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[00:00:00] Kate Grandbois: Welcome to SLP nerd cast, the number one professional resource for evidence based practice in speech, language pathology. I'm Kate Grandbois
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Episode
[00:01:43] Kate Grandbois: Hello everyone. Welcome to today's episode. We have a really, really interesting topic today that I am really excited to learn about. As our expert guest, we have Ginny Weill joining us today. She is a speech [00:02:00] language pathologist who works in a nicu, um, which is a setting I have had the pleasure of never setting foot in because I have children, and my children were never in the nicu
So welcome, Ginny.
[00:02:11] Virginia Weill: Thank you. Thank you so much for inviting me. I'm excited.
[00:02:15] Kate Grandbois: I'm so glad that you're here. This is gonna be great. Um, I wonder if you could tell us a little bit about yourself before we get started.
[00:02:23] Virginia Weill: Sure. So I, um, grew up in Maine, so I'm a New Englander. Um, I went off, I did, you know, most of my schooling undergrad here in New England, and I thought for grad school, let's get outta New England, go south.
So I went to Virginia. Um, and then I realized there that I missed the fall. I missed New England, I missed the snow. So, um, when we had an opportunity in grad school to start doing clinical placements, I found, you know, my two up in New England at hospitals. Um, and that's kind of how I found my journey back up into this area.
Um, so I [00:03:00] actually worked in Connecticut at a standalone pediatric hospital there for about eight years. Um, I did my clinical fellowship year there. I did a clinical placement there and they were gracious enough to, uh, invite me to stay a little longer. So I started out in outpatient therapy actually. So, you know, doing your typical autism AAC voice, um, articulation.
And then slowly as I became more competent, I got invited to start to do some more inpatient work. Um, so I started to see more of the medical side of things, more of the medical side of patients and how a speech pathologist can help these kiddos, um, in the hospital. Um, and then I started doing more swallow studies.
So I did mbss, the modified barium swallow studies. I started to do fees. Those are the fiber optic endoscopic evaluation of swallowing along with the otolaryngologists or the ENTs. Um, I started, you know, throwing myself into clinics and being a standalone pediatric hospital, we had countless [00:04:00] clinics. So I did aero digestive clinic, um, cleft pallet clinic, voice clinic, fees clinic, and even feeding team.
Um, and then in my last few years there I was, um, I started to get into the nicu and then, um, you know, about four years ago, this hospital that I'm currently in had a nicu speech pathology position, stars aligned and I actually was able to move back home to Maine. So I've been here at the hospital that I currently am at for a little over four years, where I'm focused more in the nicu.
But of course I still do, you know, countless swallow studies. I do fees with our ENTs. I do a couple clinics here, the Aero Digestive and the Cleft Palate Clinic. Um, and then I starting to focus more on cardiac and aero digestive patients. Also on the pediatric floor. So like outside of that NICU group, but just on pediatrics.
Um,
[00:04:56] Kate Grandbois: so you really went from an [00:05:00] outpatient SLP in a hospital, really immersed yourself into the medical world. I mean, I am not that familiar with what happens in a nicu. I'm about to learn from you, but I imagine it is a much more intense medical environment when compared to, let's say, an outpatient AAC clinic, which is where I was.
[00:05:16] Virginia Weill: 110%. And I think, you know, all of the experience that I had up until that point prepared me for the high intensity of the nicu. You know, if I had just gone from outpatient or the school systems, if I had a placement in, I don't think mentally I could have handled the nicu. I think I had, you know, having all those years of experience, um, kind of preparing me and getting me, getting my feet wet and how do I talk to a physician?
How do I argue with a physician respectfully? Um, how do I talk?
[00:05:48] Kate Grandbois: Oh, I wanna hear that story. Oh gosh, I think we all wanna hear that .
[00:05:54] Virginia Weill: Um, but yeah, it really prepared me for the nicu, so I'm very thankful for all the experience I had at that hospital. It [00:06:00] really, um, prepared me for my love. And my love is the NICU and the families and the patients, and.
[00:06:06] Kate Grandbois: Well, I can't wait to hear more about it. Before we get into all of the good stuff, we do have to read our learning objectives and financial and non-financial disclosures, so I'm gonna read through those as quickly as I can to get them over with, and then you can shower us with all of your knowledge and teach me everything about the nicu.
All right, learning objective number one. Identify three roles of the SLP in the NICU. Learning objective number two, identify two reasons why thickening with cereal is not recommended in the NICU, and learning objective number three, identify two possible etiologies of strider in an infant disclosures.
Ginny Wild's financial disclosures.
[00:06:43] Kate Grandbois: Ginny receives a salary working in a NICU as part of a level one trauma hospital. Ginny is a member of Asha Sig 13. Kate, that's me. My financial disclosures. I am the owner and founder of GrandboisTherapy and Consulting, LLC and co-founder of SLP Nerd Cast my non-financial disclosures.
I am [00:07:00] a member of ASHA Sig 12 and serve on the AAC Advisory Group for Massachusetts Advocates for Children. I'm also a member of the Berkshire Association for Behavior Analysis and Therapy, MASS aba, the Association for Behavior Analysis International and the Corresponding Speech Pathology and Applied Behavior Analysis special interest group.
Okay. All of that stuff is behind us. I'm here. I'm ready to learn from you. I'm very excited. Why don't you start off by telling us a little bit about. What it is, like the first learning objective is there are three roles of the SLP in the nicu, and I can only really guess what one of them is. So I'm really excited to hear more about what that is actually like for you on a day in and day out basis.
[00:07:40] Virginia Weill: Sure, of course. Um, so before I get into that, um, exactly what my role is in our nicu, I just wanted to talk a little bit about what the NICU levels are. So there's not just a nicu, there's actually four different levels. Um, and the one I work in is actually, well, we have kind of two, A level two and a level [00:08:00] three.
Um, so a level two is just a special care nursery. We call ours a continuing care nursery or ccn. Um, this is intermediate level care for moderately preterm infants. Um, they maybe need a little bit of respiratory support, mostly working on feeding and growing. Um, and then our level three nicu, which is really our NICU here.
Um, high level diagnostics, um, intensive care, um, a lot of surgical subspecialties for cardiology. Um, and the level four, which is not us, but like for example, Boston Children's is a level four and they can do things like ecmo, the um, mechanical oxygenation. So here in our NICU at our level two and three primary job, oral stimulation, um, a lot of times we'll do oral stem on our trached, invent kiddos that are not necessarily safe to orally feed yet.
But we wanna keep positive learning experiences and positive oral experiences, um, frequent throughout the day. [00:09:00] Um, we do, this is a lot feeding and swallowing assessments at bed, at bedside. Um, we can dive into a lot more of that later. We do our modified barium swallow studies or video fluroscopic swallow studies.
