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Feeding the infant with congenital heart disease

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Kate Grandbois: Hello, everyone. Welcome to SLP Nerdcast. We are here today with a guest who is going to discuss congenital heart disease, which is something that we've never really talked about on this podcast before. So we're very excited to welcome [00:02:00] Nashifa Hudamomen. Welcome, Nashifa. Hi, guys.

Nashifa Hooda Momin: It's a pleasure to be on with you guys. Yeah, we're excited for this conversation. And Nashifa, you're here to discuss feeding. infants with congenital heart disease. But before we get started, can you please tell us a little bit about yourself for our guests who might not know you?

Yeah, absolutely. Um, so my name is Nushita. As you guys mentioned, I've been a practicing speech language pathologist for about 11 years. I currently work in an acute inpatient, um, children's hospital and work primarily with pediatric feeding and swallowing and pediatric dysphagia. And my passion is working with infants with congenital heart disease, um, specifically infants with single ventricle physiology.

Um, and I am wrapping up my doctorate this month. Um, we'll be actually graduating this upcoming August and, uh, speech language pathology from MGH Institute of Health Professions and outside of the speech bubble, I like to read. Listen to podcast, um, a [00:03:00] run, uh, and really just hang out with my kiddo. Um, she's five.

So it's a lot of fun times right now with her. That is so exciting. Congratulations in advance. So we're recording this episode in the summer of 2024. And by the time our listeners are listening to this, it may be some, maybe winter out. We're not sure. But, that's really exciting about the doctorate, so congratulations.

Kate Grandbois: Or we talk about all of the good stuff. I'm going to go ahead and read our learning objectives and disclosures, and then we will learn everything about a topic that I genuinely don't know anything about, which is always the most fun. All right, here we go. Learning objective number one, identify three common feeding problems observed in infants with congenital heart disease.

Learning objective number two, describe at least three medical considerations that directly impact feeding in infants with congenital heart disease. And learning objective number three, describe at least two feeding strategies utilized in therapy to enhance oral feeding skills , for [00:04:00] infants with congenital heart disease.

Disclosures, Neshifa's financial disclosures, Neshifa is an employee of Children's Healthcare of Atlanta. Neshifa received an honorarium for participating in this course. Neshifa's non financial disclosures, Neshifa has no non financial relationships to disclose.

Kate, that's me. I am the owner and founder of Grand Bois Therapy and Consulting LLC and co founder of SLP Nerdcast. My non financial disclosures, I'm a member of ASHA SIG12 and serve on the AAC Advisory Group for Massachusetts Advocates for Children. 

Amy Wonkka: Amy's financial disclosures, that's me. Uh, I'm an employee of a public school system and co founder of SLP Nerdcast.

And my non financial disclosures are that I am a member of ASHA, I'm in Special Interest Group 12, and I also participate in the AAC Advisory Group for Massachusetts Advocates for Children. All right, Ms. Shiva, maybe before we even get into the first learning objective, could you just give us a little bit of background on typical heart function?

Nashifa Hooda Momin: Yeah, absolutely. I think that's a great place to start [00:05:00] off. Um, so let's talk about what the components of a heart. The heart is composed of four chambers. We have the left atrium, the right atrium, the left ventricle, and the right ventricle. And then there are also four valves, which are the aortic valve, the mitral valve, the pulmonary valve, and the tricuspid valve.

So overall, what's happening is that the right side receives deoxygenated blood from our superior inferior vena cava. And that pumps it to from the right side of the heart to the lungs to then get oxygenated. And then that brings it back to the left side of the heart. And then that goes up to our aorta to then be pumped out to the rest of the body.

That's in the most simplistic terms of what is happening to our blood. Um, and then But I do think if we want to talk about more specifics, I like to like walk through like what the blood if I was a drop of blood, where would I go? It's something that I always talk about. So if you had blood that was entering the body, um, and you need it to get oxygenated, the blood is going to go towards the heart from, like I mentioned, the superior [00:06:00] inferior vena cava.

and it enters into the right atrium. And from there, it's deoxygenated blood. It then goes through the tricuspid valve to the right ventricle, and then from the right ventricle, it goes into the pulmonary valve into the lungs. And like I mentioned, that's where the blood then gets oxygenated. So then the blood then returns from the, to the left side of the heart through the pulmonary veins and goes to the left atrium through the mitral valve to the left ventricle.

And then from the left ventricle, it goes through the aortic valve to the aorta and then it's pumped out to the body and that's oxygenated blood going to the rest of the body. So that's normal heart physiology. And then I feel like it's also important to talk about fetal circulation because that's different.

Um, and the reason that's different is the oxygenated blood that the fetus is getting in the mom is all oxygenated. There is no process of Deoxygenated to oxygenated. It's oxygenated blood is coming from the mom and it's going to the fetus. And that [00:07:00] happens through the process of three fetal shunts. Um, and so during fetal circulation, all the oxygen, the nutrients from the mother's blood are transferred across the placenta to the fetus.

Also, I think it's important to note that when a baby is in utero, the baby's lungs are mostly fluid filled, so the blood is not going to want to go in the direction of the lungs, especially when it's when they're in utero, because there's a lot of pressure and a lot of times you'll hear this referred to as pulmonary vascular resistance.

So the three fetal shunts. The fetus that the fetus relies on in utero are the ductus venosus, the foramen ovale, and the ductus arteriosus. So now let's talk about blood flow in utero, right? So you have the ductus venosus and what happens is that that branches off near the liver and goes straight to the inferior vena cava and then sends that oxygenated blood, remember it's going to be oxygenated, to the right atrium.

So from there it's a little different because the blood can in two ways, right? So [00:08:00] Like I mentioned with normal cardiac physiology, we're kind of going from the right side, going to the lungs, and then coming to the left side, and then being pumped out. But here, what it can do is it can cross from the right atrium straight to the left atrium through, um, the second fetal shunt, which is called the foramen ovale.

And remember, it's oxygenated. Our goal is really just to get that oxygenated blood everywhere in, in, um, the fetus, right? So that's the second fetal shunt. The second way is kind of the typical way we were talking about, which is going from the right side to the right atrium, down to the right ventricle, and then up through the pulmonary artery.

And there's another fetal shunt. called the ductus arteriosus. And remember how I mentioned that the lungs are very fluid filled, right? So if I was a drop of blood, I don't want to go in that direction. I'm going to do anything I can to find a different route. And so a lot of times what happens is from the pulmonary artery, it'll go up through the ductus arteriosus straight to the aorta and then be pumped out to the rest of the body.

