Question: Providing cheek support in the NICU
If an infant has an inefficient suck because of lack of buccal fat pads and often slightly low tone the combination can result in too wide a jaw excursion and a very inefficient suck. Why would you not give jaw and cheek support (as needed) to make the whole coordination process easier and less fatiguing? If the baby’s resulting suck then is strong enough to receive too fast a flow, I would think that the solution would be to use a nipple with a slower flow rate, not eliminate the support that improved the suck. If nurses are giving too much support, it would also help to provide the training to create guidelines for the amount of support that is just right for each infant.
With all of our NICU babies, the value or adverse effect of strategies requires consideration of a number of underlying and related issues. One must consider the whole infant, i.e. co-morbidities (respiratory, airway, sensory-motor, and GI) when looking at supportive/compensatory techniques for feeding/swallowing.
Sucking pads are believed to develop in the last month of intrauterine life, so approximately 36 weeks in utero. So they are not available to many preterms. In normal postural/oral-motor development, the cheeks and lips are not active (i.e. not used) for feeding in the normal newborn until he is 3-4 months of life. Prior to that time, the cheeks/lips (they work as a system) posture on the nipple/breast for stability–they do not actively form an anterior seal to obtain the fluid bolus. As a result, the nutritive suck is achieved through a strong “tongue-palate” seal. I have seen a couple newborns and preterms with, unfortunately, multiple hemangiomas that eroded the cheeks and lips right after birth; each was able to feed effectively (no cheek support needed) due to an intact tongue and palate, and, therefore, a tongue-palate seal.
Even with a slow flow/controlled flow nipple, our vulnerable preterms can get too much flow, too large a bolus. When we add cheek support, we will increase the flow rate and the bolus size. Because most preterms have very strong sucks, often too strong for their own good, and are “stuck in sucking” much of the time, as Pamela Lemons wrote, caregivers must look at the dynamic, or synactive, impact of all interventions on each other. So if cheek support is used, it affects more than the suck, in other words. Increasing the flow rate, or doing so inadvertently through cheek support, is not supportive for preterms’ swallowing safety. While it will increase intake (efficiency of feeding), it is likely to result in physiologic instability. This may or may not be apparent as aspiration events in preterms are most often silent in my clinical experience. The anatomy of the preterm and the physiology of the swallow predispose the infant to easily overfill the valleculae; this, combined with a tendency toward increased work of breathing and an increased respiratory rate, along with neuromotor and neurologic immaturity, can render the airway unsafe. The preterm is unlikely to be able to make the dynamic adjustments required as the pharynx reconfigures itself from a respiratory tract to an alimentary tract and back to a respiratory tract with each swallow, especially if it occurs in the presence of flow that may readily move to a rate beyond his capacity.
We can provide the postural stability to offset lack of sucking pads through effective swaddling with limbs to the body midline, elbows inside the blanket, a sidelying position, neutral head neck flexion with slight tilting down of the chin, and offer effective external pacing based on the infant’s continuous feedback to help suck, swallow and breathing remain coupled and synchronous.
Over the last 25+ years working in Level III NICUs, I have rarely needed cheek support to facilitate safe and effective feeding; those occasions have been with sick newborns, not preterms.
I have also observed preterms offered cheek support during a Video Swallow Study (to assess its impact on the swallow, as it was being used at bedside by well-intentioned caregivers), overfill the valleculae and penetrate or aspirate as a result. Matthews wrote years ago that, with preterms, it is not the work of “sucking” that makes feeding challenging but the work of trying to “breathe” in the presence of a flow they cannot manage safely, which in turn then inhibits/disrupts breathing.
If volume is the overriding goal, cheek support may be viewed as a critical tool by some caregivers, and often unfortunately is. As there is hopefully a paradigm shift from “Volume Driven” to “Infant Driven” feeding in NICUs, the reasoning behind not using cheek support for preterms will hopefully be more readily understood by our nursing colleagues. Until then, helping our nursing colleagues understand the “why” behind our protective strategies, and the why behind strategies that are not viewed as supportive, is a good interim step.