Article review: “A novel approach to assess oral feeding skills of preterm infants” by Chantal Lau and E.O. Smith (2011) Neonatology. 100:64-70.

The tool described, developed by a well-respected NICU researcher, Chantal Lau, used a subject population of “healthy” preterms. Healthy preterms are those without co-morbidities, and defined in her paper as “feeders and growers” with a primary diagnosis of prematurity — clinically stable, demonstrating signs of  “immature” systems, e.g., immature lung function, that resolved with maturation. These are NICU infants for whom therapy is not typically consulted, as they tend to progress with maturation, precisely because they do not have co-morbidities.

Excluded from her study population where infants with co-morbidities, including respiratory (Chronic Lung Disease, vent course, respiratory sequelae secondary to being  born at < 28 weeks gestation), GI, airway, neuro, lower BW). These co-morbidities have been shown to significantly increase the transition time to full PO feedings in NICU infants and also place these infants risk for adverse feeding outcomes through the toddler years and often beyond. See: Kirk et al (2006)” Risk factors for poor feeding progression in preterm infants” Journal of Investigative Medicine 54-s98; Jadcherla et al (2010) “Impact of prematurity and co-morbidities on feeding milestones in neonates: A retrospective study” JPerinatology 30:201-208.

The tool described in Lau’s article does not have applicability to the NICU population we see as NICU SLPs, as it was not studied with that population. We can profile relative risk for feeding problems in the NICU population we see and assign a relative number value for risk through use of the NMI (Neonatal Medical Index). See Shaker & Woida (2007) ‘An evidence-based approach to nipple feeding in the NICU: Nurse autonomy, developmental support and teamwork” Neonatal Network 26:77-83. Lau’s tool is not appropriate for the typical NICU infants on our caseloads.

Indeed, the focus of the tool Lau describes is on volume transfer and intake, historically a key measure of feeding success. However, many NICUs are witnessing, and in some NICUs SLPs are leading, a movement away from volume-driven feedings in the NICU (numbers, intake) to “infant-driven feeding” (quality of the feeding, positive experience, during which  the feeder relies on the infant’s feedback from  moment to moment to guide co-regulated responses). Hopefully in your NICU a culture change is underway.

Q & A Time:  As you know, Swallowing and Feeding, and the infants and children we serve,  are my passion. I am dedicated to clinical exchange through bringing you new research, problem-solving patients and sharing ideas about current clinical issues.

A recent SLP graduate asked, “What is the best way to get some good foundational training to begin Pediatric Swallowing treatments in a Hospital/Out Patient setting?”

Answer:

A broad foundation in pediatric feeding and swallowing is essential for pediatric practice in outpatient or acute care This includes: normal development, atypical presentation, sensory-motor underpinnings, assessment components critical for a differential, the range of interventions from neonates to school age and their evidence-base, and problem-solving strategies. I find it most helpful for clinicians new to the specialty of pediatrics to gain knowledge, skill and experience in an outpatient setting, which provides exposure to variations of normal as well as pathology, typically with a wide range of etiologies. It allows one also to gain experience in supporting families in crisis, but on a less intense scale than acute care. Acute care by its nature requires a higher level of expertise and ability to complete a differential, and presents patients that are more high-risk; the foundation gained through outpatient practice is invaluable. Knowledge gained from seminars, observations, mentors and the literature can together set the stage for effective pediatric practice. What I know for sure is that learning goes on, no matter how long you have practiced in pediatrics. After almost 35 years in Speech-Language Pathology (I got my Masters in 1977 :-), not a day goes by without my learning something, from another SLP, an RN or MD or an article I read, and that is both the joy and the responsibility of our profession.
Catherine