Problem Solving: Preterms with possible tongue tie

Question:

I am feeding a bit frustrated and just curious what others are thinking. I recently worked with twins in the NICU:  born at 24 + 6, BPD, one with history of bowel perforation and IVH grade II and the other with PVL. Both had G tubes placed while in NICU.  I did VFSS on both while in NICU. One did well with small volumes; she was able to DC home with small amounts of thin liquids via preemie nipple and small amounts of breast feeding. She was making slow but steady gains and showed good comfort.   The other one had some difficulty with swallow safety with abnormal VFSS.  He DC to home on small volumes thickened liquids via bottle and mom was also working on small trials of breast feeding with him as well.  Wonderful parents.  The babies had fantastic and very consistent RNs during their NICU stay; it was one of those times where you felt like everything was working well for these babies with histories of extremely preterm births and multiple co-morbidities.  The parents set up OP therapy services right away; they were told fairly quickly that both babies had tongue / lip / cheek ties and would benefit from a consult with a dentist to do the releases. The RN and neonatology staff came to me immediately and questioned this as the parents had reached out to them with concern.  I advised then to suggest the parents get a second opinion from one our ENTs who routinely work with our NICU babies during their stays and on follow up.  Thoughts?

Answer:

We do see preterm infants with lip and tongue ties that can adversely affect lingual thinning and cupping and effectiveness of tongue-palate seal. This in turn can lead to diminished volume transfer and lead to early fatigue, as the ineffective effort yields less than ideal intake and tires the infant. The infants you describe however also clearly have additional/other potential etiologies for their limited PO intake (24 weeks, CLD, GI and neuro co-morbidities).

The possible restrictions as identified by the OP SLP, if they are indeed present, could further contribute to their feeding challenges. However, the ties in and of themselves, if they are present, are likely not the reason these infants required G-Tubes, rather, their co-morbidities were. The ties would create further struggle.

Unfortunately, depending on how the OP SLP explained her concerns to the parents and how much she considered the co-morbidities these twins present (which are known to highly influence feeding success), there may have been the impression created that the G-Tubes were “not necessary”. The OP SLP may have been clear that the ties would create further challenges and weren’t the primary problem, yet the family, wanting to hear the G-Tubes were “never necessary”, took away a much different message. The NICU team (who hopefully recognizes the co-morbidities these twins presented are associated with increased G-Tube requirements), had an obligation to explain (or re-explain) the bigger picture to the family –i.e., co-morbidities matter when it comes to feeding (research shows that), and,  if there are indeed ties, which can unfortunately be missed at times, then correcting the ties, if ENT chooses to do so, would not change the need for the G-Tubes.

It is all too easy to instead assume that missing the ties, if they indeed exist, is why the infants received G-Tubes. Well-intentioned NICU staff may have reacted without understanding that “co-morbidities matter” (this is my most-used mantra during my NICU work and teaching) — but they do! Too often it seems co-morbidities don’t matter, as decisions/prognoses/plans about feeding are made by the medical team without regard to the infant’s co-morbidities. I find if we follow the co-morbidities, then our differential, prognosis and plans for these infants are likely to be appropriate.

I would reach out to the OP SLP, find out what she noted as indications of ties exist that might have been missed, share insights regarding the stamina and co-morbidities that created the need for GTube while you followed them in the NICU, and build a relationship through which there can be sharing and learning.  

I would also follow-up with my NICU colleagues to continue the conversation and reinforce the bigger picture that I referenced above. Too often SLPs can become the “reason” a preemie gets a GTube, or so it seems. This notion, which can discredit us as a profession or as individuals unfortunately in the eyes (and voices!) of some team members, and then by connection, some families, will change only with continued conversations. This is one of those times, Linda. Your likely recommendation for a GTube during their NICU stay wasn’t made lightly and I am confident was appropriate. The dialogue you have now is important for you, your team and for families fortunate to have your care in the future.

I hope this is helpful.

Catherine

 

Problem Solving: Reflux in the NICU

Question:

Regarding NICU preemies/infants, what are recommendations/guidelines utilized for concern with reflux (e.g., thickener, rice)? Are more behavioral and positioning strategies utilized first (e.g., HOB elevation, hold upright 30 min after feed) or is initiation of formula change/diagnostic imaging (MBSS) preferred? Also, if thickening, is there another approved way besides rice?

Answer:

I am responding specifically to preterms in the NICU. Those discharged to home may have GI follow and/or pediatricians manage their care, which allows for more options and perhaps even more variation in practice. There are no agreed upon guidelines from NICU to NICU, often there is variability even among your group of neonatologists. Let me share what they and my GI friends have kindly taught me over the years along with what I have learned along the way.

