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Kate Grandbois: Welcome to SLP nerd cast your favorite professional resource for evidence based practice in speech, language pathology. I'm Kate grant wa and I'm Amy
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Episode
Sponsor 1
Kate Grandbois: Hello, everyone. Welcome to SLP Nerdcast. We are here today to talk about a topic that is very new to Amy and I, uh, we are here with Neshifa Hudamoman to talk about feeding in the ICU. Welcome [00:02:00] Neshifa. Hi Kate and Amy. I am so thrilled to be chatting with you guys today. Thank you for having me on. Now Neshifa,
Amy Wonkka: you are here to discuss early feeding and developmental care in a cardiac ICU, which is.
a really specific topic, but as we were discussing before we hit the record button, actually applies to so many of us who are working in the field of speech language pathology. Um, before we get started, can you please tell us a little bit about yourself? Sure.
Nashifa Hooda Momin: Um, so as you guys mentioned, my name is Nishifa, and I've been a practicing speech I've been a speech language pathologist for about 11 years.
I currently work in an acute inpatient children's hospital and work primarily with pediatric feeding and swallowing and pediatric dysphagia. My passion is working with infants and children with congenital heart disease. More specifically, single ventricle physiology, and I work primarily in the cardiac intensive care unit and our step down unit, which is called the CACU.
Um, and I recently stepped into a new role as [00:03:00] an allied health research scientist, so I get to support, um, evidence based practice, quality improvement, and research in my institution. And then finally, I'm wrapping up my doctorate in speech language pathology from MGH Institute of Health Professions.
We'll be finishing this August. So super excited about that. Outside of the realm of speech language pathology, I like to run and I like to read. And that's about me.
Kate Grandbois: So many things. So that's very, that's very exciting. Um, your role sounds really interesting and I feel like I could talk to you for a thousand years about the doctorate, but that's not why we're here.
Let's move on to read our learning objectives and disclosures, and then we will jump right in to learn more about feeding in, uh, infants. Learning objective number one, participants will be able to identify three reasons for the importance of neurodevelopmental care in the cardiac ICU.
Learning objective number two, participants will demonstrate the ability to accurately [00:04:00] identify a minimum of three feeding problems commonly observed in infants with congenital heart disease. Learning objective number three, participants will be able to identify three strategies to improve culture and education on PO feeding in a cardiac unit.
Disclosures, Neshifa's financial disclosures, Neshifa Neshifa is an employee of Children's Healthcare of Atlanta. Neshifa also received an honorarium for participating in this course. Nishifa's non financial disclosures, Nishifa has no non financial relationships to disclose. My financial disclosures, I'm Kate, I am the owner of Grand Bois Therapy and Consulting LLC and co founder of SLP Nerdcast.
My non financial disclosures, I'm a member of ASHA SIG 12 and I 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.
Amy Wonkka: Amy's disclosures. That's me. My financial disclosures are that I'm an employee of a public school system and co [00:05:00] founder of SLP Nerdcast.
And my non financial disclosures are that I am a member of ASHA Special Interest Group 12, and I participate in the AAC Advisory Group for Massachusetts Advocates for Children. All right, let's get started. Uh, Neshifa, why don't you start us off just telling us a little bit about congenital heart disease?
What What is it? What is the definition? Yeah,
Nashifa Hooda Momin: absolutely. And I think that's a great place to start because before we dive into neurodevelopment, I think it's good to just understand our foundation. So when we talk about congenital heart disease, it's any type of structural abnormality in the heart that's present at birth.
And these defects can widely vary based on their severity and impact in heart function. And the way that I like to Um, categorize them, or the easiest way to think about them is acyanotic defects and cyanotic defects. So when you have an acyanotic defect, it's often an abnormality in the structure, which may be like a hole between the chambers, like the ventricles or the atriums.
And, um, some examples of this could be like a [00:06:00] ventricular septal defect, which is essentially a hole between the two ventricles, or an atrial septal defect, which is a hole between the atriums. And what ends up happening is that, uh, When the blood is being circulated through the heart, what the blood that is already oxygenated goes back from the left side of the heart to the right side of the heart to re oxygenate.
So these babies, clinically, will often be, have increased work of breathing, they'll have, um, endurance issues, they may, like I said, they'll have tachypnea. Um, but again, this is one of those things where it's like an inefficient system, um, and once they have surgery, they generally will do well. The other type of defect is a cyanotic defect.
And what a cyanotic defect is when you have insufficient oxygenation going to the rest of your body. And this is, this is a little bit more serious, right? And so what ends up happening is that blood that's from the right side, that's not oxygenated yet. It hasn't gone to the lungs. will cross over to the left side and then that blood will get circulated to the rest of the body.
So when we see these kids clinically [00:07:00] before any type of repair, any type of surgical repair, you'll see that these babies often may have like blue fingers and toes because remember that our fingers and toes are the furthest away from our heart. So it's usually a telltale sign like when you see these infants, um, at bedside.
Um, and then these kids are often similarly going to have work or breathing issues, endurance issues, um, and then they'll need some type of surgical repair. So congenital heart disease can impact one in 120 in the United States. It's a relatively and actually the most common birth defect that we often see with, um, infants.
Kate Grandbois: Okay. I have a follow up question. I, first of all, I feel like I need a refresher on the structures and function of the heart. Absolutely. , so I want to say something back to you to make sure I've understood it
and I'm going to use a word that prior to this recording, I'm not even sure I could pronounce. Essentially, what you're saying is infants who are born with congenital heart disease can fall generally into two [00:08:00] categories. One is a cyanotic and the other is cyanotic.
Nashifa Hooda Momin: Is that
Kate Grandbois: correct? I'm getting, I'm giving myself all the A pluses for pronunciation.
Um, and of, and of those two, of those two categories, the cyanotic category is um, Would you say more severe or has a larger impact on the child's body and oxygenation overall?
Nashifa Hooda Momin: Absolutely. right on it.
Kate Grandbois: Hooray. I'm so glad I got it.
Nashifa Hooda Momin: You brought up a great point. I think we could talk a little bit, just very, very simplistically in terms of blood circulation, right?
So when we have blood circulation in our body, we have deoxygenated blood that comes in from our, I'm not going to get too particular. It comes to the, right side of our heart, and it goes into our right atrium, and then it goes into a valve, and then it goes to our right ventricle. From there, it'll go in through, into our pulmonary artery, and then it'll [00:09:00] go into our lungs to get oxygenated.
