Shaker Seminars Finalized for 2016!

February is already flying! Hard to believe that in a little over three months will be back on the road again. This time away to refresh, relax and refocus is a blessing that I always look forward to. I’ll be traveling coast to coast in 2016 and I hope our paths cross this year. Maybe I will see you at NANT in April and watch for my webinar for Dr. Browns’ coming in March. After that, I’ll see you in Chicago, Atlanta, New York City, Denver, San Jose and San Antonio!

So many of you have asked……and here it is!

You can now download my finalized 2016 brochure! Go to the Brochure TAB on my website.
Registration is open and on-site locations are posted under the Lodging/Directions TAB.

BTW, are there other seminar topics you would like me to consider for 2017? Send an email to pediatricseminars@gmail.com.

See you down the road!

Catherine

Problem-Solving with Catherine

I recently received an email with questions from an experienced SLP posed by the neonatologists at her large level IV NICU regarding swallow studies. There are of course no black and white answers, and the evidence-base is lacking, we know, but thought I’d share my comments/perspectives.

Her questions follow. My responses are in italics:

” A lot of concern has come to light regarding how we perform MBSS.  The physicians feel it is not a fair assessment given altered positioning, transport to the fluoroscopy suite which may negatively impact regulation and physiology of these infants, and strategies used.  The swallow study is only a moment in time and looks at physiology not just aspiration (or bolus mis-direction), so, given that, the data we can extrapolate during an instrumental assessment may be more useful, than they realize, to help complete a differential and develop a plan of care. 

Would you mind answering the following:

1. Do you always assess in sidelying?  If semi-reclined, do you start that way and transition into sidelying routinely or if you feel this position may change outcomes? If swaddled elevated sidelying is the typical positon the infant is fed in, yes; if not, I would look at typical position, and then determine if objectifying sidelying as a helpful intervention is indeed justified by the added exposure, based on physiology observed, co-morbidities and interventions trialed.

  2. Do you feed for a certain time frame or percentage of the volume that infant consumes bedside, prior to the study To build in a fatigue factor, I would observe briefly under fluoroscopy at the start of feeding and then feed off line with periodic imaging as indicated for that infant’s differential and based on what is typical for him. That way we see physiology at the start and then intermittently to objectify impact of fatigue on physiology over time.

3. Are there parameters for duration between studies if you note significant clinical improvements during bedside feeds? I typically image as infrequently as possible. If we are not chasing the ‘aspiration” event but rather assessing physiology in radiology, my sense is we then focus on and ask ourselves what component(s) of the etiology (or etiologies) observed on the previous study may have changed in the interim. And if the etiology or etiologies have not resolved, why radiate the infant again with little potential for change in physiology? Too many MDs want us to keep repeating studies to “look for aspiration” and therefore if we “just do one more study” maybe we won’t capture aspiration, right? And then we don’t “capture aspiration” in that moment, and someone concludes incorrectly, therefore, that the infant “passes”, is “safe to feed”, is “cleared to eat”?? That is the thinking I believe that incorrectly follows when the procedure is inadvertently presented as such or viewed as such. That is not the best use of the procedure nor in the infant’s best interest when we look at the “cost ” long-term of added radiation (which we know the AAP is quiet concerned about, especially with infants). The type of “revised” thinking that I am advocating for is often out of the box for many of our neonatologists, but I find that once we have this level of critical reflective thinking and dialogue with neonatologists, then they better understand the role of physiology (normal versus altered versus impaired) and the judicious use of video fluoroscopic swallowing studies in the NICU. They too can learn to look beyond aspiration if we guide them. But it starts with us and these conversations. The dynamic nature of swallowing in the context of the infant’s co-morbidities must always ground us and guide our clinical reasoning.

I hope this is helpful to my NICU colleagues!

Catherine

http://www.Shaker4SwallowingandFeeding.com

Happy Holidays…

I am pleased to post my 2016 brochure that many of you have been asking for. My teaching will take me across the US and hopefully close to where you live. Only one location is still in the works, which is California in September 2016. A few details pending, which I hope will be sorted out very soon. Do you work in California and think your facility might be a back-up option? If so, thanks for emailing me.

