., & Wilkinson, A. R. (1976).
Cardiovascular changes in newborn lambs during apnea induced by stimulation of
laryngeal receptors with water. Journal of Physiology, 256, 350–360.
Harrison, H. (1993). The principles for family-centered neonatal care. Pediatrics, 92(5),
643–650.
Harrison, H., & Kositsky, A. (1983). The premature baby book www.aapi-online.org/
nicuglossary.htm. New York: St. Martins Press.
Hartnick, C. J., Hartley, B. E., Miller, C., & Willging, J. P. (2000). Pediatric fiberoptic
endoscopic evaluation of swallowing. Annals of Otology, Rhinology and Laryngology,
109(11), 996–999.
Hawdon, J. M., Beauregard, N., Slattery, J., & Kennedy, G. (2000). Identification of
neonates at risk for developing feeding problems in infancy. Developmental Medicine
& Child Neurology, 42, 235–239.
Hepper, P. G., & Shahidullah, S. (1992). Habituation in normal and Down's syndrome
fetuses. The Quarterly Journal of Experimental Psychology, 44B, 305–317.
Hill, A. S., Kurkowski, T. B., & Garcia, J. (2000). Oral support measures used in feeding
the preterm infant. Nursing Research, 49, 2–10.
44
Hooker, D. (1952). The prenatal origin of behavior. Lawrence, KS: University of Kansas
Press.
Horowitz, F. D. (1990). Targeting infant stimulation efforts: Theoretical challenges for
research and intervention. Clinics in Perinatology, 17, 185–195.
Howard, J., Parmelee, A. H., Kopp, C. B., & Littman, B. (1976). A neurologic comparison
of pre-term and full-term infants at term conceptual age. Journal of Pediatrics, 88, 995–
1001.
Humphrey, T. (1969). The prenatal development of mouth opening and mouth closure
reflexes. Pediatrics Digest, 11, 28–40.
Humphrey, T. (1970). Reflex activity in the oral and facial area of the human fetus. In J.F.
Bosma (Ed.), Oral Sensation and Perception, 2nd Symposium (pp. 195–233). Springfield,
IL: Thomas.
Individuals with Disabilities Education Act Amendments of 1997, PL 105-17, 20 U.S.C.
§§ 1400 et seq..
Itani, Y., Fujioka, M., Nishimura, G., Niiusu, N., & Oono, T. (1988). Examinations in older
premature infants with persistent apnea: Correlation with simultaneous cardiorespiratory
monitoring. Pediatric Radiology, 18, 464–467.
Kavanaugh, K., Meier, P., Zimmermann, B., & Mead, L. (1997). The rewards outweigh the
efforts: Breastfeeding outcomes for mothers of preterm infants. Journal of Human
Lactation, 13, 15–21.
Klaus, M., & Kennell, J. (1976). Maternal-infant bonding: The impact of early separation
or loss on family development. St. Louis, MO: C. V. Mosby.
Kliethermes, P. A., Cross, M. L., Lanese, M. G., Johnson, K. M., & Simon, S. D. (1999).
Transitioning preterm infants with nasogastric tube supplementation: Increased
likelihood of breastfeeding. Journal of Obstetric, Gynecologic, and Neonatal Nursing,
28(3), 264–273.
Koenig, J. A., Davies, A. M., & Thach, B. T. (1990). Coordination of breathing, sucking
and swallowing during bottle feedings in human infants. Journal of Applied Physiology,
69, 1623–1629.
Kohda, E. H., Hisazumi, H. E., & Hiramatsu, K. (1994). Swallowing dysfunction and
aspiration in neonates and infants. Acta Otolaryngology (Stockholm), 517(Suppl.), 11–
16.
Korner, A. F. (1990). Infant stimulation: Issues of theory and research. Clinics in
Perinatology, 17(1), 173–184.
Korner, A. F., & Thoman, E. B. (1972). The relative efficacy of contact and vestibular-
proprioceptive stimulation in soothing neonates. Child Development, 43, 443–453.
Kramer, S. (1985). Special swallowing problems in children. Gastrointestinal Radiology,
