Q & A Time: Working at more than one hospital…

Q & A Time: Problem-Solving with Catherine

Question: There are several different hospitals with NICU’s in my general area and many of our nurses float between hospitals. Periodically one will question the differences in speech services in the different NICU’s. In particular one NICU has a plethora of SLP’s who work there full time (contracted in) and typically feed a majority of the babies every day (or so I am told). Comparatively, our NICU has one SLP (me) where I typically feed the babies on my list once every 1-2 weeks  – with a tx focus more on sensory stim, tongue thrust reversal, NNS and oral reflex stim. I am wondering what other NICU’s are doing around the country? How often do you see each baby and is feeding part of your tx at each visit? Thank you in advance,

Answer:
Roles of the SLP in the NICU vary depending on the particular NICU, and, of course, on the SLPs perspective, expertise and passion, as well as logistics of budget, staffing and training.
Some NICUs are much farther along in the transformation from volume-driven to infant-driven feeding. As such, they can more readily benefit from a more consultative model similar to what you describe you describe. Even so, typically, our presence on a regular basis is critical and builds the relationships necessary to give us value in the NICU as a resource for research, the latest information about swallowing/feeding and outcomes, guiding parents, providing in-services, and having “casual” conversations with staff (both MDs and RNs) as colleagues, which provide a basis for mutual respect and problem-solving together both in the present and the future. This provides the basis for “belonging” to the team. It does not happen overnight but it is a journey every NICU therapist, I believe, mustembrace.

Due to the positive influence of maturation, as well as the adverse effects of changes in medical status (i.e., decline,weaning of supports, fluctuations in the influence of current and new-onset co-morbidities etc.), a frequency of every 1-2 weeks would be very limiting. It doesn’t typically allow for the collaboration from day to day with RNs/Neonatologists, problem-solving, parent teaching and guided participation, updating of suggestions, as well as actual therapy to improve function, be it for feeding readiness or safe and efficient swallowing/feeding. Preterms and often sick newborns in NICU change daily; our input is critical regarding resulting changes in  recommendations/suggestions, progression to PO, and for advocating for neuro-protection for the developing preterm, for whom the “work” of feeding may present new and perhaps more concerning safety issues over time. Nothing in NICU is static. Each day, each session, each interaction with caregivers/staff brings a new perspective and perhaps a different level of support needed from day to day.

I hope this is helpful.

Catherine
Catherine S. Shaker, MS/CCC-SLP, BRS-S
Board Recognized Specialist – Swallowing and Swallowing Disorders
http://www.Shaker4SwallowingandFeeding.com

Q & A Time: Problems-Solving with Catherine

Question: This week I had a baby who was only 34 wks, 1 day (born at 29 wks) and doctors were pushing PO feeding and discharge (because I have a magic wand that can get a baby feeding in 24 hrs- sarcasm noted :). With a slow flow nipple, pacing to 3, and inclined/sidelying position, the baby had 3 episodes of desaturations and one episode of bradycardia. So, I talked with the doctors about trying the Bionix Controlled Flow nipple. I have used it 2 consecutive days, and baby’s intake was 6 cc’s on the first day with advancement to setting “2” and 11 cc’s on the second day, with advancement of setting “3”. No more episodes of bradycardia/desaturations. Pt does have some stress noted as I advance settings, but I normally will stop advancing if pt shows signs of stress and he has seemed to tolerate it as we keep going. I’ve also implement pacing to help.
My question was, what types of patients benefit best from using these bottles? It seems as if it’s a good way to work on swallowing on the young babies (34-35 wks) without going quickly to a MBSS and giving them time to grow. If pt was 36+wks I would be quicker to move towards a MBSS, but bc of his age, I kind of want to give him time and practice before I radiate him so young. Does that line of thinking make sense? This is only my 2nd time using the bottle and it seems to be working well- giving the baby practice every day without overloading him. Any other specific cases in which this bottle worked well? Thanks in advance for your input! Sorry such a long post!