Um, we do fees with ENT. Um, we work a lot with communication and cognition. Um, specifically right now we have a lot of trached and vent kiddos are a little bit older, and so we're doing a lot of communication language, cognition and, you know, collaborating with OT and PT during those sessions. Um, and then this is day in and day out collaboration with families and the team.
Um, they listen a lot to our recommendations in terms of whether we wanna get other people involved, like the pulmonologist, the ENT, the gastroenterologist. Um, and then another thing that we do is education. Education for the nurses. The physicians, a lot of the families. Um, and yeah.
[00:09:56] Kate Grandbois: Okay, so you just blew my mind.
I would've said, uh, [00:10:00] feeding and swallowing . That was the one thing I was pretty sure a speech pathologist did in the nicu. I have a lot of questions. I'm wondering what oral stimulation looks like. What does that, what do you do? What does that look like?
[00:10:11] Virginia Weill: It's a fancy term for, for example, offering a pacifier, offering a pacifier dipped in the mother's milk or in formula.
Um, we do a lot of like, uh, perioral stimulation, like massage to the cheeks, to the chin, to the lips with glove finger to the forehead. Miss that specifically is for the kiddos who have had tape on their face a lot, have had like the masks for breathing, and they just are so, um, hypersensitive, hyper aware of anyone that touches their face.
They have this knee jerk reaction and so we kind of have to calm those senses, um, so that they can tolerate things around their mouth and their face again.
[00:10:54] Kate Grandbois: I feel like before we get any further, I wanna address a, a thought that I keep having, [00:11:00] which is that these are tiny, tiny humans. I mean, it, it's something when you just said, I don't know if anybody's watching this on YouTube.
They probably saw me frown when you said they've got tape all over their faces. Cuz I'm imagining this, you know, little preemie, these little babies with tubes and tape. I mean, that, that must be challenging.
[00:11:17] Virginia Weill: Yeah, it's very hard. And you know, the nurses do such an amazing job with, you know, two person cares to really try to calm the one nurse will calm the baby and really contain them and then the other nurse, you know, does the feeding tube or the diaper change or you know, whatever medically they need to do.
But it's so important and our NICU was so great at really making sure and trying to protect the baby from all this noxious stimuli.
[00:11:42] Kate Grandbois: And I love the idea of considering, you know, on this show we talk about person-centered care all the time, um, and really bringing an individual's values or a family's values into our care.
So when you're talking about trying to create positive [00:12:00] experiences and taking into consideration the level of sensitivity on the face where they, that might not be a critical piece of keeping them alive, per se, right? Or a critical piece related to preventing aspiration.
[00:12:16] Virginia Weill: But it's a critical piece of their quality of life, their tiny little faces, because they're still creating, I mean, their brain is still growing so much and creating all these different pathways and every stick, every tape removal, every gag on the pacifier, every cough on a bottle, you know, that's gonna set them up for those positive or negative experiences down the road, or, you know, it's so every little thing counts.
And so we have to do everything in our power to protect them.
[00:12:42] Kate Grandbois: Okay. So going back to, um, the different roles of the SLP, so you also mentioned collaboration and education. I have to assume that this is a huge part of your job when someone so little is so medically fragile.
[00:12:59] Virginia Weill: [00:13:00] Absolutely. So, um, we, as the therapist, we get invited a lot to the NICU skills fair.
So from an education for the nurse standpoint, I mean, the nurses, even if they've been there decades, they still learn something new from us. You know, it's still beneficial for us to update them on the newest research out there in terms of nipple flow rates or, um, formulas that are no longer existing anymore.
Or, you know, positioners, you know, for OT and PT. So it's, you know, every day we are talking to nurses and, you know, obviously the families can get into that later. Um, on the importance of reading the baby's feeding cues. If they're sleeping, you let them sleep. You don't need a stick of bottle in their mouth.
Um, why it's important not to do, you know, popsicles or lollipops with trach kids. You know, why it's just as important and to do the pacifier dip of the mother's milk, you know, so it's, it's education every day to ensure the best care for these little ones.
[00:13:59] Kate Grandbois: And collaboration too. I'm [00:14:00] sure there are a lot of critical decisions being made in a moment's notice, um, information from all your different colleagues, not just nursing, but you've, you've listed so many already, cardiology, pulmonology, I mean, I'm sure these little babies being in the NICU have many people on their medical team, and I'm sure you have to do, you have to be a really effective communicator and collaborator to facilitate those decisions.
[00:14:26] Virginia Weill: Absolutely. And, and now that babies are being born sooner and sooner, earlier and earlier, um, you know, pulmonary, a lot of them are on oxygen pulmonary involved a lot from the beginning. Um, and you know, the impact of breathing on feeding, it's huge. And so communicating with the pulmonologist on kiddos that we think are aspirating.
When do we do swallow studies? When do we thicken? Um, and, you know, the cardiac babies, you know, if they go in for surgery and maybe they have a vocal cord paralyzed afterwards, depending on where the, the surgery was, you know, getting ENT involved to take a look. And so it's all [00:15:00] that. You know, communication back and forth.
What's going on in your head? This is my plan. What are your thoughts on my plan? Um, so it's always, you need to always have good communication skills and, and be willing to listen and compromise too.
[00:15:14] Kate Grandbois: Well now, you know, I'm gonna ask the question that I wanted to ask before. How do you disagree respectfully with the physician?
[00:15:21] Virginia Weill: Oh, um, actually one of the case studies that I wanna talk about, there was a little bit of a disagreement. Um, I, what I do is I verbalize my most up to date evidence based practice, what I feel is gold standard. Um, I usually explain why I am not recommending what they would like me to do, um, and then I leave it up to them to make the choice of what to do.
Uh, it's, it's, it's challenging and, you know, sometimes it is, like, for example, right now we have a kiddo in the NICU and the doctor really wants to use cereal to [00:16:00] thicken. And I really don't want to use it be, but she's,
[00:16:03] Kate Grandbois: oh, because of that second learning objective we haven't gotten to yet. Why not to use cereal?
[00:16:08] Virginia Weill: But she wants to use it because guess what? It's full of carbs and it's gonna make the baby gain weight. I get it. But at the same time, we have to protect her lungs. She's still on oxygen. She was on a lot of oxygen a week ago. So it's, what are we gonna do? So tomorrow we're gonna sit down together and we're gonna have a discussion with the, um, registered dietician, the physician and myself and, and problem solve and see how we can make sure this baby gains weight for brain development, but also protects their lungs.
So,
[00:16:37] Kate Grandbois: holy moly. So, I mean, these are really, really heavy decisions. Not only are you talking about potentially life altering clinical decisions, but this is also, again, just a tiny little person. I keep thinking about that.