Then that oxygenated blood will return through our pulmonary vein, and go to the left side of the heart, so now we have oxygenated blood. blood and it'll go to the left atrium through a valve through the left ventricle and then that left ventricle will send it to the aorta for systemic blood flow. So that's why when you have blood that goes from the right to the left side without any oxygenation without it all going to the lungs, um, That's when we can have a cyanotic defect.
Now I will say as a disclaimer, it's not that the whole full 100 percent of the blood is going from the right side to the left side with no oxygenation. Um, we could talk more about structural, um, anatomy and that would take us, uh, onto a different path, but I, I, there are mechanisms in place in terms of the structure of the heart to have a little bit of that blood flow going to the lungs.
It's not just like a one way street.
Kate Grandbois: What's amazing about this is that you're a speech pathologist. Yeah, and we are here to talk about speech pathology, and I can't wait to make [00:10:00] this connection. So, so keep keep going. Tell us more.
Nashifa Hooda Momin: So, so to then kind of switch into neurodevelopment, right? So we were just talking about cyanotic defects, right?
When, think about when the baby is in utero. So when the baby is in utero, the same thing is happening at that point. If they have a cyanotic defect, then oftentimes that blood that is being passed is not all of that is not going to be going to our brain. So when these babies are born, especially with critical CHD, and we can talk about some of the diagnoses that you see as critical CHD being like Tetralogy of Low, Transposition of the Great Artery, Hypoplastic Left Heart Syndrome, Hypoplastic Right Heart Syndrome.
Those are more synodic defects. We often see a lot of neurodevelopmental issues. So that's kind of what I wanted to talk a lot about today, is that you know, why is this such a hot topic for infants with congenital heart disease? It's, and it's often because it's something that we're not always thinking about.
Um, now I will say a lot of the research and we'll talk through a lot of the research, [00:11:00] um, is now this is at the forefront. Um, but yeah, is that, yeah, that's, that's just a little bit about, you know, congenital heart disease and neurodevelopment.
Amy Wonkka: And just, just to go back to the, what you were saying about having a cyanotic, um, form of congenital heart disease and the fact that that is also happening in utero, um, I wonder if you can, and I know you're going to talk about neurodevelopment, but just talk about the importance of oxygen when we're thinking about, um, the development of a brain.
Nashifa Hooda Momin: Yeah, exactly. So imagine, um, well, when, when we'll talk a little bit about this later, when we talk about like neurological insults and whatnot that happened, it perioperatively postoperatively, even what we see preoperatively, but when you aren't getting adequate oxygenation to the brain. That's obviously going to cause changes in your brain function, but also the brain is what controls the rest of our body.
So there's just a lot, uh, we need to have a hundred percent oxygenation right now. If we were to go, [00:12:00] um, to the doctor and they put a pulse ox on us, we would have a hundred percent oxygenation. The cyanotic babies. If we, right after birth, if we were to check their pulse ox, it would not be at 100%. It would be around 75 to 85%.
Um, again, it'll depend on the type of structural abnormality, but that's not considered what we would say normal or typical, right? Um, so it's definitely a concern and definitely something that we have to address pretty quickly after they're born.
Kate Grandbois: And for everyone listening who is kind of, you know, either working in a medical space or even in a school.
And thinking this is, you know, the first time that we're the first time that they're hearing about congenital heart disease in its intersection with speech language pathology. You had mentioned before we hit the record button that this is a relatively new field. Is that true?
Nashifa Hooda Momin: That is true. So that's the interesting thing about it, right?
So, um, so much has changed in the field of congenital heart disease and the management of congenital heart disease. So much [00:13:00] has even changed in, um, how we take care of kids in the ICU. There's been surgical advancements, there's been ICU advancements, there's just knowledge advancements. advancements in congenital heart disease.
There's knowledge about neuro development at this point, and so with all of this information with specifically the surgical ICU advancements, the mortality rates among the Children with CHD born with CHD has decreased. But there's a lot At the same cost that we've seen an increase and, um, more neuro, uh, neurological abnormalities and neurodevelopmental impairments.
Um, and so we have to remember that yes, cardiac intensive care is life saving. Um, and it's, it's so big for a caregiver who has an infant with congenital heart disease, but it does come with a lot of environmental and tactile stress, um, that is placed on the infant in an ICU setting. And that's why we're talking about neurodevelopment.
Amy Wonkka: And for those of us who haven't been in that environment, either, you know, in our personal life or in our professional life, can you, can you give us just a little window into [00:14:00] what the cardiac NICU looks like, what that intensive care environment sounds like and looks like?
Nashifa Hooda Momin: Yeah, absolutely. Um, so it's interesting cause I, um, I guess being in the field for now, I, 11 years, um, and working in the ICU, I have so many new graduate students.
Students that when they, um, meet like a medical SLP, they their goal is I want to work in the NICU setting and I think that's fantastic because I, but I think that's because also many people don't know that you can work in a cardiac ICU and it's, um, equally fun, um, at least in my perspective. And so what a cardiac ICU is, essentially we can have babies that are, um, we can have neonates and we can also have full term babies.
But it's any baby that, that, specifically in my institution will come to our institution when they likely need some type of intervention, whether that is a surgical intervention in the operating room or whether that could be a cath intervention or whether that's just, Hey, let's bring them in. Let's do a full workup and see if we can [00:15:00] manage this as an outpatient, um, and then get them home and then bring them back when they're bigger and healthier to do that surgical intervention.
But these are the kids that are going to likely need some type of cardiac intervention because Because of their congenital heart defect for me. Um, specifically, I work in an ICU setting and like I mentioned in a step down unit as well. And so A typical day is, um, oftentimes if a baby is transferred over into our unit, we'll all often do like a pre op or pre op feeding before they have any type of surgical intervention.
I'll see them post operatively after any type of surgical intervention. And then especially these kids that may require multiple interventions, I'll follow them along and make sure that I'm supporting them in their feeding. Because keep in mind, You know, similar to a NICU baby when they're born, they're gonna need all that support to, to feed, right?
But now add that component and then add the surgical component to it with them having surgery quite early on. Um, and it, it is a really stressful environment and they need [00:16:00] all the support from a speech language pathologist, even a PT and an ot, really like a multidisciplinary team.
Kate Grandbois: As you're talking, I'm making these frowny faces because I mean, it's just, you know, thinking about these tiny little human beings in this very experiencing this trauma.
