Episode 4: Is feeding the new play? Are all pacifiers created equal? Pediatric Feeding, Speech, and Language with Emily Zimmerman
Is feeding the new play? Are all pacifiers created equal? What are long-term speech and language outcomes for preterm infants? Pediatric Feeding, Speech, and Language with Emily Zimmerman
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(0:11) Tiffany Hogan: Welcome to Episode 4 of See Hear Speak Podcast. In this episode, I speak with Emily Zimmerman about her diverse work on pediatric feeding, speech, and language.
We talk about her recent studies in which she asks these questions: Is feeding the new play? Are all pacifiers created equal? What are the long-term speech and language outcomes for preterm infants? How do maternal scent and visual cues impact feeding? And are there quantitative ways to assess infant suck? Per usual, we end our conversation with Emily describing her current, most exciting project, and her favorite children’s book.
Don’t forget to check out www.seehearspeakpodcast.com to sign up for email alerts about new episodes and content, read a transcript of this podcast, access articles and resources that we discussed, and find more information about Emily. Also, don’t forget to subscribe to the podcast in Apple Podcast or wherever you are listening.
(1:17) Tiffany Hogan: Thank you for joining me today. Emily Zimmerman, please introduce yourself.
(1:22) Emily Zimmerman: Well thank you so much for inviting me to participate in your podcast, and thank you for creating such an innovative and fun way to disseminate ideas and discuss very interesting topics to the field. My name is Emily Zimmerman as you said, and I’m an assistant professor in the Department of Communication Sciences and Disorders at Northeastern University here in Boston. My area of expertise is in infant feeding, particularly infant suck patterning and how it relates to subsequent neurodevelopment.
(1:52) Tiffany Hogan: We have so many personal connections, having gone to the University of Kansas around the same time, and fun fact: it was very cool that you were an undergraduate working on my dissertation in Hugh Catts and Holly Storkel’s lab, which was great. And then I was so excited when you moved to Boston and then we were pregnant at the same time, and my babies have been in your studies, and so I’ve always just been a big fan of your work and I’m excited to learn more about it and share it with our listeners.
Language outcomes in preterm infants
(2:20) Tiffany Hogan: So we’ll go ahead and get started. Recently you published a meta-analysis on early language outcomes in children born premature, and that was published in the Journal of Speech, Language, and Hearing Research. I’d love for you to tell me a little bit more about that paper’s findings.
(2:36) Emily Zimmerman: Yes, absolutely. So for the past thirteen years, I’ve worked with the preterm infant population. And beyond wanting to learn more about their sucking and feeding skills and development, I’ve always been fascinated about their neurodevelopment and progress after they leave the NICU. And that is an acronym for the Neonatal Intensive Care Unit. So this meta-analysis asks the question: do infants born very premature (so that’s less than 33 weeks gestation) and who are very low birthweight (and that’s less than 1500 grams) catch up with their full-term peers in their language ability by early school age? So we defined early school age as greater than or equal to 5 years and less than 9 years. So we really focus in on this age point because I think it’s very critical for—as you’re entering school—what kind of services you’re going to be getting. So are these two cohorts treated as equal, are they presenting equally as they’re entering school? So we found through the meta-analysis that preterm infants scored significantly worse on the total language, receptive language, expressive language, phonological awareness, and grammar, compared to their full-term peers. They did not score worse than their peers in their pragmatics skills. So to answer my overarching question: no, they do not catch up to their peers in regards to these domains. And these results are consistent with other meta-analyses examining language skills in children born preterm at school age. But it’s important to note that the differences we found weren’t extremely large. So often the differences were 0.5 to 1.5 standard deviations below the mean. And while this is good, it’s troubling because often schools require the child to be 1 to 2 standard deviations below the mean. So we have this population that’s not scoring as well, who’s at risk, compared to their peers, but they are likely not getting the services they need.
(4:39) Tiffany Hogan: So they don’t really qualify for the services oftentimes, because they’re falling kind of in that subclinical range, and I think it’s important to note that with the meta-analysis, you’ve pulled together lots of different studies, so the findings are quite robust, because you’re pulling together thousands of subjects and looking at a conclusion across studies. So then, what can SLPs do with this information to help these children?
(5:03) Emily Zimmerman: So that’s a great question. And for me I really think the long-term care for this population should start in the NICU. And it’s really that fine balance between education and overwhelming. So you’re dealing with these parents at—for some parents—the hardest part of their life. They’ve become a mom, their child is sick... And most people don’t know about the NICU, and the NICU environment, and what to even expect. So the short-term goal is leaving the NICU, and learning to feed, and really kind of thriving in that short term. But I think kind of educating the families that beyond the NICU, beyond your time here, as your child develops, they’re going to be at risk for speech and language and even reading difficulties. And providing them with the resources—and even the knowledge that these differences may not be robust. For example, there was one study that showed that teachers can identify children in their classroom that were born preterm with really high accuracy, and it’s because of how they behave. It’s kind of these really small differences in processing speeds that they’re seeing, so I think the education needs to start early. Also encouraging—a lot of NICUs have follow-up clinics, or local resources, that—depending on how preterm the infant is—that they would then qualify to go into. But encouraging early intervention… so we know that preterm children who’ve been exposed to EI have significantly higher cognitive, language, and social scores compared to children who did not. So really kind of taking advantage of these resources that we have. The other thing is that I think SLPs who work in the schools have the right and should ask about development. So, I had a brief stint in my life when I was a 6th grade SLP, and I always wondered the etiology—how did this start, when did this start, were you in the NICU—because a lot of the differences I saw had a developmental beginning. And I wanted to know that story and what is unfortunate is when you enter school age, that story somehow is lost. And I think that you might treat an individual who was born at 25 weeks—really young preterm—different than somebody whose term maybe didn’t have that developmental history. So I think that is important to know—not that preterm infants should wear a scarlet letter or a P their entire life. But I think this knowledge would help you to say, “Okay, this child may not qualify, but what are some standardized and non-standardized, really functional metrics that we could be using to get a more global view of this child, to improve function?”
