Q & A Time: Problem Solving with Catherine
Infants of diabetic mothers in the NICU
Question: It seems as if our NICU has had an influx lately of infants whose mothers were diabetic. I have found these babies to be very poor feeders. I am sure those of you who work in the NICU have had these babies also. I want to get some feedback from my colleagues about treatment techniques with these infants. Besides pacing and using slow flow nipples are there any other techniques you use with these babies?
Answer: I agree that Infants of Diabetic Mothers (IDMs) are a challenging population. Due to the high sugar environment in utero, their blood sugars are initially off, and as a result they are very sleepy. Poor state regulation with the resulting inability to sustain alertness and drive/stamina for feeding is common; as their sugars normalize, we expect their state regulation to begin to normalize. They often also have increased WOB and intermittent tachypnea. This not only affects safety of suck-swallow-breathe coordination, but also stamina secondary to respiratory fatigue. Unfortunately, these infants are often term or near term, though not always. They can look “bigger” though they are often a bit low tone, most often described as being “doughy” as this is not typically true hypotonia (i.e., with a neurological etiology) but can be more transient. That said, if an IDM makes slow progress in feeding skills, neonatologists will often study the infant’s head, as these infants are at high risk for brain malformations due to the intrauterine environment.
Most helpful interventions include: alerting techniques, re-alerting when infant becomes passive (so he is active with the feeding); avoiding any prodding or passive manipulation of the nipple/bottle/infant’s cheek or jaw–these interventions increase flow passively and can create safety issues and lead to feeding refusals; swaddling securely in flexion for feeding, supporting all limbs to body midline, hands near face–and re-swaddling after alerting infant versus feeding him “unswaddled”; use of a slow flow nipple to optimize swallow-breathe coordination–avoiding medium and high flow nipples that empty the bottle but are not supportive of coordinated feeding; I tend to not use chin/cheek support, as it increases flow rate and bolus size, which is often problematic if there is truly low tone. Also helpful is co-regulated pacing based on the infant’s continuous feedback regarding swallow-breathe timing and physiologic stability; concentrating the formula to increase caloric density so infant does not have to take as much volume while he is learning; respecting the infant’s signs of disengagement and not steering them back to sucking when they disengage; providing thoughtful and consistent anticipatory guidance and guided participation for all caregivers and especially families so they can understand and support the infant’s developmental strivings and emerging skills.
The biggest challenge as I see it with these infants in the NICU is getting everyone on the same page so we all let the infant guide us, via his communication, versus doing whatever is necessary to empty the bottle.