Problem Solving: Feeding Readiness in the NICU

Question: Non-nutritive oral motor therapy in NICU – when do you use it and why and what result do you see? As a warm up to oral feeding to help organize? In 30-32 weekers to prepare for oral feeding? In patients who would be nil by mouth for an extended time? Patients who are not able to feed orally due to severe aversion (usually due to gastro issues)? What is the latest research on this? I’ve read articles for and against.

Answer: A few thoughts for you. I don’t conceptualize what I think you are describing as oral motor but rather “feeding readiness”, which encompasses a different concept, a much broader, yet more defined, infant-guided approach in the context of the preterm’s unique co-morbidities.

Conceptualizing the feeding-related services we provide in the NICU as “feeding readiness” and “supporting safe/functional PO feeding” can help neonatal nurses and neonatologists better understand the value we add to the NICU team. Unfortunately, well-intentioned but stressful cares and/or feedings may wire the infant’s brain away from eating, and indeed lead to later feeding aversions. The literature on feeding outcomes in former preterms includes reflections on the high percentage of former preemies with enduring feeding problems, far beyond the NICU. It impacts the infant-parent relationship and multiple domains.

I would avoid “oral-motor work” designed to focus on 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 learning 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). Careful attention must be paid to physiologic stability, especially its impact on WOB and RR., during all infant-guided readiness experiences Progression to pacifier offered via rooting response for sucking with co-regulated pacing, f/b tiny droplets of EBM on a pacifier offered via rooting response for purposeful swallows 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 (intrauterine)and help caregivers embrace the critical impact this intervention can have if offered in a neuroprotective infant-guided way.

Also, know that in addition the benefits of mother’s milk (EBM) 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 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. But one can do this with gentle infant-guided touch via a caregiver’s gloved finger as well.

The key is that any feeding readiness experiences 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 offering EBM 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.

In the NICU, every experience matters, as I like to say. Practice in and of itself, only 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. Infant-guided experiences are essential to neuroprotection.

I teach these concepts and their underpinnings in my NICU seminar and cite relevant research, but I have yet to find anything published or researched specific to what I am describing, which provides the supported oral-sensory-motor learning I find so beneficial to our preterms. Its evolution is a part of my practice since 1985 in Level IV NICUs.
I hope this is helpful.



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