(7:52) Tiffany Hogan: It seems, if I recall correctly, when I was practicing in early intervention, it was around 2 that you stopped kind of subtracting, right? So it’s like, “Oh, they were born 6 weeks early,” and so then you subtract when you’re determining eligibility or where they fit. So you’d say, “Oh, developmentally, they were 6 weeks early, so instead of 18 months they’re more like 17 months.” But then at 24 months, it’s like magically, that’s gone. And so I think parents, and maybe even service providers—including speech pathologists, may get the impression that it is something that is now gone from the child’s history. That it’s not pertinent as much anymore. So, it sounds like you’re saying a speech pathologist could advocate for having this information in a kindergarten screener, or just constantly thinking about, “What was the birth history?” And then advocating for those children. Giving a watchful eye if they don’t qualify by whatever standard, and making sure that they’re getting the best support for their development long-term.
(8:52) Emily Zimmerman: Absolutely. And I think that what’s interesting for research when we follow the neurodevelopment, we continue to adjust. So we—as researchers looking at these scores—we always adjust. And clinically, it changes that too. And what we know about development is, nothing’s magical about 2. Development doesn’t work this way. So it’s on a continuum. So, I just kind of push people to be mindful that these differences aren’t going to be so obtuse that it’s going to be clear. So it’s going to be a little bit muddled at school age, and so I think it’s up to the parents, and it’s up to the SLPs, especially at that early childhood, to try to learn more and ask these questions even if it’s not provided.
(9:35) Tiffany Hogan: I love how you say that speech pathologists who have the opportunity to work in the NICU can then even at that moment—even though it’s a life or death moment—it’s very, very stressful, to say the least, for many reasons. But you’re still letting the parent know, long-term, please be on the lookout for this. And so then they’re the ones that carry that history, and can ask the questions, and can bring it forward, and can get that information out. So it kind of is two-pronged. From the parent side, plus the SLP side, later on in elementary school. So that makes sense.
(10:06) Emily Zimmerman: And so much of that empowerment comes from the education. And if they don’t know, they can’t empower and get the resources that we know that they want for their children.
Language and prosody during feeding
(10:16) Tiffany Hogan: Makes a lot of sense. And I—something I love about your work is that you do think holistically about the child. So, not only developmentally speaking, but also how speech and language and feeding—how they tie together. So my son Kellen was recently participating in a study in your lab about language and prosody of feeding, and you mentioned that that study is now in press. So I’m excited to hear more about those results.
(10:43) Emily Zimmerman: Yes, and thank you for participating. Thank you, Kellen. So in this study, we looked at full term infants between 6 and 13 months. And the aim was to determine the language and prosody mothers use with their infants during feeding. So, as you said, I am interested in this intersection between feeding and speech and language development, but also how they interact and what is really normal for how we should be interacting with our child during mealtime. And that is unknown. So the article is called “Is feeding the new play? Examination of the maternal language and prosody used during infant feeding.” And it is in press right now in the Journal of Infant Behavior and Development with my amazing co-authors Kate Connaghan, Jill Hoover, and two recently graduated master’s students from Northeastern, Danielle Alu and Julie Peters. So for this study we recorded maternal spoken language and prosody across four conditions. The adult-directed baseline, play, solid feeding, and milk. And what we found was that mothers used significantly fewer verbs and more utterances per minute in the adult-directed baseline compared to the play or solid conditions; that the type-token ratio was significantly higher during milk compared to play or solid feeding; and that the vowel duration and peak fundamental frequency were significantly higher during play compared to the adult-directed baseline. So overall, our findings suggested that mothers are acting different and behaving different with their children during these different conditions. Particularly what was interesting was that feeding offered a more diverse, lexical opportunity for the child. Because if you think about it when you’re giving the kid a solid food, you’re labeling things differently, it’s much different than play, and the expectations are a little bit different too. In addition, we found that maternal prosody during solid feeding was very similar to what was being used during play. So mothers are acting very similar when they’re feeding their infants solid food as they are during play. So really, the take-home from this paper is: Is feeding the new play? And I would argue that it’s actually more robust than play. And the reason is that feeding is an obligatory behavior. For young infants, feeding is done as many as 8 times a day. For older infants, the infants in this study, it’s done at least 3 times a day, where the mother and infant come together, and they’re challenged. I mean, I get very challenged feeding my own kids. It’s a challenging time, it’s a stressful time. And it’s something that you have to do regardless. Play—I like playing with my kids. Play is great, but it’s not mandatory. And the other thing is that feeding is something that happens regardless of culture, race, socioeconomic status, this is the time for early attachment and bonding. And it really sets the stage for kind of early parenting. So what we know also is that feeding can be quite different—the experience between mother and child—between different cohorts. So for example if you were in the NICU, you know, your attachment, you might feel, is potentially strained, or is potentially even heightened. You’re going to have different responses when your child is constantly choking. So all of these kind of back and forth, I argue, really lay the foundation for what we need from moms and caregivers later for language development. But we’re also seeing that moms are treating feeding differently. And I think that’s really great. And I think that potentially if a child has both feeding and speech and language goals, can’t they be combined and treated together in a way where, potentially, we’re increasing the vocab and the lexical diversity during solid feeding, and during play we’re focusing on other tasks.
