Problem Solving: NICU services

Question: Recently I have accepted a new and exciting position at a specialty hospital where I am one of 2 SLPs working solely in the NICU. The rest of the NICU therapy team is composed of OTs. Both OT and Speech provide feeding and swallowing assessment and treatment. Speech interprets the MBSs while OT provides the feeding during these studies, which works great! The potential challenge we see is how do both therapies provide services to an infant and her caregivers without creating a duplication of service when both disciplines treat feeding and swallowing? Does Speech take certain diagnoses, such as all clefts, craniofacial anomalies, etc. and OT the “feeders and growers?” Or do we divide the new orders in half? Has anyone else dealt with, or are you dealing with this? What solutions have you found?

Answer: Actually, all staff in the NICU either support or do not optimally support feeding/swallowing in the NICU, from the first day of life. To the extent that self-regulation is supported during all activities and interactions, the infant wires his brain and entrains the sensory motor system optimally. This then supports the integration of subsystems that underlie safe and effective feeding. Through co-regulation with the infant, i.e., contingent responsiveness by the feeder to the infant’s continuous feedback during feeding, the infant’s self-regulation and therefore physiologic stability, and safe swallowing, can be optimized.

Swallowing and feeding are viewed and supported within the context of the whole infant, the entire team, including the family, and the medical complexities/co-morbidities. A focus on infant-guided versus volume-driven feeding is essential to minimizing stress during feeding. Recent studies have shown that stress in preterms is associated with changes in the structure of the brain. So all of us in the NICU have the potential to either support or constrain the infant’s development, through feeding, both in the short-term in the NICU and in the long-term.

The science and evidence-base regarding neonatal swallowing, its relationship to physiologic stability and postural control, the influence of flow rate on airway protection, the relationship of sucking rate, bolus size and respiratory pattern to safe swallowing must be well understood. Recognizing the uniqueness of the preterm’s anatomy and swallowing physiology, his signs of engagement and disengagement that signal stability versus disruption of the swallow-breathe sequence, awareness of adaptive/compensatory behaviors during feeding, and what are supportive versus non-supportive interventions, are all essential.

Those who support feeding/swallowing in the NICU have the responsibility to bring this level of information-base to the infant and his family, in order to guide the entire team toward infant-guided co-regulated feeding.

Problem Solving: Benefits of sidelying position for infants

Question, with my responses in BOLDHi Catherine – I was hoping to pick your brain on the sidelying position. I am wanting to understand more how and when people are using this technique. The information I have received has been mixed on the safety and purpose. I saw that you mentioned it in your response so I was hoping to get your take.

We have a unit in the area that uses it for all of their babies. I have seen a lot of kids who are still being fed in this position at 3-6 months of age. This can of course be problematic – any intervention must be used by therapists with thoughtfulness and critical thinking. I suggest to parents to determine readiness after discharge to move to a more typical position by “asking” the infant during a feeding, i.e., attempt to feed the infant in the more typical position and then observe – if the infant does as well as he did in sidelying, or better, in terms of feeding quality (based on stress signs specific swallowing and breathing, or lack thereof, which they have learned before discharge), then try changing to that position for feedings. If the infant does not do as well quality-wise with feeding, he is “telling you” he is not ready for the change in position. I find that about a month after discharge is a good time to “ask” the infant. Just basing it on age is not useful as age itself has little relevance to the prerequisites for a more challenging position, developmentally, posturally and swallowing-wise. We had one child that appeared to have asymmetrical facial features and in the end determined it was from always being fed in that position with a hand on his face and sleeping in that position as well. Those problems may have been co-occurring versus due to use of sidelying –I have not had that happen—but we (ST, OT in NICU) also reinforce thoughtful variety in infant experience. Variety is the key for infant’s at all ages – non-feeding times need to offer a variety of sensory-motor/postural experiences critical for motor learning.