So that's kind of how fetal [00:09:00] circulation works. And the reason I think it's important to talk about this is because when we talk about congenital heart disease, These fetal shunts are so important for a fetus, um, because once the baby's umbilical cord gets clamped, the baby is no longer getting that oxygenation and nutrients from the mother, and that's when things start to change, right?

So that's when our lungs expand, um, the alveoli in our lungs are clear to fluid, there's an increase in the baby's blood pressure, and there's a significant decrease in those pulmonary pressures, which then causes, um, um, which then usually results in the closure of the foramen ovale as well as the ductus arteriosus.

Again, like the ductus arteriosus can take a bit to close, but all of that changes in pressure, changes in pressure will usually cause these to close. And then if you have an infant with congenital heart disease, that's when it really starts to put pressure on to how are we going to manage that.

Pulmonary and systemic flow for these patients, especially are critical congenital heart disease. So that's just a [00:10:00] brief introduction. I always like to start with blood flow because I think physiology is extremely important. And if you can understand general physiology, it helps us better understand, um, what's going on and why clinically they present the way that they do and how we as providers can provide strategies to support them.

Kate Grandbois: So yeah, I love that you said that that was a brief review. I, every time I talk to you, I am so astounded by how much, you know, I'm also astounded by the fact that we have the same degree that you're a speech pathologist, because this is very complex. I mean, I think as a field, maybe we get a little bit of this background knowledge in graduate school.

I really appreciated that refresher of I haven't used the word, you know, I haven't looked at the chambers of the heart in I don't even know how many years so that was really, really helpful. I have a question, just because I want to make sure everybody has a solid understanding of what the anatomy and physiology is here.

When you say a shunt, [00:11:00] can you describe what that is? 

Nashifa Hooda Momin: Yeah, so it's essentially like the almost like with the direction of flow, um, I think that's the best way to explain it. So, shunts can be two things. So shunts can be like the direction the blood is being shunted from the right to the left side. The blood is shunted to from the left to the right, right side, but they can also be a shunt that you're actually placing to help make the blood go in a specific direction.

Kate Grandbois: Okay, that was that that was that definitely answers my question. So thank you. And then I also want to, you know, say this back to you to make sure I've understood some of the basic fundamentals here. So we have, um, Uh, typical anatomy and physiology of blood flow or of the heart and blood flow in adulthood.

And then we have this in utero experience that is significantly different from post clamping of the umbilical cord. And that's kind of the big, that's where the show begins. I assume for these, for these little babies. Okay. Now that we've, now that I have my bearings and I apologize to anyone in the audience who already, who already knows all of these things, 

Nashifa Hooda Momin: I [00:12:00] do not.

I think it's great. That's kind of what makes our field so fun, right? That we can all do so many different things with our degree. 

Kate Grandbois: Very true. Okay. So now that we have a solid understanding of the basic anatomy and physiology here, what is the, once that, once the baby's, uh, once the umbilical cord is clamped and things start to change, what happens next when something is not going well?

Nashifa Hooda Momin: Right. So, um, that, that's a great question. So depending on the type of diagnosis, like you will, that's going to depend on the intervention. So if you have a patient, like I mentioned, that has critical congenital heart disease at our institution, we are not a birthing hospital, but the patient, That's being delivered at an outside hospital will then be immediately transferred over to our facility and then there's going to be usually just generally there's going to be an echo where the patient's likely going to be in prostaglandins.

So [00:13:00] prostaglandins are a way to keep the ductus arteriosus open to then help that balance of that pulmonary and systolic. Um, so there's going to be a lot of interventions that will happen, especially if you're an infant with critical congenital heart disease. Now, if you're an infant with, um, and we'll talk a little bit about this.

I'll kind of define what congenital heart disease is. But, um, when you say you have a patient that has like an a cyanotic defect, they're generally doing okay. That patient may be okay to go home and be followed closely with the cardiologist until they're ready for their intervention if they need a surgical intervention.

So we can go, um, okay. In different ways, depending on the critical severity of the congenital heart defect. 

Kate Grandbois: Okay, and so this brings me to my next question, which is, what is congenital heart disease? You already mentioned we were going to talk about that. And on top of that, when that, you know, do we know ahead of time in uniro, that a baby has congenital heart disease?

Like, what is the, what's the [00:14:00] sequence there, and what is it? That's 

Nashifa Hooda Momin: it. Love it. Okay. So congenital heart disease is any type of structural abnormality in the heart that's present at birth. And these defects can widely vary in their severity and their impact on heart function. So remember we talked about the four chambers and the four valves.

If anything is underdeveloped or if there is potentially like we will like to refer to it as like a hole between the two atriums or between the two ventricles, it's going to impact the way the blood is going to flow. And that's going to, that's going to be your defect, right? So that is a general explanation of what congenital heart disease is.

And um, yeah. Interestingly, it's one of the most prevalent, um, type of anomaly that we see in, in, in, in terms of congenital malformations, which is super interesting. And then it impacts one in 120 babies born in the United States. So it's pretty common. Um, but in terms of your question of like, what is what happens, right?

So you get the, how do you get this diagnosis? When do you get this diagnosis? So yeah, usually around 20 weeks when you go for [00:15:00] your 20 week ultrasound. Um, it could be diagnosed at that time, at which point they may notice that there is something, um, different, uh, in terms of normal physiology for the heart and they'll refer out to get more testing done.

So you can get a prenatal diagnosis of congenital heart disease. There are times that. it can get missed completely and that can be, um, something that can happen because of potentially it, it got missed because it was a fluke, but it could also be because there wasn't great prenatal care, um, for the mother.

So it is something that you can catch postnatally. A lot of times you'll clinically see this in the child, if it's especially a postnatal diagnosis, um, where we don't know, of course, prenatally and the patient is born clinically. There are going to be signs that the patient is in distress and they'll really quickly figure out that it is congenital heart disease.

Um, but yeah, so it can be prenatal, postnatal, really both ways. [00:16:00] And what causes it? So in the majority of the cases, there's no known cause. There are certain things that have been shown to increase the chances of having congenital heart disease, like a family history of congenital heart disease, genetics, environmental factors, or a combination of all.

And, um, it, when we talk about congenital heart disease, it can really be broken into two different categories. It's the easy, I think it's the easiest way to really understand that you have a cyanotic defects and cyanotic defects. And I've kind of talked a little bit about that, but an a cyanotic defect is when you have too much blood going to the lungs.