(14:45) Tiffany Hogan: That is really amazing, too, to think about all we have to manage as mothers, working or not, and that you could think about an activity that you have to do—like you said, it’s obligatory, you’re feeding your children—and that you could use that activity as a springboard to then accomplish other goals and stimulate their cognitive linguistic abilities. It’s a very cool finding, I think it’s great. And as someone who studies literacy, we often think about using a book. Book time, right? And that has become, I think, something that parents work towards, but it is not obligatory. It just isn’t. So even if you have the goal of doing it every day, or it’s part of your routine, it’s not something you have to do, and sometimes it does go by the wayside. And that’s completely understandable. But when you’re working on everyday activities, you’re going to feed your child. So it just is a very cool finding to see that this could be a nice platform for this type of simulation.
(15:41) Emily Zimmerman: Yeah, and I think that this was a preliminary finding, with full-term infants who were not having feeding difficulties. So of course we expect there to be differences across different kind of mother-infant dyads of different populations and different ethnicities, but I think it’s really important to consider feeding in this way.
(16:04) Tiffany Hogan: It sets a nice foundation for future work.
(16:06) Emily Zimmerman: Yeah. Absolutely.
Pacifiers and infant feeding
(16:07) Tiffany Hogan: So when I think about speech and feeding, something that comes to mind for me is pacifiers. So you recently wrote a paper that was titled “Not all pacifiers are created equal.” And I’d love to hear more about this paper as well, because it seems to be a hot-button issue right now, is—do you use the pacifier? Do you not use the pacifier? How long do you use the pacifier? And I’d love to hear what you have to say about pacifiers in general and this paper.
(16:30) Emily Zimmerman: Yeah, so I’m a pacifier guru. We’ve talked about how when we had our babies, pacifiers were not really offered in the NICU—not in the NICU—in the well-baby nursery. And you know, what the rationale and reasoning is behind that. And in general, I definitely am someone who supports breastfeeding, I breastfed my own children. But I also think you can do both. So we know that healthy full-term babies are able to kind of switch and modify to different kind of experiences to their oral environment. So, you give a baby one pacifier brand, another pacifier brand, et cetera… this article kind of looks at how they modify and I’ll discuss this in a minute, but... in those first few weeks it is extremely important to have that time at the breast to establish breastfeeding. But what I find problematic is the kind of blaming of poor breastfeeding outcomes on pacifier and bottle nipples. So often these infants need those alternative nipple types because breastfeeding is hard. And breastfeeding is harder than bottle feeding. It’s kind of the Olympics of infant feeding, if you will. So I guess I tend to defend populations like preterm infants or other infants who are doing poor at sucking and feeding because they need that practice, particularly with a pacifier. So there’s been a host of studies that have shown that non-nutritive suck before your oral feeding, either by breast or bottle, tends to make babies more alert and ready to feed. They take feeds faster, they’re kind of more proficient at feeding. So I use the analogy all the time that you wouldn’t just go play a soccer game. You would then start with some skills, you know, sucking on a pacifier to get that rhythmic pattern down before adding the additional demand of swallowing a bolus to the task. So you know, you wouldn’t just hop on the soccer field and expect to win the tournament. You need these kind of foundational skills. So these kind of notions led me to really find some data to support some of these ideas. So not all pacifiers are created equal. It kind of stemmed from the idea of: when you’ve been in Toys“R”Us, or Buy Buy Baby, or any of these infant stores, you go down the pacifier or bottle aisle, and it’s two or three aisles, and it’s so overwhelming. Do you get purple, green, “I love Mommy,” “I love Daddy,” scented, orthodontia… all of these choices seem really archaic with obviously no research to back it. So what we did in this study is we looked at 7 commercially available pacifiers, and we kind of pushed and prodded and did all sorts of fun things. So this was done with mechanical engineering students. And we had them squeeze and look at the pull compression with a linear actuator. And quantitatively measured how these pacifiers differ. Then we gave the tip of the pacifier a ratio number. So, I mean, anecdotally, you probably remember when your kids had pacifiers they were either round or more flat-headed… so we kind of took these different features and gave them different ratios and gave them different letters. And what we then did is took 3 different pacifiers—so we used the Soothie, the GumDrop, and the Freeflow pacifier—that all have really salient differences in their pull stiffness, with 2 different pacifier nipples offered. And we clinically tested how 16 full-term, healthy infants less than 6 months sucked on these various pacifiers. So we used the custom non-nutritive suck device we have in my lab. So when this is attached to the pacifier, we can see in real time the infant suck pattern. And what we found was that pacifier compression, pull stiffness, and the nipple shape yield different suck patterning. Put simply, healthy infants modify their suck to adapt to the different features presented by the pacifier. So this is really important because we really need to be mindful of how we’re assessing infant feeding. So, often, the gold standard because of lack of devices or different questionnaires, and different methods, is for an SLP or developmental specialist to put a gloved