What is Neonatal Therapy?

How physical, occupational and speech-language therapists help preemies thrive

Neonatal Therapist with Preemie Baby in NICU
David Joel/Getty Images

When babies are born early and have to spend time in the NICU, they are surrounded by a team of caregivers. Doctors, nurses, respiratory therapists all take a leading role in the daily care of babies small enough to fit into the palm of your hands.

But there are others - many others - who have vital roles in caring for premature babies.

One very important group of people who provide care for NICU babies are Neonatal Therapists.

I recently spoke with Sue Ludwig, who is the founder of the National Association of Neonatal Therapists, to learn more about neonatal therapy and what preemie parents should know about this important person in their baby's life.

Below are Sue's answers to some of the most common questions about Neonatal Therapists. To hear the entire conversation, click here to listen to the podcast.

What does a Neonatal Therapist do?

"Most people think of babies in the NICU as just trying to survive. Nurses and physicians are saving those babies lives. But meanwhile, the babies are still developing - their brains are developing, their muscles, their bones, their whole sensory systems are developing. We can’t forget about that part. We can’t wait until later and then go address those things. 

What neonatal therapists do is help those babies continue to develop like they would have in the womb, but in this strange new environment of the NICU. 

What are the different types of Neonatal Therapists?

"Occupational Therapists, Physical Therapists and Speech-Language Pathologists have a history of working together in a rehabilitative way.  In the adult world, occupational therapists generally help with every day living skills, physical therapists help with mobility and strength, and speech-language pathologists help with speech, language and feeding safety. There is definitely an overlap between the disciplines.

So, in the NICU, the occupational therapist is going to be concerned with the baby’s every day living skills, which include how they grow, develop, learn to eat, bond with their parents, and attach. It's  every day life skills, but for a premature infant.

Physical Therapists in the NICU might look more at posture and tone and movement patterns and how those things might affect mobility,

Speech-Language Pathologists in the NICU would be looking at feeding and swallowing and they would also be looking at communication. Even though that might seem strange in the NICU, these babies do communicate. We all have to understand what that language is like is for them. They communicate by how they move, how they respond or how they don’t respond to things. Communication starts early and we know that babies are actually learning language even in the womb. So a speech language pathologist might ask "are we adapting the background noise environment so that the infant can actually hear meaningful language in the NICU?” If we’re not, if it’s too loud, they’re not picking up that critical meaningful language and not developing those early skills.

What does a typical day look like for a Neonatal Therapist?

"Sometimes we might be doing a feeding assessment, once a baby is eating by mouth.  We might be assessing their readiness, how they suck and swallow, how safe they are with feeding. 

We might see other patients who are much tinier and more fragile, and in that case I would work with the nurse. I would be there with them while they are doing their nursing care. We know that just basic care for these babies is stressful, especially the tinier or more fragile they are. In my job as a therapist, I would to use my hands, and use what I know about how this baby is currently wired developmentally, and I would support the rest of their body systems while they are getting their care. What this does, even though it looks simple, is help the infant use their own abilities to calm their nervous system down. But they really can’t do it on their own. So I’m facilitating what I know helps them tolerate things, helps them feel safe, helps them develop strategies over time to soothe themselves.

We're preventing a lot of noxious experiences for the for the babies, so that touch doesn’t always mean that something bad is going to happen. Care doesn’t have to be a super stressful thing every 3 hours. Because when that happens every 3 hours for days and weeks and months, without that support, it’s a different kind of brain and sensory system that that baby is going to develop. 

The nurses and therapist work in tandem when it’s done well. I’m helping the nurse and she’s helping me, and we’re both helping the baby.

I'm also doing a constant assessment of development - is the baby moving symmetrically? Is the baby moving in an age appropriate way at 23, 24, 25, 26 weeks? Really understanding how development changes over that continuum and assessing whether or not that seems to be on track, and identifying things early that may not be on track.

The ultimate goal for me is to teach the parent to do what I do. Because that way they learn to read their own infants cues about when they’re stressed and what comforts them and they become the support for their infant in that moment and every moment. 

What are your suggestions for preemie parents?

There are a few things that are really great to do, almost no matter what the exact patient situation is.

One of those is advocating for what is called skin-to-skin holding, or kangaroo care. That's when you have your baby in just a diaper, on your bare chest with a blanket or wrap over you. In most situations, whether they're tiny and on a ventilator or whether they're older, kangaroo care typically can happen. It's worth asking all the time. I wouldn't assume your baby is too sick or too small.  It's worth asking no matter what. Because babies are more stable there than in the incubator. Plus, you're holding your baby, and you get to bond. There are so many good benefits.

The other is learning the kinds of touch that comforts the baby. Most preterm infants might not respond the same way to moving and handling that we would picture for an older baby. So light stroking is usually over-stimulating to them. So just put your hands firmly on the baby - hand on their head and hand on their feet - and just hang out, providing a nice firm touch and just being there, without a lot of patting and tapping or stroking like you might want to do. But being there with that nice firm touch is great for them.

Doing this kind of touch when babies are being fed by tube is great, giving them human touch while they're being fed, because we're starting the pattern of feeding that feeding is about being with another human. Even though they're not eating by mouth - yet - if you are pairing it with some human touch, from the beginning, we can better prepare their whole system for feedings.  Later on, when they're mature enough to feed by breast or bottle, it's not their first experience with feeding being nurturing, in connection with another person. Biologically, feeding for an infant is never in isolation. Providing that human touch is so important for their brain development. 

Also, feeling comfortable when you go up to them, talking to them. And not feeling like is this weird because this is in a hospital, or I don't know if they can really understand them or hear me..  - Treating them like your baby, talking to them. They know your voice, parents. They know your voice We can not fool them as caregivers - they know your voice from the inside out. And so it's soothing to them.

The other thing is asking the staff "what can I do? Can I change the diaper? Can I take my baby's temperature? What can I do to parent my baby right now?"  That changes depending on how old your baby is, how stable your baby is, but you should always be able to do something. So, pressing the nurses - "What can I do? No really, what can I do right now? I want to parent my baby. What does that look like right now?" Keep asking, every day. 

What can hospitals do when they don’t have a Neonatal Therapist?

"Every level 3 NICU should have a therapy presence, for sure. Maybe they only have one, but the goal is having a multi-disciplinary team presence in every NICU. Raising the awareness of the hospital administration is crucial.

While there are some NICUs that don’t have a therapy presence or they’re working on a therapy presence in their NICU, there are other NICUs that have an entire team of neonatal therapists up to 7, 10, even 15 therapists depending on the size of the NICU.  It’s certainly an emerging process. 

For NICU staff members, know that we do have nurse members, respiratory therapist members, physician members in our membership. Some of them are members of NANT for that reason. We even have a year-long mentoring program that is online, and is intended for new neonatal therapists. But we've had 2 nurses who asked to do the training so they better understand what we do.

For much more of the questions and answers with Sue, listen to the entire podcast at Every Tiny Thing.

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