Problem-Solving: Offering Tastes on NCPAP

Question: I am a Registered Nurse in a regional NICU where we take care of level 2, 3 and 4 infants. I am also co-chair of our dysphagia committee. We are currently doing a swallowing therapy-Therapeutic tastings. The current protocol allows therapeutic tastings to be done with our premature infants > 32 weeks adjusted gestational age that are on respiratory support as high as nasal cpap of 5 cm H2O. These tastings involve small volumes (0.05-0.1ml) of the infants current feeding administered to an infant using a syringe and adapter while infant is sucking on a pacifier, pumped breast or finger. The therapeutic tastings can be ordered to be administered 0.05-0.1 ml every 30 seconds up to a total of 2 ml TID by SLP, nursing staff or parent. Our medical team recently asked the dysphagia committee if it would be safe to do therapeutic tastings on infants that are on respiratory support higher than nasal cpap of 5 cm H2O (not including intubated infants). Is there any research supporting or disputing doing swallowing therapy such as our therapeutic tastings with an infant on respiratory support > nasal cpap of 5 cm H2O?

Answer:

This question is not answered currently in the literature,  so,  as you have alluded to, caution and critical reflective thinking are essential.

Of course current level of respiratory support required is only one piece of the equation, as GA and other co-existing co-morbidities, WOB, respiratory history (arduous versus non-arduous course) are some key considerations that will affect risk to invade the airway, create undue stress that may adversely affect neuroprotection, and potentially then lead to maladaptive behaviors and aversions.

Take a look at Louisa Ferrara’s paper ( Bidiwala, A. A., Ferrara, L., Islam, S., Pirzada, M., Barlev, D., Sher, I., & Hanna, N. (2016). NEWS FROM THE NICU AND PICU: Effect Of Nasal Continuous Positive Airway Pressure (ncpap) On The Pharyngeal Swallow In Neonates. American Journal of Respiratory and Critical Care Medicine, 193, 1.

Results suggested that the driving force/flow under CPAP appeared to predispose infants to aspiration under fluoroscopy. I wonder if true pacifier dips — via droplet of EBM on pacifier tip— versus using a syringe where bolus size or speed of bolus delivery cannot be as readily controlled — would be a better option. That is what I prefer when the infant appears ready from multiple perspectives to initiate tiny tastes. It offers cautious opportunities for purposeful swallows but with a greater safety margin.

Due to the fragile nature of a premie requiring CPAP, I would have parents not deliver tastes but rather have parents learn along with the SLP or RN —how to recognize respiratory stress cues at baseline and with tastes, state modulation baseline and changes, swallowing behaviors (both audible and visible), postural/sensory-motor baseline and changes, signs of disengagement both subtle and more overt ——while the SLP or RN offers  the tastes and uses anticipatory guidance to explain what infant is communicating.    The complexity of what we are asking the infant to do clearly requires “in the moment” immediate infant-guided responses from the caregiver to optimize safety.  It is worrisome to expect parents to recruit the level of clinical reasoning required in these uncharted waters, as it is with the first PO feeding.  I find parents typically benefit from, and appreciate, learning along with the caregiver to build understanding of the multiple “avenues” of preterm infant communication during tastes as well as future PO experiences.  See Shaker, C. S. (2018). ‘Mom, You Got This’: Feeding is communication. When we help NICU caregivers interpret what their preemie is telling them during feeding, we support the parent-infant relationship. The ASHA Leader, 23(10), 54-60.

Offerings that are arbitrarily every 30 seconds perhaps may not take into account the infant’s ability or desire to continue. Alternatively, infant-guided offerings would best utilize infant communication from moment to moment to determine when an infant may be ready for another tiny taste.

I hope this is helpful.

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