This document discusses the importance of early speech and language stimulation for pediatric patients with prolonged hospitalization. It presents the case of "Baby A", a 10-month-old male with a complex medical history including prematurity, respiratory distress, esophageal atresia, and recurrent tracheoesophageal fistula who has experienced prolonged hospitalization. Baby A's speech and language skills were significantly delayed according to an evaluation. The document then reviews research showing risk factors like prematurity, medical complications, and lack of linguistic input can negatively impact language development in hospitalized infants. It emphasizes the speech-language pathologist's role in advocating for early intervention to support optimal development in these patients.

1. Rush is a not-for-profit health care, education and research enterprise comprising Rush University Medical Center, Rush University, Rush Oak Park Hospital and Rush Health.
The Importance of Early Speech and
Language Stimulation for Pediatric
Patients with Prolonged Hospitalization
Alisa Wang, B.S.
Department of Communication Disorders and Sciences
Rush University
Rush University Medical Center
Chicago, IL
Case Supervisor: Erin Miller, MS, CCC-SLP
Case Moderator: Dr. Kerry Ebert, PhD, CCC-SLP
September 14, 2016
This work was supported by the Illinois LEND Program [Grant Number: T73MC11047-09-00; U.S. Department of Health and Human Services—Health Resources
and Services Administration (HRSA)].

2. Learning Objectives
• To discuss the importance of early speech and
language stimulation for patients with medically
complex courses that undergo prolonged
hospitalization.
• To recognize the speech-language pathologist’s
role as an early intervention advocate for
patients in the Pediatric and Neonatal Intensive
Care Units (PICU and NICU).
• To identify the different contributing risk factors
that affect language development in infants that
have prolonged hospitalization.
2

3. Baby A – General History
• 10 month old male
– Born at RUMC in Summer 2015
– 34 gestational weeks (premature)
– Birth Weight: 1790 g
– Transferred to NICU for prematurity and
respiratory distress
– Mother admitted marijuana use during
pregnancy

4. Baby A – Medical History (cont.)
• NICU
– Active Problem List:
• 34 weeks gestation of pregnancy (prematurity)
• Respiratory distress
• Esophageal atresia (EA)
• Tracheoesophageal fistula (TEF)
• Small for gestational age (SGA)
• Anemia of prematurity
• Patent foramen ovale (PFO)
• Esophageal anastomotic breakdown
• Steroid exposure

5. Baby A – Medical History (cont.)
• NICU (cont.)
– 8 OR visits that included the following
procedures:
• Ligation of TEF
• Thoracotomy
• EA repair
• Esophageal dilation
• Chest tube
• G-tube and J-tube placements

6. Baby A – Medical History (cont.)
• PICU
– Active Problem List:
• Esophageal atresia (resolved)
• Tracheoesophageal fistula (recurrent)
• Persistent emesis (likely due to reflux)
• Aspiration pneumonia (secondary to persistent
reflux, emesis, and dysphagia)
• Gastric reflux
• R side rib fracture (likely due to previous
thoracotomy)

7. • PICU (cont.)
– 3 OR visits including the following
procedures:
• Balloon dilation of esophageal stricture
• Endoscopic cauterization of TEF
• Esophageal dilation
• Esophagogastroduodenoscopy (EGD)
Baby A – Medical History (cont.)

8. • Teenaged parents (full-time students)
• Communication difficulties
• Limited transportation resources
• Toddler sibling requiring childcare
• Resulted in contractual commitment of
visitation 2-3x/week and phone contact on
non-visitation days
• PICU staff supervision due to incidents of
aggressive suctioning
Baby A – Social and Family History

9. A question for the first years –
If Baby A were a typically developing baby,
what are the first sounds you would expect
him to produce?

10. A question for the second years –
If you were seeing Baby A for a speech and
language evaluation, what assessment
would you use?