As 2015 draws to a close, I count my many blessings, including the opportunity to share my passion for swallowing and feeding with you and your colleagues.
Through teaching, my website, list serve contributions and the thought-provoking emails we exchange regarding challenging patients and the evidence-base, I hope I have inspired you and your passion. May the New Year be especially good to each of you, and I hope our paths cross in 2016.

Merry Christmas and happy holidays!
Catherine

Reflection in the NICU

Those of you who practice in the NICU will enjoy this article by my colleague, Suzanne Thoyre PhD RN, on the use of reflection during the assessment of feeding in the NICU. Together we developed the Early Feeding Skills Assessment Tool (EFS) which is referenced at the end of this article.  The focus herein is viewing an assessment as providing opportunities for infant communication.

I believe that when we conceptualize feeding as a relationship–based experience, we then see our role during feeding as dynamically attending to infant communication from moment to moment, responding contingently to support physiologic and behavioral stability, and therefore averting stress for the infant. This then supports neuroprotection, which is our ultimate goal with both preterm and sick newborns in intensive care. Dr. Thoyre does a wonderful job capturing this concept. Because it is written by an NICU RNs, it is information that will likely be helpful to you in your conversations about cue-based feeding with your nursing colleagues.

“The feeder maintains a goal to optimize the feeding through assessment of infant cues. Assessment skills are deepened through a process of focused observation and reflection on what is being learned (from the infant).  The feeder uses all modalities available to observe and interpret infant communication (both physiologic and behavioral), and reflects on the meaning of the infant’s cues. Cue-based feeding is therefore more than learning to respond to infant distress; it is also learning from the infant how to anticipate what they will need and providing appropriate support so they can have as successful a feeding experience as is possible. Through this process, the feeder supports and strengthens the infant’s efforts, and respects and protects their limits. Assessment of the skills an infant brings to the feeding is essential if we are to provide feeding support that meets the infant’s needs.”

Enjoy this article.

Thoyre Coregulated Feeding Neonatal Nurses 2013

It will inform your practice!

Catherine

Problem-Solving with Catherine

Hi Marla,

I am late weighing in on this interesting discussion. At the end of that post you asked about protocols for “infants with swallowing dysfunction in terms of breastfeeding”.

I am assuming you are asking about infants who are bottle-feeding and breastfeeding and had a swallow study done that showed an impairment or alteration in swallowing physiology with bottle-feeding that resulted in bolus- misdirection and potentially aspiration?

An infant may indeed have an alteration or impairment in his underlying swallowing physiology that will adversely affect the biomechanics of swallowing and lead to bolus mis-direction both toward/into the laryngeal and/or nasopharyngeal airway. In infants of course, who are by nature obligate nasal breathers, the mis-direction and its etiolog(ies) must be carefully considered.

Because of the unique physiology of breastfeeding, it is uncommon that infants will show overt decompensation with breastfeeding but possible. I have found clinically that those infants who decompensate during breastfeeding often have a true alteration or impairment in swallowing physiology. Breastfeeding is actually easier than bottle feeding, even for preemies, so it is possible an infant may not experience an alteration or impairment of swallowing physiology at breast though it was observed in radiology with bottle-feeding. Take a look at the multiple “gold standard’ writings of Paula Meier, Goldfield and Nyquist regarding the unique physiology of breastfeeding suggesting it is likely most supportive of airway protection for infants.

My clinical experience and reading of the literature has lead me to hypothesize  that those infants whose etiology for impaired swallowing physiology is flow rate and/or coordination of suck-swallow-breathe, in the presence of normal structural integrity of the airway and oral-pharyngeal mechanism, may do quite well with breastfeeding. Breastfeeding optimizes flow rate regulation and provides “windows of opportunity” for breathing so well described by Goldfield; it is this then that likely optimizes bolus control. However when there are issues with structural integrity of the airway (i.e. vocal cord paresis/paralysis, laryngomalacia, tracheomalacia) the “protective nature” of breastfeeding may no longer be realized, if you will.

