Greetings from Florida!

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What a fast year this is! I cannot believe it is already June. It is a balmy 97 degrees here today. Staying inside in the air conditioning seems the best to me, though my German Shepherds still seem to have the energy to play ball and enjoy the sunny blue skies☺

I am looking forward to my new seminar The Advanced Clinician in Pediatric Dysphagia: Taking it to the Next Level coming up soon in Dallas. So many of you have contacted me about finally having access to a seminar like this. We’ve designed it to “feed your mind”, get you thinking an sharpen those problem-solving skills. What makes an advanced clinician “advanced”? It’s not just having information. It’s how you use the information you have, what sense you make of it in light of the big picture, and how you apply it dynamically to each pediatric patient. Correlating co-morbidities, clinical data and the infant/child’s behaviors is at the heart of completing a good differential. We’ll look at case studies, including those you bring on DVD or a flash drive to share with the group and problem-solve.

And we’ll discuss lots of current hot topics including:

Everyday challenges “in the trenches”

Critical thinking about HFNC (high flow nasal cannulas) and feeding

Cortical learning underlying feeding/swallowing

Use of NMES in pediatrics :Contraindications, risks, benefits, cautions

“Post-Traumatic” feeding disorders

Thickening: What do we know? What to do?

Oral motor treatment in pediatrics : Not just exercise !

Breastfeeding: What the SLP needs to know
The “steps” to eating

FEES in pediatrics

Enhancing respiratory function for swallowing/feeding

And more!

……….Come ready to take it to the next level ! ……………….

See you in Dallas!

Catherine

Problem-Solving with Catherine

Problem-Solving with Catherine
Question: Apparently our hospital has a new grant for ‘Music Therapy’. I thought it was for the Pedi cancer patients, but I see one of my NICU babies is on their list. Someone comes twice a day and has a pacifier connected to a machine that plays music when the infant sucks hard enough. Per the nurses report, the music therapist said the infant was ‘getting better’ w his sucking (stronger? longer? NNS?). This particular baby is a 48 wk., 4 month old (born at 32 weeks/twin). He is still <5 lbs. and has BPD, no endurance, reflux and an aversion to nipple feeding (GT was planned for this past Monday, but he has a UTI). I feel like this topic has been address before here, but I am just not capable of figuring out how to find it. I was wondering what the feeling is from our community – helpful and good, tiring and bad, case by case?

Also, I am not sure how pt.’s are chosen to participate in the music therapy and I only became aware of it yesterday because infants father thinks it tires baby out and “Nobody cares what (he) thinks.” I have a call out to the music therapist herself too. Any input would be appreciated! Danielle
Answer:
 Music Therapy in the NICU often includes PALS (Pacifier Assisted Lullaby) as you mentioned below, though it may include only the playing of music and singing while the infant is held by the Music Therapist.

We must all be thoughtful as we evaluate devices that are designed or marketed to develop a skill. It is the thoughtful use of a modality, or the thoughtful decision not to use it, based on the clinical assessment of our patient and the evidence, that should be our guide, both in the NICU or in any other level of care in which SLPs are a part of the team.

My NICU clinical experience for almost 30 years suggests that PAL (Pacifier Assisted Lullaby)  is not an answer for the feeding/swallowing problems preterm infants present, and may actually inhibit functional skill (i.e., feeding). The issue for preterm infants is more complex than a “sucking problem.” Feeding problems in the NICU are rarely so simple, though sometimes a “poor suck” is unfortunately perceived as the reason for many of them. Learning to feed, both effectively and safely, is a complex, multifaceted challenge for preterm infants.1