[00:16:48] Virginia Weill: I know. Yeah. So it's, you know, it's all about communication and, um, communication and education.
I feel like. [00:17:00] Because that's the only way you can communicate effectively is to educate them as to why you're recommending what you're recommending.
[00:17:07] Kate Grandbois: Right. Okay. Well, out of all of the roles that you've mentioned, which was, which was many, I wonder if you could tell us a little bit more about the feeding and swallowing piece and lead us into that second learning objective and why you're gonna go into this meeting tomorrow about not thinking, not thickening with cereal.
[00:17:25] Virginia Weill: I would say currently right now, the, the earliest baby we have born, I think was maybe 23 weeks.
Right. 23 weeks. Wow. To 40 weeks. Some of them are born at term, but they have, you know, certain diagnoses that place them at risk for, um, feeding issues or breathing issues. Um, so yeah, so I, you know, I start to see babies typically right now when they start to bottle feed our breastfeed. Usually the lactation consultants, um, see most of just the solo breast feeders [00:18:00] or chest feeders.
Um, you know, if they have concerns about aspiration they'll bring in the speech pathologist, but most of our kiddos are bottle feeding that I specifically see. Um, and if they're born this early, they don't have that coordinated suck swallow breath that they need for air way protection. And so my role is to basically teach that.
Teach that by choosing the right bottle, by choosing the right nipple flow rate, um, choosing the right position that they're fed in, you know, cradle versus side lying on the left versus on the right. Um, you know, pacing them, meaning, you know, emptying the nipple so that they cue the baby to stop and catch their breath.
Um, so this is what I do day in and day out and it's a lot of education for the families. It's cause new, cause a lot of families have babies born full term first and then this now a pre, and they're like, I don't know how to feed a kid. My baby, you know, this is how I fed him before. What do you mean sidelying?
[00:18:56] Kate Grandbois: So I was just having these thoughts while you were talking [00:19:00] because I have two babies. I had two full term babies who never visited the NICU and feeding my babies, I breastfed my babies, but feeding them was one of the most stressful experiences of my early parenting life. Now they're older and they give me a whole other headache of stressful problems, but this is a tremendous stressor on these families.
I have to imagine, I'm imagining myself in that position having just physically experienced birth, or maybe they've been there for a while and you're healed a little bit, but even so, you have got a sick, a sick baby in the nicu that the counseling piece for you must be critical. It must be a huge part of what you do.
[00:19:50] Virginia Weill: It is, and you know, it's the nurses, you know, when the babies transition from our NICU into our continuing care nursery, the nurses and the NICU almost [00:20:00] say like, it's to graduation. It's closer, one up closer to going home because we kind of label our continuing care nursery. That's the feeders and growers.
Those are the kids that are learning how to feed and then they'll go home. And the nurses and even our, the, the feeding therapists, we say to the families when we meet them, not in like a pessimistic, you know, glass half empty way, but feeding is what's gonna keep you here. It is the hardest thing to learn because the baby is in control.
The only way you can speed up your discharge date is by just reading your baby's cues. And even if that's letting the baby sleep through a care time or sleep through a feed. You are still helping them get to that end goal of going home. And I think that's the hardest and most frustrating thing, certainly for these families who have been there since 28 weeks and now their babies are 38 weeks and the moms and dads have been in there every single day.
[00:20:54] Kate Grandbois: Oh my gosh. The stress. I can't even, yeah, I mean, you're, you're, you're not sleeping. [00:21:00] You're not even in your own home. You may have had to take extended or unpaid paternity or maternity leave. There are so many stressors that go into those first few weeks of parenthood alone. Um, so I, I, I can't imagine as the professional, as the speech pathologist focused on feeding, knowing that that is the root of what they need to do in the nicu or to, or to, as you said, quote, graduate from the nicu.
That's a tremendous, that's a tremendous responsibility. Yeah.
[00:21:32] Virginia Weill: And I try to, you know, say to the families, I try to be gentle, you know, and just provide that education. Give them the handout, you know, once your baby starts to feed in the nicu. But if they don't and they start to push their children, or they, you know, aren’t respecting the baby's cues and, and forcing that bottle into their mouth, that's when I start to try to scare them almost because I want them to know that, like we've talked about before, every little thing you do now you're gonna set them up for either [00:22:00] success or failure with feeding down the road, being a picky eater,
Kate Grandbois: no pressure.
Virginia Weill: Yeah. Right. I mean, but that's sometimes what parents need to hear because we, in the medical profession, I feel like sometimes we talk so softly, we talk very gently because we don't wanna scare people.
We don't, cuz you're already in a stressful situation. But when these little ones lives and feeding, you know, trajectories are in the balance. You do want the best for them. And if the family isn't listening, then you have to say, Hey, do you want a clear communicator? Yeah. Do you want your kid to be a picky eater?
Do you want your kid to go home with a feeding tube? You know, this is, we're trying to avoid this, so you need to listen and follow these recommendations. Um, we don't encounter that too often, but unfortunately, you know, it does exist.
[00:22:46] Kate Grandbois: It does happen. Well, and, and as the clinician. Putting on your counseling hat on and knowing when to be direct.
Knowing when to do active listening. Yeah. Knowing when to softly educate, knowing when to let them have a grieving, stressful moment [00:23:00] because they're new parents under a lot of duress. I feel like those are all the counseling skills that we need, um, that we don't necessarily get in graduate school. So I always love, I feel like counseling is such a huge part of our jobs across the continuum of scope of practice and speech pathology.
So I always like to just pause and highlight that for a second. Um, I wonder if you could, just thinking again about our sec, our second learning objective and the thickening, the with cereal, how do you, how do you get there? I assume you mentioned bedside swallow, you mentioned mbs. I assume that there is an assessment or procedure that happens first.
[00:23:36] Virginia Weill: Yes, of course. So, um, I actually have a little case study if you would be okay with me kind of going through that, like how we in this kiddo, we actually, um, thickened, um, after a little discussion with the medical team. Um, so, let me give you a little background here. So this patient, this baby, um, was born late preterm and at outside hospital.
She was transferred to us on day of life [00:24:00] three for prematurity, but also desaturation specifically with feeding. Um, she also
[00:24:06] Kate Grandbois: desaturation, what do you mean, desaturation?
[00:24:09] Virginia Weill: So the oxygen levels go down.
[00:24:10] Kate Grandbois: Oh, oh, uh, oxygen desaturation. Yes. Okay.
[00:24:14] Virginia Weill: Um, so we call them dsat. So, but also saturations. Uh, she also had hypoglycemia at birth and needed some oral glucose gel.