There is no way to study my hypothesis since we cannot observe breastfeeding under fluoroscopy. However, working closely with pulmonologists, ENTs and neonatologist’s, we have together carefully considered each infant, his co-morbidities and what we know from the science of breastfeeding to inform our decisions about breastfeeding given objective data obtained during bottle-feeding.

I suspect your question, which is a good one, may have been prompted by infants who had a swallow study with the bottle from which “aspiration” findings are being generalized to breastfeeding. I don’t think it’s that simple, as I hope my thoughts above suggest.

Unfortunately the complexity of the infants we follow requires us to pause, and think in the “gray zone” as I like to call it. No quick answers but rather reflection, carefully weighing that infant’s history, co-morbidities, clinical and instrumental findings and the evidence-base to complete a solid differential. From there, we dialogue with the team to develop a plan of care and interventions to hopefully minimize risk while optimizing both neuroprotection, skill progression and the infant-mother relationship. It is a challenging balancing act every day for us and so we keep asking questions and learning

I hope this provides some food for thought and is helpful.
Catherine

Greetings from Florida! 

 

It’s like a Fall day here, with temperatures in the upper 70s, breezes and gentle sunshine. Hard to believe it is already mid-October!

This year has flown by! I just returned from a weekend of learning in Boston and am excited to “digest” what I learned and consider its impact on my clinical practice. This week I am off to Texas for my final 2015 seminars. I grew up there and so going back is especially amazing. I am expecting attendees from across the US and internationally, which will add to everyone’s learning experience, including my own.

I have had many requests for my 2016 schedule, which is not yet finalized.
Perhaps it might help you as you plan your 2016 Continuing Education to know at least those dates which are determined. I expect to have the full schedule finalized before Thanksgiving.

May To Be Announced – likely Chicago area:
Pediatric Swallowing and Feeding: The Essentials
Pediatric Videofluoroscopic Swallow Studies
Tracheostomy and Swallowing: Pediatrics to Adult

June 9-13 Atlanta
The Advanced Clinician in Pediatric Swallowing and Feeding
Pediatric Videofluoroscopic Swallow Studies
NICU Feeding and Swallowing: In the Nursery and After Discharge

July 13-17 NYC
Pediatric Swallowing and Feeding: The Essentials
Pediatric Videofluoroscopic Swallow Studies
NICU Feeding and Swallowing: In the Nursery and After Discharge

August 11-15 Denver
Pediatric Swallowing and Feeding: The Essentials
Pediatric Videofluoroscopic Swallow Studies
NICU Feeding and Swallowing: In the Nursery and After Discharge

Sept To Be Announced – likely San Jose CA area
Pediatric Swallowing and Feeding: The Essentials
Pediatric Videofluoroscopic Swallow Studies
NICU Feeding and Swallowing: In the Nursery and After Discharge

Oct San Antonio, TX Oct 12-16
Pediatric Swallowing and Feeding: The Essentials
Pediatric Videofluoroscopic Swallow Studies
The Early Feeding Skills Assessment Tool: A Guide to Cue-Based feeding in the NICU
I hope our paths cross in 2016! Stay in touch with me.
Catherine

Problem-Solving with Catherine

Question:
Hello!  I work in a children’s hospital with a level 4 NICU.  Our SLPs know that thickening is our last resort, so to speak, in terms of interventions that we provide for these infants (positioning, nipple flow rate, etc.)  Our hospital is currently using rice cereal to thicken feedings if needed based on MBS.  We are exploring GelMix as an option, but this hasn’t been cleared by our Neos or GIs.  Does anyone have any evidence/research to support using a combination of 50/50 breast milk and formula and thickening with rice cereal?  We know that rice is broken down in breast milk, but if we do a 50/50 mix, is that enough for the rice to bind and maintain a thicker consistency?  Do any of you have protocols for those infants with swallow dysfunction in terms of breast-feeding?  Thank you so much for any feedback!!

Answer:

At the end of that post you asked about protocols for “infants with swallowing dysfunction in terms of breastfeeding”.