10, 259–265.
Kupfer, D. J. (1998). Developmental plasticity: Is it the “plastics” of the 90s? In D. M. Hann,
L. C. Huffman, I. I. Lederhendler, & D. Meinecke (Eds.), Advancing research on
developmental plasticity, integrating the behavioral science and neuroscience of mental
health (pp. 9–16). Bethesda, MD: National Institute of Mental Health, National Institutes
of Health.
Lacerda, F. (2001). Is LBW a risk factor for linguistic development? Acta Paediatrica,
90, 1363–1364.
Latini, G., Del Vecchio, A., De Mitri, B., Giannuzzi, R., Presta, G., Quartulli, L., Rosati,
E., Scarano, B., & Pili, G. (1999). Scintigraphic evaluation of gastroesophageal reflux
in newborns. Pediatria Medica E Chirurgica, 21(3), 115–117.
Lau, C., Alagugurusamy, R., Schanler, R. J., Smith, E. O., & Shulman, R. J. (2000).
Characterization of the developmental stages of sucking in preterm infants during bottle
feeding. Acta Paediatrica, 89, 846–852.
Lau, C., & Hurst, N. (1999). Oral feeding in infants. Current Problems in Pediatrics, 29,
101–128.
Lau, C., & Kusnierczyk, I. (2001). Quantitative evaluation of infant's nonnutritive and
nutritive sucking. Dysphagia, 16, 58–67.
45
Lau, C., & Schanler, R. J. (1996). Oral-motor function in the neonate. Clinical Perinatology,
23, 162–178.
Leader, L. R., & Baillie, P. (1988). The changes in fetal habituation due to a decrease in
inspired maternal oxygen. British Journal of Obstetrics and Gynecology, 95, 664–668.
Lecanuet, J. P., Granier-Deferre, C., Jacquet, A. Y., Capponi, I., & Ledru, L. (1993). Prenatal
discrimination of a male and female voice uttering the same sentence. Early
Development and Parenting, 2, 217–228.
Lemons, P. K., & Lemons, J. A. (1996). Transition to breast/bottle feedings: The premature
infant (review article). Journal of the American College of Nutrition, 15, 126–135.
Lester, B. M., & Tronick, E. Z. (1990). Introduction: Guidelines for stimulation with preterm
infants. Clinics in Perinatology, 17, xv–xvii.
Lindower, J. B., Atherton, H. D., & Kotagal, U. R. (1999). Outcomes and resource utilization
for newborns with major congenital malformations: The initial NICU admission.
Journal of Perinatology, 19, 212–215.
Lindrea, K. B., & Stainton, M. C. (2000). A case study of infant massage outcomes. MCN
American Journal of Maternal and Child Nursing, 25, 95–99.
Lipsitt, L. P., Reilly, B. M., Butcher, M. J., & Greenwood, M. M. (1976). The stability and
interrelationships of newborn sucking and heart rate. Development Psychobiology, 9,
305–310.
Logan, W., & Bosma, J. (1967). Oral and pharyngeal dysphagia in infancy. Pediatric clinics
of North America, 14, 47–61.
Lucas, A., & Cole, T. J. (1990). Breast milk and neonatal necrotising enterocolitis. Lancet,
336, 1519–1523.
Macedonia, C., Miller, J. L., & Sonies, B. C. (2002). Power doppler imaging of the fetal
upper aerodigestive tract using a 4-point standardized evaluation. Journal of Ultrasound
in Medicine, 21, 869–878.
Mandich, M. B., Ritchie, S. K., & Mullett, M. (1996). Transition times to oral feeding in
premature infants with and without apnea. Journal of Obstetric, Gynecologic, &
Neonatal Nursing, 25, 771–776.
Marler, P. (1991). The instinct of vocal learning: Songbirds. In S. E. Brauth, W. S. Hall, &
R. J. Dooling (Eds.), Plasticity of Development (pp. 107–125). Cambridge: The MIT
Press.
Fifth consensus conference on newborn ICU design: Recommended standards for newborn
ICU design. (2003). Journal of Perinatology, 23(Suppl. 1), 3–24. <person-group person-