Meaning that you have a so remember, let's talk through that physiology like we talked about. So you have the blood that goes from the right side of the heart and makes it to the left side of the heart. Um, and say that there's a hole between the two atriums, um, or between the two ventricles, the blood that's oxygenated then goes back to the right side of the heart to then get re oxygenated.

So what we like to call it, that is left ventricle. to [00:17:00] right shunting, right? So that blood that was already oxygenated has gone back to the right side to then go back through the system again. So clinically, this patient is going to have a lot of endurance issues. They're going to show clinically, they're going to show work of breathing there.

And clinically, as a speech language pathologist, our interventions are going to be based around that. So that's an a cyanotic defect. And cyanotic defect. Um, there's also so cyanotic defect. There's also there's decreased blood to the lungs. And the reason is because what's happening is that the blood is going from the right to the left side, meaning that it's not all getting oxygenated.

And these are the babies when we look at their oxygen saturations. Prior to any interventions, they're not going to be at 100%, right? They're going to be at 75 or 80, 85, somewhere around there. Again, this is going to depend on the type of cyanotic lesion that they have. Um, and we like to refer to this as right to left shunting and some examples.

Um, you'll see this a lot, um, In the [00:18:00] literature, and just in when you're talking about congenital heart disease, we talk about the five T's, and there's more than the five T's of cyanotic lesions, but um, there's truncus arteriosus, there's transposition of the great arteries, there's um, tricuspid valve abnormalities, tetralogy of fallot, and then TAPBR, total anomalous pulmonary venous return.

But that is kind of the two different types of congenital heart disease. 

Amy Wonkka: And you mentioned that if you have one of these cyanotic injuries, you may see oxygen levels like in the seventies. Can you remind us what is normal? What should we be seeing? If we're seeing something 

Nashifa Hooda Momin: in the seventies, we should be at a hundred.

So imagine when we go to our doctor's office, you know, when they put the, um, the little. on and then they look at the rhythm. So that's supposed to be at a hundred percent or they'll put the little sticker on around your finger to check, but it should be at a hundred percent. So that's a real big difference.

Yeah. And so remember when we were talking about the fetal [00:19:00] circulation, so during, um, uterine utero, what's happening is that foramen O'Valley and that ductus arteriosus are bypassing the bypassing those pathways. But once they close after birth, that's when these complications start to really pop up for critical infant with critical congenital heart disease.

Um, so at that, that's why, that's why we have to try to optimize keeping that ductus arteriosus open so that we can balance that circulation. We're getting, we're getting blood to our lungs, but we're also getting blood systemically, um, until the patient has their type of intervention. 

Amy Wonkka: So this is something that's affecting the whole baby, you know, I mean, the oxygen level across their entire body, their entire system, what are important things for us to be thinking about if you're working in an environment like that?

What are things that you need to be thinking about if you have a patient like this 

Nashifa Hooda Momin: going on? Absolutely. So when we're thinking about working with this population as a speech language pathologist, I think it's important for us to think outside of the box. I think that, you know, we can sit there [00:20:00] and treat the symptoms as it goes.

But like I mentioned, I really think it comes down to physiology and really understanding what's going on to the patient. fully to then be able to provide the specific interventions that they need. So again, I am giving a very inpatient acute lens because that's where I work. We'll talk a little bit about outpatient as well.

Um, but in my head and I, I like to break it down into four categories. I like to think about post surgical complications, airway considerations, GI considerations, and comorbidities. And those are all medical things, but they really truly impact oral feeding success. So when we talk about post surgical considerations, many of these infants, um, after they have any type of intervention, they're going to be on sedation and pain medications.

And this can cause nausea, constipation, drowsiness, and that can impact oral feeding. So a great example is think back to when you had a procedure or any, or know somebody that had a procedure or surgery, think about how. they felt or [00:21:00] you felt weaning off medication and it can make you feel really out of it and nauseous and I obviously can't say we're 100 percent that's exactly how a baby feels but it's a consideration you don't feel great right um and and then when you have a speech language pathologist that comes Right right after they have surgery and they're nauseous.

We have to make sure that we're not just like giving them a recommendation and that is the single recommendation. We have to remember that it's that this their journey is going to be very variable. It's going to change. They're going to feel better soon and then we need to be very adaptable and our assessments need to be ongoing because oral feeding is going to be changing very rapidly or especially post operatively.

And then we also may see withdrawal symptoms, um, this can be in response to the medications that they have. Some infants are more sensitive to this if they've had in utero drug exposure. Clinically, these patients may, we may see tachycardia, tachypnea, hypertension, irritability, tremors, decreased alertness, and all of that is going to play a role on our clinical assessment for feeding, right?

So [00:22:00] making sure that we're adaptable and knowing that our plans are going to be consistently changing. Um, chylosuffusion is another post op consideration or chylothorax. Um, and what that is, it's a buildup of fluid in the space around the lungs, um, in the chest cavity. And this happens because of injury with.

To the thoracic duct, um, and this results in the buildup of Kyle in the plural space. And this is a Kyle is a fluid that's made by your intestines when you eat that. Um, so the reason why am I even talking about this? It's because if a patient has a, um, a Kyla suffusion or Kylo thorax, they're going to be recommended to be put on a low fat or nonfat diet.

So imagine a patient maybe who'd been orally feeding with breast milk or formula who then now has this complication. They have to be on this low fat, non fat diet. So that could be the introduction of formulas like Toler X or Infopor, which are okay, but for a patient that's been having yummy, delicious formula or breast milk, and then you're [00:23:00] introducing this new formula, it's not as palatable, and that has definitely impacted oral feeding success.

On the other hand, I have seen patients completely chug a full bottle of Toler X, but it is just another consideration that we have to be thinking about. Um, And then there's also a high risk of stroke, hypoxic brain injury, cardiac arrest, secondary to any type of medical intervention. We know that when we're thinking about, um, the physiology, there are a lot of neurological complications we see after cardiac surgery or after cardiopulmonary bypass.

So that's the first category. 

Kate Grandbois: Um, yeah, I know you have other categories that you want to walk through, but I just have a quick sidebar question. I'm thinking about my experience feeding my own children, what I know about infant development and how important fat is. And how important from a nutritional standpoint, so I know we are not nutritionists, but in this moment, when you have a baby who is now having a, you know, a nonfat diet recommendation or other feeding specifications that [00:24:00] could impact their nutrition, how much of that is a balance and how closely are you working with nutritionists and pediatricians to make sure that they're getting the nutrients that they need for development?