I am assuming you are asking about infants who are bottle-feeding and breastfeeding and had a swallow study done that showed an impairment or alteration in swallowing physiology with bottle-feeding that resulted in bolus- misdirection and potentially aspiration?

An infant may indeed have an alteration or impairment in his underlying swallowing physiology that will adversely affect the biomechanics of swallowing and lead to bolus mis-direction both toward/into the laryngeal and/or nasopharyngeal airway. In infants of course, who are by nature obligate nasal breathers, the mis-direction and its etiolog(ies) must be carefully considered.

Because of the unique physiology of breastfeeding, it is uncommon that infants will show overt decompensation with breastfeeding but possible. I have found clinically that those infants who decompensate during breastfeeding often have a true alteration or impairment in swallowing physiology. Breastfeeding is actually easier than bottle feeding, even for preemies, so it is possible an infant may not experience an alteration or impairment of swallowing physiology at breast though it was observed in radiology with bottle-feeding. Take a look at the multiple “gold standard’ writings of Paula Meier, Goldfield and Nyqvist regarding the unique physiology of breastfeeding suggesting it is likely most supportive of airway protection for infants.

My clinical experience and reading of the literature has lead me to hypothesize  that those infants whose etiology for impaired swallowing physiology is flow rate and/or coordination of suck-swallow-breathe, in the presence of normal structural integrity of the airway and oral-pharyngeal mechanism, may do quite well with breastfeeding. Breastfeeding optimizes flow rate regulation and provides “windows of opportunity” for breathing so well described by Goldfield; it is this then that likely optimizes bolus control. However when there are issues with structural integrity of the airway (i.e. vocal cord paresis/paralysis, laryngomalacia, tracheomalacia) the “protective nature” of breastfeeding may no longer be realized, if you will.

There is no way to study my hypothesis since we cannot observe breastfeeding under fluoroscopy. However, working closely with pulmonologists, ENTs and neonatologist’s, we have together carefully considered each infant, his co-morbidities and what we know from the science of breastfeeding to inform our decisions about breastfeeding given objective data obtained during bottle-feeding.

I suspect your question, which is a good one, may have been prompted by infants who had a swallow study with the bottle from which “aspiration” findings are being generalized to breastfeeding. I don’t think its that simple, as I hope my thoughts above suggest.
Unfortunately the complexity of the infants we follow requires us to pause at each juncture in the clinical process, and allow ourselves to think in the “gray zone” as I like to call it. Not expecting quick answers but rather allowing reflection, carefully weighing that infant’s history, co-morbidities, clinical and instrumental findings and the evidence-base to complete a solid differential. From there, we dialogue with the team to develop a plan of care and interventions to hopefully minimize risk while optimizing both neuroprotection, skill progression and the infant-mother relationship. It is a challenging balancing act every day for us and so we keep asking questions and learning.

I hope this provides some food for thought and is helpful.

Catherine

Problem-Solving with Catherine

Question: Currently have a 6 y/o pt on an inpatient rehabilitation unit.  She is trach and vent dependent following necrotizing pneumonia.  She is allowed to have cuff deflated 3x/day and can use a pmv while cuff is deflated although she is only tolerating for approximately 30 minutes a day. Getting ready to do an mbs, would you assess pt with cuff down and speaking valve on in addition to cuff inflated?  Do people generally wait until a pt is able to tolerate speaking valve for a certain amount time prior to taking pt to mbs.  Is it always safer for a trach patient to eat/drink with speaking valve inline?  We are having some disagreements on the treatment team.  Thanks for your advice/opinions.

Answer: We don’t know much about her history and other co-morbidities, which might affect next steps and treatment plan. But given what we know: it’s great that she is tolerating cuff deflation and is tolerating the PMV for 30 minutes at a time. While in radiology, I would also observe her with the cuff deflated and the PMV in place. That will give you some objective data about the effect of the PMV on swallowing physiology in comparison to physiology without the PMV in place. Typically in pediatric patients we do often observe better driving force on the bolus and better pharyngeal clearing, likely associated at least in part with restoration of subglottic pressure. Also, the restoration of taste and smell is critical for our pediatric patients to help either normalize or enhance the oral-sensory system, which is such a critical variable in both healthy and medically fragile pediatric patients.