group-type="editor">Martin, G. I.</person-group>
Mathew, O. P. (1991). Science of bottle feeding. Journal of Pediatrics, 119, 511–519.
May, J. T. (1984). Antimicrobial properties and microbial contaminants of breast milk—
An update. Australian Paediatric Journal, 20, 265–269.
McCain, G. C. (1995). Promotion of preterm infant nipple feeding with nonnutritive
sucking. Journal of Pediatric Nursing, 10, 3–8.
McCain, G. C. (1997). Behavioral state activity during nipple feedings for preterm infants.
Neonatal Network, 16, 43–47.
McCain, G. C., Gartside, P. S., Breenberg, J. M., & Lott, J. W. (2001). A feeding protocol
for healthy preterm infants that shortens time to oral feeding. The Journal of Pediatrics,
139, 374–379.
McFarlane, J. K. (1975). The science and art of nursing. Australian Nurses Journal, 5(6–
7), 28–30.
McVeagh, P., Howman-Giles, R., & Kemp, A. (1987). Pulmonary aspiration studied by
radionuclide milk scanning and barium swallow roentgenography. American Journal of
Diseases of Children, 141(8), 917–921.
Measel, C. P., & Anderson, G. C. (1979). Nonnutritive sucking during tube feedings: Effect
on clinical course in premature infants. Journal of Obstetric, Gynecologic and Neonatal
Nursing, 8, 265–272.
Medoff-Cooper, B. (1991). Changes in nutritive sucking patterns with increasing gestational
age. Nursing Research, 40, 245–247.
46
Medoff-Cooper, B., McGrath, J. M., & Bilker, W. (2000). Nutritive sucking and
neurobehavioral development in preterm infants from 34 weeks PCA to term. American
Journal of Maternal Child Nursing, 25, 64–70.
Meier, P. (1988). Bottle- and breast-feeding: Effects on transcutaneous oxygen pressure and
temperature in preterm infants. Nursing Research, 37, 36–41.
Meier, P. (1990). Nursing management of breastfeeding for preterm infants. In S. G. Funk,
E. M. Tournquist, E. T. Champagne, L. A. Copp, & R. A. Wiese (Eds.), Key aspects of
recovery. New York: Springer.
Meier, P. P., Brown, L. P., Hurst, N. M., Spatz, D. L., Engstrom, J. L., Borucki, L. C., &
Krouse, A. M. (2000). Nipple shields for preterm infants: Effect on milk transfer and
duration of breastfeeding. Journal of Human Lactation, 16(2), 106–114.
Melnyk, B. M., Alpert-Gillis, L., Feinstein, N. F., Fairbanks, E., Schultz-Czarniak, J., Hust,
D., Sherman, L., LeMoine, C., Moldenhauer, Z., Small, L., Bender, N., & Sinkin, R. A.
(2001). Improving cognitive development of low-birth weight premature infants with
the COPE program: A pilot study of the benefit of early NICU intervention with mothers.
Research Nursing Health, 24, 373–389.
Menon, A. P., Schefft, G. L., & Thach, B. T. (1984). Frequency and significance of
prolonged apnea in infants. American Review of Respiratory Disease, 130, 969–973.
The Merck Manual of Diagnosis and Therapy. Disturbances in newborns and infants. 1999.
17th Edition. Section 19. Pediatrics, Chapter 260.
Miller, A. (1982). Deglutition. Physiological Reviews, 1, 129–184.
Miller, A. (1999). Neuroscientific principles of swallowing and dysphagia. San Diego, CA:
Singular.
Miller, A., & Dunmire, C. (1976). Characterization of the postnatal development of superior
laryngeal nerve fibers in the postnatal kitten. Journal of Neurobiology, 7, 483–494.
Miller, J. L., Sonies, B. C., & Macedonia, C. (2003). Emergence of oropharyngeal, laryngeal
and swallowing activity in the developing fetal upper aerodigestive tract: An ultrasound
evaluation. Early Human Development, 71(6), 61–87.