So for a feeding therapist, um, anytime a baby has difficulty managing sugars or the mother was a diabetic during pregnancy, um, sometimes that can impact, um, brain development and the impact on feeding may delay their feeding skills a little bit. So that's also a very important red flag for me to kind of think of in terms of chart reviewing before I go see this kid.
Um, she started developing desaturations, requiring a little bit of oxygen at the outside hospital. And then once she was transferred to our nicu, we quickly weaned her down to room air, which is great. It's a good sign. Um, and then the nurse reached out to [00:25:00] me about the concerns with feeding. Um, luckily at our hospital and our nicu, um, we get automatic orders.
So anytime a baby's admitted, uh, either in our hospital or from an outside hospital, we get automatic orders and it's our decision of whether we see them that day or the baby may be too young or too medically complex. So we kind of, we wait and defer until they're more appropriate. Um, and of note, this baby did not have a nasogastric tube in place, an NG tube, um, which typically a lot of our NICU kiddos get one placed just to start fluid and hydration.
Um, so I get called up to go see this kiddo. Um, I feed her with, so our hospital, our NICU carries a Dr. Brown's bottle system, and we have all the nipple flow rates out there for Dr. Brown's. So I started her with the Dr. Brown's preemie. Um, because of her age, I felt she was appropriate and should probably be able to handle this flow rate.
However, she immediately started coughing. Her face turned color [00:26:00] to blue gray.
[00:26:01] Kate Grandbois: Oh my gosh, I'm already having so much anxiety for you. This is what, just what you do on a regular basis. I'd be so nervous.
[00:26:06] Virginia Weill: I know. It's, it's, and the parents are standing there too, so it's, you know, you have a crowd. The nurse is standing there.
Cuz you know, as a speech pathologist, we are the experts in feeding and swallowing. We are.
[00:26:19] Kate Grandbois: We, I'm not, yeah. ,
[00:26:21] Virginia Weill: they're watching, they're seeing what I'm doing, you know? Right. Um, and of course oxygen drops. She has desaturations, which would be associated with that color change. So I stop and I say, all right, let's try the ultra preemie.
So Dr. Browns makes an ultra preemie, which is pretty slow. Um, but when I gave it to her, she was inefficient. She couldn't get anything out. So she was sucking like eight times before she could swallow, which. It's not, that's not efficient, it's not functional for a baby. So I went back to the preemie. I tried to do strategies like nipple half filled and pacing, didn't work, coughing, changing, clear signs of aspiration and distress.
So I stopped the [00:27:00] feed and I said, I'll come back at the next one and I'm gonna see if I can find a different bottle system that hopefully the flow rate is between the ultra and the preemie. So we're hitting somewhere in the middle. So that was the plan. So I come back, so this time I'm, I try all the Avid bottle system.
So they've come out with a new nipple flow rate and, um, we're still all the feeding therapists here, still trying to figure 'em all out. But I try the two slowest flow rates and she still gulped, face turned color desaturating. Um, so I stopped that, went back to the preemie again, tried to pace a little bit more, like literally every suck.
I was giving her a break to catch her breath. Still coughing, oxygen dropping. So I actually turned to the family who witnessed all of this very stoically and I said, you know, I am gonna talk to the doctors, but I am gonna recommend consideration of a little feeding tube in the nose for just, you know, short term as she continues to grow and [00:28:00] her brain continues to develop.
I said, she's still a little early, she may just need some more time. And they were totally on board.
[00:28:07] Kate Grandbois: So as you're going through this process, at what point would you recommend an mbs?
[00:28:14] Virginia Weill: So this kiddo, if I wanna say she was 36 and change, not even 37 weeks yet. So typically at our hospital, we don't recommend an MBS until about 38 weeks.
Now, of course, Our kids, yes. Because we want them, we wanna maxi, I mean, it has radiation and we wanna maximize. Their neurodevelopment time so that when we finally do the modified, we're not setting them up for, you know, for failure in the sense of, uh, false positives for aspiration, or they still are so discoordinated because they're just still too early.
Like we know that they're not gonna be coordinated and they're not gonna do well in terms of airway protection. So that's why I did not jump on the modified barium swallow study. So I [00:29:00] went out to the team and luckily they were rounding right then and there, and I told them everything. I saw what I talked to the family about, that I recommended the ng, and the doctor said no.
And I said, oh, oh, okay. Well we can't continue to feed like this. It's not safe, you know, airways,
Kate Grandbois: why did they say no?
Virginia Weill: Well, because they wanted to try thickened feeds. And I said,
Kate Grandbois: here we go.
Virginia Weill: Uh, yes. And I said, thickened feeds for a kiddo under 38. Typically we don't recommend, just like we typically don't rec, recommend a swallow study for under 38 weeks.
And they said, well, she's showing enough clinical symptoms at bedside that, uh, she's aspirating in, that she's in distress. So wouldn't she show those same signs with thickened if she were aspirating thickened? Because what I said is the, you shouldn't, if a, if a patient, whether it's an adult or a baby, is showing signs of aspiration, we don't, with thin liquids for example, we don't know if [00:30:00] we give 'em thickened.
They may silently be aspirating thickened. So that's why we need to test using an instrumental swallow study to make sure that they're actually safe on the thickened. And certainly with these babies, a lot of times they don't have the mecca, the cough mechanism yet to tell us. That they’re aspirating, right?
[00:30:17] Kate Grandbois:Tiny little ribs and they're tiny little muscles.
[00:30:20] Virginia Weill: And the lor, was it the laryngeal? The cough reflux doesn't even develop until past 40 weeks. So if this baby is younger than 37 and coughing with feeds, she's probably aspirating a lot. But that's why I said I think we should hold off on thicken and just give her a few days with a feeding tube.
And the team still wanted to do thickened. So this is a perfect example of, I said my, what I knew was evidence based, correct? Um, and I explained my rationale to why, but I also saw their side of, well, if she's showing such gross signs of, of aspiration with thin, wouldn't she show it with thickened? [00:31:00] Which I, I can't really argue with.
I can say, actually, you're probably right. My gut is that she still would cough, um, or desaturate, or her face would change color. So I said, all right, at the next feed, I will try thickened feeds. And it was not cereal though. It was a, a formula that we use that's naturally thicker and she did great. I know.
Kate Grandbois: It has a happy ending.
Virginia Weill: She did a happy ending. I'm so glad to hear that. So that's, that's, I think the, the, the piece here is yes, you have disagreements with people and you may be wrong and they may be right, but at the same time you learn from each other, you know, and the patient really is, is the reason why you do all this and who you're protecting.
And so as long as she looks safe and she doesn't drop her heart rate, or doesn't drop her oxygen, and she's taking her volumes and she's growing that I'm happy. And the medical team is happy. Right?