Um, and, and being in, I don't know, I'm imagining, I'm imagining an ICU. There's bright lights, lots of beeping. I mean, tell us a little bit about what these tiny little humans experience on a day in day out basis.
Nashifa Hooda Momin: So if you think about, um, in an NICU setting or an ICU setting, specifically the cardiac, um, ICU setting, you have, say the baby is born, right?
And say the baby has congenital heart disease. It's a cyanotic defect and say it's a single ventricle, um, defect. That patient is going to require pretty quick intervention and our hospital is not a birthing hospital. So the first thing that's going to happen is the baby is going to be separated from their mom [00:17:00] quite early on and they're going to come into our ICU setting.
At that point, They're going to likely get some type of echo. They're going to get lines placed. Um, they're going to have, um, the medical team is going to come and kind of look at their echo and look at, you know, kind of what their, like the, what their blood work is. Um, oftentimes we may initiate PO feeding, but the first couple of days, especially before any intervention for a high risk infant is pretty chaotic.
There's a lot going on. There's a lot of, um, Healthcare providers trying to get in and kind of do their assessments prior to any type of intervention. So I hope that is that answering kind of generally what
Kate Grandbois: it does and I you know, I'm just thinking about what impact These experiences will have on on the infant, uh, i'm just you know, looking at some of your talking points about about what they experience in terms of procedures, interactions.
These are brand new babies been, who have been separated from their moms. I mean, this is like a, this is [00:18:00] huge. This is very layered.
Nashifa Hooda Momin: So it's interesting if you look at the, um, European research, um, based NICU studies, specifically NICU, not cardiac ICU. They have found that an infant can have in a day in the hospital can have anywhere between zero to 14 type of procedures.
And another study by Cruz and colleagues that was done in 2016, they found that infants in a typical day were having anywhere between seven to 17 procedures. And these would include, um, He'll, um, like a heel touch to get blood, um, nasal endotracheal suctioning, any type of placement of peripheral venous catheters.
And so the interesting part about all of this is that once a child reaches that threshold of pain, all non Non painful experiences will be perceived as pain, um, and the infant will often shut down. And interestingly, only 5 percent of the touch in a hospital setting is considered positive. All that 95 percent of the rest of that is considered either medical or, [00:19:00] uh, or painful.
Just putting it into perspective of kind of like what an infant goes through.
Kate Grandbois: I have to imagine that this has a massive impact on their nervous system.
Nashifa Hooda Momin: Mm hmm.
Kate Grandbois: And I wondered, what does it mean when an infant shuts down?
Nashifa Hooda Momin: So oftentimes you'll see like a baby, well, uh, I see this quite a bit with PO feeding. Um, and PO feeding, I mean by, is per oral specifically, so eating by mouth. Um, if I'm feeding a baby that is generally having like, uh, it's stressful for them. They're tachypneic. Um, it doesn't feel good. Potentially they aspirate or maybe they're just a, a preterm infant and they're just It's super overstimulated.
Shutting down will often be that they look sleepy, right? Their eyes will close, they'll kind of disengage. Their body, their body like tone will change. Um, and you kind of, a lot of times it can be perceived as Oh, they got sleepy, right? Um, but they really truly just shut down. They're like, they can't take anymore.
And so you'll see this kind of like, um, stagnant or no response. Um, and, and [00:20:00] not in a. serious way, but in a way of like, Hey, I'm not going to engage in this activity. I'm not going to engage in this for the next step. I'm not going to PO feed. And so a lot of times, um, you'll often see that. And I feel like, I mean, outside of the world of NICU and babies, I think we're similar in the same way, right?
When we're overstimulated to some level, we like to back down our nervous system. Well, like wants to get that. And so I, I, it makes sense, right?
Amy Wonkka: Yeah. Sort of just having that self preservation mechanism to just be like, this is too much. Yeah. I've got to take a little break here. Yeah. Yeah. Yeah. In your talking points, you also had some information just about brain volume.
And so thinking, thinking about all the things, right, thinking about the oxygenation piece that we talked about earlier with the cyanotic babies, thinking about nutrition and how much it might just be a struggle to get adequate nutrition. All of those things together are obviously important for development.
Um, yeah. [00:21:00] Can you talk to us just a little bit
Nashifa Hooda Momin: about that piece? Absolutely. Um, so interestingly, there was a study done by Scotting in 2021, and they found that infants with CHD had smaller brain volumes than a typically developing infant. So what they looked at specifically was 10 infants with the postmenstrual age of, uh, 39 to 54 weeks, and then they compared it, um, and those were the typically developing infants with, um, 10 infants with CHD, um, and what they ended up finding was that the infants with CHD had a smaller, had smaller brain volumes, and so some of the inclusion inclusion criteria.
And what I mean by, um, inclusion is that what types of infants we're talking about with CHD. These were the more critical CHD, so Tetralogy of Fallot, Transposition of the Great Arteries, Coarctation uh, uh, Hypoplastic Left Heart Ventricle, Hypoplastic Right, um, Ventricle. So again, are more, uh, critical CHD.
And then in another study, um, by Litsch et al. in 2009, They also looked at infants [00:22:00] with critical LCHD, and they looked at 29 infants with hypoplastic left heart syndrome and 13 with transposition of the great arteries. And they found a one month structural difference in brain development. And so then what does that mean?
Right? And so I, I always, I love the study because it really puts into perspective as a healthcare provider on how, what does it mean? How do I, what do I take with this information? Right? So an infant, imagine an infant born at 38 weeks with hypoplastic left heart syndrome, their brain is going to be similar to that of a 34 weeker, right?
So to take that one step further, how do you suppose that the infant's development and maturation is at that stage? Given that it says 38 weeks versus what our perception and actual development support the infant is actually getting, um, and so when we think about just to kind of think about in utero development and the milestones that the baby is kind of achieving in gestation around 34, um, To 36 weeks is when that non [00:23:00] neutral to suck on a pacifier really matures.
And that sucks while a breed coordination for PO feeding that matures around 37 to 44 weeks. So now if we add that layer on, then what, what are we, what are we expecting from the baby versus what? We should be expecting from the baby. Um, so I, I like to talk about this because it puts into perspective how we, when we work with this particular population, we really kind of have to take a step back, look at what their existing research.
We have to look at the patient in general. We have to look at their cues. We have to put it all together before we just have these like unrealistic expectations and almost like push the baby too hard. And we're kind of heading in that wrong direction neurodevelopmentally.