Morris, B. H., Miller-Loncar, C. L., Landry, S. H., Smith, K. E., Swank, P. R., & Denson,
S. E. (1999). Feeding, medical factors, and developmental outcome in premature infants.
Clinical Pediatrics, 38, 451–457.
Moses, K. (1983). The impact of the initial diagnosis: Mobilizing family resources. In J. A.
Mulick & S. M. Pueschel (Eds.), Parent professional partnerships in developmental
disability services (pp. 11–34). Cambridge, MA: Academic Guide.
Narayanan, I., Mehta, R., Choudhury, D. K., & Jain, B. K. (1991). Sucking on the “emptied”
breast—Non-nutritive sucking with a difference. Archives of the Disabled Child, 66,
241–244.
Newman, L. A., Cleveland, R. H., Blickman, J. G., Hillman, R. E., & Jaramillo, D. (1991).
Videofluoroscopic analysis of the infant swallow. Investigative Radiology, 26(10), 870–
873.
Newman, L. A., Keckley, C., Peterson, M. C., & Hammer, A. (2001). Swallowing function
and medical diagnoses in infants suspected of dysphagia. Pediatrics, 108(6), 1–4.
Nijhuis, J. G., Martin, C. B., & Prechtl, H. F. R. (1984). Behavioral states of the human
fetus. In H. F. R. Prechtl (Ed.), Continuity of neural functions from prenatal to postnatal
life. Clinics in developmental medicine. Oxford: Blackwell.
Nyqvist, K. H., Rubertsson, C., Ewald, U., & Sjoden, P.O. (1996). Development of the
preterm infant breastfeeding behavior scale (PIBBS): A study of nurse-mother
agreement. Journal of Human Lactation, 12(3), 207–219.
Palmer, M. M., Crawley, K., & Blanco, I. A. (1993). Neonatal Oral-Motor Assessment
Scale: A reliability study. Journal of Perinatology, 13(1), 28–35.
Parker, S. J., Zahr, L. K., Cole, J. G., & Brecht, M. L. (1992). Outcome after developmental
intervention in the neonatal intensive care unit for mothers of preterm infants with low
socioeconomic status. Journal of Pediatrics, 120(5), 780–785.
47
Phifer, C. B. (1991). The study of early feeding and drinking behaviors. In H. N. Shair, G.
A. Barr, & M. A. Hofer (Eds.), Developmental psychobiology: New methods and
changing concepts (pp. 189–205). New York: Oxford University Press.
Pickens, D. L., Schefft, G., & Thach, B. T. (1989). Pharyngeal fluid clearance and aspiration
preventive mechanisms in sleeping infants. Journal of Applied Physiology, 66, 1164–
1171.
Pickler, R. H., Frankel, H. B., Walsh, K. M., & Thompson, N. M. (1996). Effects of
nonnutritive sucking on behavioral organization and feeding performance in preterm
infants. Nursing Research, 45, 132–135.
Plaxico, D. T., & Loughlin, G. M. (1981). Nasopharyngeal reflux and neonatal apnea: Their
relationship. American Journal of Diseases of Children, 135, 793–794.
Porges, S. W., & Lipsitt, L. P. (1993). Neonatal responsivity to gustatory stimulation: The
gustatory-vagal hypothesis. Infant Behavior and Development, 16, 487–494.
Prechtl, H. F. R. (1984). Continuity and change in early neural development. In H. F. R.
Prechtl (Ed.), Continuity of neural functions from prenatal to postnatal life. Phildelphia:
J. B. Lippincott.
Rakic, P. (1991). Plasticity of cortical development. In S. E. Brauth, W. S. Hall, & R. J.
Dooling (Eds.), Plasticity of development (pp. 127–161). Cambridge: The MIT Press.
Rose, S. A., Feldman, J. F., Rose, S. L., Wallace, I. F., & McCarton, C. (1992). Behavior
problems at 3 and 6 years: Prevalence and continuity in full-term and preterms.
Development and Psychopathology, 4, 361–374.
Rose, S. A., Gottfried, A. W., & Bridger, W. H. (1978). Cross-modal transfer in infants:
Relationship to prematurity and socioeconomic background. Developmental