11. • Spring 2016 (8 months old)
• Rossetti Infant-Toddler Language Scale
– Interaction/Attachment – 3-6 months
– Pragmatics – 3-6 months
– Gestural – no test items for child’s age
– Play – 3-6 months
– Receptive Language – 6-9 months
– Expressive language – 0-3 months
Baby A – SLP Services

12. • Preterm infants have consistently been identified as
having both receptive and expressive language
difficulties.
• 43 mothers and infants
– Infant birth weights under 2,000g
– Born at less than 36 weeks gestation
– Assessed for language at 7, 13, 26 corrected months
– Free from obvious neuro/congenital anomalies
– Medical conditions varied (determined using Hobel Scale
of Perinatal Medical Complications)
Cusson, R.M. (2003). Factors influencing language development in preterm infants. Journal of
Obstetric, Gynecologic, & Neonatal Nursing, 32 (3), 402-409.

13. • Language development in preterm
infants was delayed at 26 months
corrected age.
– Receptive delayed to a mean of 23 mos
– Expressive delayed to a mean of 21 mos
• Overall development was grossly within
normal range by 26 months corrected
age (not including language.
Cusson, R.M. (2003). Factors influencing language development in preterm infants. Journal of
Obstetric, Gynecologic, & Neonatal Nursing, 32 (3), 402-409.

14. • Infants that demonstrated high irritability in the
neonatal period was associated with lower language
scores.
• Receptive language scores:
– Negatively correlated with length of hospital stay.
– Positively correlated with birth weight and gestational age.
– Positively associated with enhanced maternal sensitivity.
• The Apgar score at 5 minutes correlated positively
with expressive language.
Cusson, R.M. (2003). Factors influencing language development in preterm infants. Journal of
Obstetric, Gynecologic, & Neonatal Nursing, 32 (3), 402-409.

15. • A meta-analysis of 12 studies to determine the language
abilities in children who were very preterm (VPT) and/or
very low birth weight (VLBW).
• Expressive Language
– 3 studies
– VPT/VLBW had overall lower scores than control children.
• Expressive – Semantics
– 7 studies
– VPT/VLBW scored significantly lower than control children.
• Expressive – Grammar
– 1 study
– Non-significant difference between EPT/VPT groups and control
children
Barre, N., Morgan, A., Doyle, L.W., Anderson, P.J. (2011). Language abilities in children who were very
preterm and/or very low birth weight: a meta-analysis. The Journal of Pediatrics, 158 (5), 766-774.

16. • Receptive Language
– 4 studies
– VPT/VLBW had overall lower receptive language scores than
control children.
• Receptive – Semantics
– 2 studies
– VPT/VLBW had a significant reduction in scores compared to
control children.
• Receptive – Grammar
– 1 study
– VPT/VLBW scored lower than control children but the statistical
analysis revealed a low fail safe N statistic.
Barre, N., Morgan, A., Doyle, L.W., Anderson, P.J. (2011). Language abilities in children who were very
preterm and/or very low birth weight: a meta-analysis. The Journal of Pediatrics, 158 (5), 766-774.

17. Barre, N., Morgan, A., Doyle, L.W., Anderson, P.J. (2011). Language abilities in children who were very
preterm and/or very low birth weight: a meta-analysis. The Journal of Pediatrics, 158 (5), 766-774.

18. • 36 infants with a birth weight of ≤ 1250g
• 16 hours of adult speech, child vocalizations, and
background noise recorded in the NICU using LENA
– At 32 weeks’ gestational age
– At 36 weeks’ gestational age
• Sound environment was broken down into
– Language
– Monitor Noise
– Silence
– Other Noise (ventilators, isolettes, etc.)
Caskey, M., Stephens, B., Tucker, R., Vohr, B. (2011). The importance of parent talk on the
development of preterm infant vocalizations. Pediatrics, 128 (5), 910-916.

19. Caskey, M., Stephens, B., Tucker, R., Vohr, B. (2011). The importance of parent talk on the
development of preterm infant vocalizations. Pediatrics, 128 (5), 910-916.
• The characteristics of
the infants included in
the study.