Nashifa Hooda Momin: Absolutely. So I will say that the diet is temporary. It's not, um, something they'll be stuck on for a whole year and nutritionists, um, are so critical. So just to kind of give you a little layout of how our teams are set up, especially in the ICU setting, we have the physician, we have a nurse practitioner, you have maybe an advanced practice, um, advanced practice practitioner.

I think that's APP. Um, and then a nutritionist there, a pharmacist there that are, you know, All rounding on every single patient every single day, and that similar model is also there in our step down unit. Um, and so I, like, it is a huge consideration because we are watching their weight game very, very closely.

I will say that it's usually temporary and, um, You know, pediatricians or cardiologists that they get discharged to are also kind of keeping an eye on it. I [00:25:00] think the big thing is making sure that that Kyle stops building up. And once we, that resolves, then you can kind of resume back to your normal diet.

Yeah, that's helpful. Um, so the second category that I wanted to talk about is airway and respiratory considerations. Some of our kids will require prolonged intubation. Um, and that can place a lot of strain on the vocal folds. We may see this after extubation. So usually I'll be able to assess this with vocal quality.

Um, if especially If I've seen the patient preoperatively and done feeding with them preoperatively and I see them postoperatively, operatively, and I can usually be like, wow, their voice doesn't sound like their baseline. A lot of times their caregivers are great about saying, no, they're definitely not as loud as they used to be, um, you know, picking up on if they have, obviously, if they're crying and they're not vocalizing, then we know there's some aphonia.

Um, dysphonia and hoarseness, really assessing that, so that can be a consideration. Another thing is that infants that are super [00:26:00] critical may end up, um, in a situation where they may require ECMO, which is extracorporeal, extracorporeal membrane oxygenation. And for our cardiac patients, we usually use VA ECMO, um, but it's a temporary solution to offload the heart and the lungs.

Um, but we have also seen that ECMO can, we've seen right sided vocal fold paralysis, and I think that has to do with the placement of the catheters for ECMO, so that's another consideration we have to be thinking about, especially when we're doing our clinical assessments and working with oral feeding.

And speaking about vocal paralysis, a lot of our infants with congenital heart disease will, especially the ones that have surgeries near their aorta, like a PDA, um, and Norwood and aortic arch surgeries, they all have a really high risk of recurrent laryngeal nerve damage, um, and that is going to impact vocal paralysis.

Vocal fold, you know, closure and can cause vocal fold paresis or paralysis. Um, so that's another consideration. And just to kind of review the recurrent laryngeal nerve, um, it [00:27:00] supplies most of the intrinsic muscles of the larynx. It functions for speaking, breathing, and the opening of the vocal fold. So if an injured, we're going to see that vocal fold paresis and paralysis.

And again, clinically, what I'm going to be looking at is this patient is, has dysphonia or aphonia. They may have some stridor. Um, or and then that's going to put them all at an increased risk for aspiration. So definitely a lot of airway considerations. There's a few more. Um, so phrenic nerve damage is another thing that can happen.

Uh, the phrenic nerve originates around cervical vertebrae four, um, and it goes over the heart. And if there's any type of damage post operatively, sometimes we'll see these kids where their respiratory rates are really high. So say, You already have an infant that, um, preoperatively, their respiratory rate was in the 70s, which is high.

Um, and then postoperatively, their respiratory rate's in the hun in the hundreds. And just to kind of put that into perspective, that's like per minute. So imagine, like, 70 breaths per minute, now bumped up to 100. And you're asking them [00:28:00] to take an oral, like, orally feed. Like, take a bottle. It's a lot. to do right in terms of coordination.

It's really hard to coordinate your sex while breathe coordination when you're breathing that fast. And so in that particular population, these kids may require a diaphragm implication, which is another type of intervention that they'll have to do to help kind of help with that phrenic nerve damage that could have happened with surgery.

Um, other considerations are subglottic stenosis. This was something that I, um, came across recently, maybe It's not as common, but it's something that popped up for one of our cardiac patients, and it's interesting because this is something that, you know, you may not even be thinking about, but it's a patient that like, for example, they get extubated, and they're actually doing well, going along in their post op course, and then they start to get worse with their feeding.

They have Schrader, you're noticing that, Um, they're more noisy. They're having more signs of aspiration, almost where you would have seen more improvement. Um, and so this happened with one of the patients that I was working with and we [00:29:00] ended up doing a fees on the patient and noticing that there was subclotic stenosis.

And so then they had to go to the OR for a dilation. But again, it's something that you would, it's in our head that like after surgery, we're only going in the pathway of improvement, but as speech language pathologists, especially in this type of setting, You just kind of have to be on your feet and being able to read and advocate for your patients and knowing that, hey, this is, this doesn't sound right, um, because you get so close to your patients.

And then finally thinking about respiratory support. So that is something that a lot of our patients are going to need. And so think about an infant who is on five or six liters of high flow. Um, and then you're again, like the same concept, you're requiring, you're asking him to take a bottle of water.

when they're already have this baseline work of breathing and then they have all this extra flow that there's no research to say like, hey, you can't feed babies on five liters or less or five liters or more, six liters or more. But like, you have to look at the infant as a whole, right? If they are. are really to Kipnick [00:30:00] and you're asking him to take a bottle without strategies or, or with strategies, like the plan is going to be very dynamic in the sense for that baby.

So those are some airway considerations. 

Kate Grandbois: There are so many considerations. There are so many considerations and the whole time you're talking, I'm thinking this is a tiny little person. Yeah, I know. 

Amy Wonkka: Well, and it's, it sounds like it's, it's just, it's a lot, it's a lot of problem solving in a very fluid, in what can be a very fluid environment, right?

So you're thinking about so many different variables. I know you had mentioned gastrointestinal considerations. That's like a system, a system we haven't gotten to yet. What are some of the gastrointestinal considerations? 

Nashifa Hooda Momin: Absolutely. So there's, um, there's a, you have to think about reflux. Um, obviously a lot of our babies have reflux.

Some are symptomatic, some are not. There has been some literature to show that infants with CHD do have a higher percentage of having reflux. Um, another consideration is necrotizing intercolitis. Um, so necrotizing intercolitis has been a little bit more prevalent in infants with congenital heart [00:31:00] disease.

More specifically, um, Our single ventricle population. Um, so again, just in the reason we talk about these things, why is this important? Why does it relate to oral feeding? If you are having issues GI wise, it's going to be hard to push through oral feeding. And if you're not addressing these issues, you're kind of going to be dealing with another slew of issues, like.

oral aversion in the long run, right? So like being able to clinically look at your patient and see that they're having signs of reflux is something that you need to be pick, you pick up on and tell the team so then we can adjust medications or adjust strategies, whatever needs to happen, right? But if you power through with oral feeding, then the patient's eventually going to clinically not be interested to eat.