Psychology, 14, 643–652.
Rossetti, L. (1986). High-risk infants: Identification, assessment, and intervention. Boston:
College-Hill/Little, Brown and Co.
Sameroff, A. (1968). The components of sucking in the human newborn. Journal of
Experimental Psychology, 6, 607–623.
Sameroff, A. (1973). Reflexive and operant aspects of sucking behavior in early infancy.
In J. F. Bosma (Ed.), Fourth symposium on oral sensation and perception: Development
in the fetus and infant (pp. 3–8). Bethesda, MD: U.S. Department of Health, Education,
and Welfare.
Sasaki, C. T., Suzuki, M., & Horiuchi, M. (1977). Postnatal development of laryngeal
reflexes in the dog. Archives of Otolaryngology, 103, 138–143.
Schmidt, R., & Levine, D. (1990). Early discharge of low birth weight infants as hospital
policy. Journal of Perinatology, 20, 396–398.
Schrank, W., Al-Sayed, L. E., Beahm, P. H., & Thach, B. T. (1998). Feeding responses to
free-flow formula in term and preterm infants. Journal of Pediatrics, 132(3 Pt 1), 426–
430.
Sedin, J. M. (1999). Speech and language skills in children who required neonatal intensive
care. Acta Paediatrica, 8, 371–383.
Shaker, C. (1999). Nipple feeding preterm infants: An individualized, developmentally
supportive approach. Neonatal Network, 18(3), 15–22.
Shaker, C. (2000). Setting the stage: Clinical practice in the neonatal intensive care unit.
Rockville, MD: American Speech-Language-Hearing Association.
Sheridan-Pereira, M., Ellison, P. H., & Helgeson, V. (1991). The construction of a scored
neonatal neurological examination for assessment of neurological interity in full-term
neonates. Journal of Developmental Behavioral Pediatrics, 12, 25–30.
Shiao, S-YPK, Brooker, J., & DiFiore, T. (1996). Desaturation events during oral feedings
with and without a nasogastric tube in very low birth weight infants. Heart & Lung. The
Journal of Acute & Critical Care, 25, 236–245.
Shiao, S-YPK, Youngblut, J. M., Anderson, G. C., DiFiore, J. M., & Martin, R. J. (1995).
Nasogastric tube placement: Effects on breathing and sucking in very low birth weight
infants. Nursing Research, 44, 82–88.
48
Siddell, E. P., & Froman, R. D. (1994). A national survey of neonatal intensive-care units:
Criteria used to determine readiness for oral feedings. Journal of Obstetric, Gynecologic,
and Neonatal Nursing, 23, 783–789.
Smith, M. E., & Hart, G. (1994). Nurses' responses to patient anger: From disconnecting to
connecting. Journal of Advanced Nursing, 20(4), 643–651.
Smotherman, W. P., & Robinson, S. R. (1990). The prenatal origins of behavioral
organization. Psychological Science, 1, 97–106.
Stevens, B., Johnston, C., Franck, L., Petryshen, P., Jack, A., & Foster, G. (1999). The
efficacy of developmentally sensitive interventions and sucrose for relieving procedural
pain in very low birth weight neonates. Nursing Research, 48, 35–43.
Swigert, N. (1998). Source for pediatric dysphagia. San Diego, CA: Singular.
Symington, A., Ballantyne, M., Pinelli, J., & Stevens, B. (1995). Indwelling versus
intermittent feeding tubes in premature neonates. Journal of Obstetric, Gynecologic, and
Neonatal Nursing, 24, 321–326.
Symington, A., & Pinelli, J. (2001). Developmental care for promoting development and
preventing morbidity in preterm infants. Cochrane Database of Systematic Reviews(4),
CD001814.
Taniguchi, M., & Moyer, R. (1994). Assessment of risk factors for pneumonia in dysphagia
children: Significance of videofluoroscopic swallowing evaluation. Developmental