The most recent study I am aware of in Laryngoscope 2013 (Ongkasuwan et al, “The effects of a speaking valve on laryngeal aspiration and penetration in children with tracheostomies”) concluded the PMV did not demonstrate a decrease in laryngeal penetration or aspiration. However, this was small sample with quite varied ages and indications for tracheostomy. Most unfortunately, the study only looked at occurrence of aspiration and penetration. As Bonnie Martin Harris has so wisely stated, aspiration and penetration are neither sufficient nor necessary for a swallowing impairment.

So for this discussion, it reminds us that in radiology with this child it will be important to look beyond the effect of the PMV on just “aspiration” and “penetration”. Consider its effect on her swallowing physiology, and its components, which underlie safe bolus transport.

Let us know what your impressions are, Stephanie, so we can further inform our clinical wisdom.

Catherine

Catherine S. Shaker, MS/CCC-SLP, BCS-S
Board Certified Specialist – Swallowing and Swallowing Disorders

Problem-Solving with Catherine

Problem-Solving with Catherine

Question: 
We have a set of 27 week twins who have a 3-year old sibling who was a 24 weeker in our nursery. The 3-year old had a g-button placed before discharge from the NICU (poor feeding, often did not awaken for feedings or show any feeding cues before discharge). She eventually had a fundoplication at 6 months because of persistent emesis/gagging. At 3 years of age she will drink some liquids but does not eat. She gags as soon as her g-button feedings are started and will gag when she sees someone else eating. 2 weeks at a local feeding clinic (a year ago) resulted in this child screaming for 2 weeks and the parents stopped the program and have not sought any other help. The current twin siblings (infertility treatment with medication–first sibling had a twin that did not survive) are also having significant feeding aversion. Mom did not breastfeed the 3-year old, but was consistently in the NICU to feed/care for the infant and provide consistent feeding experiences. The current twins were recreationally breastfed for several weeks before any bottles were given. The female twin is much like her sibling, in that she often will not awaken for feedings at 40 weeks corrected age (she does still have a sm/mod PDA and is consistently tachypneic. The male twin has had persistent gagging and vomiting for weeks. He has more of a desire to eat but takes a long time to “warm up” to the idea with out gagging. Offering a shorter (preemie) nipple seemed to minimize the gagging, especially with the male, and though he takes partial feeds, he frequently vomits during or after the feeding whether nippled over 30 minutes or gavaged over 2 hours. Multiple formulas have been tried (including 7 days of Enfamil AR and 7 days of Neocate, plain MBM,etc) but the vomiting/gagging persists. These parents are sooooo sad that the twins are behaving much like the previous child, but they see a future with 3 children who do not eat. This family lives in a very small town and have little access to feeding therapy. Any suggestions? The male twin had a tongue tie which was clipped several weeks ago. The female twin also has a tongue tie that we have asked ENT to visit, as her mother’s nipples became very painful last week when more breastfeeding attempts occurred. Mom says the babies also gag at the breast. Thanks for any suggestion.

