Q & A Time: We are currently devising an Infant-Driven Feeding Protocol for our level 3 NICU…

Question: We are currently devising an Infant-Driven Feeding Protocol for our level 3 NICU and have come across some differing opinions regarding our definitions of what are and are not significant episodes (or events) for RNs to be noting and charting. Nursing in our NICU feels that 02 desaturations should only be documented if they are below 85% AND lasting 20 seconds. This seems like a fairly long amount of time to the speech-pathology staff. By not charting shorter events, we are concerned that nursing will not recognize the need for intervention in infants who are experiencing incoordination of their suck-swallow-breathe or who may be aspirating. I am curious what other NICU’s use and qualify as “significant feeding events” as well as if you differentiate between feeding-related oxygen desaturation/apnea/bradycardia and other A/B/Ds. Most literature I have been reviewing regarding 02 desaturations only states the % as a requirement.
Answer:
Your frustration is shared by many I suspect. There are multiple levels to this concern, and that it is often a challenge for SLPs as we try to build the culture of feeding that creates a level of concern for all physiologic instability, even those events that don’t “last as long” as that NICU’s criteria, or those more subtle behaviors during feeding whose early onset signals an imminent event of physiologic decompensation.

Each NICU will have its standards about how the significance of an event (apnea, bradycardia, desaturation) is defined. Depending on the prescribed range of saturations tolerated/accepted for a particular infant (usually its specified in an order), a particular saturation value will have different meaning. Most often as I teach  across the US and consult at NICUs,  85% is most typically the lower limit acceptable. Issues of probe placement, correlation of HR with pulse rate reading, and symmetry of the saturation wave, are all important variables when determining if a saturation level displayed is “real”.

Most NICU charting requires that the desaturation charted includes context of the event (i.e. sleeping, feeding, being held, during another type of procedure). By the time the saturation registers on the monitor, time has already lapsed from the time the event occurred to when the monitor captures it and then the number you see is an average over that time period. In the context of feeding, whether it is apnea, bradycardia or destauration, the infant will have given cues or shown behaviors that reflect the beginning of decompensation long before the monitor registers it. So the monitor read-out becomes a confirmation, with objective specificity (i.e., how low the HR dropped, how low the sats dropped, how long the infant held his breath), of what we are already observing while watching the infant feed. That is why we discourage RNs from watching the monitor while they feed infants and encourage all feeders to watch the infant. By the time the monitor tells you there is a problem, the infant is already in trouble.

That said, the objective information from the monitor helps to put the event in perspective, and is thus valuable. Even if the sats don’t “stay down” 15 seconds, the fact that something caused them to drift down during feeding warrants further consideration, such as why did that happen? what might be the etiology (i.e. obstruction of the airway with part of the bolus, laryngospasm due  to EER during feeding, a low hematocrit that resulted in desaturation with the aerobic demands of  feeding etc.). So you see the bigger question or challenge in this scenario is helping the staff embrace the bigger concept that the infant’s experience of feeding  is closely tied at a fundamental level to the infant’s physiologic stability, and that swallowing and breathing, and the extent to which they stay coupled or become uncoupled, has the potential to result in bolus mis-direction of many types and indeed airway compromise.

The physiologic impact of feeding which results in A/B/Ds is concerning to SLPs in and of itself, regardless of the lowest numbers or the length of the event. That is because we are tuning in clinically to what the infant is doing at that moment, during the event and after the event (i.e. tuning in to color, respiration, WOB, suggestion of bolus mis-direction, swallow-breathe coordination etc.) and using all the information the infant gives us, including his non-physiologic stress behaviors, to then prophylactically and contingently respond with interventions to help the infant maintain or re-gain stability during feeding.

Many wonderful neonatal nurses also use the paradigm I just delineated when they provide watchful vigilance during PO feedings with preterms. There are likely some of these RNs in your unit and they should be a part of developing/refining/implementing your infant-driven feeding protocol. Perhaps think of forming a feeding council to bring this forward as a team, and seek out a neonatologist as your champion to be a part of the group as well. The change away from a volume-driven NICU brings forth many issues, and more of them are likely ahead as you tackle this change in feeding culture. Having a feeding council or committee to begin the collegial discussions is essential for buy in, for re-looking at “old ways” or less helpful ways of doing things, and for discussing your NICU’s guidelines for events, their current significance and their possible significance in an infant-driven culture.

Changing the culture of feeding, which goes hand in hand with implementing cue-based feeding, is a process that takes time and requires interdisciplinary collaboration and much  thoughtful reflection. This question and others that arise during this process, and how they are considered and determined, will drive how well your  NICU evolves and how readily they implement feeding focused on the infant and include you in this journey.

——————————————-
Original Message:
Sent: 08-30-2012 01:53 PM
From: Danielle Lipke
Subject: NICU feeding protocol

We are currently devising an Infant-Driven Feeding Protocol for our level 3 NICU and have come across some differing opinions regarding our definitions of what are and are not significant episodes (or events) for RNs to be noting and charting. Nursing in our NICU feels that 02 desaturations should only be documented if they are below 85% AND lasting 20 seconds. This seems like a fairly long amount of time to the speech-pathology staff. By not charting shorter events, we are concerned that nursing will not recognize the need for intervention in infants who are experiencing incoordination of their suck-swallow-breathe or who may be aspirating. I am curious what other NICU’s use and qualify as “significant feeding events” as well as if you differentiate between feeding-related oxygen desaturation/apnea/bradycardia and other A/B/Ds. Most literature I have been reviewing regarding 02 desaturations only states the % as a requirement.