And then you're going to have another issue. Um, and then finally comorbidities. So how do existing comorbidities impact the patients? Um, we know that there are underlying genetic syndromes like Trisomy 21, Kabuki, Turner's, DeGeorge, that are often seen with CHD, and we also know [00:32:00] that they Um, and so, um, you know, with baby can impact feeding.

We see, like, poor muscle tone with them. Oral motor dysfunction, structural abnormalities. And so with an infant with CHD, it just adds, like, another layer of complexity to oral feeding. Um, some other comorbidities are cleft palate, trach and bent, tracheal malaysia, laryngomalasia, vascular rings, vocal fold paralysis, um, and again, there can even be congenital subglottic stenosis.

So it's, it's something that, you know, We have to also be putting into the picture. I almost like to think about it as a formula. It's not a formula, but like there's a lot of things you have to think about to make a feeding plan for a particular patient. 

Kate Grandbois: I have another question and I know you have some, you're giving us so much.

important information. I am, I'm, I'm just, again, I, every time I talk to you, I'm kind of floored by how fluently all of this comes out of your mouth because it's so much information and it's so helpful. And I have a question that is a little bit of a sidestep and maybe we'll get to this in more detail and you can, you can push it off, but.

[00:33:00] Yeah. As you're talking about comorbidities, I'm thinking about the parents. I'm thinking about, you know, they've, they've just had a baby. Maybe they knew ahead of time that there were going to be some genetic issues. Maybe they didn't. Maybe they knew they were going to, there was going to be a congenital heart disease.

issue. Maybe they didn't, but there's so many professionals involved. There's so much triaging. There's so much coordination. It sounds like you're, you know, just constantly trying to put out fires is, is, is what, depending on, on what's going on with the kiddo.

And at what point do you have a conversation with the family and really put your counseling hat on to feel, see how they feel about what to do? component of this is more or less urgent or, you know, long term implications for some of these things. This just feels like a very complex issue where counseling would really have to be at the forefront of all this.

Is that a, is that a reasonable assessment? [00:34:00] 

Nashifa Hooda Momin: Huge. Yeah, absolutely. So a lot of things I think in this, in this career or in this, um, job that I've been in, I guess for a while now, one, the importance of learning how to effectively communicate with the team and that multi, we talked about multidisciplinary, interdisciplinary, Transciplinary like buzzwords all the time, but truly how important it is to have this conversations with the team to come up with a plan that's very patient centered, but in terms of counseling with caregivers, it is at the forefront.

So when we're meeting caregivers, sometimes. Um, if it's a baby, like I mentioned with critical congenital heart disease, they may be transferred over to our hospital and there may or may not be a caregiver on the first assessment because a lot of times we are consulted immediately when they're admitted for babies under three months.

But as the minute we meet the caregivers, it is, hey, we are speech language pathology. Most of the time they're like, well, my baby's not ready to speak right now. Um, and then, you know, kind of explaining what the role is that we're [00:35:00] here to really work on feeding and swallowing and What we're anticipating.

What are common complications? How are they feeling? What have they done? How is a lot of it? It's also even like, Hey, how mom are you pumping? Is that how's that going? And what can we get for you and, and advocating for them as well as like a unit, um, and then providing that education. And the great thing is because we are consulted preoperatively, we've established those relationships.

very, very early on and then follow them through the surgery and then follow them through step down. Um, and then make sure that we plug them in right into outpatient. We have a rehab, um, outpatient case manager who helps them, plugs, plugs our cardiac patients right into outpatient therapy. So there is a lot of, um, Treating the patient and assessing the patient.

But it's like, like you said, you have to have your counseling head on at all times when you're interacting with caregivers. Um, and I will say, thinking kind of about long term implications. I think that I will say that [00:36:00] I've. I've learned that you never know, and I'm kind of on that boat of, hey, by the time they get to step down, I'll have a general idea of kind of what the next steps are going to outpatient, but it's hard for me to meet a baby on day one and know what's going to happen, so I'm usually very transparent on, hey, like, Let's take this one step at a time.

These are kind of my goals for, for your baby. Um, and, but I also want to hear what you're thinking and, you know, what, what your goals are, um, for feeding, because I think that's important to understand, especially when we're thinking about breastfeeding and, and how that can be sometimes challenging for an infant with multiple lines and, um, you know, just the complexity of where they are, but listening to that.

So then you can advocate again to the team that this is kind of what the caregiver is thinking. I hope that answered that question. 

Kate Grandbois: It did. And I appreciate you. I appreciate you taking a second to hold space for that only because it just, again, it just feels like such a complex work environment, a complex baby, a complex patient, you know, [00:37:00] family dynamics.

So I, I appreciate you answering that question. All right. Let's talk about the feeding part. Yeah. What? Okay. So why? Why? How is feeding related to all of this? I don't know. It seems like a dumb question. There's so much going on. 

Nashifa Hooda Momin: There's so much going on. Um, so outside of all these considerations, now you have all of this to think about.

These infants are going to have an increased cardiopulmonary load, which is going to result in decreased endurance. So they're going to be very easily fatigued. So that cardiac output that they have is insufficient to meet the metabolic and energy demands of the body, especially. Especially when it is related to oral feeding.

So oftentimes, what we see as their clinical presentation, we'll see, um, I mean, depending on the age of the infant, we may see poor state control. And the reason I'm even mentioning that is, remember that they're already, they already are very easily fatigued. And then imagine how that impacts their state control, especially as a newborn infant.

Um, they are going to have baseline tachypnea with reduced baseline saturations, [00:38:00] especially if you're a cyanotic. Maybe you're going to see that poor coordination of oral feeds again because of that underlying tachypnea, underlying fatigue issues. You may see oral aversion. That oral aversion can happen for various reasons.

It could be the fact that this patient was intubated for two, three weeks, we have to be thinking about, like, how long they had that endotracheal tube between their vocal folds.

And then, and then now, we're gonna come on and try to be like, hey, let's take a pacifier, hey, let's take a bottle. And it's a lot of negative excitement. and we're trying to like add the oral feeding component. It could also be, oral aversion can be because the patient has a, is a single ventricle baby and they have poor blood flow to their gut and that's gonna result in feeding intolerance.