finger—and put their finger in the baby’s mouth. And say, “Oh, that’s a good suck,” or, “This could be better.” I would not be very accurate or consistent on that type of metric. And what happens when we’re not quantitatively assessing this skill is that the infants actually suffer. So they can get feeding aversions, and they also get quite confused. So based on this “Not all pacifiers are created equal” paper that’s in AJSLP, what we found is that there’s such a wide variability; and healthy infants are able to adapt and modify as needed, but babies who have sucking difficulty have more challenges. And that is often what is done when we’re working with infants with feeding issues—is you start with one pacifier or bottle, then you switch, and then you switch, and then you switch. So I almost compare it to if we were trying to study infant walking. We would either have the child barefoot or we would put on tennis shoes at 12 months. We wouldn’t say, “Now here’s a stiletto, here’s a winter boot, and here’s a sandal.” Because the baby’s going to adapt and modify differently, and especially if this is challenging for them, you might think that the baby has a delay when really you’ve just offered the wrong pacifier and assessed it. So it might be weak because you’ve given them the stiffest pacifier on the market. So these things, although rather intuitive at times for healthy full-term infants, are actually quite important for infants who are struggling with these types of behaviors.
Research tools and methods
(22:41) Tiffany Hogan: That makes a lot of sense. That’s really important work, and I have to just step back and say: so, wow—do you have, like, a fake baby head? Like, how does this work? I just want to think about the process a little bit too, and shine the light on—you know, you did this work, and you’re looking at these differences, but to get to that point where you can even do this work, you worked with engineer students… yeah, tell me about that.
(23:06) Emily Zimmerman: So, this initial kind of pushing and prodding was just from a linear actuator. So how it was set up, it’s like… you put a pacifier against a hard surface, and then the actuator kind of slowly over time compresses it until it’s fully compressed, and then that gives you the newtons per millimeter that are the force required for that pushing. That being said, we have recently done a really fun capstone project with mechanical engineering where they created a baby head that sucks. For me to do more measurements and do more metrics on these types of—I guess, different types of pacifiers, different types of bottles—to be kind of mindful. And then this way you can kind of adapt the system rather than getting all these different babies in the lab—which is also an arduous task.
(23:56) Tiffany Hogan: So that’s a very cool new technique. And I’m just wondering what are some of the other new technologies you use to determine feeding difficulties, and to stimulate feeding in the NICU?
(24:07) Emily Zimmerman: Yeah, so, as I’ve said, assessment of feeding is really the first step. I think it really needs to be quantitative. And again, the guesswork—we need to work together as researchers and clinicians alike, to kind of reduce that, to reduce the feeding aversions that can last a long time. So there’s been a host of new technologies and questionnaires that have been created to help make feeding more quantitative. Some technologies and devices: one is the NTrainer device. I worked with this device during my doctoral work with Steven Barlow. Where we would go into the NICU and assess their suck, and then the NTrainer gives kind of a pneumatic pulse within the pacifier that gives the baby a gentle stimulus that matches what we expect for the non-nutritive suck.
(24:54) Tiffany Hogan: So it’s an actively moving pacifier.
(24:56) Emily Zimmerman: Right. So it just kind of goes—if you were to look at a video of it, it just goes up and down, very gently. It’s very innocuous. The other is an NFANT (it’s spelled “infant” without the I) device, and this is something that attaches to different bottles and it helps to quantitatively measure how much the baby’s taking, and how quickly they’re taking it. Ultrasound is often done to look at tongue movement during the feeding. Manometry is also done to look at pressure throughout the swallow but also with the ability to look at the esophagus and what’s happening at that level. So those are different technologies that are available and I actually recently completed a systematic review on those listed technologies in the SIG 13, so you can find more information there. In addition to technologies, there are some really great questionnaires that clinicians and researchers and parents can use to really detect the presence of feeding and swallowing difficulties. So one is the Infant and Feeding Questionnaire. This is by Julie Barkmeier-Kraemer and colleagues. One is the Neonatal Eating Assessment Tool, or NeoEAT, by Britt Pados and colleagues. Another is the Behavioral Pediatrics Feeding Assessment Scale, by Crist and colleagues. And those are just to name a few. But I would really encourage clinicians working in this area to be mindful that the quantitative aspect is there, and needs to be accessed… but I think researchers and clinicians are doing more and more to make quantitative assessment and real-time assessment available.
Infant suck development
(26:37) Tiffany Hogan: That’s fantastic. So on top of this quantitative aspect, you also study just general influences on successful suck related to feeding. So for example, you found that infants have more suck attempts when looking at faces in the presence of maternal scent, which indicates potential links between visual preference and suck behavior. And I’d love to learn more about these findings and others from your lab, because I think this gives us a more global sense of what a speech pathologist can do and a clinician can look for in thinking about stimulating feeding.