Kate Grandbois: And I know we're going to get to this at some point, but I can't, I can't help but think about the long term implications of all of this across all the variables we've talked about the trauma and separation from the mom at birth, the lack of nutrition or risk of lower nutrition, the neurodevelopmental [00:24:00] changes.
I, I wonder if maybe this is a dumb question, but Are there guidelines for adjusted age when you're talking about brain volume like we do for preemies?
Nashifa Hooda Momin: No, because I don't think it's consistent across all babies with CHD, right? I think, um, and I think this is still something that we're learning more and more.
I think in general, we can all agree that infants with cyanotic lesions are just at a higher risk because we know in utero, they were also not getting the best oxygenation, right? But. Um, I don't think there's any guidelines in specific to be like, Hey, these particular infants, we're going to do it this way.
I think in general, we know that critical CHD is just a higher risk population. Um, but it's interesting because, um, another point that I kind of wanted to bring up is really when we think about these kids and we think about, we were talking about interventions when a baby goes to, um, has any type of intervention, they get put on maybe Bypass, for [00:25:00] example, cardiopulmonary bypass.
And a lot of times as speech language pathologists, and I'll say I'm guilty of this, like, our assumption is that, oh, well, you know, now that we're kind of going under cardiopulmonary bypass, and then they're likely going to have any type of neurological insult on top of everything that's going on, and post operatively, we might see an insult.
But interestingly, one thing that I also found, um, interesting about our specific population is that, um, There's actually preoperative concerns as well, like we've been talking about, right? And so in a study that they looked at in 2019, they looked at 70 newborn infants with critical or serious CHD, and they did an MRI prior to surgery.
And what they ended up finding was that 39 percent had some type of cerebral lesions, with white matter injury being the most prominent lesion. Um, and there were a few cases of arterial ischemic stroke. And so again, like, why am I bringing this up? Because I think when we think about neurological insults with populations in general, with babies or adults, we always tend to think [00:26:00] about, you know, During surgery, like perioperatively and postoperatively, and oftentimes we're not even thinking preoperatively.
Um, and I, I can say that I've done that myself, and I still do, because I think it's when you don't see it, when you can't visualize, um, something, then it's hard for us to, like, take that into consideration.
Kate Grandbois: And I have to assume, just as a clinician, Your consideration of where the patient is at baseline is a really important component of the interventions you choose post op, right?
And what you're talking about is, is evidence related to what that baseline looks like in terms of potential lesions or, or other, of all the things, all the exposures, all of the, you know, traumatic experiences that this tiny little baby has gone through.
Nashifa Hooda Momin: Yeah, absolutely. And we really, as a clinician, like you mentioned, we have to look at the whole continuum.
We have to look at them [00:27:00] from intrinsically when the baby was in utero. We have to look at it preoperatively, how clinically they present. perioperatively, postoperatively, and then to take it one step further, we also have to think about outpatient. I think one of the areas where I feel like the disconnect often happens is between a hospital setting and an outpatient because as a healthcare provider, I, and I'm, I'm trying to be better about this, but like, how do we make sure that caregivers realize that this is something that we need to be thinking about even as they get home?
And even if the, the CHD may be repaired, That there are some other considerations we have to continue to think about and then how do we make sure that they get plugged into outpatient and they take it seriously because again, when you can't visualize something, it's hard to take it seriously. Sometimes it's hard to think about like, okay, well, you know, I had my Heart defect is done.
And now, you know, the speech therapist might be saying or the, um, the healthcare provider is saying that I need to do all this outpatient testing and yada, yada, yada. And I have to go to the cardiologist appointment and I have a PCP appointment. I have three [00:28:00] other kids. Like it sometimes becomes less important, but I think we have to emphasize the importance of it because there are, uh, considerations we need to be thinking as, as they, as these children start to grow.
And to, to that point, um, the American Academy of Pediatrics found that infants who needed heart surgery, specifically cyanotic lesions, um, and those cyanotic lesions that had comorbidities such as prematurity or prolonged hospitalization were at a higher risk for developmental disabilities. And there's also research showing that, um, The more critical the CHD, the more, um, sorry, the more severe the cognitive impairment that we may, we may see with this particular populations and so a lot of these challenges that we see these in the challenges that these infants have won't often be seen.
Um, and I think that's a of times kids are being seen or teased out to school age. And so is it? Is it that they develop in school age? Or is it just that they were missed until that moment, right? And I think it's because I think they're just missed until that moment because the child isn't going to be pushed.[00:29:00]
In a school setting until their school age, right? They may it may. They may just make it right by they may. It may not be concerned concern, but some of the challenges that we often see is exactly that. Decade of function challenges, attention, fine motor and gross motor, academic struggles and behavioral issues.
But again, it's not that these issues just, you know, showed up at the age of five or six. I think it's just the fact that nothing, nobody was like really testing 'em. They might not have been pushed until they were integrated into a school setting.
Kate Grandbois: So I am wondering now that I know this is a relatively new field, and it sounds like there's a lot of emerging evidence or a lot of, you know, in the last few years, a lot of evidence that these kids, these babies are at higher risk, are there any standard screening procedures in place or standard screening Um, protocols in place to catch some of these deficits so that we can provide the critical period of early [00:30:00] intervention.
Nashifa Hooda Momin: Yeah, so, um, I can't speak 100 percent to how other institutions are doing this, but I will say at our institution, we do have a neuropsychologist who, um, will try to plug them in with the, with her, um, and she will often do these assessments, uh, to kind of see where they are in terms of, in terms of neuropsych, and she follows them up to the age of two, and I know she's looking specifically at our more high risk population again, um, but I think it's something that truly is needed everywhere.
And I'm, I'm hoping that as we, you know, we're learning about all of this and I, I hope this then becomes like regular standard care practice for a lot of our critical CHD babies.
Amy Wonkka: So, I mean, I don't want to lose the, the, the piece about this is life saving care for so many of these infants. So even though it is, you know, in a stressful environment and they're experiencing challenges and they may experience prolonged challenges, it's also, um, [00:31:00] It's also potentially it's life saving.
Um, are there, are there any, um, strategies or is there any research around things that can be done when they're still in the NICU or in the step down unit, um, that might just help facilitate
Nashifa Hooda Momin: positive outcomes? Yeah. And I think that's a great point. So that's the thing, like we've talked about all this research, right?