So every time they eat, they may throw up, because we're trying to figure out that nice balance of what they can tolerate. And so then now they've associated every time that I get food in my belly I throw up and I don't want to eat so That can be a reason for oral aversion. They may have decreased hunger cues because they're on continuous feeds because of that poor feeding intolerance.

We just [00:39:00] talked about, um, also dysphagia. Dysphagia is extremely, extremely prevalent with this population. Um, to kind of take it back to literature, there was a study done in 2022 by Nirwana et al, um, and they looked at 374 patients retrospectively. Um, and I encourage you guys to read it. It's a great paper, but really they found that 70 60 percent of these patients had oral dysphagia and 64 percent had pharyngeal dysphagia.

And there are specifics in terms of like aspiration and silent aspiration and vocal fold involvement. And so like, it's a dysphagia is extremely prevalent with this population, which obviously explains why speech was so involved. Um, but, What are we thinking about as speech language pathologists with these diagnoses?

We have to be thinking about the patient clinically. So again, we come to bedside, and if they have increased work of breathing, then we're working with our skills to give them the strategies to help kind of work around that work of breathing while also orally feeding. Um, but say if they're a cyanotic baby, they may still have that work of breathing, but in our heads, we also have to be [00:40:00] thinking about, okay, so they're cyanotic, How is the blood flow going to their gut?

Do I need to be kind of thinking about that, depending on their physiology? Okay, what about their brain? Are they getting great blood flow to their brain? These are the things that I like, like to be thinking about, even though they may not be at the forefront of our treatment, um, because long term we're going to be thinking about this, right?

So like, again, like advocating for, educating our caregivers, but advocating for the patient and then also thinking about next steps, right? Um, And like to kind of think about that blood flow that that might be blood flow to the brain thinking about neurodevelopmental delays down the line. 

So as SLPs, other things, other common strategies that we think with this population is what position are we going to use to feed them, right? Cause these are, most of the time I'm working with infants, um, nipple selection and then the use of pacing, right?

So babies under three months, I think my go to is elevated sideline. My preemie flow nipple, like a Dr. Brown preemie nipple or, um, an extra [00:41:00] slow flow nipple and then offering pacing, meaning. Offering a breath between, because remember, these are babies that are going to be potentially feeding for the first time, especially if it's a newborn, and they may not have that successful abrief coordination, and then you're kind of supporting there, but also that underlying CHD where they already have endurance issues and fatigue issues, so offering pacing for that.

And then a huge, huge part of, uh, speech language pathology with feeding is making sure that the bait feeding is very cue based, meaning I, I feel like sometimes, um, it feels. You know, when a baby can't speak, right? But the way that they communicate is through cues, right? And I think there's so much you can get from, um, feeding a baby with their cues, with the way they move their hands, with the way they move their, um, with the way they make grimace and like, you know, Have gaze aversion or have stopped feeding and changes in vitals.

I think there's so much going on in a feeding that is not with words, but you can pick up on. And as a speech language pathologist, it's a dialogue, right? So as a feeder, I'm watching those cues, and I'm [00:42:00] adjusting my strategies to make sure that I'm supporting the feed. And then really empowering our caregivers to do the same.

So yeah, that's a little bit about like, what yeah. What is feeding with this particular population and what a speech therapist may do with this particular population? Um, yeah. 

Amy Wonkka: What if PO feeding is not appropriate at that time? Like, how, how are you making those determinations? How, how are you working with the team to help identify some indicators that might be telling you, Hey, Not quite ready for this just 

Nashifa Hooda Momin: yet.

That's a great question. Um, and so as our role, it's, um, important for us to look at those cues that we talked about and then seeing, Hey, can I offer strategy? And if that strategy doesn't work, then really knowing when to stop. And then, like you said, advocating for them to say, Hey, like that, we may not be ready because of X, Y, Z.

And oftentimes what all often see is like breathing difficulties, meaning that. Maybe, um, their respiratory rate is in the [00:43:00] 90s or 100s, and they're really not even with strategies and everything that I'm trying. It's just not going well, and I'm seeing a lot of stress signs. They may have decreased alertness where they're not even participating.

They may be medically unstable. For example, that could be, um, Changes in color. I might see like a desaturation event while I'm PO feeding or signs like I'm like I feed them and they're gagging and hiccuping and turning away and pulling back and shutting down gaze aversion like I mentioned, or they're extremely disorganized despite all the strategies.

Another one that I have seen is like fingers playing where they're going to try to stop and put the stop sign up. Um, so what is again? What does all that mean? We have to stop. We have to support Um, and advocate for their needs promoting safe feeding so we can prevent long term issues down the line long term issues like over time.

Um, so, yeah, those are some of the strategies. 

Kate Grandbois: And how does that conversation go with the family, especially for maybe moms who really want to [00:44:00] have that skin to skin breastfeeding time? You know, there are so many emotional components to feeding your child. I have to imagine that if you are seeing signs of distress or any signs that PO is not an option at the moment, that could be a really difficult conversation to have.

Nashifa Hooda Momin: Yeah, absolutely. And I think that that does come up quite a bit. Um, and I, one thing that we promote a lot of is non nutritive breastfeeding, as long as the infant is stable and not showing signs of stress with that. And what I mean by non nutritive breastfeeding is if the mom is interested, um, Having her pump prior, putting the patient to skin to skin and then eventually to breast to really just work on those oral skills, um, and have that bonding time with mom and the infant.

And again, it really just depends on the infant. So if the infant is showing signs of stress, if the infant is showing medical instability, I think like, hey, like, what if we just do skin to skin, right? We don't even have to do non nutritive breastfeeding. Let's do skin to skin. Um, and it is, it is a little bit of a culture change too, [00:45:00] right?

Because I feel like. A lot of times our focus can be very hyper focused on the medical things and so kind of taking that step back like you mentioned and really seeing where we are, what we can do what we can control and a lot of times when we can't control, we can still promote that bonding experience and and do the skin to skin and.

Give room for that. So yeah, it's again a very much like you've mentioned It's very counseling very reading the room reading the situation and promoting and advocating for your patient And it's interesting because I do feel like that's one perk of being a rehab therapist PTOT or speech is that you really get to know these families, um in a different level and understand kind of what the dynamics are of that family and Provide that insight to the medical team and, and our medical teams are fantastic and have been so supportive and, um, are 100 percent like on board to support, like make sure that care is very patient centered 

Kate Grandbois: [00:46:00] now.

So what happens next for these families? 

