If you haven’t read it yet, be sure to check out the first blog post in this 2-part series, Milestone or Modern Convenience?  – Part I: Overuse of the Sippy Cup and Pacifier, to learn important information about an infant’s need for sucking and the risks involved with overuse of the pacifier and sippy, cup!

Now that you are familiar with the pluses and minuses of pacifier and sippy cup use,  what about when the parents are ready to help baby “give up” the sucking habit?   Again, as the resource for all things infant and toddler, we can suggest the following tried and true strategies.

Strategies for Breaking the Sucking Habit

Cut back – When ready to begin weaning, cut back on the time that the pacifier and/or sippy cup is available to the child. If the pacifier has been available to the child all day, every day suggest cutting back its availability to only nap and bedtime.  As for the sippy cup, cut back its use to only when the family is out and about.  When at home suggest offering the child a straw or open cup in its place.

Go cold turkey…if the child is ready – If going cold turkey is the method of choice pass along this wisdom: if the child is not ready, he may find something else to suck on, like a thumb or fingers.  However, if ready, this method may work just fine.  Suggest that, if going cold turkey, it is a good idea to rid the house (or at least baby’s line of sight) of all pacifiers and/or sippy cups.  If they remain in the cabinet or drawer, baby will know and will want them!

Provide additional comfort – In preparation of weaning a baby from the pacifier and/or sippy cup, provide him with an additional comfort item. If the child’s only “lovey” is the pacifier or sippy cup, having a back up “lovey” will still allow the child a comfort when his first choice is gone.

Understand that routines may change – Warn your families that routines may change when weaning baby from the pacifier and/or sippy cup, especially if it is used as the child’s primary comfort item. When the pacifier/sippy cup is gone, the child may need assistance with calming, temporarily;  swaddling, rocking, singing and some extra cuddles may be necessary until baby learns how to calm himself without the help of his pacifier or sippy cup.

Give the pacifier or sippy away to a new baby – Sometimes parents can convince the child to give up these items with some incentive.  However, it is suggested that the new baby receiving the child’s old pacifiers/sippy cups not live in the same house.  It will be more difficult for the child not to suck on a pacifier if there is one nearby.  Some parents are also able to negotiate a trade with their child:  “If you leave your pacifier under the Christmas tree, Santa will take it with him and leave you a present!”  If the child is ready, this trick is a gem!

Strategies for Parents to Avoid

Some tips to warn parents to not try are:

Never, ever cut the pacifier nipple and give it to the child – Yes, if there is no nipple for the child to latch onto they will be less interested in sucking the pacifier.  However, the risk of choking is too great to ever recommend this as a means of pacifier weaning.  Pacifiers have to pass what is called a “pull test” (PDF, New Window) during manufacturing. A cut nipple would not pass this pull test and would be deemed as unsafe for a child to have.

Do not shame the child for wanting to suck on his pacifier or sippy cup – Toddlers and preschoolers typically do not respond to being shamed into giving up the pacifier or sippy cup.  Telling the child that in order to be a “big kid” he must give up his most prized possession may just make him want it more.  And who can blame him, who really wants to “grow up” anyway?!

Do not recommend putting something that tastes bad on the nipple of the pacifier and/or sippy cup – I have known families to dip the nipple in chili powder to convince their toddler to stop sucking on his pacifier.  One sweet little guy I knew still wanted his pacifier so badly that he licked the chili powder off, little by little, chased it with water and eventually got his paci back.  Again, this is a case of the parent wanting the child to make the decision to give up the comfort item.  Not gonna happen!  Sometimes the parent has to be just that and take control.

So we wish you good luck as you head into the magical world of the paci and sippy cup.  It holds a strong spell on many little ones, but with the right guidance and when our families are ready, we can help them help their children kick the habit!

Do you have any suggested weaning methods to add to this list? 

What would you say to encourage your families to follow through with weaning their child?

Lacy Morise, M.S. CCC/SLP educates families on the risks involved with over-use of the pacifier and sippy as an early intervention speech-language pathologist in the West Virginia Birth to Three Program.  She guiltily confesses to allowing all of her children to abuse the use of the pacifier!  She owns Milestones & Miracles, LLC a company devoted to educating families about child development and the importance of PLAY!  Check out her website and blog and follow her on Facebook, Pinterest, Twitter and YouTube.

Website:  www.milestonesandmiracles.com

Blog:  www.milestonesandmiraces.com/blog/

Facebook: https://www.facebook.com/milestonesandmiracles

Pinterest: https://www.pinterest.com/milestonesm/

Twitter: https://twitter.com/MilestonesM

YouTube: https://www.youtube.com/watch?v=HmuWPFDcqZ4

The post Milestone or Modern Convenience? – Part II: What to Do When the Convenience Becomes a Hard to Break Habit appeared first on Early Intervention Strategies for Success.

Although shocking to many, the sippy cup is NOT a developmental milestone.  Nor is sucking on a pacifier, for that matter.  But why do we (therapists, parents and caregivers) celebrate these acquired “skills” as developmentally appropriate achievements?  Why do we allow these “skills” to happen for much longer than they should?  Is it just easier to always have a pacifier (aka mute button) in the baby/toddler’s mouth?  Sippy cups are so easy to take along with us everywhere, how can it be harmful if a preschooler continues to exclusively drink from one?

Benefits of the Pacifier and Sippy Cup

The pacifier is a great thing for infants. It meets a physiological need to suck and allows baby a way to comfort himself. It may reduce the risk of SIDS as it appears to allow baby’s airway to remain more open and prevent baby from falling into a deeper sleep. Not to mention the other fringe benefits like quieting rowdy babes, helping them sleep longer and making outings and car rides more enjoyable for all.  It certainly has a “place” in an infant’s world!  And the sippy cup is an awesome convenience must-have.  Drinks can be toted everywhere with baby/toddler and a sippy’s use means less spills to stain the carpet!  Beautiful!