20. Caskey, M., Stephens, B., Tucker, R., Vohr, B. (2011). The importance of parent talk on the
development of preterm infant vocalizations. Pediatrics, 128 (5), 910-916.

21. Caskey, M., Stephens, B., Tucker, R., Vohr, B. (2011). The importance of parent talk on the
development of preterm infant vocalizations. Pediatrics, 128 (5), 910-916.

22. Caskey, M., Stephens, B., Tucker, R., Vohr, B. (2011). The importance of parent talk on the
development of preterm infant vocalizations. Pediatrics, 128 (5), 910-916.

23. • Preterm infants begin making primitive
vocalizations as early as 8 weeks before
EDD.
– Demonstrated increase in:
• Vocalizations over time
• Conversational turns between infant and parent
over time
• Vocalizations during parent visits
• Vocalizations during parent feedings vs. nurse
feedings at 32 weeks (but not at 36 weeks)
Caskey, M., Stephens, B., Tucker, R., Vohr, B. (2011). The importance of parent talk on the
development of preterm infant vocalizations. Pediatrics, 128 (5), 910-916.

24. A question to contemplate –
When considering all of the factors resulting
in Baby A’s lack of linguistic input, how
would you expect this to affect his language
development?

25. • Per ASHA, the speech-language
pathologist’s roles and knowledge and
skills in the NICU include:
– Communication and swallowing/feeding
evaluation
– Communication and feeding/swallowing
intervention
– Parent/caregiver education and counseling
– Staff (team) education and collaboration
SLP Services in the Acute Setting with Pediatric Population

26. • In addition to feeding, SLPs can
implement speech and language
intervention strategies:
– Counseling and parent education regarding
mother-infant interactions.
– Encourage individualized caregiver and
parental involvement with infant.
– Provide early speech-language therapeutic
services when deemed necessary.
SLP Services in the Acute Setting with Pediatric Population

27. • Transferred to the general pediatrics floor.
– Will be transferring to La Rabida Children’s Hospital after
discharge.
• Currently in stable condition
– Most recent surgical TEF repair was unsuccessful (continued
esophageal leak)
• Most recent SLP evaluation:
– Play skills à 6-9 months level
– Gesture skills à 6-9 months level
– Expressive language skills à 3-6 months level
– Receptive language skills à 3-6 months level
– No adverse reaction to facial touch or oral cavity touch
– Very social and engaging
– Imitating vocalizations of /dada lala gaga/
Baby A – Current Updated Status

28. • When treating pediatric patients in the
NICU/PICU, we have to consider all
factors that may affect their language
development in addition to any dysphagia
or cognition issues.
• As SLPs working with neonatal and
pediatric patients in the acute setting, we
are in a unique position to advocate and
intervene to ensure a patient’s optimal
development.
Take Home Points

29. American Speech-Language-Hearing Association. (2004). Knowledge and skills
needed by speech-language pathologists providing services to infants and families in
the nicu environment [Knowledge and Skills]. Available from www.asha.org/policy.
Caskey, M., Stephens, B., Tucker, R., Vohr, B. (2011). The importance of parent talk
on the development of preterm infant vocalizations. Pediatrics, 128 (5), 910-916.
Cusson, R.M. (2003). Factors influencing language development in preterm infants.
Journal of Obstetric, Gynecologic, & Neonatal Nursing, 32 (3), 402-409.
Field, T. (1977). Effects of early separation, interactive deficits, and experimental
manipulaitons on infant mother face-to-face interaction. Child Development, 48,
763-771.
Reilly, R.N. (2016). Metalinguistic Skills, Emergent Literacy and Children with
Language Impairments [PowerPoint Slides]. Retrieved from https://
rulearning.rush.edu/webapps/blackboard/content/listContent.jsp?
course_id=_23433_1&content_id=_427144_1&mode=reset
Rossetti, L. (2006). The Rossetti Infant-Toddler Language Scale. East Moline;
LinguiSystems.
Small for Gestational Age. (2016). Retrieved from http://www.stanfordchildrens.org/
en/topic/default?id=small-for-gestational-age-90-P02411
References