Nashifa Hooda Momin: Oh, outpatient, right? So let's so there I know I'm more inpatient, but I do, you know, interact with a lot of our outpatient providers and, um, and it's an important factor and these patients come back and we're always in constant communication, like I've talked about, but when these patients get discharged, we have to think about where that patient is at that current time.

Okay, so, okay. One thing is, like, I always come kind of back to, like, where, where is the patient? Are they repaired or are they unrepaired, right? So you may have a patient that is Let's just say it had a prenatal diagnosis. They come to the hospital. Let's say it's a cyanotic defect, like Tetralogy of Flow.

Clinically, they're doing well. The medical team decides, hey, you know, the patient is stable and we can send the patient home. And then we'll, that patient will follow up with cardiologists. And then when they're will kind of determine their plan for surgical intervention when they're a little bit older, because [00:47:00] again, sometimes we know that literature has showed that a baby when they're bigger and healthier, um, and have kind of some more meat on them, they're going to do well, right?

With surgery. So sometimes that's the option, right? So these patients may go to outpatient therapy and clinically, these patients are going to be unrepaired. So they might have that baseline worker, breathing, working really hard. And in fact, that might actually get them Get worse as they get ready, getting ready to need the surgery.

And so as a speech therapist, it's going to be more like, Hey, I need to provide strategy. So the patient may come in and say they're using a level one nipple, and they're feeding in sideline. They're not really using pacing. It takes them 20 minutes to feed. They're doing fantastic. Okay, well, week three, they come in and you notice that the patient's actually really struggling.

They're pulling, they're tugging. Okay. Okay, let's kind of go down to a newborn nipple or a preemie nipple and offer some strategies, maybe a 10 minute rest, like a break at 10 minutes, give him a rest break and then start over again, maybe adapting the plan. And it can even be that the, and this has happened in the past where [00:48:00] the outpatient speech therapist is the one that reaches out to the cardiologist.

And it's like, hey, this patient is not finishing their feeds. They're really tugging. They're really not doing well. And then they get followed up. And usually right around that time is when they need that surgical intervention. So it really is a lot of communication and being in that setting, knowing that, hey, this patient is struggling and we need to advocate and do something about it.

On the other side, you may have a patient who's repaired, right? So the patient comes in, say this is a, um, a, a cyanotic defect. We were talking about a cyanotic defect before, but, um, they come in, say they're a. BSD. Um, and they have their, initially they had endurance issues. They worked in the inpatient, had some strategies.

They get to outpatient. And this is the kid that might actually do great. And this is the patient when you might be like moving up along the totem pole, right? You might be making their, maybe their nipple was at preemie. You're going to go to a level one. Maybe they'll go from elevated sideline to cradled upright.

And we're kind of moving them along the process of like, Hey, like. Let's get [00:49:00] them fully orally feeding if they aren't already and supporting the caregivers as they need them. So those are kind of the two things that I feel like generally we're thinking about as they get to outpatient. Um, but one of the major challenges that I hear, um, is the, How, navigating recommendations from various providers, so, you know, say the patient, an inpatient had, um, we found that the patient had vocal fold paralysis, so ENT was following them, and say they were discharged with an, with an NG tube, so you have GI following them, um, and then you have cardiologists, then you have the pediatrician, and then you have the speech language pathologist, right, or, or OT, PT, whoever is involved.

Say the patient comes to, so, therapy, and as a speech language pathologist, I feel like I'm ready to push them, but I'm not sure, and I can't really get in touch with everyone because I'm in my outpatient bubble, and it's hard to get, walk over, and just ask someone a question. So I feel like that's a really big challenge, is to kind of navigate these, Recommendations from the so many, many [00:50:00] providers and then trying to see documentation and then making a plan and feeling confident about, Hey, can I make this plan on this particular patient?

Because it seems a little complex. So I feel like that's a big challenge that I hear a lot, um, from a lot of our outpatient colleagues. Um, and I, I'm hoping that there's a better way at some point that we can, we can support these families. And instead of this, I feel like working in a little bit of a silo, even though we are multidisciplinary, but we are in our individual islands when we get to outpatient.

Um, but yeah, but I feel like that's a big challenge.

And then lastly, um, I kind of do think that, um, one of the big things that I, I, I want to kind of highlight is that even when we talk about repaired and unrepaired, we really have to be thinking longterm, right? So remember, we were talking about, you know, Cyanotic and like thinking about, um, blood flow, right?

So how is the blood going to their gut? How is their blood going to their brain? And thinking about, like, long [00:51:00] term implications. So even if you have a baby that's doing well, PO feeding, um, and say they have a cyanotic lesion, again, like, how are we making sure that they're plugged in to getting assessments and thinking about neurodevelopment and thinking about the long, um, term implications of that?

So I think that's another outpatient thing that we, I mean, I think it's an inpatient and outpatient consideration, but it's something that we all need to be thinking about. So I feel like those are some things that come up when I think about outpatient. 

Amy Wonkka: Yeah, just monitoring for those referrals to early intervention when they need to be made.

I wonder if you can bring us back just thinking about the infants and the families who you're working with. Um, what are some of the, some of the helpful things that you have learned in your time in this position? 

Nashifa Hooda Momin: Yeah, so I will have to say that, um, My lens changed quite a bit when I became a mom myself, and I think realizing how it's much more [00:52:00] than just a b c d.

These are the things that we're going to do. This is how, um, feeding works in this inpatient setting all the way to outpatient. It's really, um, as kind of Kate mentioned, thinking about the family and putting them in the center of the care, right? So, um, one of the things that I feel like that I have learned is Being being more mindful about the recommendations I'm making.

So, for example, making sure that the plans are feasible for our families, um, thinking about what are their social determinants of health, thinking about health equity, thinking about what are the logistics of going home, like, um, one thing that came up was a we had a family recently that had nine Children, and we were recommending, um, thickening for this particular population.

The mom was not at bedside. So yes, the patient needs thickening. But how do how do I make sure that this is going to be a feasible plan? Right? Will they have the resources? So really, getting that time to talk with mom and seeing like, [00:53:00] Hey, what can I do to make this work? And will this work? Because what's the point of making a recommendation if we're just if it's not going to work?

So I think that's been one of the biggest things that's changed is to think about feasibility. Um, yeah. And really take a minute to understand what the caregiver's goals are themselves. Um, so that's been a huge, I feel like, change. For me, um, that I am, and I think I still have a lot to learn and a lot to grow on, but that's been something that I've been really trying to focus on more recently.