Risks of Over-Use

But aside from these benefits, there are risks associated with the over-use of both.  Pediatricians and family physicians recommend weaning or stopping pacifier use in the second six months of life.  Shocking I know considering how many toddlers we see with pacifiers in their mouths!  The sippy cup can be skipped all together if natural development is occurring with no issue.  Created for convenience, the sippy cup now has an entire market (and aisle in most stores) devoted to it!  However a baby can transition to a straw (as early as 9 months) or open cup just as easily and drinking from both of these IS developmentally appropriate.

Key Points to Keep in Mind

As trusted resources on development, it is our job as early interventionists to inform families of both the positives and negatives of (prolonged) sucking.  Some points to keep in mind as you discuss these “milestones” with parents and caregivers:

Prolonged sucking on a pacifier puts children at (a higher) risk for misaligned teeth. As those tiny white pearls are erupting, the pressure of the nipple of the pacifier can cause teeth to move around and shift. Also, the pressure can cause their hard palate, the roof of their mouth directly behind the front teeth, to change. It can push the palate forward, again changing the position of the teeth. In his research, J. Poyak concludes, “The greater the longevity and duration of pacifier use, the greater the potential for harmful results.”

A sippy often allows access to drinks all day long for a toddler.  Not necessarily a bad thing, depending on what is in the sippy.  If it is a sugary drink, the sugar increases the risk of developing cavities.  The Medline Plus article titled, “Tooth decay – early childhood” states, “When children sleep or walk around with a bottle or sippy cup in their mouth, sugar coats their teeth for longer periods of time, causing teeth to decay more quickly.” Also, if a sippy is the only way a child gets liquids the developmentally appropriate skills of drinking through a straw and open cup are inhibited.

If children are allowed to have a drink (in a sippy or other cup) all the time, they may fill up on liquids and not eat meals as well, negatively impacting their nutrition.

Although inconsistent, research suggests a relationship between prolonged sucking and speech delays.  Barbosa et al. (2009) concluded in their research of 128 Patagonian preschoolers that, “The results suggest extended use of sucking outside of breastfeeding may have detrimental effects on speech development in young children.” When speech sound development is negatively impacted, so is the child’s intelligibility of speech making it difficult for others to understand them.

Sucking on a pacifier increases a child’s risk of developing otitis media (ear infection).  The AAP (American Academy of Pediatrics) and AAFP (American Academy of Family Physicians) advocate for limited to no use of the pacifier in the second six months of the child’s life to decrease this risk.

A pacifier or sippy cup that is always in the mouth of a child, even when the child is walking around, puts him/her at a higher risk for mouth injuries.  A 2012 study by Dr. Sarah Keim of Nationwide Children’s Hospital in Columbus, found that “a young child is rushed to a hospital every four hours in the U.S. due to an injury from a bottle, sippy cup or pacifier.”  When little ones are just learning to walk, doing two things at once requires a bit more coordination than they are capable of!

Besides the physical risks, beyond the age of 1 a stronger emotional attachment to the pacifier (or sippy cup) makes it increasingly difficult for the child to detach. The pacifier/sippy goes from meeting a physiological need during infancy to providing emotional comfort to the toddler when scared, upset or sleepy.

However, it is our job to know and respect the individuality of each child.  Therefore it is best practice to reassure parents that we recognize they know their child best.  We all want our children to be happy and if using a pacifier and/or sippy is what’s best for them and their family, that is okay.  Our job is to inform the families we serve the best we can.  Equipping them with knowledge on why prolonged sucking may be detrimental to their child allows the family to make the final call.  Education and Support, that’s what we are there for.

Have you ever had the “prolonged sucking” discussion with any of the families you serve? 

How might you begin this conversation with a family?

Today’s blog is Part I of a two-part series on prolonged sucking and what we can do to educate families about it.  Stay tuned for “Part II – What to do When the Convenience Becomes a Hard to Break Habit” next week featuring ideas you can share with families who are ready to wean their child off of the pacifier or sippy!

References

Barbosa, Clarita, Sandra Vasquez, Mary Parada, Juan Carlos Velez Gonzalez, Chanaye Jackson, N David Yanez, Bizu Gelaye, and Annette Fitzpatrick. “The Relationship of Bottle Feeding and Other Sucking Behaviors with Speech Disorder in Patagonian Preschoolers.” BMC Pediatrics. N.p., n.d. Web. 20 Mar. 2015. http://www.biomedcentral.com/1471-2431/9/66

EG, Gois, HC Rubeiro-Junior, MP Vale, SM Paiva, JM Serra-Negra, ML Ramos-Jorge, and IA Pordeus. “Influence of Nonnutritive Sucking Habits, Breathing Pattern and Adenoid Size on the Development of Malocclusion.” Angle Orthod.4 (2008): 647-54. Print. http://www.ncbi.nlm.nih.gov/pubmed/18302463

Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance/Counseling, and Oral Treatment for Infants, Children, and Adolescents (n.d.): n. pag. Web. 18 Mar. 2015. http://www.aapd.org/media/Policies_Guidelines/G_Periodicity.pdf (PDF, New Window)

Hauck, Fern R., MD, MS, Olanrewaju O. Omojokun, MD, and Mir S. Siadaty, MD, MS. “Do Pacifiers Reduce the Risk of Sudden Infant Death Syndrome? A Meta-analysis.” PEDIATRICS5 (2005): E716-723. Do Pacifiers Reduce the Risk of Sudden Infant Death Syndrome? A Meta-analysis. PEDIATRICS. Web. 17 Mar. 2015.  http://pediatrics.aappublications.org/content/116/5/e716

Keim, Sarah A., MA, MS, Erica N. Fletcher, MPH, Megan R.W. Tepoel, MS, and Lara B. McKenzie, PhD, MA. “Injuries Associated With Bottles, Pacifiers, and Sippy Cups in the United States, 1991-2010.” N.p., n.d. Web. 19 Mar. 2015. http://pediatrics.aappublications.org/content/129/6/1104.long