I have been part of the team in two large level III NICUs, and many of those babies have been extremely preterm. Many have respiratory distress syndrome (RDS) or CLD (Chronic Lung Disease), requiring intubation and ventilation, and/or need supplemental oxygen in the course of their recovery. We have not observed a direct detrimental effect on non-nutritive suck (NNS). These infants typically demonstrate effective non-nutritive sucking when ready to initiate bottle feeding, with respiratory issues being the paramount barriers. We have found that the NNS typically emerges with development and positive support during care. For all infants, our nurses provide excellent oral care, including developmentally appropriate hand-to-mouth, rooting and pacifier activities, to support development of non-nutritive sucking. For infants with delays in onset of oral feeding due to medical status or those profiled as likely to be high-risk fragile feeders, the speech-language pathologist is added to the team to provide positive early pre-feeding and graded swallowing experiences. This helps the infant make the transition to nutritive sucking more safely and effectively.2

The challenges preterms encounter in learning to feed are most often the direct sequelae of residual respiratory problems. These problems (e.g., tachypnea, increased work of breathing, compensatory breathing behaviors, breath-holding) jeopardize the coordination of sucking, swallowing and breathing. 1  This can lead to respiratory fatigue and incoordination, or indeed adverse events such as choking, coughing and color change. Even infants with excellent NNS can have significant problems learning to suck nutritively because their drive to suck is often stronger than their physiologic sense of oxygenation.3

Very often the co-morbidities of early gestation, lower birth weight and attendant respiratory sequelae make feeding a challenge. The NNS, for which PAL was developed, has not been the issue delaying discharge.

It is also important to recognize that the NNS and the nutritive suck are very different in their rate and rhythm due to the addition of fluid with nutritive sucking. This renders non-nutritive and nutritive sucking different developmental skills. Lingual patterns on ultrasound have shown significantly greater displacements and excursions when a preterm infant was sucking nutritively vs. non-nutritively on a pacifier.4

The NNS is not in itself a predictor of nutritive success (i.e., bottle feeding), research has found.5 
NNS is just one of several domains that require consideration when contemplating the introduction of oral feeding. While found to be helpful, typical non-nutritive interventions have not been shown to decrease length of stay.6

A recent study reported that a non-nutritive stimulation program in an NICU did not result in earlier weaning from an nasogastric (NG) tube or earlier discharge when compared to similar infants without that intervention.7

In addition, PAL is designed to foster, and has as its outcomes, longer sucking bursts. Longer sucking bursts are problematic for the preterm. Longer sucking bursts may inadvertently, and often do,  result in respiratory decompensation, increase in  WOB and overall respiratory effort. This “drain” on the infant’s respiratory reserves can have detrimental effects on the functional skill of feeding,8 as PAL is often provided just prior to a feeding. During PALS, the focus  by the Music Therapist is only on sucking, and as a result, the infant’s communication about its effects on breathing may not be recognized or understood by the Music Therapist

.

Also, during PAL, it is likely at the preterm infant is not able to stop on his own at the appropriate junctures to take a series of deep breaths. This is directly related to immaturity, i.e. the drive to suck can inhibit the drive to breathe in the preterm, as he cannot register changes in CO2 versus O2, which can be a by-product of continuous sucking. So we often see a continuous sucking pattern with the pacifier and with PO feeding.9

While continuous sucking may sound like a hallmark of skill, in the preterm infant it can destabilize the autonomic system, lead to breath-holding or insufficient breaths, which can lead to desaturation, and potentially a cascade of events leading to decompensation.

So sucking, faster sucking or engaging in longer sucking bursts, is not necessarily good for the preterm and typically is not. Sucking can’t be looked at in isolation, as it is part of a dynamic physiologic event that has multiple system implications/effects. 10

When the focus is on sucking itself, i.e. with PAL, we are not providing the preterm with the careful support required to integrate breathing with sucking. Then sucking activities provided can actually be detrimental to motor-learning, and potentially increase stress on a physiologic level.11  This can then lay down neural pathways that, instead of facilitating positive learning, may move the infant away from learning to feed.12

While it may seem to some that enhancing sucking can be the answer for feeding issues that delay discharge, it is just not that simple. NICU infants learning to feed require dynamic, infant-guided supportive strategies during both pacifier sucking and during feeding, based on watchful vigilance and continuous feedback from the infant. The focus is on physiologic stability, active participation of the infant, and coordination of sucking with swallowing and breathing.5
   
This approach is more likely to promote readiness for  and eventual swallowing safety, support adequate nutrition, and result in the earlier discharges we have seen in the NICUs I have been fortunate to work in.