(27:09) Emily Zimmerman: Absolutely, so the majority of my work, when I’ve looked at the emergence of suck and how suck changes throughout development, has really used the sensory system. And this is because in the womb, the infant is surrounded by a rich, potent, kind of hierarchical order of senses that emerge and come together throughout the infant’s time in the womb. And what happens is when a baby is born prematurely, they’re removed from that really rich environment. And we’re able to save the lives of so many younger preterm infants through advances in technology, but what is happening, and what researchers and clinicians are really questioning is then, what is the developmental consequence of this? So when an infant spends three, four months in the NICU, what is happening is they’re replacing the really rich womb environment with an environment that’s really noxious. So they have tubes stuck to their face, they’re not getting any perioral or oral stimulation… In the womb, starting at 15 weeks, the infant is sucking and swallowing. So they’re getting none of that experience. And other key sensory features are lost and also overstimulated. So, for example, there’s over 250 odiferous compounds in amniotic fluid, but when you’re born preterm, you have, often, cannulas in your nose, and you get no exposure, so it’s a really, kind of, sterile environment. You don’t even smell mother’s breastmilk often. Another sense that’s overstimulated is… It’s really loud and bright, and those are later emerging senses. In the womb, it’s kind of darker with a little bit of a dim light at times as the uterine wall thins, and the acoustic sounds are mother’s heartbeat and mother’s digestion, and some acoustic sounds from the environment, but we know that there’s a lot of filtering that goes on. So the NICU is a real trade-off of life-saving environment, which is amazing, but now the focus has really been to how can we recreate the womb? And when we don’t have the recipe for the womb, or what exactly is happening, what is intuitive between mom and baby? And that’s always the rules I try to abide by when coming up with research paradigms… What is safe? What is appropriate? You know, I wouldn’t put an electric toothbrush on an infant’s face; that doesn’t make sense. So I try to think about the physiology, think about the senses. So some of my work—I’ve looked at olfaction, I’ve looked at vestibular. So that’s a sense that was what my dissertation focused on. So, in the womb, the infant’s constantly getting vestibular stimuli, and that’s really taken when the infant’s born too soon. So for this study, we looked at full-term infants in my lab, and we actually expanded on another study that was done in the literature that showed that full-term infants look longer at social stimuli—so that social stimuli was the mother’s face—compared to nonsocial stimuli, which was a car, and that this response was more robust in the presence of maternal scent. So how we attained maternal scent was that (or how they did it in this study and it’s also how we did it) was that mothers wore an oversized shirt to bed… (Did you do this study too?)
(30:33) Tiffany Hogan: I did! I’m remember this now!
(30:35) Emily Zimmerman: As I’m describing this now, you’re smiling… It was lovely!
(30:37) Tiffany Hogan: Yeah!
(30:40) Emily Zimmerman: My daughter was the test subject for this study, too. So the shirt was then kept in a sealed bag. So, we then extended on this study to add our non-nutritive suck device. So we replicated everything where we had the child looking at two different stimuli—social versus nonsocial—they were smelling the scent of their mom, and then we gave them our custom, non-nutritive suck pacifier. So we were able to replicate the initial finding that infants looked longer at social stimuli compared to nonsocial stimuli in the presence of maternal scent, but a novel finding from our study was that infants had more suck bursts when looking at the female face. Again, I think this seems rather intuitive… Babies are used to probably sucking and breastfeeding and looking at mom, but this starts to encourage us to think of linkages between the visual system and the suck system, but also what a cheap and user-friendly way to elicit suck in young infants… You know, that’s always kind of the overarching goal is how can we translate this type of a result in full-term infants into the NICU or to populations in need of sucking and feeding assistance. So that was a fun study with some, I think, intuitive findings, but also really important findings.
Applying findings to populations in need
(32:05) Tiffany Hogan: So do you think that… Or do you have hope, I guess, based on the work that you’re doing—and is this what you envision that in the future—the NICU will be a more womb-friendly kind of place? Like what do you envision?
(32:17) Emily Zimmerman: Yeah! I mean, with the advances in technology and the ability… you know, I’m almost, like, thinking of pods of each external wombs… So what’s interesting is that from the crowded NICU beds, what they’ve done to try to improve the acoustic environment and the lighting is they’ve moved NICUs to single suites, so you can control the lighting, you can control the sound. But what is actually happening is that is also a little bit of a model of deprivation. So even if the infant wasn’t getting really loud noise, they were getting some… So when nursing isn’t in there, when parents aren’t visiting, the baby gets nothing. And this is also the case in cardiac ICUs. They wonder why these infants aren’t thriving, and aren’t doing well developmentally, and it’s because of this lack of exposure. So I think while we, kind of, explore these new settings and new technologies, we just also have to be mindful of the impact of human voice, human scent… All of these features. And that’s why skin-to-skin and kangaroo care… That is the gold standard, really, of what the infant needs. You have mom, you have mom’s scent, you’re moving up and down (and it doesn’t have to be mom… a caregiver), but you’re moving up and down, so you’re getting some proprioception, you’re getting some vestibular. You’re kind of getting this multi-modal world while also forming this really rich attachment.