Natale, Ruby, PhD, PsyD. “Risks and Benefits of Pacifiers.” American Family Physician79 (2009): 681-85. – American Family Physician. Web. 18 Mar. 2015. http://www.aafp.org/afp/2009/0415/p681.html

Poyak, J. “Effects of Pacifiers on Early Oral Development.” Int J Orthod Milwaukee4 (2006): 13-6. Print. http://www.ncbi.nlm.nih.gov/pubmed/17256438

Regulatory Summary for Pacifier (n.d.): n. pag. U.S. Consumer Product Safety Commission. Web. 18 Mar. 2015. http://www.cpsc.gov//PageFiles/120645/regsumpacifier.pdf (PDF, New Window)

“Tooth Decay – Early Childhood: MedlinePlus Medical Encyclopedia.” S National Library of Medicine. U.S. National Library of Medicine, n.d. Web. 17 Mar. 2015. http://www.nlm.nih.gov/medlineplus/ency/article/002061.htm

Zardetto, CG, CR Rodrigues, and FM Stefani. “Effects of Different Pacifiers on the Primary Dentition and Oral Myofunction Structures of Preschool Children.” Pediatric Dentistry6 (2002): 552-60. Print. http://www.ncbi.nlm.nih.gov/pubmed/12528948

Lacy Morise, M.S. CCC/SLP educates families on the risks involved with over-use of the pacifier and sippy as an early intervention speech-language pathologist in the West Virginia Birth to Three Program.  She guiltily confesses to allowing all of her children to abuse the use of the pacifier!  She owns Milestones & Miracles, LLC a company devoted to educating families about child development and the importance of PLAY!  Check out her website and blog and follow her on Facebook, Pinterest, Twitter and YouTube.

Website:  www.milestonesandmiracles.com

Blog:  www.milestonesandmiraces.com/blog/

Facebook: https://www.facebook.com/milestonesandmiracles

Pinterest: https://www.pinterest.com/milestonesm/

Twitter: https://twitter.com/MilestonesM

YouTube: https://www.youtube.com/watch?v=HmuWPFDcqZ4

The post Milestone or Modern Convenience? – Part I: Overuse of the Sippy Cup & Pacifier appeared first on Early Intervention Strategies for Success.

Abby has significant motor delays. Her mother asks you some version of this question during every visit: “Is it my fault that Abby isn’t walking yet?” or “What did I do to cause this?” The question itself makes you uncomfortable, because you can’t really answer it well and because you feel like you’ve tried to answer it for the past several weeks. Each time Abby’s mother asks, you say that you don’t really know what is causing Abby’s delay but what’s important is that we keep supporting Abby’s development so that she can learn to move. You and Abby’s mother both recognize that this is the best one you’ve got…so why does she keep asking?

Emotional Questions Matter

It can be incredibly challenging to manage the emotions that pop up during EI visits – both with parents and within ourselves. When we see a parent struggling with guilt over her child’s developmental delay or disability, it can be difficult for us to know what to do or how to help. With a question like this about fault, it can be especially challenging because we really don’t have the answer. In most situations, the child will have a delay and we won’t know what caused it. It might be easy to think, well, it doesn’t really matter what caused it…what matters is what we do now. However, it probably matters ALOT to the parent.

When a parent asks a question like this, it’s important that we have an honest and appropriate answer. It’s also important to recognize (and say so) that sometimes we don’t have the answer but we can still acknowledge the emotions behind it. Abby’s mother is not hoping that her service provider will place the blame on her shoulders; instead, she may be hoping to share her anxiety and fear with someone she trusts. You may be the person she’s chosen to voice her fear to…what do you do then?

Answering this Tough Question

Here are a few things to consider when a parent asks you if it’s her fault:

Be honest and be kind

In most cases, the answer is that you really don’t know what caused the delay. Most likely, it wasn’t something the parent did, and you can say that too. If you DO think it was something that happened (or didn’t happen) in the child’s environment, like when a child has experienced neglect or there is a history of substance abuse, you can be gentle about this and redirect the focus of the conversation to what the parent is doing well now. I remember working with a parent who struggled to interact with her child during the day because she had so much else to do. Honestly, I felt that the lack of interaction had probably affected the child’s communication and interaction skills. Rather than answer “yes, not paying attention to him contributed to this delay” – which I would never say because how do I really know? – we talked about the changes she’d made since she found out that he needed more interaction and I praised her efforts. It was a tricky conversation because she did have a learning curve, but as she began to feel more like she was making a positive impact on her child’s development, the guilt she felt about the past seemed to lessen.

Acknowledge the parent’s feelings

I think it’s very appropriate to ask the parent to tell you more about how she’s feeling. You might invite it by saying something like “You’ve asked me that question several times on the last few visits. We can talk more about how you’re feeling about Abby’s development if you like.” You can open the door and see if she decides to share more. Inviting this discussion can also be tricky, though, because what comes through the door could be more than you can handle. Since most interventionists are not counselors, follow your instincts. If you suspect that the parent could benefit from more professional support, or maybe even another parent to talk to, offer to make that connection or see if the service coordinator can help. Sometimes, interventionists are afraid to have these conversations because they might distract from the “real” work of the visit. I would suggest to you that the real work might not be possible, or be unnecessarily challenging for the parent, if these feelings are left unacknowledged.

Acknowledge your own feelings & examine your own response

If a parent asks a question like this over and over, it could be because she is not getting an adequate answer. If you avoid answering, she may sense that and think you really do think it’s her fault. While we can’t be in control of how a parent interprets what we say, we can be mindful of the messages we send. Reflecting on your tone of voice, the words you choose, and your body language are important.

Follow your answer with encouragement

The question might really be a cry for hope and encouragement. A parent who asks this question may be very worried about the future. Follow your best answer by pointing out what the parent is doing well, how it’s a wonderful thing that she’s involved in early intervention, and that the child is making progress (if this is the case). Offer genuine reassurance and help the parent see that, regardless of why or what happened in the past, she has the opportunity now to make a big difference in her child’s life and you are there to help her do that.

