Problem Solving: Infants of Diabetic Mothers in the NICU

Question:
Recently, I have seen a number of infants born to diabetic mothers (IDMs) who are LGA, but with an otherwise stable medical status who are persistently poor feeders. I frequently find myself scratching my head and wondering how to address this problem so these babies can be discharged home, but without much success. Do you have any experience, input, or suggestions to help guide our treatment?

Answer:
Babies who are infants of a diabetic mother often receive the label “LGA” (large for gestational age) but their “greater size” does not mean “greater maturity”, although this may be the presumption of some NICU caregivers. Indeed due to the high fat storage related to being an IDM, their tone is often “doughy” and they are not like “big babies” when it comes to feeding. This unfortunately sets them up to be expected to feed like “big babies” by some NICU caregivers. From the beginning of PO feeding initiation, these expectations are not reasonable, given their medical history.

Besides poor state regulation leading to poor drive to feed, added issues for IDMs can be increased work of breathing, which can lead to respiratory fatigue. Our neonatologists have us follow these infants, and expect significant improvements in feeding over about 2 weeks, once blood sugars are stable. If progress with feeding is not forthcoming, the neonatologists usually do neuroimaging studies such as a CT of the brain to look for brain malformations. Infants of diabetic mothers are at risk for brain malformations due to the altered “fetal environment” secondary to maternal diabetes. Slow flow rate, external pacing to limit bolus size and support coordination, attention to respiratory behaviors during feeding, re-alerting, avoiding passive “prodding” to empty the bottle and judicious interim use of gavage feeds are all useful interventions.

Therapists are essential to the infant’s team, to model patience and infant-driven feeding, to promote careful attention/response to the infant’s cues and behaviors, and to share strategies and rationale with bedside caregivers and families. Too often, “getting the baby home” can overshadow what needs to be a period of recovery and supported learning for the infant.

Problem Solving: 6 y/o with trach and aspiration PNA

QUESTION: I work in a special education setting with preschoolers and kindergarten age students.  I have a 6 year old student who choked on a hot dog at age 2.  He suffered anoxia and was being revived for nearly an hour.  He suffers from seizures and is on heavy seizure meds. He is quadriplegic and tube fed.  He has a PM valve and last year he would produce vocalizations at times when he was awake and alert. I was doing orofacial sensory stimulation to encourage movement of his articulators.  He tolerated it well and I did observe increased movements of his jaw tongue and lips.  Since last year his ability to remain awake and alert and to respond during school hours has really decreased. He has been less and less available for any kind of speech therapy.  He has a private nurse during school hours.  His mother does not communicate well with the school.  During this past winter he was absent for a few weeks.  I discovered through his teacher that he had been hospitalized for pneumonia. One of his private nurses shared that it was aspiration pneumonia and that he aspirated his saliva. Since then I have been very wary about doing oral-facial sensory stimulation that stimulates salivation.  We have an IEP meeting approaching soon and I plan to ask his mother about this and to get more information from her.  I am not sure what to do about providing oral sensory stimulation if what the nurse relayed is indeed accurate.  Any feedback from the group about this would be greatly appreciated.

ANSWER: With the clinical picture and co-morbidities you describe, his anoxic event likely caused a significant neurological insult. It is not uncommon that one of the sequelae with such children is swallowing impairment, such that the child does not have the postural/neuromotor, oral-pharyngeal-sensory-motor prerequisites that provide the essential underpinnings to swallow his saliva. He likely immuno-compromised which can increase risk for aspiration pneumonia. It is very possible he is aspirating his saliva at rest, as he may lack the ability to gain the needed mouth closure and tongue control to then drive the saliva bolus intraorally and pharyngeal, which causes accumulated saliva to then often take the path of least resistance toward the airway; he likely lacks then the sensory awareness to perceive saliva is approaching/entering his airway and perhaps the neuromotor skills to generate an effective cough. Good oral cares and oral hygiene will be essential to reduce the potential for bacteria-laden saliva to be aspirated.

I am not sure what oral-facial input you are providing, but it did not “cause”  the aspiration pneumonia itself, although in some children it may increase saliva production at that moment during therapy. Specific deep sensory input to muscles to support active movement may be provided from a neurodevelopmental treatment (NDT) perspective.  An NDT approach in this situation would be like “PT for not only the body but for the mouth” as one mom put it; this muscle based approach combines facilitation and inhibition and works directly on the muscles. I took an 8 week NDT course with PTs and OTs years ago to learn this approach, and it has been invaluable. With such children as you describe, using an NDT approach, I have observed clinical improvements in head/neck control, the driving force of the tongue, ability to use the cheeks/lips, and, as a result, swallowing.
You need more information to make sense of where to go next. Maybe mom would sign a release to allow your team to get more information, and contact his past therapists to better understand his co-morbidities, medical history/status. That may help you understand the changes in mental status you describe (his reduced alertness and awareness); all of this information should be the guide for you about continuing therapy or discontinuing therapy, and what to focus on in therapy, not the fact that he had aspiration PNA.

I hope this is helpful. You are doing a good job asking questions. As you get more information, you can continue problem-solving. He would be a complex and challenging patient for any of us.
Catherine