So then what, we know all of this, what are we doing about it? Right. So interestingly, there is now research about looking at neurodevelopment in CHD. And what they found is they thought there was a study by Peterson or a paper by Peterson in 2018. Um, and some of the strategies they talked about for specifically for our CHD babies that do kind of overlap with our NICU population is massage, uh, skin to skin kangaroo care, which, um, again, that's definitely something that we use in the NICU, developmentally supportive positioning.
Now, um, I want to say this is more specific to, you know, when the patient is intubated or that when the [00:32:00] patient is in ECMO, like, we can still do developmentally supportive positioning in these critical time periods. Q based feeding and PO feeding, and I'm, we'll talk a little bit about the importance of PO feeding and the PO feeding project that we did at our institution, pain management and procedural support, and what I mean by that is that We don't want to over sedate our population because then we're missing these developmental critical windows where we need to be involved and working with this particular population.
Um, so yeah, that's kind of like what's going on currently.
Kate Grandbois: I have to assume, I have to assume that there is a lot of coordination of care that is happening to be able to provide the supports that we know are going to try and counterbalance all of the negative experiences.
So everything from educating other staff members, collaborating with parents, you've already mentioned collaborating with a neuropsych for follow up. This has to, I guess All of that collaboration really has to be built [00:33:00] upon some foundation of infrastructure within your within your workplace. And I have to imagine that if that's not there, all of these pieces are not going to be executed well.
Nashifa Hooda Momin: Yes. So I agree. And I think that one of the great things I feel like at least what I at least what I feel at our institution, everyone there wants to be there. Everybody is so, uh, eager to support these infants, and I think that's what's making that difference. And I, and this isn't, this is, I'm sure, all across the United States, like, when you work with this particular population, you are passionate about change, you're passionate about patient outcomes.
But at our, um, institution, there's a couple things that we're doing, um, structure, or like, I, I don't know if it's structurally, I don't know if that's the word, um, that we're doing, um, to help support neurodevelopmental care. One of them is, uh, neurodevelopmental rounds. And so neurodevelopmental rounds, it was actually created by our child psychologist.
And, um, what it is is it's a what it's once a week rounds and we round on four patients. So about four patients for the hour. It has a [00:34:00] physician champion. The primary nurse for that patient will be on the rounds. And then our rehabilitation staff, PT, OT, and speech will be in rounds. Um, This is currently being revamped with like, you know, COVID obviously kind of shifted a lot of things, but we're kind of revamping it at this point.
But what we're talking about is these are the patients that often, um, we're not, we want to bring neurodevelopment into the lens, right? So we're like, Hey, This patient is a high risk patient that is going to be here for a long period of time because they're waiting for a heart, um, and, or this patient has a VAD and they're going to, they're waiting for a heart, or this patient is a single ventricle baby who is too, uh, fragile to go home, so they're going to stay here in the interstage period, or this patient sustains some type of neurological insult and they're going to be in this institution for a period of time.
At that point, And it really at any point when the patient is there, we have to start thinking about development, right? Is the patient getting tummy time? Are we doing cycled lighting? Are we doing the things that you would be doing in a home setting that [00:35:00] we don't do in a hospital setting? Because it is important for brain development.
We know that if we took CHD in hospital out, we know there's all this research that this, these are the things that we need to be working on in a, for a typically developing infant. But sometimes that gets put on the back burner. And so we're trying to bring light to that when they're inpatient. Um, The second thing we have is a neuroprotective care council.
Um, It was created in 2018. It's supported by a physician champion and the team includes a PTOT speech, a pediatric psychologist, um, and nursing. And we have quarterly meetings and quarterly goals. And so some of the things that we've worked on so far that have been, um, super interesting have been mobilizing patients.
And I mean, intubated patients, intubated babies, like getting them out of the bed into the mom's arms for skin care. kangaroo care. And we've had kangaroo thons, um, neonatal temp management. So thinking about the importance of temp management, because that can really change our vitals and put the baby in a crisis, uh, promoting oral feeding.
We'll [00:36:00] talk more about that. And then, um, incorporating parent feedback into our practice. Cause what are we, if we aren't really putting the parent Um, giving them a chair, a seat at the table. Sorry, I said that wrong, a seat at the table. Um, because it is important. At the end of it, we can think we're doing all the right things, but we have to have that perspective from the caregiver as well.
Amy Wonkka: Can you talk to us a little bit more about the feeding piece? Just how many, how many of the babies in general are able to do PO feeds when they come to you? And what does that process look like as you're working with them over a prolonged period of time? Sure.
Nashifa Hooda Momin: Yeah, absolutely. So, um, if we, if the patient comes to the hospital, um, and they are medically stable, we are going to try to PO feed the baby, uh, preoperatively.
The only thing I would say we're probably not going to PO feed is if they're intubated, obviously. And, um, if they are, um, on ECMO or something, if they're really, truly stable. There is not an option to PO feed. Otherwise, we're going to have [00:37:00] some type of involvement, whether that would be, um, offering a pacifier, pacifier dips or oral feeding, and we will try to oral feed as much as we can, and as, um, when the medical team says, says we get clearance for them.
Um, so the project that we did to kind of emphasize this PO feeding was, um, in 2019, we had done an internal survey with our CICU nurses. Um. Just about neurodevelopmental care and interestingly, the knowledge deficit we found was all around feeding. Um, it was about how to feed a baby, like what position to use.
There's so many nipples, what's appropriate. Um, what is like the speech therapist is always talking about signs of aspiration. What is the sign of aspiration? Like how, what feeding, feeding related deficits, right? Um, knowledge deficit. Um, so the purpose of our project really was to get CICU nurses, uh, you know, give them the strategies and kind of.
address this deficit. Um, and so I will say it's so important because as [00:38:00] a speech language pathologist, yes, if we're consulted, I'll go feed the patient, but I'm not feeding the patient around the clock. I'm not there at night. And so the nurses really, truly are the core of promoting feeding in a unit. Um, so knowing that is important.
So what we ended up doing is two speech language pathologists, one of them being me, myself, um, educated two nurses that were our nurse champions for PO feeding. And then all four of us together kind of came up with, well, had this project. So two nurses, um, and specifically were kind of like the support when the nurses had any questions.
And then as the speech language pathologist, we were involved in doing didactic teaching with the nurses and new nurses, and then also doing hands on teaching. So the purpose of the project was to educate CICU nurses on the strategies of bottle feeding, given the knowledge deficit, and the way that we set this up was that we had To speak to speech language pathologists that were primarily in the cardiac units, and we worked with two nurses that then became our P.