There will be times when answering Abby’s mom’s question are easier than others. Just remember that this question is probably harder for the parent to ask than for you to answer. Answering it as best you can and following it with encouragement for what’s to come can be just what is needed.

How have you answered this question before?

What do you do when a parent expresses fear or anxiety over the child’s delay or disability?

Share your insights and suggestions below in chat.

The post Abby’s Mother Asks Again: “Is it my fault?” appeared first on Early Intervention Strategies for Success.

Joey is 25 months old.  He was referred to his local early intervention intake coordinator by his parents secondary to their concerns about his intelligibility and inability to effectively communicate his needs or wants.  They reported that he uses approximately 15 words but “talks in such a garbled manner” that both parents and Joey’s older siblings become frustrated when they don’t know what he is saying or requesting. When asked to describe Joey’s speech, his father noted that it sounds like: “babble-babble-babble-mama-babble-babble-babble, as if he knows he should be talking in longer sentences but he doesn’t have the vocabulary yet to form the actual sentence”.  His mother added that he sometimes sounds like he is humming around his words: “mmmmmmm-ball-mmmmm”.  Joey loves playing with balls.  His family often takes an extra ball with them to Joey’s brother’s soccer practice.  While his brother practices, Joey and his Dad kick the ball. According to Joey’s parents, they find his speech particularly frustrating before meal times; they noted that he loves to help them choose and prepare food for snacktime every day, but that they often don’t understand which foods and/or drinks he is requesting or suggesting.

What to Do? What to Do?!

We see this quite often, don’t we?!  Parents will often come to us with concerns about their child’s intelligibility and “speech skills” because they have difficulty understanding the messages that their children are trying their hardest to convey.  As a speech-language pathologist (SLP), my first goal with this child would be to conduct a comprehensive communication assessment by collecting a speech and language sample.

Within this play-based sample, I would listen for those three speech-related red flags that I presented in the March Talks on Tuesdays webinar and in my previous blog post: 1) initial sound deletions; 2) distortion or consistent difficulty with vowels; and 3) deletion of LOTS of sounds—the child uses only one or two consonant sounds. Ultimately, however, above and beyond my observations regarding Joey’s speech productions, I would assess whether he is using the language skills that are developmentally expected for his age.

Typical Language Development vs. Expressive Language Delay or Disorder

Keep in mind that we expect children to have a vocabulary of at least 15-20 words by 18 months, although typically developing children often have more than 50 words and are beginning to string simple, repetitive 2 word phrases together (e.g. more drink, my juice) by this age.  By 24 months, we expect a children who are typically developing to use AT LEAST 50 words and to combine lots of different phrases. Between 18-24 months, children may still use some jargon to expand their sentence length and to attempt to provide “more information” in their messages.  If you have a child who is 20-24 months and using a lot of jargon and not a lot of words, however, you are probably looking at a child who has an expressive language disorder.

Is It a Language Disorder or a Speech-Related Disorder?

Toddlers who are extremely difficult to understand are often still using a lot of jargon when they speak because they lack vocabulary…or have difficulty with grammatical markers… or struggle to put words together into phrases.  All of these are skills that are expected by two years of age.  We typically expect that jargon (which can be defined as “babbling with intent”) will begin to fade at about 18 months and completely dissipate by 24 months.  If a toddler has an expressive language delay or disorder, his intelligibility will be affected as he will often continue to use a lot of jargon in lieu of words.  Instead of recognizing that the jargon is a substitute for real words or grammar that SHOULD have developed, we often misinterpret the jargon to be speech sound production errors.

In this scenario, Joey’s desire to communicate is there…his speech is continuing to develop…his language skills are not. Therefore, most toddlers, including Joey, who are difficult to understand will be diagnosed with a language disorder—not a speech-related disorder!  It is the language (or lack thereof) that is most likely having the greatest impact on this child’s intelligibility.  Unless Joey presents with any of the speech-related red flags, his speech will most likely continue to develop as his language skills are addressed in early intervention!

Why Not Provide Traditional Articulation Therapy Anyway?

Early speech and language skills are acquired and used primarily for communicating during every day, natural social interactions. Traditional articulation therapy focuses on the repetition and drilling of target sounds…there is nothing natural about this process. Early intervention is intended to be embedded into families’ every day, natural activities and routines to ensure that children are processing the information that they are learning in order to utilize these new skills within their own environment—this is known as authentic learning.  Targeting articulation directly and drilling toddlers to produce speech sounds is the furthest thing from “natural” that there is!

Optimal early communication intervention services are provided in natural environments, which offer realistic and authentic learning experiences for the child and promote successful communication with the caregivers. Authentic learning can maximize children’s acquisition of functional communication skills and promote generalization of newly mastered behaviors to natural, everyday contexts. In order for a child to process information, it needs to be presented within a normal, naturally occurring event or opportunity in his or her own environment.  Using flashcards to teach sounds or words, or creating superficial teaching opportunities like pushing the child to imitate specific sounds in isolation (e.g. “say /ba/”), is not going to work.  Infants and toddlers truly do not learn speech or language through artificial methods.  For most children, when functional language and communication needs are addressed within the natural environment, speech will develop as well (ASHA, 2008)!

What Would This Look Like for Joey and his Family?

My first suggestion for Joey’s parents is to support and encourage him to continue to produce the sounds and words that he IS producing within the routines that he most enjoys.  If he makes ANY sounds, imitate those. If he uses any word approximations or words, repeat them back to him! Continue to imitate his sounds and words…and then expand on them a bit.  If Joey says “babble-babble -nana-babble-babble-juice” while choosing foods for his snack, repeat his word approximations and words back to him:  “Banana!  Juice!”  Then, I would coach his parents to expand on his verbalizations: “You want bananas and juice for snack today! Let’s have bananas and juice!”  Let him know that what he is attempting to say has been heard and IS important.  I would encourage his parents to provide him with articulate models of his words and to provide a model of a complete sentence in order to facilitate Joey’s expansion of his message.

