Q & A Time with Catherine

Question: Our department is rolling out a new oral care protocol.  I am “on the fence” about this and I am worried that this practice may create more harm than good.  However, we have lots of little ones on vents, HFNC and many “gut” babies that will be NPO long term.  Many of these kiddos are at very high risk for infection and I think anything that can be done to prevent infection would be extremely beneficial.  I have been asked to assist in developing the protocol and giving input as to how to go about delivering the colostrum w/o inflicting negative stimuli to oral cavity (this was my hesitation w/ the program).  I am thinking perhaps the program should only include kiddos 30+ weeks as they may be more tolerant of oral stimuli. I thought maybe attempting to find a silicone swab of sorts to deliver colostrum via oral massage to gum ridge/buccal cavity may be appropriate.  Any thoughts?   Thank you!

Answer:
The benefits of mother’s milk (MBM) to the mucosa via tiny trace droplets that may promote purposeful swallows and oral-sensory-motor mapping is being considered by many NICUs as an early approach to supporting readiness for infant-guided feeding in the future and to prime the sensory-motor system along with nuzzling at the breast (kangaroo mother care). There is a very tiny “paintbrush” one of the reps has (sorry I cannot recall which) that can support a very gentle limited offering of MBM to the lips or this could be offered via very gentle well-graded touch.

The key is that this should be offered when infant is at his best respiratory wise (both in terms of respiratory support being required and his WOB and RR), he is actively engaged and maintains physiologic stability, and should be offered using infant-guided principles of interaction. Resting the infant and use of co-regulated pacing to assure that respiratory stability is fostered from moment to moment, are essential to support a neuro-protective experience that promotes both safety and positive learning. Some NICU caregivers may need guidance to view this experience in such a light, as opposed to a “task” that one “must complete as a part of cares.”

We recognize that, in the NICU, “practice” is not the key, but what is, is the experience, and how it is both offered and received by the immature emerging neuronal pathways and oral-sensory-motor system. Practice of course, makes permanent the neuronal pathways that are recruited and mapped; it does not in and of itself create the pathways that underlie function or skill; it can unfortunately lead to maladaptive behavior and stress if done as a task and/or offered in a programmed way. So yes, there is potential for this initiative to do more harm than good.

I would avoid “oral-motor work” designed to focus on jaw work or oral-motor skills per se at this juncture as it would be too invasive and not appropriate. You are describing preterms who are both fragile and still many weeks prior to term. Were they not born too soon, they would be fetuses experiencing motor and oral-motor learning in utero; their oral-motor movement patterns would be evolving in the context of the containment provided by the uterus, with hands on their face and in their mouth (and alternating touching the placenta per research). They would be integrating their structurally-intact aero-digestive system by 17 weeks of life, swallowing several ounces of amniotic fluid each day.

Focus on structuring experiences outside of the uterus that most closely align with the ideal sensory-motor environment and help caregivers embrace the critical impact this intervention can have if offered in a neuro-protective infant-guided way.

I hope this is helpful.




Catherine


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