O. Champions, [00:39:00] and we educated them on strategies and everything that we would be telling the nurses. And then the speech language pathologist worked on a two part system. One was doing didactic education to the nurses. Um, and then the second part was a hands on course or hands on practice. So So the didactic part was where the nurses would come and new nurses would be on board and it was part of their onboarding education.
They would meet with a speech language pathologist and we would talk about topics like CHD and medical complications, feeding difficulties in infants with CHD. Like what are, what do we anticipate with this particular population? What are the feeding strategies? When to appropriately use these strategies?
And this included positioning the different types of nipples in the, um, in our system. the use of pacing, and then we talked about the importance of developmentally, developmental feeding, and signs of aspiration. Then, they had two to four weeks where they would be clinically practicing in the ICU or step down unit, and then we would meet again for hands on practice.
And the reason I loved this kind of model was [00:40:00] because they got to take the didactic teaching and apply it and then see if What, what wasn't making sense or where they needed more clarification. And then the hands on practice, they would come with the speech language pathologist and observe us feeding, like, two to three patients for an hour.
Um, and then they would ask questions, and we would kind of have this, like, open dialogue of, Hey, like, this, I have a question about this nipple. Why did you do this? And it was great because I felt like you got the, the didactic education, then you have a little bit of hands on practice and you can fill in all the holes in the, in, in between.
Um, and so. With that, the nurses that I mentioned that were educated, they were also there to support these nurses when we weren't even around. So, like, say you're clinically seeing a patient as a nurse, and then you're feeding a patient, and you're obviously not able to get the speech language pathologist.
Obviously, we always tell them, call us if you have any questions. But say they see the PO Champion nurse, they can easily go to them and be like, hey, I have a question about this. And so there's a little bit of that support in the unit as well. And so what we ended up finding is that nurses [00:41:00] reported an increased confidence in their ability to recognize early signs of aspiration and feel empowered to reach out to speech language pathologists.
And we saw, um, an increase in speech consults within that unit, as well as appropriate use of swallow studies with that particular population. And then some other wins that we saw was that we kind of changed a little bit of that culture that I had mentioned in one of my learning objectives, and that we changed the supply.
So in our unit, Previously we had standard flow nipples and slow flow nipples and realistically with our population and with the amount of infants that we see, we really weren't using standard flow nipples and having an inappropriate nipple for these for this population ends up causing the safety issue because what if you are unaware, then you're just going to grab it and use it.
And we really didn't need that. Right. So we ended up Switching, taking the standard flow nipples out and then replacing them with preemie or extra slow flow nipples because that's usually our go to for this population. Um, we continued this [00:42:00] education model where now every nurse that enters, um, into the ICU units has this like, um, hands on teaching or has the didactic teaching and the hands on with speech language pathologists.
And this started a long time ago and we're still doing this. And, um, we've started, we've created some more feeding guidelines so that We're promoting PO feeding in our units and including collaboration with our providers. And then now we also have automatic orders for all infants under three months.
And we're actually expanding that hopefully soon to include maybe up to six months or even up to a year. Um, so there's been a lot of wins out of this project. Um, Yeah, that's a little bit about the PO feeding project.
Amy Wonkka: That sounds awesome. It does sound awesome on multiple levels. I think it's great that you incorporated like multiple stakeholders into the initial planning with the two champion nurses.
Um, but then I feel like also just the fact that it was ongoing and multilayered, uh, how big were your trainings usually? How many nurses are you training at once?
Nashifa Hooda Momin: So back, [00:43:00] uh, like I guess a while ago, we would have about 10 to 15, but, um, our, we are transitioning to a new hospital. So recently we've had 15, 20 nurses at a time now.
Um, and we've been doing them quite frequently, but yeah, this, it, I think it could vary. Sometimes we've had like five and sometimes we've had more. It just depends on who's being onboarded into our system.
Kate Grandbois: It sounds like a tremendous win. I know you use the word win a couple of times, but just to not only make other stakeholders feel empowered and confident, but engaged and also elevate the evidence based practice in your, in the whole, within that department, within that unit, that is a tremendous win.
That's a tremendous success. Um, and I am hoping that anyone listening who is working, maybe not even in a similar workplace environment, takes away those suggestions for how to really elevate and shift [00:44:00] culture if you see need for improvement across some implementation from evidence based practice. I just, I think that's a really wonderful example of how we can, as speech pathologists, implement change.
shift our workplace culture to better embrace EBP. And then hopefully the outcome of that is elevated outcomes, better outcomes for our patients. Cause that's the whole point, right?
Nashifa Hooda Momin: Yeah. And I will say with this pro, uh, project, we have seen a dramatic increase in P. U. Pio feeding since 2016, specifically with their single ventricle population.
And I feel like it's important to say that because that's our critical population, right? So we've shifted the culture in the unit, but we've also shifted our mindset that we can do this with our, with our critical CHD patients. And then it also kind of highlights how it's not just like a lot of times when we think about like our speech pathologists or OTs are doing beating, but that's not really the case at the end of it.
Our caregivers need to be empowered, [00:45:00] our nurses need to be empowered. We all have to have that same goal. Um, and I will say one of the things that I reiterate to caregivers, nurses, and to anyone that really is in the, in cardiac is that when you have a baby, what the common things that a baby does is they poop, they sleep, and they eat.
And when you're in a critical environment like the CICU or a step down unit, especially as a caregiver, you don't have that much control. What if we were to empower you? What if we could give you a little bit of that control back and let you P. O. feed and have a little bit of that Normalcy., right?
Um, so I think it's, it's. I, I think there's a lot of interest around this. I think that, and I think that's why it was so successful because everybody wants to support this population, nurses, physicians, um, caregivers, speech language pathologists, OTs, PTs, the neurodevelopmental care team, like everybody is invested.
And I think that's why we got to see this change. So it was cool. Like you mentioned, stakeholder, having stakeholder buy in is extremely important. [00:46:00]
Kate Grandbois: I wonder if you could talk to us a little bit about the parents, because as all of this is happening, You know, and you've talked a lot about the importance of forward thinking, uh, developmental impact, discharge, carryover.
The parents are going to be the ones doing all of that. Not only that, but many of these parents may be experiencing trauma of their own. You know, being separated from their babies, complicated, perhaps they, the mother experienced a complicated birth, perhaps, et cetera, et cetera. I wonder if you could talk to us about what the role is of the speech pathologist in terms of supporting the parents and centering the parents throughout this experience.