They tell me that the lack of agreement is d/t the absence of compelling literature that clearly guides them, especially when it comes to use of medications for EERD/GERD. That said, a recent study brought to our team by our pharmacist concluded that PPIs can cause significant problems for preterms (increased risk of NEC, sepsis/bacteremia, PNA and GI infections; decreased absorption of nutrients such a calcium, iron, zinc, magnesium, B12 –and zinc is essential to function of their immune system). While use of medications has typically been infrequent and a last resort approach in the Level IV NICUs I have been a part of, evidence such as this has further decrease their use, understandably so. When risk benefit ratio is not clear, physicians will be cautious. There is risk with thickened feedings as well (such as adverse effect on GI emptying which can worsen reflux, constipation, increased risk for NEC, alterations in C02); if thickening for reflux, what is used and how much is quiet variable again r/t MD differences. Most often rice is utilized but it too can have attendant sequelae as mentioned previously, as well as potential allergenic responses and concerns for arsenic.

Instead reflux precautions are typically the first line of defense (elevating head of bed, L side down post feeding for the first hour, R side down for the second hour and beyond – when monitored; upright carry position on caregiver’s shoulder post feeding when held); avoid medium or fast flow nipples that might lead to air swallowing and exacerbate EERD/GERD, utilize co-regulated pacing to avoid air swallowing, frequent gentle burps, use of elevated elongated sidelying position for feeding (to minimize pressure gradients throughout the abdominal area that might inadvertently increase propensity for reflux).

Pump feedings that allow a slower delivery of feedings via NGT or OGT over time have been used but the literature is actually inconclusive as to its benefit, and there may be adverse effects especially on gall bladder function.

Concentrating formula so less volume is required to get the same calories is an option. However, this can backfire as the increased caloric density can actually create GI discomfort in preterms.

Change in formula to Gentle or Sensitive formulas (Enfamil Gentle Ease, Similac Sensitive, Good Start Gentle), low lactose formula (Similac Spit Up, Gerber Good Start), possibly Soy based formula (if tolerance to cow milk protein is in question), possibly Extensively Hydrolyzed formulas in which proteins are mostly broken down (Nutramigen, Alimentum, Pregestimil), or possibly Elemental formulas which contain 100% broken down proteins if suspected milk protein allergy (Neocate, Elecare). Such decisions may be made with GI or by neonatology alone.

Imaging typically starts with and UGI to look at structural integrity and if the structures are in proper rotation. An UGI is not a test for reflux; radiologists will tell you that if they do not capture reflux in the moment in radiology, that does not mean the infant does not reflux, but if they DO capture reflux on an UGI, it is such a brief and minimal volume procedure that reflux is likely a key issue for that infant. While other types of imaging are possible in a workup for GERD/EERD (Ph probe studies, reflux scans, MII), they are not typical in the NICU.

A swallow study would not be a test to assess for reflux though we may capture EER as an incidental finding during an instrumental assessment of swallowing physiology.

So, as you can see the neonatologists must weigh so many critical factors. Work with your team and their thinking, be present and learn their rationales, read the research they are discussing, contribute what you can, especially clinical interventions that are often first line. There is an evolving science and practice and being part of the team is ho we both learn and add value.

I hope this is helpful. See Dupont, C. (2017). Gastroesophageal Reflux (GER) in the Preterm Baby. In Gastroesophageal Reflux in Children (pp. 111-124). Springer. It is quite informative though there are multiple other articles. DOI https://doi.org/10.1007/978-3-319-60678-1_8

I hope this is helpful.

Catherine

Research Corner: Sensory Processing Disorders and Former Preterms

Researchers at Washington University in St. Louis conducted a study to describe the incidence of sensory processing disorder in former preterm infants at age 4-6 years. They also sought to define medical and socioeconomic factors associated with sensory processing disorder and examine relationships between neurobehavior at term and later sensory processing disorder. The study enrolled thirty-two preterm infants born <30 weeks and conducted neurobehavioral assessment using the NICU Network Neurobehavioral Scale (NNNS) at term equivalent age, and the Sensory Processing Assessment for Young Children (SPA) at 4-6 years of age.

In this sample, 50% of children presented with a sensory processing disorder at age 4-6 years based on SPA scores. Additionally, the study did not identify any association between sensory processing disorder and medical and socioeconomic factors including gestational age at birth, sex, cerebral injury, presence of NEC or PDA, amount of respiratory support, days on TPN, surgeries, race, type of insurance, maternal age at birth, and maternal marital status. They did, however, find that more sub-optimal reflexes, and more signs of stress on the NNNS at term equivalent age was associated with having a sensory processing disorder at age 4-6 years.

The authors discuss the role of the NICU environment on the developing sensory system of the preterm infant, noting that sensory development begins in utero, but must continue to develop in the NICU, where their sensory systems can be bombarded with stimuli for which they are not developmentally prepared. They also note “it is unclear whether these early markers are indicative of the impairment that followed, or if the early impairment identified on the neurobehavioral exam resulted in altered sensory experiences, leading to subsequent sensory processing disorder.” This study demonstrates that standardized neurobehavioral testing can help identify those infants most at risk for sensory processing disorder in childhood.

Ryckman, J., Hilton, C., Rogers, C., & Pineda, R. (2017). Sensory processing disorder in preterm infants during early childhood and relationships to early neurobehavior. Early Human Development, 113, 18-22.