(33:42) Tiffany Hogan: And that’s going to take that human capacity, then, to be there. I know that I heard one time that when you retire, there’s an option… You don’t have to be retired, actually… You can do it anytime, right?
(33:52) Emily Zimmerman: Yes! Volunteer cuddlers!
(33:53) Tiffany Hogan: But you can volunteer to cuddle, right?! And I have thought, ever since hearing that, I’m like, “That is going to be what I do in retirement. I’m going to go sit and hold babies.” ‘Cause there’s no better feeling…
(34:03) Emily Zimmerman: No, it’s the best!
(34:04) Tiffany Hogan: It’s the best feeling. So that’s what you’re kind of thinking, too, it sounds like. Like this idea of that human connection.
(34:11) Emily Zimmerman: Right, and it’s so hard, ‘cause these moms have… Some have to go… Most of their child’s time in the NICU is during their maternity leave, so their child will actually get out of the NICU and they have to go back to work.
(34:23) Tiffany Hogan: I have a lot of empathy for parents that have children in the NICU, ‘cause they’re faced with so many choices that are… There’s no good choice. So for instance, having to choose… Okay, I have maternity leave, and it’s a certain amount of time. Do I use it now? Do I use it later? Many, I think, choose… At least some of my friends have chosen to use it later. So that means they’re working full-time. And then at the same time, mentally, their mind is in this NICU with their baby.
(34:51) Emily Zimmerman: Right.
(34:52) Tiffany Hogan: And they want to be with their baby. So you have this kind of, like, constant conflict of… You know, how do I manage this when they’re there? And if they have other children at home, that’s… It’s just so much, I think, going on there. And so, to think about making an environment in the NICU that is more representative of the womb or what we know is good for early infant development would be such a peace of mind, I think, for these parents to know. And even just knowing that there’s a cuddler there that’s helping when you can’t be, I think would be immensely helpful for their mental health as well, and not only the child’s development but just the whole family unit.
(35:31) Emily Zimmerman: Yeah, in my dissertation when we looked at vestibular stimuli… I won’t go too much into that detail, but I would rock these babies at these frequencies and rates, but I would basically hold them for thirty minutes, three or four times a day. And we would do this rocking stimulus together. And the parents would tell me it was so amazing to know that, not only was my child getting this extra attention that potentially would be beneficial, but that you cared for our baby, and you were doing the diaper, and you were… ‘Cause I would do some of the other nursing tasks. But often, when the study was done, I would just kind of hold the baby and, you know, the babies that were in my dissertation, I still am Facebook friends with them and have seen them develop and thrive. And it’s just amazing. It’s a miracle, and it’s really the passion that drives me to do this work.
(36:24) Tiffany Hogan: That’s fantastic. I really have no clinical experience with this, except for to say, interestingly I had a dissertation grant, and as part of the dissertation grant, I had written that I wanted to visit other labs and learn about the research happening at the University of Kansas just to think more globally about research. So I actually went on a round with Susan Stumm at the time…
(36:44) Emily Zimmerman: Oh, yeah!
(36:45) Tiffany Hogan: Yeah, so, she was recruiting, and we were in the NICU, and I just remember thinking, “Wow, this is… This is very different than the work I do. But also just how impactful it could be, and what a different environment that is, and the amount of, really, trauma that these mothers are experiencing at that moment, and having to make those decisions. So it was a very interesting experience, and it made a big difference in how I think about development in general.
Work-life balance and parenting
(37:13) Tiffany Hogan: We both mentioned that we’re mothers and we have children around the same age. Although I have three, so I have an older child as well as two littles… Let’s talk a little bit about work-life balance. Managing all of this, the research that you’re doing, and then also being a mom. Do you have any work-life balance or life hacks that are your favorites?
(37:36) Emily Zimmerman: Yeah, I mean, as we kind of support each other as moms, professionally, but also trying to juggle it all, I would say that, for me, I don’t think my balance came until I had kids. And I think that… So, to tell the listeners more about myself, I started at Northeastern when I had a three-month-old. So I was always on, and I’m currently still tenure-track faculty. But I have never known this job—being a faculty member—without also being a mom. So I think I had to cut that balance and learn that balance really quick.
(38:17) Tiffany Hogan: And I have a similar experience, I’ll just say. So I started out with my first tenure-track job, and my oldest son was six months old. So I had the same thing of, like, I’ve always done this. I don’t know any different way.