Nashifa Hooda Momin: Yeah, absolutely. So as a speech language pathologist, um, when we get to bedside and are working with this particular population, oftentimes maybe the first, it depends really, Previously I would say that the first feed was always done by the speech language pathologist, but ever since I've [00:47:00] become a mom, I've realized that's a big thing, right?
That's a huge thing to take away from somebody. Um, and so I will do my very, very best if I can, if the caregiver is there to try to, if, And if they're interested in doing the oral feed to support them to do the oral feed now, I will be probably all over them and helping them position and kind of holding the bottle and like hands on with the parent.
But I, I think that that's where it starts. That's where our relationship will usually start. And then usually after the 1st or 2nd feed. It is really like, hey, like, if the caregiver is there, I want you to feed and I will support. I will, you know, usually be crouched on my knees or, um, hovering over the parent, feeling for signs of aspiration, watching the vitals, like explaining and providing strategies, maybe some hand over hand, like, hey, we're going to pace the baby now.
Hey, let's remove the bottle. Cause I see this, but really our relationship starts really early on. from the beginning. It's, hey, let's empower you to do this because the great part about this and usually how I end sessions is, hey, I'm, [00:48:00] you know, we're, it was great working together and, you know, we were going to change the plan this way, but I want you to know, you know, I'm here and this happened this way, but I can guarantee you, it's not always going to happen this way.
So when I come back tomorrow, I want you to tell me like everything that happened, how much they ate. You know, where you struggle, what came up, um, if it like, what questions you have, because you have to let that marinate a little bit. And then let's, let's just keep this going. And the great part about that is that by the time they get ready for discharge, I feel like they are pretty confident about feeding their infant.
Oftentimes I think it, like it shifts, right? They're like, no, like, I know you're saying that this is happening, but I feel this way. And a lot of times I'm like, you know, your baby and I believe you, right? Like, um, And so I do think that that's a huge thing is empowering the, of the, the caregiver. But the other thing about just the caregiver in a, um, in working with an infant with CHD and thinking about neuroprotective care is we, something that was really eye opening for me was that we, when one of our neuroprotective care [00:49:00] meetings, we had a parent who came and spoke about, their experience.
Um, and I will say that this, um, mom, their child, she took her child home on palliative care and the patient ended up passing away, but she came and kind of talked to the neuroprotective care team about just kind of her experience and what was considered normal in the ICU and what was considered normal in the CACU unit, right?
And it was so eye opening to see, like. There's, there's a lot that a caregiver is going through that we often just don't really process. Um, and so I think after kind of hearing that perspective, it's really just emphasize that we have to have to have to have a caregiver at the center of the care, right?
We have to put bring the caregiver in. We have to get their perspectives, because one, we get a holistic understanding of the patient's needs. There's more patient advocacy, because remember, we're not always there, right? The caregiver may be there watching what's going on with the patient and can advocate for, hey, like, I'm noticing every time they feed, they have a [00:50:00] desaturation event.
I know you're saying there's no clinical signs of aspiration, but why does this happen, right? Um, it could be, like, thinking about enhanced parent care management. And then another huge thing is, like, you have to start thinking about the social determinants of health for the patient. So when the patient goes home, is the plan that we're recommending feasible?
If we're recommending follow up every week, um, They live two hours away, they have, they rely on Medicaid transport, or say there's only one car with eight people in the house, is it feasible? What if we're recommending thickening, right? Is it, in, in, in terms of financially, like, that might not be an option.
So, really, really, really, we have to have these, like, ongoing conversations with a caregiver to make sure that the plans that we're recommending are feasible and we're understanding what their perspective truly is. And then like I mentioned empowerment and then, um, I think all of this truly fosters a collaborative environment.
So yeah, that's, that's kind of my little tidbit on the importance of having a caregiver in involved in care.
Kate Grandbois: I also wanted to ask [00:51:00] just in that same, through that same lens, what role counseling plays in all of this? Because in your first few days of supporting a parent, I have to assume that there has to be counseling has to be at the forefront to just kind of make space for their experience everything from their own healing if they gave birth to fear for their baby's life to I mean, there are some really big emotions in that room.
And I have to assume that if you go in with, Well, we're going to use the slow flow nipple and this is how you pace a baby like none of that's going to land because of all of the stress and, and all just all those feelings. What can you tell us about the role of counseling in these, in these environments?
Nashifa Hooda Momin: Absolutely. Um, I think that it's as a speech language pathologist, it's a skill that you definitely need. Um, and it's something that you learn that kind of reading the moment, right? There's been times where I've come in, [00:52:00] um, in communicating with the team, right? So I've come in after the nurses told me that they've gotten some news, perhaps that there's like, uh, confirmed genetic involvement on top of their speech.
And then I'm supposed to feed this baby and sometimes you just have to gauge like, is it an appropriate time or do I just need to have a moment to be there for the caregiver? Or do I need to reschedule? Do I need to take a moment and let them have their moment before I come in saying, Hey, let's feed your baby.
Let's do XYZ. So I think it's a huge skill for the speech language pathologist to have. Um, there's been times I will say that I've had to completely pivot my session and just, um, Just talk, talk to the caregiver and just listen, just listen, right? Um, and then come back at a different time and do therapy, because I think that it's important for them to have their moment and to express how they're feeling.
The second thing I'll say that I'm super thankful about is having social services, like social services with this particular population is involved very, very early on and they are incredible. Um, and so a lot of times. There's things that might come out during [00:53:00] my session, uh, that may, may not be, like, public knowledge, and a lot of times I'll, like, can, can, uh, communicate with the, you know, the caregiver that, hey, is it okay if I pass this along?
It seems like you're dealing with a lot here, and I can easily pull in social work and fill them in on what I know, but a lot of times they already know because they're excellent at their job, uh, but it is a huge, like you said, it's very, uh, emotional, and, you know, We need to have that support there. And I do believe that we try really hard to make sure that caregivers are getting that support.
Now, do I think that there's no room for improvement? No, I think there's always going to be room for improvement. It's just a high risk population that needs a lot.
Amy Wonkka: So at some point, um, hopefully the treatment has gone successfully. And the babies are going to be discharged. What does that, what does that process look like for you as a speech language pathologist? What does that look like for the families? What might that look like for if the baby's going to need to continue receiving some sort of outpatient services?
Can you just talk us through that [00:54:00] process
Nashifa Hooda Momin: a little bit? Absolutely. Um, so it can vary depending on the patient. So if we have a patient that is doing well, PO feeding, maybe it's an asianotic defect. Maybe they were the kid that, um, got diagnosed at birth and then went home and just had, you know, cuddles and love and, um, and then like required the surgical intervention.