What other authentic learning opportunities might you use to facilitate Joey’s expressive language development during snack time and ball play during his brother’s soccer practice?

What are some other ways in which you can help Joey’s family incorporate naturally occurring opportunities to embed speech sound development into these experiences along the way?

Reference

American Speech-Language-Hearing Association. (2008). Roles and responsibilities of speech-language pathologists in early intervention: guidelines [Guidelines]. Available from www.asha.org/policy.

If you missed either of Corey’s webinars, visit the Talks on Tuesdays 2015 recordings page on the VA Early Intervention Professional Development Center, or click below:

It’s Almost Never Apraxia: Understanding Appropriate Diagnoses of Speech in Early Intervention

Ditch the Animal Sounds: Writing Appropriate Outcomes that Lead to Effective Implementation

If you’d like to catch up on all of the posts in this series, visit:

What’s the Bottom Line Regarding Articulation in EI?!

ICD-10 Codes and Insurance Reimbursement: The Fun Stuff?!?

Ditch the Animal Sounds! – Who’s Ready for the Next Talks on Tuesday?!

The post Address the Language: The Speech will Follow! appeared first on Early Intervention Strategies for Success.

Preemie Pop Quiz

Do you know the stats on prematurity? Take this pop quiz to see what you know and keep reading for answer and tips you can use when supporting preemies and their families!

1. A premature birth is one that occurs before ___ weeks gestation.

2. Approximately how many children are born premature each year?

3. When do most premature births occur – before or after 34 weeks gestation?

4. We correct for prematurity up until a child turns _______ years of age.

5. Almost ___% of pregnancies with multiples (twins, triplets, etc.) result in preterm births.

6. True or False: Prematurity is the leading cause of long-term disability related to the nervous system  in children.

7. True or False: Most preemies will eventually catch up to their full-term peers in terms of developmental abilities.

Answers:

1. Premature birth is defined as a delivery that occurs prior to 37 weeks gestation. (Source: CDC, 2014)

2. Approximately 1 in 9 children are born premature each year. In 2012, 455,918 children were born premature. (Source: CDC, 2014)

3. In 2012, about 8% of premature births occurred when the infant was between 34-36 weeks gestation. Approximately 3% of premature births occurred when the infant was under 34 weeks. (Source: National Vital Statistics Report, 2013)

4. According to the Infant & Toddler Connection of Virginia, we correct a child’s age for prematurity up until 18 months of age. Other programs and medical professionals might correct up until a child turns 2-2 1/2 years of age, depending on guidelines for that program. (Source: I&TC of VA Practice Manual)

5. Approximately 60% of births of multiples occur before 37 weeks gestation. (Source: healthychildren.org)

6. The earlier a child is born, the higher the risk that the child will experience developmental and medical challenges. Even in children born as late-term preemies (between the ages of 34-36 weeks), research has found that they are at significantly higher risk for negative outcomes (Source: NIH, 2014). Being born premature places a child at higher risk for intellectual disabilities, visual and hearing impairment, respiratory challenges, feeding issues, and cerebral palsy. (Source: CDC, 2014)

7. It’s important to remember that, while preemies are higher risk for many conditions, most preemies eventually catch up to their same-aged peers!

Preemies & Early Intervention

All EI programs support preemies and their families at one time or another. Of course, not all preemies are referred to EI, or will even qualify for services, but EI can be a wonderful resource for families of those who do. When supporting families of preemies, here are a few important things to keep in mind:

Take time to listen to the family’s story – For most families, a premature birth marks a significant, unexpected and often frightening event in their lives. The family has had to adjust their lives to accommodate an unexpected hospital stay for the mother and child, quickly prepare for a child they might not have expected to arrive for months, adjust work and child care schedules, etc. They might have been visiting the child at the hospital for months following the delivery and be anxious about bringing a fragile child home. Taking the time to let them share their experience can be a powerful way to begin the early intervention relationship. I remember meeting a family of a very premature baby and in listening to their story, finding out that this child had a twin sister who died shortly after the delivery. This information was not provided in the referral paperwork and really shaped their perspective on the child we were supporting – and their underlying fear of losing her too.

Remember the family system – Because the referral we receive is for the child, it can be easy to forget the effects of the premature birth on the whole family. Parents, siblings, and extended family are all impacted by this event. It’s important to keep this in mind when considering service delivery options and how best we can support the child and family.

Keep the parent-child attachment in the forefront – Preemies are often whisked away to receive medical care immediately after delivery. Opportunities to hold and bond with the child may be different than they would have been with a child born full-term. While we don’t ask “do you feel attached to your baby?” we can observe and support that attachment process. Many believe that all relationships are based on early attachments, so keeping an eye on infant mental health with preemies is important. Observe how the parent holds, feeds and comforts the child and provide support if the parent struggles with early care.

Monitor the child’s reactions & adjust the environment – Use careful observation to monitor how the infant reacts to environmental stimuli. If needed, help the parent adjust the environment to avoid overstimulating the child. Preemies can be fussy and struggle to regulate themselves, but with a little help, can adjust well. If the child startles easily, cries often, or shows signs of overstimulation (e.g., arching, yawning, sneezing, gaze aversion, fanning out the hand), help the parent look for ways to adjust noise, lighting levels, or interactions to a tolerable level. For some preemies, using one sense at a time for interaction can help. For example, talking to and touching the preemie at the same time might be too much, so help the parents and siblings learn to do one or the other while interacting until the baby can tolerate more.

Keep a close eye on development – In Virginia, preemies qualify for EI if they’re born less than or equal to 28 weeks gestation or if they have a NICU stay greater than or equal to 28 days. Because we know that all preemies are at higher risk for developmental delays or disabilities, it’s so important to monitor development and health closely. Encourage families to keep all follow-up appointments. Monitor vision, hearing, and motor development especially closely. As the child grows, watch for any signs of delay across development. Keep in mind that correcting for prematurity up to 18 months really isn’t a magic number for catching up. It’s just a benchmark for eligibility; some preemies won’t qualify after 18 months of age as the gap between their chronological age and adjusted ages closes, but others may continue to show developmental delays and benefit from intervention.