I have been looking into the reasoning they provide families, and it is that food can then pool in the cheeks instead of the throat, to give more time to swallow, and because it’s “beneficial”. My concerns come into play in these areas: 1. Neonates don’t have buccal cavities because of sucking pads Most preterms do not have sucking pads, as they are believed to develop at approximately 36 weeks in utero. Regarding “pooling in cheeks” I don’t think that is good either. 2. Pooling anywhere is concerning, especially when you have significant respiratory concerns and are learning to coordinate the suck/swallow/breathe yes nothing should “pool”; it implies pathology 3. Possible muscle asymmetry created I have not seen this happen as noted above, with the right sensory-motor “environment”, both for feeding and non-feeding times 4. Losing focus on the underlying reason why eating is difficult and pushing before a baby is really ready. Sidelying itself does not push a baby to eat before he is ready, caregivers do. For me, use of sidelying has nothing to do with intake or pushing a preterm to feed. If I determine a preterm is ready to initiate nipple feeding (based a variety of critical domains assessed), I will typically utilize inclined sidelying (i.e. head higher than hips) as a supportive intervention.

I am completely open to learning, but just haven’t gotten much feedback from the professionals I have asked about them “why” of doing it and for which populations they are using it. I have been told my one that she uses it only with older infants that are struggling and by another that she only uses it in a temporary, transition role for 2-3 days for babes that are struggling with still after use of pacing and the slowest flow nipple. I cannot speak to their rationale but only mine, based on my clinical experience with breast and bottlefeeding of preterms, my NDT training, the literature and reflective thinking. I’ll try to hit the key points given the limited space and time. I offer more detail and problem-solving when I teach (see website below). (1) It affords more ease of anterior-posterior rib cage movement (so less effort for the preterm’s musculoskeletal system); (2) It increases lung compliance and decreases airway resistance (per work by Mary Massery, PT and Donna Frownfelter, PT who focus on breathing) (3) It decreases work of breathing due to requiring less anti-gravity movement during breathing (compared to semi-upright or cradled) (4) Makes it easier to maintain head and trunk alignment (5) Provides increased ability to generate subglottic pressure, as opposed to when upright; this may functionally assist effectiveness of cough, if indeed a cough is required, and the infant generates one (6) Bolus flow is less adversely affected by gravity as it can be in semi-upright), which can likely reduce potential for bolus misdirection (7) It is very similar to the cross-cradle position for breastfeeding, which is our benchmark for optimal oral feeding experiences (8) Clark et al, 2007 noted better oxygen saturations and less HR variability with use of sidelying with preterms (8) Suzanne Thoyre PhD at UNC-Chapel Hill, one of my colleagues, is currently studying sidelying with preterms, contrasted with cradled in arms position and semi-upright position; thus far the data are overwhelmingly supporting better state regulation, better swallowing and better physiologic stability with sidelying. (9) I have noted clear improvements in the swallow in Radiology with sidelying as compared to semi-upright with preterms.

Over the last 27 years in the NICU, I have found sidelying, along with slow/low flowrate and co-regulated external pacing, to be one of the most critical interventions to support positive and safe feeding experiences with preterms.

Problem Solving: NICU infants with GER

QUESTION: I have two infants that I am currently treating who were both preemies one extremely premature and one late-preterm. However they are both showing similar s/s that seem to be cues of bigger issues that are not clear to anyone right now. Would love some open discussion and feedback.Both have had VFSS which showed some oral disorganization however pharyngeal stages looked decent organizing in valleculae at appropriate ages. Both babies have been worked up by pediatric GI with suspected milk allergy and are on Nutrimagen.

Taught families to read baby’s cues as first tasks in plan of care and addressed nipple flow rates. One baby with similac slow flow and other with haberman. Both babies take on average one ounce and stop which is a good feed. Some feeds all feed is gavaged due to crying and fussing to point of exhaustion.