Kate Grandbois: I also have to assume that cultural competency comes into a play quite often as well in terms of cultural expectations for a, you know, for the postpartum period for the mother. I mean, there's just, there are so many layers to this population that I can't imagine Cultural competency not also being a consistent consideration as you're making recommendations, engaging in [00:54:00] counseling, all of those kinds of things.

Nashifa Hooda Momin: Absolutely. I think that, um, and that's, that's another, uh, big factor is this was like years ago where we had a family wanting to really focus on breastfeeding, um, and, um, Making sure that the plan was around that because culturally that was what was going to work and it wasn't even it was culturable.

It also came down to resources and kind of their where they were and how the feasibility how they could do things in their current setting. So I think realizing that, hey, I can't keep recommending a bottle to you if that's just not going to work. And that's not culturally what you've done where you've come from, right?

So I think taking that into consideration is huge. Um, so yeah, I, again, like very learning one of the biggest things that I've learned. Um, and that's been more at the center of my attention, I think, has been thinking about putting the patient at the center and making sure that plans are feasible, making sure we have caregiver buy in.

And we talk so much about this when [00:55:00] we talk about adults, right? Like we're like, Carryover. Like, how are we going to make sure the adults have carryover? But for our kids, it's the parents, right? Like, it's, how are we going to make sure carryover happens? It's getting that buy in from the caregiver. Um, and so I think that's, that's been huge.

Amy Wonkka: This is sort of a tangential question, not super related, but I was just curious, how often, I know you mentioned in the case of the, of the patient who you've had, who had the subglottic stenosis, that you did a fees. Um, how often are you using imaging? To help aid in your choices that you're making as far as like, maybe whether a baby is going to be PO or not, or, you know, what, what 

Nashifa Hooda Momin: some of your strategies might be.

Yeah. That's a great question. So the two types of instrumentals that we can do are, um, fiber, uh, sorry, fiber optic endoscopic evaluation of swallowing, which is a fees. And we can also do swallow studies, um, video fluoroscopic swallow studies, um, and both of those, I feel like it's interesting. I like to, I will do a swallow [00:56:00] study when I.

need to get more information. So clinic, so the thing is when you have a patient that's post op in my head also, I feel like they're recovering, right? They're recovering. They were intubated. Um, and so if I can clinically assess and I see clinical signs of aspiration, I don't know for me, if I would jump to a swallow study right away, but if I'm answering a question, so for example, The patient is fully PO feeding post operatively, no clinical signs of aspiration, but they're there every time they eat, they're having changes in their vitals to me.

I'd be like, okay, hey, let's get down to fluoro and find out, am I missing something? Or is this something related to their physiology? What's going on? Let's, let's get more information. So I feel like that's kind of when I would want to do a swastika again, it's variable and I think it's patient specific, but that's a good example.

Um, A fees is also extremely helpful because, um, so for that patient that we talked about with the subglottic stenosis, we did do a swallow study. And the swallow study, what, there was no penetration, no aspiration. And it was so [00:57:00] alarming to myself and other, um, colleagues because clinically we were hearing Strider and clinically we saw signs of aspiration.

So we were all floored. Um, and then when we ended up doing the fees. To get that different view, it was, like, we didn't even get to the fees because the minute that the ENT passed the scope, we immediately saw the subglottic stenosis and immediately they were like, this patient's going to need to go to the OR and, you know, um, next steps from there.

But I think that I like to, I think it's like, where, how will these tools help guide my plan? Right? So I don't want to, and that's another big consideration is like, when we think about Swallow Studies, it is thinking about radiation. So like, if I'm just doing a Swallow Study just to check a box, that's not, that's not the best for the patient.

So where can I add this in to clinical care that's going to help me change my clinical plan? Um, That's kind of how I feel like our institution does it for both of those [00:58:00] assessments. 

Kate Grandbois: And I think that, I mean, that sounds very much in line with our evidence based process for a lot of other things in the field.

That was really helpful to hear. I wonder in our last few minutes, if you have any advice for our audience members listening who are maybe working in a hospital, working as a med SLP, working in feeding and swallowing, but not necessarily with infants or in NICU or with congenital heart disease. What advice do you have for those individuals who might be interested in getting into this field?

Nashifa Hooda Momin: I think that I would, I think when I first started, and one of the greatest things was just being able to learn and shadow, um, from all the SLPs that were in my area. So I think starting there, and if you don't have like an ICU or, um, an ICU setting, um, then I would try to see if you could potentially, one of the things that I've had other colleagues do is PRN, and if you're, if you're interested, just to kind of get your feet wet and [00:59:00] learn what, um, Kind of an inpatient setting is and then, and really just gaining experiences and seeing and testing it yourself.

I feel like a lot of times you just have to put yourself in that situation to see, hey, like, this is something that I thrive in. For me, it's a lot, and you probably can tell from our conversation today, I'm big on problem solving. Um, I, I like to look at all the pieces of the puzzle and come up with something.

Um, and that to this kind of environment, I feel like is a great Good fit for me. And that's not to say that, you know, the same personality wouldn't be somewhere else. But when I, when I'm in the ICU setting with high stress, lots of moving parts, it works great for me. So I think that shadowing and putting yourself out there is one recommendation.

And I think learning, I think like just constant learning is an, um, Putting educating yourself on different areas and topics like for me, I feel like when I first came into the field as a speech language pathologist, I didn't want to do peds. I was very actually pro adult neuro. That's where I started.

And that's where I thought I would end. [01:00:00] And I took my position here. And Again, cardiac was not even in my radar, and I trained in the pediatric setting, and I found myself kind of like inching towards cardiac over time, but I think that it's just that learning and exposure of different areas and different topics and different people and their expertise and kind of be a sponge and soak it all in, um, and I, I think that would be my advice is just keep yourself learning, um, and, and I'll say 11 years in, I'm still I like love to just, um, in the mornings when chart reviewing with colleagues, just to say like, Hey, like, what does this mean?

Or what do you think this is? Or, um, and I, I just like, love to learn. I love to like, learn new things, which I feel like is, um, yeah, I think it's a great thing to do and a great. Right for SLP intercast. 

Kate Grandbois: Thank you so much for being here. This was just a true wealth of information. I know I've said it twice, but again, I'm just [01:01:00] astounded with how really this information flows out of your brain.

You're clearly an expert in this content area and we're so grateful for all the time you've spent with us. Um, we will put all of the references that you've given in the show notes for anyone who is listening while they are driving. folding laundry, what have you. Thank you again so much for being here Neshifa.

Really, really wonderful. 

Amy Wonkka: Yeah, it was awesome. Thank you. 

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 [01:02:00] 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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