[00:31:55] Kate Grandbois: It's a great example of leaving your ego at the door because you're not there to have an [00:32:00] argument or a pissing contest with another colleague, you're there in your case to save a little baby.
Right. And you've mentioned a couple of reasons or a couple scenarios when you wouldn't offer thickened liquids. So if they're under 38 weeks, um, you mentioned that it can create distress with, with breathing or with the lungs. Um, and it's not indicated for other pulmonary reasons, but what's with the cereal?
Why were we thickening with cereal?
[00:32:26] Virginia Weill: Yeah. So back in the day we did rice and oatmeal all the time. And then, you know, arsenic became the big thing with rice and so everyone went to oatmeal. But, um, the big thing is a lot of babies in the nicu, um, their parents are able to either purchase donor breast milk or they're able to pump themselves and have breast milk or chest milk.
So we can't thicken breast milk with cereal because of the amylase enzyme breaks down the cereal or the carb. In the mixture, [00:33:00] which then reduces the effectiveness of the thickened liquids. Does that make sense? And
[00:33:05] Kate Grandbois: that's unique to breast milk and chest milk.
[00:33:07] Virginia Weill: Just breast milk and chest milk. Yeah. Oh man.
That's like a cereals of carb, and so that enzyme breaks it down. So literally we've seen it when I first started, you know, they would do it a little bit more often, and you would see the breast milk and the cereal, and then thick, and then all of a sudden in five minutes, thin all broken down. Interesting.
It's very interesting. But that's the reason why we should not be using cereal with breast milk.
[00:33:30] Kate Grandbois: What if it's, um, formula?
[00:33:34] Virginia Weill: Formula is okay.
[00:33:36] Kate Grandbois: To thicken with cereal. For those of you listening at home, she's grimacing while she's sitting.
[00:33:43] Virginia Weill: I, I know. Even with my mask on the doctors know. Cause I can tell by my eyes I'm grimacing
Um, yes. So, you know, we weigh the pros and cons of using cereal. Um, it adds in a lot of unneeded carbs in terms of the [00:34:00] microbiome of the baby. So nutritionists, um, or the dieticians don't love it, um, because it may set these kiddos up if, you know, they're on the cereal for long term, for a high rate of diabetes, obesity, you know, down the road, which we try to avoid.
Everything we do now is impacting these kids later in life. So that's why we really try not to use. That being said, with current, uh, manufacturing issues, a lot of the formulas that we use to thicken, well actually the formula we use like nil AR is not being produced right now. So families literally are going to 10 different Walmarts and 10 different targets to try to find this formula.
And so this discussion tomorrow that I'm having with the physician and the, um, the dietician is, well, the family can't find it. We need to have another option. We need this baby to gain weight. So cereal is what we're gonna do. So that's, so yeah, cereal can be used, but it, pros and cons of it need to be discussed with the medical team and with the family so that they're aware.
[00:34:59] Kate Grandbois: What, is [00:35:00] there a reason why you are not thickening with other traditional thickening agents that you would use in the hospital for, for adults?
Virginia Weill: Like simply thick?
Kate Grandbois: Yeah. Is that a silly question?
Virginia Weill: No, not a silly,
Kate Grandbois: it's clearly me showing my, I don't work in a medical facility.
[00:35:18] Virginia Weill: Great question. So we're actually working on a thickening guideline right now for our neonates and then also just our pediatric population.
So yes, absolutely. There are tons of thickening agents out there that I love and I highly recommend, like Simply Thick, for example. It's a beautiful gel that just dissolves, um, super expensive though. Um, or another xantham gum based powder, uh, like Thicken Up. Clear. I love that. That's powder pretty cheap.
Families can find it on Amazon. The problem is you can't recommend those younger than 12 months of age.
[00:35:52] Kate Grandbois: Interesting. For dietary reasons?
[00:35:54] Virginia Weill: Dietary, but also gut. So they, um, there was a recall [00:36:00] Ooh, years ago, right? I think when I started working, um, on a certain product because they, they were, it was being used in neonates and it caused NEC or nec, necrotizing enter colitis, which is basically part of the, the gut dies and some babies actually passed away. So that's why thickening agents really got strict on what age, um, you can start to use it because of the impact on the gut.
[00:36:29] Kate Grandbois: I'm glad I asked. I'm sure it wouldn't happen in any nicu, but that, that seems very, very serious.
[00:36:36] Virginia Weill: Yeah. And actually Gel Mix is another product that came out. I'm not endorsing any of them, I'm just saying what's out there. Um, but Gel Mix just came out and that's a Cara Bean based thickener. We can use that in breast milk actually. But, here's the but, you can't use it in kids younger than 42 weeks or um, 42 weeks and they have to be six pounds.
Okay. [00:37:00] So a lot of these babies that we see usually are younger than 42. And so we have to try to find something like NL AR to use instead cuz we gotta wait until they hit that 42 week and six pound mark to try all the, the gel mix with moms.
[00:37:13] Kate Grandbois: So there's a pretty narrow window of application for that.
Yeah, that makes a lot of sense.
[00:37:20] Virginia Weill: But a lot of hospitals are using it appropriately, you know, for when those babies reach that age.
[00:37:25] Kate Grandbois: Okay. Are there any other reasons to not use cereal for thickening?
[00:37:32] Virginia Weill:No, I would say it's not in breast milk. Cause it breaks down the carbs, it breaks down the cereal, so you have an inconsistent viscosity and then, um, it's just a lot of carbs and a lot of calories, empty calories that messes up their gut biome, I mean, and sets 'em up for potential issues down the road.
[00:37:53] Kate Grandbois: Okay, so earlier in this conversation we were talking about. Before we got into the thickening and other interventions, we were talking [00:38:00] about, um, the assessment piece. And this is when you shared the, the clinical story with us about this baby who I'm so glad, had the positive outcome and did well. If there are instances where you, or, or I guess are there instances where you do recommend an MBS and have other unwanted outcome?
Like you go through an MBS and they need a persistent application of an NG tube?
[00:38:33] Virginia Weill: Yes. So the hard parts of my job are when I have to say to the family, I'm not recommending that he consistently take the bottle or be allowed to have a full volume, or I am gonna recommend a G-tube or a longer, longer means of nutrition.
Usually how I put it, um, I will say 99% of the time, I personally do not recommend strict NPO due to aspiration, [00:39:00] which I know is a very, um, controversial discussion topic between pulmonologists and the speech pathologist. And I'm sure it's different at each, um, hospital in between clinicians. Um, but I come from the background of, you know, if you, if I see aspiration on a mbs, on a baby, on a NICU baby, and I say you strict npo, how are we going to practice in this key timeframe that their brain is still developing this whole suck swallow breathe.