As you know, supporting successful feeding for preterm infants goes way beyond sucking. For those infants who indeed do have “sucking” problems, then the involvement of the SLP, who can problem-solve with reflective/critical thinking, and support the integration of sucking with breathing, in preparation for eventual PO feeding,  is more supportive and more beneficial for sensory-motor learning than a referral for PAL, in my opinion.

References
1. Shaker, C.S. (2013) Reading the Feeding. The ASHA Leader – American Speech-Language-Hearing Association.
2. Shaker, C.S. (2013) Cue-Based Co-regulated Feeding in the NICU: Supporting Parents in Learning to Feed Their Preterm Infant. Newborn and Infant Nursing Reviews (2013) 13 (1): 51-5
3. Shaker, C.S. (2012) Feed Me Only When I’m Cueing: Moving Away From a Volume Driven Culture in the NICU. Neonatal Intensive Care, Journal of Perinatology-Neonatology, 25 (3) May-June, 27-32.
4. Miller, J.L., Kang, S.M. (2007).Preliminary ultrasound observation of lingual movement patterns during non-nutritive versus non-nutritive sucking in a premature infant. Dysphagia, 22: 150-60.
5. Lau, C., Kusnierczyk, I. (2001). Quantitative evaluation of infants’ non-nutritive and nutritive sucking. Dysphagia, 16: 58-67.
6. Fucile, S., Gisel, E.G., Lau, C. (2002). Oral stimulation accelerates the transition from tube to oral feeding in pre-term infants. Journal of Pediatrics, 141: 230-36.
7. Bragelian, R., Rokke, W., Markestad, T. (2007). Stimulation of sucking and swallowing to promote oral feeding in premature infants. Acta Paediatrica, 96: 1430-32.
8. Thoyre, S.M., Shaker, C.S., Pridham, K.F. (2005). The early feeding skills assessment for preterm infants. Neonatal Network, 24: 7-16.
9. Shaker, C.S. (2010) Improving Feeding Outcomes in the NICU: Moving from a Volume-Driven to an Infant-Driven Approach. American Speech, Language, Hearing Association. Swallowing Disorders Division 13 Perspectives – Oct
10. Shaker, C.S. (1999) Nipple feeding preterm infants: An individualized, developmentally supportive approach. Neonatal Network, 18(3), 15-22.
11. Smith G.C., Gutovich, J. et al (2011) Neonatal intensive care unit stress is associated with brain development in preterm infants .Annals of Neurology. 70(4), 541-549.
12. Browne, J. V., & Ross, E. S. (2011). Eating as a neurodevelopmental process for high-risk newborns. Clinics in Perinatology, 38(4), 731.

I hope this is helpful. Good critical thinking on your part!

Catherine
Catherine S. Shaker, MS/CCC-SLP, BCS-S
Board Certified Specialist – Swallowing and Swallowing Disorders
Florida Hospital for Children
Orlando, FL

www.Shaker4SwallowingandFeeding.com

Q & A: Problem-Solving with Catherine

Question: I completed a new eval on a newborn infant, 7 weeks old.  PMH: NAS likely, looks/acts premature, removed from parents at 3 weeks and is in foster home, dehydrated upon custody, limited history.  Intake is great and she is growing/gaining since in foster home.  Last week she started struggling with feeding.  Her tongue tip remains elevated with nipple presentation.  This was present in eval.  Once she drops her tongue and accepts the nipple she will drink very well.  Great suck and coordination.  Jaw opening is limited with nipple stim to lip.  Seems like she is anchoring her tongue to stabilize her jaw.  Is this correct?  If so, what approach is needed to assist with feeding?  And what can foster mother do at home?  Various feeding positions do not assist to extend her trunk.  Stim with soft gum massager does not assist.  Her mouth is very tiny (weighs ~6 lbs.).  Suggestions, please!