(38:28) Emily Zimmerman: Right. And I think that that’s good. It’s given me… I pick my kids up every night, my husband drops off… Like, we have a very set schedule, but I also am not available a lot because of that. Or, you know, it’s helped me to prioritize. And then I had my second daughter nearly three years ago. So she’s two and a half… or two and three quarters. So that was midway through my tenure-clock. Which I actually found to be really great timing, because I felt like I needed that time, obviously to cuddle and hang out with my daughter, but I also appreciated that break from the rigor of academia to have that creative time again, to have the time to step back to see, what have I done? What are the next steps? And then, you know, have that time at home and really appreciate the cuddling, appreciate… And again, with both kids, appreciate how lucky I am to be able to… with my first daughter, I was pregnant while I was working in the NICU. So that was really eye-opening for me. I was like, “That baby right there is the same size as inside of me.” And I think being a mom and a scientist, especially in the area that I study, I am so grateful for the families that participate. My level of understanding and my ability to relate has really improved, and I think that to say that I study infant feeding and have not breastfed myself or have not fed in the middle of the night, when things are crazy, or I’m talking about the language use during solid feeding when my kid’s throwing food at my face… I understand the complexity so much more, and I also understand the role of the mother in this feeding process. Like the mother is the volitional part here. And so it’s very unlike adult swallowing, where you have someone who’s swallowed all their life and they make the choices themselves. You are the care provider, you make the choice. And really being mindful of the full kind of picture on a global level, like what is the mom doing, what are the caregivers doing… What is the pacifier doing? Then, what is the infant doing? It’s really allowed me to see kind of the full picture, but also again, be so thankful for the people who participate, be so mindful of what moms in the NICU are going through. But again, that sequence for me really worked great. So I also feel like it’s made me want to be a really nice role model. So I have two girls, and I think that’s particularly important to show my girls that they can have a work that they’re really passionate about and that they really love, but also have a mom that’s present and caring and loving (most of the time). So I have a funny story to share about this. So for the longest time, my oldest daughter thought I worked at Target because apparently we were going there a lot, there were Target bags around the house… So we once bought something and I was like, “I need to return that.” She was like, “Just do it at work tomorrow,” and I’m like, “What?” And she’s like, “When you go to Target. That’s where you work!” And I was like, “No, no. I mean, that does sound amazing, and I would probably get many discounts that I need, but…” So I told her, Clara, who’s now five, much more about what I do. So now, when people ask what her mother does, she says, “My mother is a teacher of adults, a doctor, a scientist, and a professor.”
(41:55) Tiffany Hogan: Oh, wow.
(41:57) Emily Zimmerman: And it makes me laugh and roll my eyes and… kind of laugh. ‘Cause it’s ridiculous. But I’m also so proud for her to know that… I actually, I mean, she’s not wrong.
(42:07) Tiffany Hogan: No, not at all.
(42:08) Emily Zimmerman: But I also, it makes me proud to think that she thinks of me in that way. And hopefully I’m a role model for her. And kind of a visionary for her of, kind of, how she can work really hard toward something but also have this balance that we all attempt to have on a daily, and hourly, and minute-by-minute basis.
(42:27) Tiffany Hogan: Absolutely.
(42:29) Emily Zimmerman: And then, one more thing I’d like to say is that I’m just a, really, huge fan of supporting women and young scientists, in addition to my passion for infant feeding. I think that we really need to support women as they’re embarking on this career in science, and potentially motherhood, or potentially not motherhood—it doesn’t matter, whatever choice, I think we need to be mindful and supportive. But I wanted to share with you all one of my favorite quotes, and that’s by Elizabeth Gilbert. It’s kind of a quote beyond the tenure process but also parenting. And it’s, “Don’t be afraid. Don’t be daunted. Just do your job. Continue to show up for your piece of it, whatever that might be. Olé to you!”
(43:12) Tiffany Hogan: I love that. That’s fantastic! I just think that that’s so great. Tying to all of this, I remember, as a newer clinician, being so surprised working in peds because mothers would ask me, and I had very little experience except for the clinical pediatric experience. I was not a mother myself at the time. And they would ask me so many questions that were really out of my league—diapers, tons of the pacifier questions… A lot of developmental questions about walking and the coordination and all of this. And I am so appreciative that the work you’re doing will help inform clinicians with data, because sometimes you don’t have the personal experience. And then when I did have the personal experience, I looked back and thought, “Oh my goodness!” I remember it was easy to say, “Read to your child, read to your child.” And one experience I remember having is when my oldest son started daycare, which was around 14 months, he was so sick (like all children are when they start daycare), so I was just so exhausted, and I was working. And we had this routine already set in place, though, where we were reading to him, and I remember at one point thinking, like, “I am so physically exhausted, I don’t think I can take the breath in to, like, read this book!” I was so exhausted! And thinking how, it’s just so easy to think, like, “Read every night, it’s no big deal!” And also having that guilt, and thinking, like, “Did I create that guilt for moms?” And so much of the things you’re doing-- you’re giving education about what’s appropriate, for those who might not have the personal experience. And even if you do have the personal experience you need this information, and then also just providing opportunities that, like you said, are obligatory. Just kind of pulling it all together, that there’s just so much you’re offering the field, and I appreciate it so much. I really do.
(44:53) Emily Zimmerman: Well, thank you!
(44:54) Tiffany Hogan: My sense—maybe life hack, I guess—seems a bit counterintuitive. And sometimes when I tell my students what I think about is to do good work, sometimes you have to work less. So one example I read a long time ago but I often talk about in my lab is that you can pick up a glass, let’s say just a glass that has some water in it. You can hold it up for ten minutes. It’s a long time, and you start to really fatigue. But if you put it down for just ten seconds, and then pick it back up, it’s really light again. And I think that’s a nice analogy for research in general, or the tasks that you have. You can work, work, work on them, but you can be more efficient and bring your better self—your more healthy self, mentally and physically—if you do give yourself some downtime to replenish. So I think that’s an important part of it, too, is just acknowledging that it’s okay to not work all of these hours, and that we are offering a piece to science, but we’re not offering it all, and we’re just doing the best we can with what we have.