How are they gonna practice if they can't eat anything? So what I've, you know, brought to our institution or supported it, is small volumes. So I actually have another case that I can talk about specifically about mbss, where, uh, I limited, I limited his volumes to 10 mls, 15 mls, 20 mls until he got better protected his airway better, um, and could prove that [00:40:00] his lung status wasn't being impacted by potential aspiration.
[00:40:06] Kate Grandbois: Okay, that makes a lot of sense. So, moving into our third learning objective, you've got this fancy word in here, strider. I know what it means. But I wonder if you can tell us a little bit about what it is.
[00:40:16] Virginia Weill: Yes. So this is one of my, um, uh, I don't say like pet peeves, but it's, it's something that always I wanna educate everybody on.
And I actually am doing a talk for our hospital soon, and this is one of the things that I'm talking about.
[00:40:30] Kate Grandbois: You brought a, so you have a soapbox. You brought the soapbox with you,
[00:40:32] Virginia Weill: Yeah.
[00:40:33] Kate Grandbois: So get on it. Get on up there.
[00:40:35] Virginia Weill: Yeah. So, uh, let's see, Strider. So Strider is that squeaking sound that you hear, so I'm going to imitate it cuz people say, do a good job of it.
It's that. So you can hear this when you're changing their diaper and they're crying. You can hear this just when they're sleeping, sometimes on their back, if their tongue is a little bit more floppy or their jaws recessed a little bit, you can hear like, you know, [00:41:00] like deeper sound. Um, or what I focus more on is the feeding piece of when you just hear strider with feeding, what does that mean?
Why aren't you hearing it throughout the day or throughout the, the care time with the child? And you know, I, because I'm on Aerodigestive team, I see some of these outpatients referred from pediatricians for laryngeal malaysia because they have strider and the ENT scopes and there's no laryngealmalaysia,
[00:41:28] Kate Grandbois: okay.
To level the playing field. Give me a reminder of what Ingal Malaysia is.
[00:41:32] Virginia Weill: Laryngomalaysia is basically a floppy upper airway. So you have Laryngeal Malaysia, tracheal Malaysia, and Barco Malaysia. Okay. And sometimes you can have all three. Okay. Um, and usually what I, um, deal with, if I can put it that way, more is the LaryngoMalaysia.
Cuz people wanna know why are they squeaking so much? Um, is it airway protection? Is it a vocal cord out? [00:42:00] Um, you know, in the cardiac babies who have surgery, they hit the recurrent laryngeal nerve sometimes just to move it around to get to the heart and it tweaks a vocal cord so the vocal cord doesn't move all the way.
It's kind of paralyzed in a specific position and that kiddo's gonna have strider as well. So anytime, I guess my big takeaway for this is anytime you have a patient, whether it's a neonate, outpatient, pediatric, and you hear strider, ask an ENT to take a look and see what is the reason for the strider, because it is not always laryngo malaysia.
Okay. I had one kid, um, I saw a kiddo on pediatrics. She was older, like a few months old. Came in for actually failure to thrive, meaning just her weight isn't good. Um, and I was feeding and I heard this strider. I'm like, no one's mentioned this. And so I brought it to the residents and they said, oh yeah, let's get ENT to come take a look.
She actually had a paralyzed vocal cord and they had no idea why. She had never [00:43:00] had cardiac surgery or no two cords. Both of her cords were paralyzed and like this kind of the between middle and uh, open and closed paramedial position. And, um, so thank goodness, you know, they did an MRI to make sure she didn't have any neurologic involvement, which thank goodness she didn't.
But, you know, ENT then continued to follow her about every three months and rescope her just to see what was going on with her vocal cords. So like that's, again, you've gotta get ENT involved and have them take a look at these kiddos.
[00:43:27] Kate Grandbois: That's so interesting. So is it, just to say this back to you to make sure I've understood, it sounds like any time there is strider, it warrants a referral to ENTTo get scoped.
Virginia Weill: Yep. Same with, yeah. Yes.
Kate Grandbois: And you would say that for even, would you say that for babies outside the nicu
[00:43:49] Virginia Weill: Yes. Everywhere. Any infant full term, just going to the pediatricians. Um, kiddo. Yeah. Any, even if you're visiting your friend who just had a baby and [00:44:00] they're feeding and all of a sudden you're like, wow, that kid sounds like a mouse over there.
I don't know if your friend would be open to it, but you would say, Hey, has your pediatrician recommended an ENT consult because you don't know why the baby's squeaking and you'd wanna find out.
[00:44:15] Kate Grandbois: Interesting. Okay. Okay. So you've gone over two possible etiologies of strider in infants. Um, you've mentioned to us all of the reasons why we should be concerned about a potential strider and when to refer.
The answer is 100% of the time. I, I know that you have some other case studies that you brought to us. Do you wanna walk us through those? Sure.
[00:44:39] Virginia Weill: So one of them kind of goes back to, um, your MBS question in the NICU and when it, when you redo them. So I guess another one of my soapbox things besides strider is mbss.
They are not a pass or fail, and I. Even some of my, uh, [00:45:00] colleagues will say they pass and I turn to them and I say, it is not a pass or fail. I don't know what you're, like. You are smart. Stop saying this. Um, and a lot of physicians will just say, both in the adult world and the pediatric world, well did they pass?
And I said, there's no pass or fail. It is, you are assessing. Our job as a speech pathologist is to assess the biomechanics of the swallow. You know, you are providing the team basically a risk level of whether you think airway compromise is gonna happen and why. And I think you always have to ask yourself, why am I seeing what I'm seeing?
Sure. You can list residue, you can list, you know, material in the nose, up in the nasal cavity. You can list aspiration, but that doesn't tell the treating therapist or the physicians why this is happening. They wanna know what can they do to help prevent this in the future. So I think that's where we really need to not, you know, minimize our role in a [00:46:00] patient's medical workup.
We have a huge advantage here to really show the family, the patient, the medical team, what we do and how important it is in the health of the patient. Um, it's, you know, mbss are just a moment in time, so I'm just looking at my little dots here. My bullets, mbss are not, are just a moment in time. So if you see aspiration, great.
If you don't see aspiration, it doesn't mean it's not gonna happen or it's not happening. Same with reflux cuz so many res, so
Kate Grandbois: great reminder. Mm-hmm. .
Virginia Weill: Yeah. Reflux. Well first of all, as swallow study is not a test for reflux, but if we see it, great. If we don't see it doesn't mean that your child doesn't have reflux.