However premature a child is, do your best to provide support that is individualized for the child and family while taking into account the risks associated with prematurity. Be hopeful about the future and keep in mind that the support you provide to this tiny person and his or her family could make a lifelong difference!

Let’s celebrate National Prematurity Awareness Month by sharing tips for supporting preemies and their families in the comments below! What’s your best strategy for engaging a preemie?

For more information, visit the Virginia Early Intervention Professional Development Center website to find a Prematurity topic page with links to a prematurity resource landing pad (PDF, New Window), an archived webinar (Prematurity and Early Intervention: Prevalence, Issues and Trends), a free online module (An Early Interventionist’s Guide to Prematurity), and tons of other great resources!

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Meet Chris – He and his family have moved 7 times since he was born and are now staying with friends. Chris was referred to your program by his mother at the suggestion of her friend’s mom. The referral said that Chris was 29 months old and not walking. When you arrive for the screening, you see that Chris’s legs are scissoring and he’s experiencing high muscle tone. Turns out that Chris hasn’t been to a doctor since he was 5 months old and living in another state.

Meet Aliyah – Aliyah was taken to the doctor regularly but saw a different medical professional each time, rotating through whoever was available. She is 33 months old and is using mostly “ah” sounds to mean many things. She makes great eye contact and is very social and very bright. Recently, her child care provider completed a screening at her mother’s request, which resulted in a referral to EI. Her mother was frustrated because she’s been worried for a while. Because Aliyah is so social and “so smart,” she’d been repeatedly told by many people that Aliyah would eventually talk so to just wait a little longer…

Sigh…Why’d It Take So Long to Find Chris and Aliyah?

Okay, I know I’m preaching to the choir. We’re early interventionists…early screening and identification are what we DO. Yes, we know all about it, but do others? I think an important job of every early interventionist is to help spread the word about the importance of early screening to our community partners. We want our choir to grow to include more home visiting program staff, medical partners, child care providers, social services folks, and of course families!

The reality is that no early identification system is perfect. There are so many variables that influence whether or not a child is identified early and appropriately referred for evaluation. Family preferences or instability, screener error, the “wait and see” approach, follow-through after the referral is made (by the family and the receiving program) – so many cracks in the system. We can’t fix all of the cracks but we can do our best to be sure that the information is available to those who are helping us find children who may benefit from early intervention.

Spread the Word about these Early Identification Resources!

Rather than going on about the importance of finding children and families early, I thought I’d highlight some wonderful resources. Check out these links and please, share them with your community partners!

Birth to 5: Watch Me Thrive – A federal effort to support families and providers in celebrating milestones, accessing universal developmental and behavioral screenings, increasing early identification of delays and concerns, and enhancing developmental supports.

Centers for Disease Control and Prevention (CDC) Resources – The CDC website has a plethora (love that word!) of resources for early developmental screening, too many to list, really. Check out these pages for a start:

• Child Development – Tons of resources about screening tools, research, recommendations, etc. Includes info for medical providers about how to manage screenings in their practices. You can also order lots of free materials to support your screening efforts! One interesting fact – according to the CDC site, did you know that only 1 in 5 parents report that their child has received a developmental screening??
• Learn the Signs. Act Early. – Great resources for early screening and identification of children with autism spectrum disorder.
• Hearing Loss – This is one example of a topic page that’s full of info about screening and diagnosis. Be sure to search for other similar topics too.
• Facts about Vision Loss (PDF, New Window) – This is one example of a fact sheet that community partners can use during screenings. The CDC site has lots of other fact sheets so search the site for other topics.

Identifying Infants and Young Children with Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening (AAP) – Share this resource with your local medical partners to get a conversation started about how to support screening and referral.

Developmental Screening and Assessment Instruments with an Emphasis on Social and Emotional Development for Young Children Ages Birth through Five (NECTAC) (PDF, New Window) – This booklet includes info about many screening tools, including a description, age range, time frame, scoring, psychometric info, and who may administer. A great place to start if you’re looking for good tools.

Infant/Toddler Development, Screening,and Assessment (Zero to Three)(PDF, New Window) – This training module/booklet is designed to be used with child care providers to support their knowledge.

Talking to Families of Infants and Toddlers about Developmental Delays (NAEYC) – This handout is another resource to help community partners start that conversation with families when there is a developmental concern. (The link I have for this doc is acting a little funny today but I wanted to include the handout anyhow. Try searching by the title another day to get to the handout. It’s a great one.)

There are tons of other screening resources out there. Even though we know about them, we need to continue the effort to get the word out in our communities. Let’s grow our choir and help others know about the benefits of early screening for children and families. Let’s help our community partners make sure children like Chris and Aliyah get what they need as early as possible!

Share your favorite screening and early identification resource in the comments below and let’s see if we can add to this list! Share your experiences and struggles with early screening and identification – have you met a child like Chris or Aliyah? I know I have…

You can also find more info about Screening and Assessment on the Virginia Early Intervention Professional Development Center website.

The post Preaching to the Choir about Early Screening Resources – Spread the Word! appeared first on Early Intervention Strategies for Success.

“Come look at his knees,” a concerned parent asked me.

The toddler climbed off the couch and ran, no, barreled towards me.

“Look! When he stands, his knees are touching!  What’s wrong with his legs?”

“He’s 2-years-old, right?” I asked.

“Yes,” said the mom.

“Nothing, this is typical knee alignment for his age.  Let me explain…”

Parents are most concerned about bowlegs (genu varum) and knock- knees (genu valgum) in their children. As early intervention providers, we are in a unique position to educate parents and caregivers about the normal development of hip and knee alignment, as well as assist families in deciding when it is appropriate to seek the expertise of an Orthopedist.

