Problem-Solving: PO feeding post extubation in the NICU

QUESTION:

What are your current practices regarding oral feeding infants who have been recently extubated? Understandably, these infants typically don’t cue well for a period, continue to demonstrate respiratory complications, but are often asked by providers to attempt oral trials/nippling before the infant is truly ready. Please understand that I am aware that every assessment should be individualized, and we should first take into consideration how the infant tolerates handling, NNS, etc. However, since I have spent time in adult acute care, I do not complete a swallow assessment in this population until 24 hours post extubation. Delaying swallow evaluations until 24 hours after extubation would aid in improved reduction of laryngeal edema and improved vocal quality, return of pharyngeal/laryngeal sensation, improves breathing, with an overall improvement in medical stability. It is also known that infants are at a much higher risk for silent aspiration. Do you apply these principles to our fragile infants in the NICU? I am searching for more support regarding why not pushing these babies, who may have even delivered to term but were recently intubated/extubated, is so vital for their developmental outcomes. Thank you for any support!

ANSWER:

I work in a large level IV NICU, so we see the sickest and most fragile preterms, some of those born at 22 weeks. Intubation and ventilation are avoided as much as possible, with many infants being stabilized on NIPPV or CPAP in the delivery room.

Those NICU infants who are intubated, once extubated, often require levels of respiratory support that continue to delay PO feeding. Unlike adult ICU, it is uncommon in NICU to be consulted on an infant recently extubated (within 24 hours) who now has orders to PO feed. Though it can happen, unfortunately.

Once an infant is stable on NIPPV, we will be consulted to begin support towards/readiness for oral feeding. That is great because we are part of the decisions going forward then. Even sick newborns recently extubated will often have sequelae, especially respiratory (but also perhaps neuro, GI, airway, cardiac and/or neuromotor) that create risk for airway invasion with expectations of early PO feeding. This is not always appreciated by the NICU medical team, despite their best of intentions, i.e., “lets’ get him feeding” so “he can get home”. Part of your role will be protecting these infants from good intentions gone awry through collegial conservation, bringing the research about feeding outcomes and neuroprotection, and co-morbidities that create inherent risk for bolus mis-direction.

I like to conceptualize the feeding-related services we provide in the NICU as “feeding readiness” and “supporting safe/functional PO feeding” to help neonatal nurses and neonatologists better understand not only the value we add to the NICU team, but also that learning to feed orally is not a “light bulb” moment – i.e., it’s not that all of a sudden the infant is ready . Unfortunately, well-intentioned but ill-timed, too early, stressful PO 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 also impacts the infant-parent relationship and multiple domains.

As you know, sick newborns who required intubation and ventilation cannot just bounce back, once extubated. The reasons for requiring intubation often have sequelae that adversely affect PO feeding. Fragile preterms 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

All NICU infants need supportive infant-guided learning experiences outside of the uterus. These should most closely align with the ideal sensory-motor environment (intrauterine), and early extrauterine environment of the healthy term infant. Our challenge is to help caregivers embrace the critical importance of this step in the process toward PO feeding, whether a preterm or a sick newborn.

Prior to PO feeding, the benefits of mother’s milk (EBM) to the mucosa via tiny trace droplets to promote purposeful swallows and oral-sensory-motor mapping primes the sensory-motor system along of the preterm infant or sick newborn, as can nuzzling at the breast (kangaroo mother care). The key is that 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. This may not fit the time line set to “get them feeding”. 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.

Neonatologists may push PO to get them PO feeding, let them “practice”. 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 preterm’s immature emerging neuronal pathways and oral-sensory-motor system, or the sick newborn’s altered systems. This must be considered in the context of that infant’s co-morbidities and the impact of those co-morbidities on the dynamic swallow. 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 for all NICU infants.

I teach these concepts and their underpinnings in my NICU seminar, cite relevant research and clinical wisdom to help us have conversations with our NICU colleagues. Our goal is always to promote infant guided feeding and neuroprotection. The NICU is not an easy place to work, as passions and medical fragility run high. Every day l have conversations that require me to think deeply, be kind and patient but advocate for the infant. Along the way I have built relationships with neonatologists and nurses that create the opportunity for respectful conversations even when we disagree. As you continue to build relationships with your NICU team, focus on bringing the relevant research, having collegial conversations, and thinking along with nurses and neonatologists both during Rounds and during your sessions. That opens the door for changing the feeding culture, one day at a time.

 

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