Answer: How very sad. These former 27 weekers now 40 weeks +PMA sound indeed like aversions are present, perhaps due to WOB and struggle to PO feed, as it sounds like, knowing your developmentally-supportive NICU environment, the staff have been thoughtful about supporting them. His gagging at the breast and her not waking for PO (likely not so much only respiratory fatigue as a form of purposeful disengagement due to learned stress) are signals that we need to back off on PO. I would suggest: Hold PO. (1) offer gentle tastes of MBM on mommy’s finger, (2) offer own hands to face, own hands to mouth, and (3) only nuzzle at breast with no expectation on mommy’s part that infant will latch or transfer milk (4) gentle oral cares, no swiping but instead use deep pressure input. I suggest a PEG for both of them, not that I am giving up on their ability to PO feed but rather to promote neuroprotection. Their experience of PO feeding, even with good developmental care, is right now being perceived by them as adverse and is creating stress that can wire their brains away from eating and is doing just that. Given their co-morbidities and parental stress in trying to get them PO feeding, the infants’ stress will only get worse in the short term if they continue to be expected to PO feed. It would be helpful for mom and dad to see the POPSICLE video (“Parent Organized Partnership Supporting Infants and Children Learning to Eat”). It can be found on You Tube under Popsicle Feeding Video. It is the creation of parents of former preterms who were forced to feed and had long-term feeding aversions. The families also have a website called http://www.FeedingMatters.com Their parents need to offer guarded optimism for the feeding futures of the twins. Because sister still has feeding aversions at age 3 does not mean the twins will; however if we continue down the path they are on, it will increase that risk. Every feeding experience matters, and that must be the rationale to support a different plan for the babies in the short-term. I hope this is helpful.

Catherine

Problem Solving Your NICU Role with Catherine

Question: I am a NICU therapist in a 57 bed level 4 NICU, we have a very difficult time convincing physicians of the benefit and necessity for speech therapy and OT in the NICU. Chronic babies are ordered as well as babies with a diagnosed syndrome or cleft palate etc. However babies with bleeds, long term intubation and kids with PMA of 24-28 weeks that should have a consult are sometimes overlooked. Prior to my position here I worked in home care / private practice for 17 years and saw NICU graduates with a variety of feeding and swallowing difficulties many of which stemmed from their early feeding difficulties. Is there a standard ordering protocol, an algorithm or other evidence based clinical procedural means to share with the clinical committee to convince practitioners of the value of our work and place in the unit any input would be greatly appreciated.

Answer:
It is always challenging for NICUs and their nurses to see a need for our services when they have “existed” without the benefit of collaborating with rehabilitation therapists regarding feeding readiness and support for optimal feeding outcomes. Lots of dialogue and conversations are needed with NICU staff and leaders to expose them to current research and what value you add. Focusing on those infants most at risk for feeding problems, based on the evidence, is a good place to start. Take a look at these articles on co-morbidities and feeding written by well-respected neonatal researchers. They profile who are the most at risk fragile feeders and therefore guide us as well to those who will benefit from skilled intervention to support the path to PO feeding via oral-sensory-motor readiness. This includes those born at or under 28 weeks GA, at or under BW 1000 grams and with respiratory, airway and GI co-morbidities. Enjoy these articles!

Jadcherla S.R., Peng, J, et al (2012). Impact of personalized feeding program in 100 NICU infants: Pathophysiology-based approach for better outcomes. Journal of Pediatric Gastroenterology & Nutrition 54(1), 62-70.

Jadcherla, S. R., Wang, M., Vijayapal, A. S., & Leuthner, S. R. (2010). Impact of prematurity and co-morbidities on feeding milestones in neonates: a retrospective study. Journal of Perinatology, 30(3), 201-208.

Park, J., Knafl, G., Thoyre, S., & Brandon, D. (2015). Factors Associated With Feeding Progression in Extremely Preterm Infants. Nursing research, 64(3), 159-167.

Also I wrote this manuscript in 2007. In it there is a set of criteria for referrals in the NICU for feeding support. If I were to write it today, I would add to that criteria but it can be a starting point for you to consider and use in conversations. Shaker, C.S. & Woida, A.M. (2007) An evidence-based approach to nipple feeding in a level III NICU: Nurse autonomy, developmental support and teamwork. Neonatal Network, 26:2, 77-83.

Know that creating a role in your NICU is a journey not a destination. It takes many interactions, patient successes and partnering with bedside nurses to make a culture change that embraces the inclusion of therapists when it comes to feeding. And then it needs to be nurtured every day. Be thoughtful, be informed and be a colleague. Share and listen. Build relationships with nurses who become your advocate. Support families in building a relationship with their infant through feeding, and they will sing your praises to the neonatologists!

I hope this is helpful.