Medicine and Child Neurology, 36(6), 495–502.
Tessier, R., Cristo, M., Velez, S., Giron, M., de Calume, Z. F., Ruiz-Palaez, J. G., Charpak,
Y., & Charoak, N. (1998). Kangaroo mother care and the bonding hypothesis. Pediatrics,
102(2), e17.
Thach, B. T. (2001). Maturation and transformation of reflexes that protect the laryngeal
airway from liquid aspiration from fetal to adult life. The American Journal of Medicine,
111, 69S–77S.
Tobin, D. L. (1996). Breastfeeding evaluation. Journal of Human Lactation, 12(1), 48.
Tolia, V., Kuhns, L., & Kauffman, R. E. (1993). Comparison of simultaneous esophageal
pH monitoring and scintigraphy in infants with gastroesophageal reflux. American
Journal of Gastroenterology, 88(5), 661–664.
Tornhage, C. J., Stuge, E., Lindberg, T., & Serenius, F. (1999). First week kangaroo care
in sick very preterm infants. Acta Paediatrica, 88, 1402–1404.
Touwen, B. C. L. (1984). Primitive reflexes—Conceptional or semantic problem? In H. F.
R. Prechtl (Ed.), Continuity of neural functions from prenatal to postnatal life (pp. 115–
125). Philadelphia: J. B. Lippincott.
Unvas-Moberg, K., Widstrom, A. M., Marchini, G., & Windberg, J. (1987). Release of GI
hormone in mothers' infants by sensory stimulation. Acta Paediatrica Scandinavia, 76,
851–860.
Vandenberg, K. A. (1990a). Behaviorally supportive care for the extremely premature
infant. In L. Gunderson & C. Kenner (Eds.), Care of the 24–25 week gestational age
infant (Small baby protocol) (pp. 129–157). San Francisco, CA: Neonatal Network.
Vandenberg, K. A. (1990b). Nippling management of the sick neonate in the NICU: The
disorganized feeder. Neonatal Network, 9, 9–16.
Vandenberg, K. A. (1993). Basic competencies to begin developmental care in the intensive
care nursery. Infants and Young Children, 6, 52–59.
Weber, F., Woolridge, M., & Braun, J. D. (1986). A ultrasonographic study of the
organization of sucking and swallowing by newborn infants. Developmental Medicine
and Child Neurology, 28, 19–24.
White, J., & Labarba, R. (1976). The effects of tactile and kinesthetic stimulation on neonatal
development in the premature infant. Developmental Psychobiology, 9, 569–577.
White-Traut, R. C., Nelson, M. N., Silvestri, J. M., Vasan, U., Littau, S., Meleedy-Rey, P.,
Gu, G., & Patel, M. (2002). Effect of auditory, tactile, visual, and vestibular intervention
on length of stay, alertness, and feeding progression in preterm infants. Developmental
Medicine & Child Neurology, 44, 91–97.
49
Whitfield, M. F., & Grunau, R. E. (2000). Behavior, pain perception, and the extremely
low-birth weight survivor. Clinics in Perinatology, 27, 363–379.
Wilson, C., Rubin, S., & Millard, R. (1991). Preparing rehabilitation counselors to deal with
ethical dilemmas. Journal of Applied Rehabilitation Counseling, 22(1), 30–33.
Wittenberg, J. V. (1990). Psychiatric considerations in premature birth. Canadian Journal
of Psychiatry, 35(9), 734–740.
Yang, W. T., Loveday, E. J., Metrewell, C., & Sullivan, P. B. (1997). Ultrasound assessment
of swallowing in malnourished disabled children. British Journal of Radiology, 70(838),
992–994.
Yliherva, A., Olsen, P., Maki-Torkko, E., Koiranen, M., & Jarvelin, M. R. (2001). Linguistic
and motor abilities of low-birthweight children as assessed by parents and teachers at 8
years of age. Acta Paediatrica, 90, 1440–1449.
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Roles of Speech-Language Pathologists in The Neonatal Intensive Care Unit: Technical