And I always have to say that to families. Just cause we didn't see it doesn't mean it's not happening. I believe you, your story, I believe you, you know,
[00:46:45] Kate Grandbois: and how validating that must be. I think the, the, the quote that you just said, that it's a snapshot of a moment in time is such a good reminder of what that test actually is and does.
[00:46:56] Virginia Weill: Yeah. So, um, kind [00:47:00] of, so talking about, uh, mbss in the nicu, like I talked about before, we usually don't complete them younger than 38 weeks, but of course there are those outliers. Um, and of course we've completed them before 38 weeks, but that's kind of our, our our time. Okay. Um, we usually recommend a swallow study once we've trialed all the other strategies at bedside and we're still concerned about airway compromise.
So in that first case study that I talked about, the thickening kiddo, if she had been older, if she had been 38 or 37 and change, I probably would've said, let's do a swallow study. Let's take her down and let's really see what's going on. Um, because she was showing so many overt signs of distress at bedside.
Um, we try to complete the swallow studies at around a feed time. So in the nicu, babies are fed on a certain time schedule every three hours typically. And so we try to complete the study at that time so the babies are hungry and then they are awake and rooting and engaged in the feed. Um, we feed the [00:48:00] baby downstairs and fluro in the same position that they're gonna be fed upstairs and at home.
So we're really, yeah, we're really mimicking. We're trying to the best we can, what a natural feed looks like. Um, and then I have the family or the nurses bring down all the bottles that the babies are using or could use or have brought, you know, have trialed at bedside. Just who knows, you know, maybe with an AVMP bottle they're aspirating, but with the Dr. Brown, they're not. So I have all those bottles down there to try. Um, and I think, you know, I know Boston Children's does this and so we've started to do it too where, um, certainly with Dr. Browns, we give them a new nipple for every swallow study so that we're standardizing that flow rate even more. So some kids babies will use the same ultra preemie nipple for two weeks, but if they come down for a swallow, guess what?
Whoop, you're getting a brand new one so that we know the flow rate is perfect.
[00:48:51] Kate Grandbois: Okay, that makes a lot of sense
[00:48:53] Virginia Weill:. Yeah. Um, and then in our NICU kids, sometimes we have a [00:49:00] very small window of a couple minutes that we have this baby with enough respiratory support to actually feed and go to get a good assessment.
So I know, um, I think, you know, researchers are working on the baby imp, which is similar to the MBS imp, which,
[00:49:16] Kate Grandbois: what's an imp What, what is the imp?
[00:49:18] Virginia Weill: It's a profile Impairment Profile, , and it's a standardized assessment.
[00:49:24] Kate Grandbois: I don't mean to put you on the spot, but it is an acronym. Yeah. That refers to an assessment measure.
[00:49:29] Virginia Weill: Yes. And, uh, okay, don't, okay. I'm not great with adults, but I believe the mbsm is a standardized way to complete swallow studies. Okay. And so now they're trying to create,
Kate Grandbois: you know more than me, keep going,
Virginia Weill: now they're trying to create a baby imp. Okay, so, um, where was I getting? Oh, so I, so I know like you're supposed to, you know, start with a certain consistency and kind of go from there.
But with NICU babies you have, like I said, maybe a couple minutes of time and [00:50:00] you gotta use it to the best to gain as much information as you can in that two minutes. So, for example, this kiddo that, um, we did this swallow study on he upstairs showing overt signs of aspiration, pulling off the nipple, coughing, random desaturations, random heart rate drops.
[00:50:20] Kate Grandbois: I would be terrified. I'm, I'm having secondary fear just listening to this story. Keep going.
[00:50:25] Virginia Weill: Uh, so we,
[00:50:26] Kate Grandbois: it is very, going back to what you said at the beginning, it's a very intense environment. It is giving credit where it's due.
[00:50:32] Virginia Weill: Um, so we knew he was likely aspirating within liquids, but our question was, is he safe on thickened?
So I started that specific swallow study with thickened liquids because I knew I had my two minute window to get the information I needed. And sure enough, we did it. He, we got a good assessment downstairs on the thickened. Um, unfortunately he was aspirating it. Um, and he, I then had time to still do thin liquids under fluoroscopy [00:51:00] and he was aspirating that.
But this is a perfect example of, I cleared him for very minimal amounts of PO. Meaning by mouth. Um, and I got, I got pulmonary involved, got him on some oxygen to help with his worker breathing and his tachypnea and tachypnea just fast breathing.
[00:51:18] Kate Grandbois: Um, thank you for defining that. You knew that was coming out of my mouth in two seconds.
[00:51:21] Virginia Weill: Yeah, you're, um, and then, I mean the, the end for this kiddo, he went home actually with an ng, so I did not recommend a G-tube for him. I thought he just needed a little bit more time, maybe a few weeks and then he could probably get his act together.
[00:51:39] Kate Grandbois: So through, at, even after you recommended the NG tube, was he still cleared for small amounts just to sort of keep up that positive relationship with oral motor movement, sex, swallow, braid, all of that kind of stuff?
[00:51:52] Virginia Weill: Exactly, yes. And the other positive thing is, um, I forgot to mention before, um, a lot of the kids who [00:52:00] I, who are aspirating, but I let them have a small volume, it's because they're on breast milk. Okay, so the breast milk, not the pulmonologist like me to say this, but it's a bodily fluid that the babies already know.
So if it's going into their lungs, their lungs already know what breast, what that breast milk is, and they don't react as much as to a formula with rice starch.
Kate Grandbois: Is that's true.
Virginia Weill: Yeah. So, um, like in the adult world, you know, think about the Frazier water protocol. I dunno what that is, right? Oh, okay. Um, I think it's, you know, like if you have, you have to fit all this criteria, but basically you're allowed water, free water knowing that you're gonna aspirate a little bit of it.
Same thing with ladies. You don't have protocol, but the pulmonologist say, okay, Ginny, if he is on breast milk and you're limiting the volume, I'm, I'm okay with him having a little bit to keep up the.
[00:52:53] Kate Grandbois: Okay. That's so interesting and makes a lot of sense.
[00:52:56] Virginia Weill: Yeah, I mean, that's what we do here. So, I mean, I don't know what other hospitals, I [00:53:00] know other hospitals can be a little bit more strict in terms of no strict NPO we need to protect the lungs at, at any cost.
But I think, you know, we compromise a lot here and hopefully to benefit the patient.
[00:53:11] Kate Grandbois: Well, and I think the takeaway is if you're listening and you're an SLP either in a NICU or interested in getting into a nicu, at the end of the day, this is really about collaborative medical decision making, um, and working within the, the practice of, of your workplace setting.
So don't worry, we, we know that the information you're giving us is not the end all and be all of what you should, what should've do. These are all case by case decisions, um, made with the rest of the medical team. You have covered so much ground with us today, and before we wrap up, I just have two questions.