Catherine

Seminars in Seattle

What a fabulous time I had teaching in Seattle at Seattle Children’s for 5 days. The west coast weather was fresh and breezy with none of the humidity of Orlando! Therapists from across the US attended, from as far away as Alaska and New York. It’s amazing how the same professional issues, the same clinical challenges and the same love of pediatric patients brings us together and sustains us in tough times. We problem-solved navigating thickening and not thickening, use of the PMV, considerations for feeding on CPAP/HFNC and the latest data, changing the culture of feeding in the NICU, novel ways to approach use of the tools of the trade (bottles/nipples, spoons, cups, straws) and so many interesting cases. I was honored to have Wolf and Glass, both we well-respected and internationally known NICU OTs, join us. It was memorable to discuss both our common and varied perspectives and walk away renewed by clinical questions. The five days was an opportunity for all of us as a group to advance our critical thinking and discuss key issues. As Oliver Wendell Holmes said “Man’s mind stretched to a new idea never goes back to its original dimensions”.

Now its time to focus on traveling to Houston mid-August to teach at Texas Children’s Hospital. I’ll be offering my NICU and Pediatric Videoswallow Studies seminars, as well as the Tracheostomy and Swallowing: Pediatrics to Adult seminar taught by Michele Clouse. She is known nationally for her clinical expertise with complex pediatric and adult patients requiring tracheostomy. I am also excited to have the chance to connect with Chantal Lau who is a part of the TCH staff supporting NICU. Her NICU research and writings have informed NICU practice, and her new self-paced bottle, in development, intrigues me. I so look forward to connecting with other therapists who share my passion for feeding and swallowing. In the meantime I’ll keep busy continuing work on a new manuscript for publication reflecting my current interests in neuroprotection and feeding.

As the summer passes all too quickly, I am reminded that the best way to live life is to pay full-throttle attention to our passions, our blessings and to each and every moment. And so it is time now to relax, and appreciate both this beautiful day and my family.

Reflux in the NICU

Reflux is a common issue in the NICU and with many of our pediatric patients. The evidence-base for effective interventions is rapidly emerging but is difficult for each of us to stay on top of! This paper by an NICU nurse published in 2012 is a fabulous resource. It does not just provide strategies but looks at the current evidence base as of its publication, and explains so well the “whys” behind the interventions. It is so easy to join a bandwagon and support the latest idea, but having the rationale and the data to titrate the interventions based on the unique issues and co- morbidities of a specific population, such as the NICU, is essential. I hope you enjoy this article on GER/EER as much as I have.

Click this for more info >>NICU GERD Neonatal Netw 2012 (229-41)

Catherine

Problem-Solving with Catherine

Question:


We had a patient last week that was born at 39 weeks and 4 days-no reported complications with birth history/birth.  He presented with frequent desaturations with feeds- dropping into the 70’s with color changes.  This would also occur with non-nutritive suck on the pacifier. The infant was transferred into the NICU.

Speech was consulted to complete MBSS to r/o aspiration.  This was the first contact speech had with this child. He was 4 days old at the time.  Patient presented with strong rooting reflex, tongue protrusion and non-nutritive suck.  He did present with desaturations into the 80’s with non-nutritive suck.  MBSS was completed using a slow flow nipple. Patient was eager to eat. Patient was able to establish non-nutritive suck without difficulty.  Patient had no aspiration, pooling, residuals during the study. He began to desat after 4-5 sucks-O2 dropped down to 70 and then patient recovered after 2 minutes.  Attempted pacing with patient leaving the nipple in the oral cavity but tilting slightly forward and also by removing the nipple from the mouth.  When nipple was left in the oral cavity patient continued sucking. Patient continued to have desats/color changes with each attempt of pacing- pacing was completed after 3 sucks. Oxygen levels dropped into the low 70’s and upper 60’s with each attempt.  Position change to side lying provided no benefit.

My concern with this patient was the frequency of the desaturations that occurred throughout the feeding.  There was also concern that patient did not receive benefit from the techniques used – slow flow, pacing, side lying position.  The feeling of the physician was that infants desat with feeds in our NICU all the time and we just needed to teach him to coordinate the SSB sequence.  The RN reported that it had taken over an hour to feed the patient using the techniques of pacing and side lying with a slow flow nipple.