As a child grows, from infancy to childhood, the alignment of the knee also changes. At birth, newborns are bowlegged (genu varum).  The infant’s legs slowly straighten and between 12-24 months old, the legs reach a neutral alignment. It has been suggested that the alignment of the knees improves as weight bearing increases during standing activities between 12-24 months. Knock-knees (genu valgum) reach its peak between the ages of 2 and 4 years-old and then gradually decreases. The final knee position differs depending upon the gender of the child. Sixteen-year-old females tend to have slight knock-knees as their pelvises are wider. Sixteen-year-old males tend to have slight bowlegs as their pelvises are narrower.

It makes sense then, that the reason the greatest number of referrals to Orthopedists of children between the ages of 2 and 4 years-old are for concerns of knee alignment. That’s when knock-knees reaches its peak! The change from straight (or neutral) legs to knock-knees can be disconcerting for parent.

There is good news! Eighty percent (80%) of children with bowlegs before age 2 years-old and knock-knees before age 6 years-old, will improve knee alignment spontaneously. There are various opinions about when or if knock-knees and bowlegs warrant treatment. Research has found that twister cables and other conservative, non-operative treatments are unsuccessful. Evidence suggests that therapists should measure hip range of motion every 6 to 12 months to document femoral anteversion (inward rotation of the femur; resultant knee turning inward).

Children should be referred to an Orthopedist if they have:

– Excessive knock-knees or bow legs

– One leg is more or less knock-kneed or bow legged than the other (asymmetrical)

– Knock-knees or bowlegs progressively increase

– Pain with putting weight on their legs

– One leg longer or shorter than the other leg

– Knock-knees or bowlegs persist beyond 7-8 years-old

– Position of the knees create significant cosmetic and functional disability

How have you addressed this concern with the families you work with?

References

Cheng JCY, Chan PS, Chiang SC, HUI PW.  Angular and rotation and profile of the lower limb in 2,630 Chinese children.  Journal Of Pediatric Orthopedics.  1991; 11:154-161.

Heath CH, Staheli LT.  Normal limits of knee angle in white children – Genu varum and genu valgum.  Journal of Pediatric Orthopedics.  1993; 13:259-262.

Staheli LT.  Fundamentals of pediatric orthopedics.  4^th ed.  Philadelphia: Wolters Kluwer, Lippincott Williams & Wilkins; 2008.

Campbell S, Vander Linden DW, Palisano RJ.  Physical Therapy for Children.   3rd ed.  Missouri: Saunders Elsevier; 2006.

Effgen S.  Meeting the physical therapy needs of children.  2^nd ed.  Philadelphia: FA Davis Company; 2013

Sass P, Hassan G.  Lower Extremity Abnormalities in Children.  American Family Physician.  2003; 68(3):461-468.

Ganger R.  Lower Limb Development.   www.scribd.com/doc/55666675/Lower-Limb-Development-Ganger.  Published 2011.  Accessed August 2, 2014.

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It’s Thursday, the week’s almost over, and I bet you were just thinking…man, I sure wish I had a few ideas to help (insert child’s name) use his hands to play! 🙂

You may be supporting an infant or toddler who has cerebral palsy or another neurological condition that causes increased muscle tone. If the child has tightly fisted hands or indwelling thumbs (or both), his opportunities to play and explore can be quite limited. So much of how a baby learns is through touching and manipulating things around him. Actively being able to open and close his hand, grasp toys, and hold them is an important part of early development.

Read on for a few very simple tricks to add to your early intervention toolbox!

Trick #1 – Opening that Little Hand

Here are a few ideas you can teach parents to use to get those little hands ready to explore:

Massage that little hand. Use your thumb to massage the child’s hand from the center of the palm outward using a circular motion to open up the child’s hand and fingers. For an indwelling thumb, massage it open using your thumb.

Wake up the tactile sense. Help the child rub his open hand on the carpet or another texture to wake up those nerves and muscles. Play pattycake. Explore textured books or toys.

Bear weight on those hands. When the child is in a sitting position, use hand-over-hand support to help him lean forward on his hands while they are palm down on the floor. Put the child in a hands and knees position (over your thigh or a pillow) and help him bear weight on his hands.

With these simple activities you are activating and stretching those tiny muscles. You’re also helping the child feel what it’s like to have his hand open and ready to use.

Trick #2 – Releasing a Tight Grasp

Oops, the infant’s hand is tightly fisted in your hair. You don’t want to pull his hand and you’d like to keep your hair intact, but he’s really tangled in there. What can you do?

There’s a very simple yet effective trick that will not only save your hair but is also useful in other ways too: gently bend his little hand at the wrist (palm down) to help him release his grasp. It’s that easy. Once his fingers come open, you can unhook your hair and no harm is done.

So what else is this trick good for?

Teaching grasping – If you have a child with tightly fisted hands, you can use this trick to help her open her fingers enough to slide a rattle into her palm. Try using a rattle with a thin ring or handle. Gently press the rattle into her palm and she will likely close her hand around it. You’ve just helped her move through the motor pattern of opening her hand and grasping a toy, even if she wasn’t able to do it on her own. It’s a great start.

Teaching “give me” – If the infant or toddler has a toy in hand and can’t let go (or won’t let go), you can gently bend her wrist to help her release the toy into her mother’s hand. Pair this action with the command “give me your rattle” to help her learn what the command means. Over time, you might be able to fade out bending her wrist and just touch the back of her hand as a cue to open her fingers.

This is the great thing about early intervention. It doesn’t have to be complicated. Sometimes, the simplest tricks and techniques are the most useful!

What other simple strategies can you suggest for supporting hand use with little ones with fisted hands?