Answer: 
Good problem-solving and asking questions!

Given that the infant can actively lower her tongue to the floor of the mouth and establish an effective latch, tongue-palate seal and coordinated sucking pattern, this is likely a compensation (i.e., an adaptive behavior). I see it most often in infants due to  increased work of breathing. Infants will often elevate the tongue tip to the alveolar ridge when the work of breathing creates challenges for suck-swallow-breathe. I suspect the contact/pressure of the tongue tip at the alveolus may help to stabilize the tongue in such a way that it give the feeling of a more open pharyngeal airway. This may sound funny, but one of my favorite neonatologists at my old NICU, who is a marathon runner, told me that when he runs in marathons, he often places his tongue tip at the alveolus to get through the respiratory work during the run. Knowing my great interest in the pathophysiology and co-morbidities of infants with CLD (Chronic Lung Disease,) he postulated the reason as I stated above. It make sense to me (and did to him!) , as we knew we had often seen this behavior co-occur in infants with extra breathing effort during feeding (and at rest too). Though the WOB may be slight, it can interfere with the fine coordination of swallowing and breathing, and infants make adaptations, i.e. use compensatory or adaptive behaviors to “get them through” the feeding or in an attempt to ease stress associated with breathing. Unfortunately , some of the adaptations they use can become maladaptive behaviors if the underlying issue causing the need to adapt is not addressed and rectified.

This would make sense for this infant, given his known/suspected co-morbidities, i.e. being a preterm (which would account for the increase in WOB) and NAS/Neonatal Abstinence Syndrome (which can result in frantic disorganized approach to feeding that leads to an increase in work of breathing).

The “closed jaw” is likely another adaptive behavior — the infant does not actively open her mouth until she is done breathing; when she is  done breathing, she roots, opens her mouth actively and latches. She is communicating by her behavior, as infants do, to you and to mom, and telling you how to help her. So continue to use her rooting reflex to initiate the feeding; if she does not open her mouth and root, then wait  a few  seconds and re-root her; don’t put the nipple in passively or pry her mouth open. She knows how to open her mouth when she wants to, right? 🙂  Just be patient and listen to her:-)

A swaddled elevated sidelying position with her head higher than her hips will help ease WOB and facilitate organization as well. I’d also suggest you consider a controllable flow rate (slow flow rate) as that may indirectly also help the infant manage optimally if there are even subtle breathing issues, likely with his co-morbidities. Dr. Brown’s preemie (slow flow) nipple has worked well with similar infants in my experience.

Take a look at my article “Reading the Feeding” in the ASHA leader archives or you can find it on my website http://www.shaker4swallowingandfeeding.com under the publications tab. It details infant breathing behaviors/cues that guide the feeder to understand what is happening and why.

I hope this is helpful.

Catherine

NANT Conference 2014 in Atlanta

Just returned from the National Association of Neonatal Therapists Conference in Atlanta. My presentation “The Advanced Clinician in Neonatal Swallowing/Feeding: Taking It to the Next Level was well-received. It shared the multiple ways we add value and how we can articulate the need for our involvement in the NICU. In July I’ll be expanding this topic for my newest seminar “The Advanced Clinician in Pediatric Dysphagia: Taking It to the Next level” in Dallas. I am excited about this seminar as it will be the springboard for Hot Topics, clinical reasoning with complex patients and case discussions including those attendees bring. Check out the details in my 2014 brochure on my website http://www.Shaker4SwallowingandFeeding.com

The NANT conference was wonderful and packed full of information about our NICU babies and the work we do as NICU therapists. I had the opportunity to share my passion with Lynn Wolf and Robin Glass over good food, which was a highlight of the weekend. Wolf and Glass shared their new methodology for when feeding on HFNC (high flow nasal cannulae) might be considered and the clinical reasoning that is essential in decision-making. We also heard the latest on bubble CPAP, kangaroo care and developmental outcomes. All very interesting. I’ll bring highlights from the NANT conference to my NICU and Cue-based Feeding seminars in 2014. I hope to see you this year! Catherine