Okay. The first question is about something you mentioned at the beginning of this episode, um, related to the role of the slp, which was working on communication in a nicu, communication and language. And I'm a pediatric therapist. When [00:54:00] I, when my, my intervention is games and activities and, you know, I've got my, my bubbles and my star charts and, and whatever I've got pulled together.
I'm having a really hard time imagining what communication and language intervention looks at, looks like in tiny, tiny babies, number one, but also in a really intense medical environment. So can you tell us a little bit about what that looks like?
[00:54:26] Virginia Weill: Sure. That's a great question. Uh, so funny, I'll start it with a funny thing.
Um, when I enter the room and meet the family for the first time, I say, hi, my name is Ginny. I'm one of the speech pathologists, and then I say, who focuses on feeding? Because I've had so many parents say, you're a speech therapist. Well, my kid's not talking. Like, you don't need to teach them anything. Yeah.
[00:54:49] Kate Grandbois: My, my tiny baby is, is 30 weeks old. Yeah. I'm not sure why you're here .
[00:54:52] Virginia Weill: Literally, and I totally get it.
[00:54:56] Kate Grandbois: I mean, it's related to my question, like, what does that even look like?
[00:54:59] Virginia Weill: Yeah. So, and [00:55:00] I, so I, first I start out, if they do say that I, you know, gently start sarcastically, respond back with actually I'm helping you learn the communication that your body or that your baby is giving you, you know, by the hand going up, the baby, turning their head when you give them the nipple, that's communication between the baby and to you. Um, and then the other piece of it, uh, is just. Having the babies listen to the adults talk, just the exposure to language. I know a lot of bigger hospitals are starting reading programs where volunteers just go into their room and they read books just out loud so the babies can hear language and not hear the beeps and the alarms all go on off all the time.
Um, and you know, for us, when babies reach a certain age, we kind of put them in baby rehab. We call it baby steps program, where we give the families boxes, little Tupperwares full of books, rattles, um, sensory those soft [00:56:00] books that, you know, scratching
Kate Grandbois:the crinkle ones.
Virginia Weill: Yeah, crinkle. Yeah, yeah, yeah. Um, and so I think it's at 42 weeks they start to do that.
And the nurses, the families, the therapists, the volunteers hold the baby and they literally are reading the books to these kids.
Kate Grandbois: That sounds like so much fun.
Virginia Weill: It is so much fun. The families love it. They love seeing their baby Almost normalize cuz we have them on a mat doing be tummy time, you know? Um, and then even for the older kids, like sometimes, you know, tra to invent kiddos are with us for a longer period of time, we can start to actually work on signing, you know, working on imitation of blabs.
I mean it's hard with the mask, but, um, parents. Um, working on gestures, you know, if the baby wants to get up, you know, lifting the arms up, you know, so then we kind of get more into the conventional communication, um, when the kiddos are older. But yeah, with, they're younger, it's just the exposure, exposure to language stimulation.
[00:56:56] Kate Grandbois: I, I really appreciated the description [00:57:00] of listening to human voices instead of beeps because it really sort of paints a picture in my mind of this sterile medical environment, you know, with the machines and the tubes and the plastic and the fluorescent lights and, and all of those kinds of things. And when you think about that in cont in contrast with how quickly these little brains are developing and how much they are absorbing something small, something as small as focusing on making sure that there is spoken language in the room could be, I have to assume a really big step. A really big deal.
[00:57:34] Virginia Weill: I went to, um, one course years ago, and I can't remember what hospital it was, but they actually had a routine that when the nurses did handoff, they did it in the baby's room. So the babies, like, you're just adding to the amount of language and voice.
Positive stimulation that these babies are listening to. And I just, I love that. Obviously it stick in my mind. It stuck in my mind. Um, but I, yeah, so I love it when hospitals do [00:58:00] things like that.
[00:58:00] Kate Grandbois: Yeah. That's awesome. Okay, so my second, my second question, which is my last question. Can you tell us a little bit about what an SLP can do if they are interested in working in a nicu?
So, in all of, I'm somewhat familiar with the app, with the ASHA demographics data, just because I look at it all the time for other things and I, the NICU is not listed on there, there, I have to imagine that there are not a ton. Of LPs who are employed in a nicu. So if anybody is listening and wants to get into this workplace setting, what would you recommend?
[00:58:36] Virginia Weill: I would say, um, first just from my own experience, getting medical experience in general, getting into the hospital, whether it's adults or pediatrics, so you can learn, can I thrive in this environment because outpatient is so different from, so different. Um, so once you have experience in the medical setting, getting some pediatrics, so you're starting, you're starting this, you know, [00:59:00] broad and you're gonna start narrow, narrow narrowing your, um, experience.
Um, and I found this, and I can post this later as a handout, but I found this on one of the journals. Um, they talked about a minimum of three years of experience practicing as a speech pathologist in the pediatric setting. It's highly recommended specialized mentoring in neonatal therapists, whether it's in, in neonatal therapy, whether it's in person or online.
Um, initial and ongoing participation in peer reviewed education specific to neonatal therapy is necessary for safe and effective practice, um, and mentoring mentor practice hours and established competence in the nicu. Um, so I think it's,
Kate Grandbois: is that in an article,
Virginia Weill: uh, it's a journal, a perinatology,
[00:59:48] Kate Grandbois: we, would you mind sending us that reference and we'll put it in the show notes for anybody who's interested in reading further?
[00:59:53] Virginia Weill: Absolutely. Um, and so, you know, I think I, I, and I admit it, I was very lucky the [01:00:00] stars align in how I got to where I am today. But I know that people have to work super hard to get into the nicu and it's exhausting. So if you, you know, have the pedia medical, you're in a hospital setting, you have that check that box, then you get into pediatrics, you check that box, you know, and being in a medical setting, a lot of what you do is feeding and swallowing.
So you need to make sure you have good experience with that. Um, and yeah, you know, finding a good mentor too is really important.
[01:00:31] Kate Grandbois: That's awesome. Thank you so much for sharing all of your knowledge with us today. We're so grateful for all of your time. This has been so, so wonderful to anybody who is listening.
And if you're out on working out or folding your laundry or commuting, we will have all of the references and resources listed in the show notes. Um, they will also be listed on our website. Ginny, thank you again so much for being here.
[01:00:57] Virginia Weill: You're very welcome. Thank you for inviting me.[01:01:00]
Closing
[01:01:00] Kate Grandbois: Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study, please check in with your governing bodies or you can go to our website, www.slpnerdcast.com. All of the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at info@slpnerdcast.com
Thank you so much for joining us and we hope to welcome you back here again soon.
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