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Miguel is 19 months old and lives with a large family that includes his parents, three older siblings, an aunt, and his grandparents. He qualified for early intervention due to delays in gross motor development and low muscle tone. He’s also showing some slight delays in his expressive communication. During his assessment and subsequent intervention visits, you notice that Miguel’s family often carries him around or keeps him in a pack-n-play during the day. His family is also very skilled at meeting his needs, so much so that he barely has to vocalize to get what he wants. The more you get to know the family, the more you wonder…does Miguel truly have developmental delays or are his developmental differences due to how he is cared for?

What’s Causing Miguel’s Delays?

Wondering why Miguel is showing delays is a normal part of the detective work we do as early interventionists. We believe that when we can find an environmental factor, then maybe we can help the family make changes to eliminate it. Sometimes this is true, such as when a child is in an under-stimulating child care environment and we can help the family find a better option. Other times, though, the factors in the environment are grounded in family values and cultural beliefs that are much harder to change. We have to question whether or not it is even appropriate to try to change family values or beliefs? Is that our place?

Cultural Differences in Child Rearing & Independence

Based on their cultural beliefs, Miguel’s family defines their role in his child rearing as taking complete care of him and ensuring his safety. Miguel is included in all family activities and is well-cared for and very well-loved. The female caregivers in his life (mom, aunt, sisters, grandmother) all share the responsibility of caring for him, carrying him around, and meeting his needs. They use the pack-n-play to keep Miguel safe from all of the traffic in the home, fearing that he would be stepped on if left on the floor to play since he can’t move out of the way yet. Developing Miguel’s independence is not a priority for them as, in their culture, he is considered a baby for the first few years of his life. This is different from our typical American view of infancy and early milestones. This difference doesn’t make their cultural view wrong. It does complicate matters, though, since our assessments and intervention processes don’t often adequately consider cultural differences.

Does It Matter?

You might be thinking “does the cause really matter?” and I’d say that yes, it does. Perhaps a more important question to ask is what Miguel’s parents think. Asking them when children are expected to walk and talk in their culture can give you an important clue. If they say that they think Miguel should be walking and talking by now, then the door is open to discuss intervention. If they say no, then talk about their interest in early intervention. It’s fine to talk about what we expect developmentally in typical American culture so that they understand why we are concerned (our perspective) and have information on which to base their decision. It’s important to have this discussion, though, with respect for their cultural values and beliefs.

If you were Miguel’s service provider, how would you support his family? Would you address your observations? How would you provide intervention suggestions that were sensitive to his family’s cultural beliefs? 

Does it matter that his delays might be related to his caregiving and culture? Why or why not?

For more information about cultural competence, visit the VA Early Intervention Professional Development Center’s Cultural Competence topic page and the Cultural Competence (PDF, New Window) resource landing pad.

The post Are Cultural Differences Truly Developmental Delays? appeared first on Early Intervention Strategies for Success.

During the assessment, the professional team members notice some soft neurological signs in Seiko’s development, such as an indwelling thumb, slight scissoring of her legs, and low muscle tone in her trunk. Seiko was referred to early intervention by her pediatrician because she is 14 months old and not yet sitting or crawling. According to her parents, the pediatrician told them that Seiko was delayed because she was born early but that she’ll probably catch up. As the professional team members talk to the parents about the assessment findings, you can tell that they are trying to be gentle with describing the significant concerns they see. The parents look rather stunned and ask you a tough question: “Why didn’t our pediatrician catch these signs earlier?”

What Do You Do?

What a difficult situation to be in. Have you been there? Imagine being the parents, hearing these findings from relative strangers who have just met their daughter for the first time. These findings, which can sounds pretty frightening or confusing, understandably make them wonder why the pediatrician they trust never brought this up. Before jumping to conclusions about the pediatrician, consider these two questions:

Do the parents always see the same pediatrician, or do their well-child and sick visits rotate through whichever doctor or nurse practitioner is available?

Do the parents routinely take their daughter to the doctor? How long has it been since the child has been seen by the pediatrician?

If the child isn’t seen regularly or has seen different doctors for brief visits, it’s possible that these signs were missed. Possible, but not necessarily the only explanation.

Answering the Tough Question in the Moment

You might not know all of these answers, and you certainly don’t want to answer their question by immediately asking more questions. You do, however, need to address the elephant in the room and provide some guidance. First, it’s okay to be honest and admit that you don’t know why the doctor hadn’t addressed these signs before but that he referred them to early intervention which is a good start. You can assure the family that you will help them communicate with their pediatrician by sharing a copy of the IFSP (with their permission) and making a phone call to discuss the findings in detail if that’s helpful. You can also discuss an additional referral to a specialist, such as a neurologist or developmental pediatrician, who can provide another opinion. Always ask the parents if they have any questions and how you can help before you jump in and make calls or referrals.

After you’ve provided some reassurance, I think asking a few more investigative questions can be very appropriate to help you problem-solve those next steps together, such as:

Have they noticed these signs before? – If not, I’d wonder if these signs represent a new problem. Or maybe they’ve always been there but the parents didn’t know that they were red flags, which is okay. These things aren’t always easy to notice when you don’t know to look for them.

What has the pediatrician said about Seiko’s legs, hand, or muscle tone? – It’s quite possible that the doctor mentioned these signs and that he has been monitoring them. It’s possible that a “wait and see” approach is at play here. (I know this makes us early interventionists cringe but it does happen.)

Has the doctor ever mentioned seeing a specialist? – It’s possible that a referral was suggested or made to the neurologist but the family wasn’t ready to see the specialist, preferred to wait, or didn’t understand why it was suggested so didn’t keep the appointment.

There are many possibilities in this scenario so be careful what you assume. It is absolutely possible that the doctor missed these signs, but it’s also possible that there’s more to the story. Regardless of the reason for why Seiko is 14 months old with possible signs of cerebral palsy, the most important thing now is to help the family find the resources they need to support her development. When the family is ready, the team should proceed with writing a meaningful IFSP, initiating services as soon as possible, and connecting the family with an additional referral to help them find answers.

How have you handled this situation? What words would you use to preserve the pediatrician-parent relationship?

If the parents consent, how would you handle communication with the pediatrician after the assessment?

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