Answer: You don’t mention much about his history except that he was a 29 week GA infant. As a former 29 weeker, this infant likely has respiratory co-morbidities. I suspect he is in RA as you don’t mention any NC02. Not sure how early your NICU typically discharges but for a 29 weeker, discharging at 34-35 weeks PMA is not typical; an infant with his history is unlikely to be even a marginally-skilled feeder by that post menstrual age (PMA). He likely needs careful co-regulated pacing to support coordinated swallows.

It is true that swaddled sidelying and limiting the bolus size are  key interventions with preterms, as is using a slow/controllable flow rate.

A couple thoughts for you.

The external pacing you report providing with the slow flow nipple every 3 sucks may not have been a match for his needs. What I think of as providing  “pacing” is to  impose breaks from sucking to facilitate a pause in sucking, to allow for swallowing without delay, and then support the immediate initiation of several deep breaths. If the caregiver arbitrarily imposes a break in sucking at predetermined junctures, i.e. every 3 sucks, we take the infant’s communication from moment to moment out of the equation. The infants communication tells the caregiver when to impose a break, That is why I like the term “co-regulated pacing”–that means the infant and the caregiver have a reciprocity during feeding such that one guides the other. For a description of  the communication signals the infant uses to guide the feeder, you can look at the ASHA Leader February edition 2013 for the article I wrote entitled “Reading the Feeding”  in the NICU. You can also find it on my website www.Shaker4SwallowingandFeeding.com under the TAB “publications”. If we use the infant’s communication to guide the pacing, you then don’t arbitrarily pace at 3-5 sucks for example. You support the infant from moment to moment. So maybe with a slow flow nipple, i.e. Enfamil’s, you might see he showed you cues after one suck or two sucks; if so, waiting until 3 sucks may have given him a bolus that was too large, or that delayed the re-initiation of breathing too long, and caused swallowing and breathing to become uncoupled.

The Bionix bottle/nipple can also limit bolus size but I find the design of the nipple is not developmentally-supportive for the oral-sensory-motor system of the preterm. While its shape is consistent with what the evidence-base suggest is optimal, the hard tubing running down the center of the nipple (which is necessary to regulate flow in Bionix design) provides an atypical stimulus for the tongue, not like the breast certainly (which is soft and moldable during breastfeeding) and not like a typical bottle nipple (which can be compressed with no “hard” input).

For preemies, who already are in an altered sensory environment and are wiring their brains outside the uterus, we must all be thoughtful about any sensory input we provide/offer. Every experience matters in the NICU, especially with feeding. So I encourage you to look at Reading the Feeding, go back to the slow flow nipple and use all the other good interventions you mentioned. Watch the baby; let him guide you about what he needs and co-regulate the feeding. You don’t need the Bionix bottle in my experience.

I agree that going to radiology is not the next step given what you have told us.
I hope this is helpful

Catherine
Catherine S. Shaker, MS/CCC-SLP, BRS-S
Orlando, FL
http://www.Shaker4SwallowingandFeeding.com

Hi!

This week I had a baby who was only 34 wks, 1 day (born at 29 wks) and doctors were pushing PO feeding and discharge (because I have a magic wand that can get a baby feeding in 24 hrs- sarcasm noted :). With a slow flow nipple, pacing to 3, and inclined/sidelying position, the baby had 3 episodes of desaturations and one episode of bradycardia. So, I talked with the doctors about trying the Bionix Controlled Flow nipple. I have used it 2 consecutive days, and baby’s intake was 6 cc’s on the first day with advancement to setting “2” and 11 cc’s on the second day, with advancement of setting “3”. No more episodes of bradycardia/desaturations. Pt does have some stress noted as I advance settings, but I normally will stop advancing if pt shows signs of stress and he has seemed to tolerate it as we keep going. I’ve also implement pacing to help.
My question was, what types of patients benefit best from using these bottles? It seems as if it’s a good way to work on swallowing on the young babies (34-35 wks) without going quickly to a MBSS and giving them time to grow. If pt was 36+wks I would be quicker to move towards a MBSS, but bc of his age, I kind of want to give him time and practice before I radiate him so young. Does that line of thinking make sense? This is only my 2nd time using the bottle and it seems to be working well- giving the baby practice everyday without overloading him. Any other specific cases in which this bottle worked well? Thanks in advance for your input! Sorry such a long post!
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Mandi Hatfield
Augusta GA
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