(45:53) Emily Zimmerman: And science has no guarantees. Science is a long journey with several different stories—some of which I’ve shared today—but something that I always remind myself of is, when the choice comes to… sometimes, you know, work does need to be the choice, and sometimes home does need to be the choice. But I will never regret not working more. I think, like, I would regret not being with my kids more. So I try to find that balance in that way, but again, it is always hard, and it’s just that—a balance.
(46:25) Tiffany Hogan: And it’s a learning process, overtime.
(46:27) Emily Zimmerman: Absolutely.
(46:28) Tiffany Hogan: But having said that, you’re working on so many cool projects. So what are you working on right now that excites you the most?
(46:35) Emily Zimmerman: Yeah, so we’re doing a project right now, looking at the interplay between sucking, oral feeding, and vocal development. So we’re looking at the infants at three months and then we see them again at twelve months, and we’re trying to see, kind of, which of these early oral motor, oral feeding behaviors is best predictive of how the child will be at twelve months of age. So kind of taking my passions and, kind of, all of these studies that I’ve done to examine bits and pieces… A lot of the data available linking speech and language is really retrospective to… So they’ll take case studies that have said, or reports that show that kids who have speech and language difficulties had a history of feeding. So there’s a lot of prospective data, kind of, missing in this line of inquiry. So I’m really excited about that, and then I also do environmental health research. So I look at sucking and feeding but also the neurodevelopment in a cohort that I follow in Puerto Rico with a large, large team that I’m just a member of—called CRECE. That’s our child environmental health program center, and there, in that grant, we’re using non-nutritive suck as kind of an early index of brain health and brain integrity. And we’re hoping to pair those data with prenatal environmental exposure. And then we also study the developments of these children to age four, using different feeding metrics but also speech and language and motor… So that’s a really fun project that really expands… makes my world even bigger when I think about infant feeding ending at the mom, it really takes me back to a macro level to think about the environment effects on this relationship, on the ability of mom to even access the materials, or maybe she’s exposed to a lot of phthalates which is then causing her child to have these delays. So that’s really opening my mind to different areas within our field, and also the extent to which SLPs should be mindful of these toxicants given that they’re the etiology for a lot of the developmental delays that we’re seeing.
(48:49) Tiffany Hogan: That’s really cool. So how… If you happen to be a mom in Boston who has a baby, how would you get involved?
(48:56) Emily Zimmerman: So if you’d like to learn more about the lab, you can like us on Facebook, which is the Speech and Neurodevelopment Lab page, you can visit our lab website, so if you just put Speech and Neurodevelopment Lab in Google… I’ll send you the link so you can post it on your resources, or you can email us at email@example.com.
(49:21) Tiffany Hogan: That’s fantastic. And you have the best newsletter. I love it as a parent who’s participated in your studies because it talks all about the studies that have come out, your presentations, your students and grants, and I just think that’s fantastic.
(49:31) Emily Zimmerman: Well, thank you. And it’s my lovely students in my lab who spend the hard work on that, so I appreciate their help.
Favorite children’s books
(49:37) Tiffany Hogan: That’s great. And the last question I like to ask on this podcast of my guests is, what is your favorite children’s book? So it can be from your childhood or one you’re reading to your children right now.
(49:46) Emily Zimmerman: As a kid, I remember loving… As a young kid, loving the Madeline books. But I remember reading all the Roald Dahl books with my mom and dad and brother and being flabbergasted by the things they would do, and how they would do it, and just really finding that, like a time to connect with my family. Recently, I bought myself a childhood book that I really liked, called Little Dracula’s Christmas.
(50:11) Tiffany Hogan: Ah, I’ve never heard of it!
(50:12) Emily Zimmerman: It’s a really crazy book about Dracula, who tries to capture Santa. And I spent an exorbitant amount on Amazon for it because it was, like, the last copy. And clearly I was feeling nostalgic. And so when I got it home and I read it, and I was like, “Okay, yeah.” And I was so excited to read it to my kids, and they could have cared less. And so… But Little Dracula’s Christmas…
(50:35) Tiffany Hogan: But for you, it’s very meaningful!
(50:36) Emily Zimmerman: For me… And then when I read it, I’m like, “Mom! What were you thinking?! This book is morbid!”
(50:42) Tiffany Hogan: That’s hilarious! Goes to show how the reading is more about the connection and memories, right?
(50:47) Emily Zimmerman: Exactly.
(50:50) Tiffany Hogan: Well thank you so much, Emily, for this very stimulating conversation, and I think the listeners are going to love learning more about speech, language, and feeding, and pacifiers and breastfeeding, and everything! So thank you!
(51:00) Emily Zimmerman: Thank you so much!
(51:06) Tiffany Hogan: Check out www.seehearspeakpodcast.com for helpful resources associated with this podcast, including, for example, the podcast transcript, research articles, and speaker bios. You can also sign up for email alerts on the website or subscribe to the podcast on Apple Podcast or any other listening platform, so you can be the first to hear about new episodes. Thank you for listening and good luck to you—making the world a better place by helping one child at a time.
Tiffany P. Hogan,