My question to the group is how typical is this especially in a term infant? Is there something we can do differently to help this baby?  I am concerned with the level of stress that feeding may be causing him and how do we help to decrease this if the above techniques are not working?

We are waiting on cardiology but the feeling of the physicians is that this is just a coordination problem since it only happens with the nutritive and non-nutritive suck.

Thanks for your thoughts.

Answer:
Desaturations with non-nutritive sucking in an otherwise healthy newborn is not normal. The question is, is he really a healthy newborn? The results you provide from the swallow study and your clinical assessment both suggest that, despite typical interventions (such as positional changes, co-regulated pacing and flow rate regulation), there is something about the aerobic demands of sucking that result in his inability to adequately oxygenate.

The neonatologist’s statement that “infants desat with feeds in our NICU all the time and we just needed to teach him to coordinate the SSB sequence” minimizes a critical component of completing a differential in the NICU — context and co-morbidities matter. Desaturations in and of themselves have limited meaning; the meaning of the desaturations is best understood in the context of each individual infant, his history and co-morbidities. Desaturations with the pacifier is often  for instance observed in a preterm infant with cardio-respiratory co-morbidities who is allowed to suck continuously on a pacifier; co-regulated pacing can often avert that.

The behavior this term infant presents gathers meaning, and directs the next steps in a differential, only in context: history/co-morbidities, what other behaviors co-occur with the desaturation events, as well as the important clinical data that the interventions you trialed during the swallow study did not avert the decompensation. This, then, is a very different picture than what the neo considered. The impression is one of pathology. While the infant did not aspirate or apparently mis-direct the bolus during the VFSS, the integrity of his feeding/swallowing is impaired. Competing the differential of “why “will require cardio-respiratory work up. I have seen many infants for whom impaired feeding is the impetus for a cardiology consult and often that is the unsuspected co-morbidity. Let us know what cardiology finds.

Sad that the staff fed the infant for hour. Someone was not listening to the infant’s communication, which likely showed disengagement long before. We don’t know the caregiver’s perception of her role in feeding NICU infants, but I suspect it is to get the volume in. The caregiver actions adds one more factor in a feeding/swallowing differential.

In the thread there have been mention of a couple possibilities I’d like to touch on. Offering oxygen in some cardiac presentations can actually worsen the infant’s status. Oxygen, one neo told me when I was first starting in the NICU almost 30 years ago, can be toxic. Again the neonatologist’s looking at the possible co-morbidities is essential to guiding management.

Concern that the infant may be “working too hard” using a slow flow nipple  was also mentioned. It is not uncommon for NICU nurses to share that concern as well. Actually research has shown just the opposite,that it is not the work of sucking that fatigues infants, it is the work of trying to breathe in the presence of a flow rate beyond the infant’s capacity. Studies have shown that infants who received a flow rate they can regulate actually take more volume than when offered a free flowing nipple. The concept is that during feeding, fighting the flow to breathe adversely affects ventilation, i.e., the infant breathes less often because he is spending more time swallowing; the less time spent in deep breathing, the more likely saturations are to decrease and stamina suffers. A slow flow rate is also most like the breast flow, which has been shown as well in the literature to be a key factor in maintaining physiologic stability during breastfeeding, even in tiny preterm infants. The literature regarding breast flow is quite instructive for those of us who support bottle feeding in the NICU.

So increasing flow rate for this infant, as you suspected, Ginger, would indeed make the situation worse. The fact that your interventions which are clinically sound did not improve saturations is a key factor that the neo just did not consider. If we increase the flow rate, we would see further physiologic decompensation, as he would breathe less often, perhaps we might even see true bolus mis-direction, as the infant may “open the airway” to catch a much needed breath, and then mis-direct the bolus. The infant’s physiologic stability, his ability to regulate multiple systems and his experience of the feeding would be worsened. In addition, the negative learning that has already unfortunately likely taken place would be exacerbated.

I hope this is helpful.

Catherine