And then they come to the, they come to get their surgical intervention, intervention. They meet the medical team and speech language pathology and rehab. And Um, maybe for them, it could be as easy as just, Hey, like, we're going to recommend outpatient services should you need it, but you're fully PO feeding, you're doing fantastic.
Um, and then, you know, giving that information and they may just go, go home. I think general practice for most of us as rehab is to make sure that you still have plugged in, even if you may not need it, because you never know what's going to happen, right? But then if you have the example of a cyanotic baby who is likely going to require more support, I [00:55:00] may or may not, but I would imagine so, um, like I said, standard practices that we're going to try to get them plugged into all different types of therapy, outpatient, PT, OT, and speech.
Um, and then the other component of that is like, say you have a family, like we talked a little bit about the social determinants of health. Like we're not. They're not going to be able to attend these appointments. It's going to be a lot. They need to have service at home. Well, social work and, um, has a way, uh, for at least in Georgia, it's called babies can't wait.
And I'm sure it's different for every, um, state, but essentially it's a way for therapy to be in the home setting. I will say it's a great option. Um, it does, it just depends on the availability of a, of a therapist that can go and, um, See these patients at home. So that's definitely something to consider.
But I will say that having therapy is having therapy and versus not having therapy, right? Especially when you need it. And we have to think about what's feasible for the caregivers. Um, and then you can also have the super critical [00:56:00] infants with a single ventricle physiology. who require three different pallet palliation surgeries.
Um, and that particular population, we do set up outpatient, but we have a dedicated single ventricle clinic, um, where we'll be following up with them outpatient as well. So there are a couple of things that are in place, but it does, I will say that it's, it's a lot to consider because PCP, right? Your pediatrician, you're still going to have outpatient services.
Um, You're probably going to have, like, a cardiology follow up appointment, um, and then if you're more critical, you may require more, more things, right? Um, it is a lot on the caregiver, so it's, it's, we always want to make sure that it's feasible, so we try to provide options and try to see where the caregiver is and what their, um, needs are and try to meet those needs.
Amy Wonkka: And in terms of the babies who have more complex feeding needs, do you typically get enough opportunities while the baby is in your NICU or in [00:57:00] your step down unit to work with the families to where they're feeling comfortable with the feeding before they go home?
Nashifa Hooda Momin: Yeah, so oftentimes it, I will say that it does depend if you have a critical CHD baby, like someone with single ventricle physiology, those patients, I do feel like generally we get a little bit more time because they're a little bit high risk and we're not going to discharge them right away.
Um, so I do get that time. Does that mean that they all go home full PO feeding? No. And so a lot of times. These kids may go home with enteral support, like an NG tube and maybe taking some by mouth, um, and not in general, just in CHD in general, that could be the case, that could be the case for a cyanotic lesion as well, where we worked on it, um, we weren't able to get to full PO feeding because perhaps there's a genetic comorbidity, and so they may be going home with enteral support, um, and then with the goal of hopefully getting to full PO feeds.
Kate Grandbois: You've shared so much information with us today and I, I feel smarter [00:58:00] and I, I, I, I mean, I'm serious. There's been so much that's been new to me personally. One of my takeaways from this conversation is that this relatively new field, even though the vast majority of the field of speech pathology in general does not work in a cardiac ICU, it sounds like this has implications for all of us, especially for You know, working in early intervention, um, in all of pediatrics, looking at that medical history, being a little bit more aware of the long term impact of a congenital heart defect.
Um, I wonder if there's anything else that you'd like to share with our audience that we haven't gone over yet.
Nashifa Hooda Momin: Yeah, I think one, one thing I'll say as a speech language pathologist is that I love how we all can do such different things and then take different parts of our lives to do other things and learn about it. I will say if you're in the world of, um, I guess in a hospital setting, um, I feel like you probably can echo this, but it's so [00:59:00] important for multidisciplinary communication, um, and collaboration with this particular pop, especially this particular population.
I will say that I practicing for 11 years and I say this all the time and, uh, learning. I love learning and there you're always going to learn and always keep yourself open minded to opportunities to knowledge. Um, and. You know, there's there's no end. And I think that's the one fantastic thing about speech is that even being in my doctorate program right now, um, that I've had the opportunity to meet such different speech language pathologist with vast knowledge on different areas that I have no idea about.
And it's. It's so interesting to just collaborate and learn from them because I think there's still so much overlap between us, right? Like you, uh, you guys all mentioned when we were before we recorded like offline, just thinking about like, how does this, how does this come into effect as the patient, um, is, well, not the patient as a child is five, six years old in a school setting, right?
[01:00:00] Like, so And the only way we're going to know that is to talk to each other and collaborate and learn from each other. Um, so I think it's, I guess my take home message is keep learning, have an open mind, collaborate. Um, because there's so much that we can learn and grow and, uh, contribute to the world of speech language pathology.
Amy Wonkka: I totally agree with you. I mean, I feel like, I've learned to echo Kate. I've learned so much just in our like hour long conversation here. But I do think, you know, as somebody who works in a really different environment than, than a NICU, um, I am still seeing students in my case who are coming in and I might read in their history that they have these like medical conditions as part of their medical history.
And I think just having a better understanding of what that actually very helpful as the person who's treating them much later on, um, in their course of development. And so we have so much to learn from each other as speech language pathologists, but we also have so [01:01:00] much to learn, like you had said, from other disciplines where, where we work closely together.
Uh, we didn't really talk about it too much today, but I'd imagine, you know, for instance, you're working really closely with OT and PT to think about, you know, positioning and all of those pieces. Um, so yeah, I think having an open and collaborative mindset is so important. I totally agree with you.
Nashifa Hooda Momin: I agree.
Um,
Kate Grandbois: thank you so much for being here with us. This was really wonderful. We're so grateful for your time. To anyone listening, whether you're in a hospital setting, working as a med SLP, working in a school, working in pediatrics, whatever it is you're doing, we hope that you found some value in this conversation because it does touch so many of us in the field.
Nashifa, again, thank you so much for your time. All of the references mentioned will be in the show notes and you can use this episode for ASHA CEUs. Everything you need is in the show notes. Thank you again so much for being here.
Nashifa Hooda Momin: Of course. Thank you for having me. It was great chatting. Thanks so [01:02:00] much.
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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