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Roles of Speech-Language Pathologists in the

Neonatal Intensive Care Unit: Technical

© Copyright 2004 American Speech-Language-Hearing Association. All rights reserved.

Philosophical Perspectives on Care in the NICU

Participate in discharge planning and contribute to a smooth, seamless

Principles of Preferred Practice in the NICU

Family-centered care and developmentally supportive care. Family-centered care

Team participation in the NICU. A team of specialists from varied disciplines

Federal legislation regarding intervention in the NICU. Federal legislation related

multidisciplinary system,” for infants at risk for disability or developmental delay

Neonatal psychology and communication. Patterns of early communication

physiology of the upper aerodigestive tract. However, the swallowing component

Communication and developmental assessment. As part of their overall evaluation

Evidence Related to Outcomes of Treatment

Auditory stimulation (AS). Although not studied extensively, AS may enhance

Tactile/Kinesthetic stimulation (T/KS). Tactile (rubbing/stroking) and kinesthetic

Outcomes with Feeding Focused Interventions

Outcomes With Specific Etiologies

Severe respiratory complications (SRC). Infants with SRC experience an increased

Parmelee, Beckwith, & Sigman, 1986); and behavioral problems such as

Counseling and Support

Family Participation. The importance of including the family of the infant in

Equipment. Monitoring equipment is an integral element of the NICU, and families

SLP Education and Training Needs

Comprehensive education is needed for accessing the rapidly expanding

Neonatology, a medical subspecialty of pediatrics, emerged in the 1960's. Separate

Philosophical Perspectives on Care in the NICU

An SLP's communication evaluation of an infant involves observation and

Swallowing and feeding evaluation includes assessment of an infant's readiness

SLPs are responsible for providing specific education to families regarding

Principles of Preferred Practice in the NICU

Family-centered care and developmentally supportive care. Family-centered care

The etiology of prematurity is not fully understood. Primary etiologies of

preterm infants exhibit feeding difficulties. Neonates with prolonged respiratory

Team participation in the NICU. A team of specialists from varied disciplines

The NICU is increasingly configured to better address the medical, developmental,

Federal legislation regarding intervention in the NICU. Federal legislation related

CNS and Behavioral Plasticity. The effects of the interaction of genetic

Lecanuet, Granier-Deferre, Jacquet, Capponi, and Ledru, (1993) in their studies

Neonatal psychology and communication. Patterns of early communication

Neonates give cues to caregivers as to their well-being or stress while at rest, as

Self-regulation is the infant's ability to maintain physiological homeostasis in

Neurophysiology of the infant swallow. Knowledge of the neurophysiology of the

Physical Assessment and Treatment

Clinical feeding and swallowing assessment. An SLP's standard pediatric clinical

The SAIB incorporates specific observations in the categories of alignment, areolar

SLPs follow a protocol for radiographic examination of swallowing. Protocols for

Instrumental assessments of swallowing may be combined with information from

Communication and Developmental Assessment

The SLP, as part of their overall evaluation of communication and development,

Neurological Examination (Sheridan-Pereira, Ellison, & Helgeson, 1991), and The

Evidence Related to Outcomes of Treatment

Broad Considerations for Intervention

Unvnas-Moberg, Widstrom, Marchini, & Windberg, 1987) hypothesized that

Auditory stimulation (AS). Although not studied extensively, AS may enhance

Tactile/Kinesthetic stimulation (T/KS). Tactile (rubbing/stroking) and kinesthetic

Guidelines for Intervention

Evidence-based oral feeding focused intervention. Knowledge of the normal

Nurses commonly report evidence-based interventions directly related to

The ability to nipple feed is preceded by rhythmic, NNS accompanied by even

Nonnutritive sucking (NNS) facilitation. Multiple studies have revealed the

Transition to breast/bottle-feedings. A survey of NICUs in the United States

A review of literature by Lemons and Lemons (1996) resulted in practical