Had parents swaddling babies for first several months and now older baby still likes swaddle at time and younger baby is in phase where as soon as mom swaddles she begins to fight and scream.
Both babies have had EGD with no remarkable findings other than which we already knew GERD/EER. Both babies on appropriate H-2 blocker for reflux.

I have had several colleagues comment that they have had similar cases in past and never felt they got anywhere and I just can’t except the we don’t know answer. These two girls cases will drive me crazy until we find the right combination for them as you would expect they both show significant aversions to each and every feed and parents report their best feeds are the “dream feeds”. I would love whatever input is out there to help me continue to piece these girls puzzles together. Thank you!!!

ANSWER: It sounds as though GER/EER may indeed be part of the picture. it is helpful that they did an EGD to ruleout Eosinophilic Esophagitis; not often done in NICUs. That at least tells us that positive intervention strategies due to GI issues will include: frequent burps, not allowing gulping, reducing air swallowing and smaller more frequent feedings, all of which will help these preterms.

The specifics of the post don’t mention GA or current PCA for either infant but we know one is extremely preterm (so I am thinking at or under 28 weeks GA) and one is a late preterm. We know from the literature that the extremely preterm infant is profiled as a high risk fragile feeder due to her co-morbidities, which include very likely respiratory co-morbidities. For her, that may be a bigger influencing factor than the EER. There is the potential for increased WOB and intermittent tachypnea at baseline , and then a subsequent increase in both due to the aerobic demands of feeding, with resulting respiratory fatigue. Her signs of disengagement (i.e., signalling she is done via not rooting or not continuing to suck) may indeed be driven by respiratory issues as much as the effects of EER. Your description of her recent feeding behaviors strongly suggests a primary respiratory issue adversely affecting feeding. I’d tend to stay away from thickening as it has its own adverse sequelae in neonates and stay with effective “co-regulated” external pacing combined with a slow controllable flow rate, sidelying and respect for infant’s signs of engagement and disengagement. Sounds like you are already doing that. Depending on her history, asking/expecting her to take all feeds PO may be beyond her capacity to do so. Caregivers who, with good intentions, “feed past her stop signs” with a focus on “volume-driven” versus “infant-guided” feeding experiences may indeed reinforce negative learning and wire those neural pathways which will ultimately move her “away from” the desire to feed.

The late preterm infant, surprisingly, is in a group, “late preterms”, who, according to the most recent literature, are more likely to be re-admitted for poor feeding than extremely preterm infants. That is because they too have the key co-morbidities, which often get less notice as they are perceived as “a little newborn” by some caregivers. These co-morbidities include respiratory, due to immature lungs and RDS (although more subtle than infants of younger GA)but still adversely affecting coordination and drive to feed. In addition, their other common co-morbitidites often include decreased postural control, hypoglycemia and jaundice, and reduced state regulation (all of which can reduce drive to feed and result in poor endurance and suboptimal intake). Re-alerting strategies are important for this group, as is controllable/slow flow and co-regulated external pacing in a swaddled sidelying positon.

The infant you mention below, whom you fed at 9-12-3 sounds as if she may be the former extremely preterm infant. Her adverse overt behavior of coughing, combined with uncoupling of breathing and swallowing (reflected in gulping, eyebrow raise, eyebrow furrowing and movement into extension) suggest the workload may be beyond her skill level and she may be becoming an unsafe feeder at times, despite having no bolus mis-direction during the VFSS. Look to see if feeders are truly offering co-regulated external pacing; her adverse behaviors you mention below suggest a need for better co-regulation, i.e., breaks could perhaps be offered more contingent on her signs of impending incoordination, to avert stress behaviors by facilitating a stable burst-pause pattern and better swallow-breathe synchrony.

Helping all caregivers recognize that we cannot push preterms beyond their capacity is critical. I think you are providing wonderful infant-guided support. Be careful to not get pulled into the “volume means success” mantra that for years was the guide in the NICU. Both infants, from the limited description, are preterms who may not be able to be full PO feeders in the near future, but they can be supported to have positive experiences no matter what amount they take.