Problem-Solving: Pacifier Dips in the NICU

Question:

As ST/OT therapists, we have been doing feeding readiness and oral stimulation via pacifier dips for infant with controlled volumes, comfort during cares, etc….  Some of us do them as pacifier dips: milk in a medicine cup/medela bottle lid and some of do a mixture of the pacifier dips along with having the infant actively suck, offering 1 drip via a 1cc syringe.

The question has come up: Is there a standardization across the board regarding how and when to do pacifier dips/syringe drips?  The concerns with syringe drips, is that the bolus may be larger than with dips.  Another concern that I have is with oral organization, removing the pacifier multiple times makes the infant relatch and reorganize.  Versus allowing an infant to suck and offering syringe drips with time in between, allows infant to remain orally organized.

Is there a standardization? What do you guys practice?  Any research out there regarding the benefits?

Answer:

Pacifier dips can provide the opportunity for purposeful swallows that create the motor maps for swallowing in the course of a PO feeding. Supportive elongated swaddled sidelying, careful titration of bolus size, support for the swallow-breathe interface and physiologic stability all become essential components of our intervention that support infant-guided learning as co-morbidities permit.

Once the infant is tolerating a dry pacifier with physiologic stability utilizing co-regulated pacing, I use my gloved finger to place a tiny droplet of EBM or formula on the tip of the pacifier, and then offer it using the infant’s rooting response, when engagement, GI comfort, WOB and RR permit.

Re-latching in a supportive context can allow for prolonged resting to focus on respiratory reserves in between offerings, with when one is first introducing pacifier dips. This is especially true for infants for whom respiratory or airway co-morbidities are part of the differential. After resting, recruiting the root-to-latch sequence again, followed by onset of non-nutritive sucking promotes the motor mapping required for PO feeding.

Then one can begin to allow the pacifier to remain in the oral cavity, when infant is ready for that added aerobic workload. With the pacifier in the infant’s mouth, I can wait until WOB and RR look optimal, then deliver successive tiny droplets on the pacifier hub (I do it with my gloved finger to assure it is only a droplet). With each droplet I would be providing imposed breaths  to assure they are timely and sufficient, via use of contingent co-regulated pacing. Use of deep tactile cues at the cheek corner or at the anterior alveolus during imposed pauses creates the sensory-motor learning for future PO feeding.

I am not aware of standardization. I think it is more about being thoughtful and informed about why this intervention can help, what to consider and how to support both neuroprotection and safety, as we progress through this important step toward PO feeding in the NICU. The infant’s communication should always guide us.

So much goes into planning and executing this intervention, though it can appear quite simple. I hope this is helpful

 

Problem-Solving: Advocacy for SLP staffing in the NICU

Question: I am seeking your help as we fight for increased SLP staffing in our Neonatal Intensive Care Unit.  Do you have  any resources to justify more staffing and resources?

Answer: There is little to no data about NICU SLP services out there , and we always have to build the relationships that create respect for the value we add. This takes much time collaborating, thinking along with our medical and nursing colleagues, and building that open mind with each infant with whom we work, one by one.  As a former  Rehab leader, I found that was my only way to over time build the recognition of the need for our services , i.e our value to the infants, their families and the team. This then generated the referrals that needed to be seen.  Then when MDs were not happy if referrals were delayed due to inadequate staffing,  leadership could relook at budget to allow us  to allocate more staff.  Now, as a front line NICU staff person, I continue to build relationships and then let my leader take the next steps.

I have found it very successful  to utilize a co-morbidity-based approach to advocating for feeding needs   —  See: Edney, S. K., Jones, S., & Boaden, E. (2018). Screening for feeding difficulties in the neonatal unit: Sensitivity and specificity of gestational age vs. medical history. Journal of Neonatal Nursing.

The only article I know of looking at utilization in the NICU was this one  —- Ross, K., Heiny, E., Conner, S., Spener, P., & Pineda, R. (2017). Occupational therapy, physical therapy and speech-language pathology in the neonatal intensive care unit: Patterns of therapy usage in a level IV NICU. Research in developmental disabilities, 64, 108-117.

I hope this is helpful.

Problem-Solving: Variability in Breastfeeding Success

Question: A colleague reached out to me regarding her 3-week-old baby. She has some successful breastfeeding feedings and some that are not. Pediatrician suspects posterior tongue tie. Would that be possible if many feedings are perfectly successful?

Answer:

Feeding and swallowing are both dynamic systems, with multiple and varying influences from moment to moment and from feeding to feeding. Completing  a differential about what is causing the reported variation in feeding, and what may be the contributing the etiology(ies),  is a complex endeavor, to which many of the responses thus far have alluded. It is important to remember that multiple systems contribute to feeding/swallowing skill and the interplay, i.e., synactive relationships, amongst those systems, must be peeled apart .

None of the  systems that underlie function for nutritional intake exists in isolation. These systems include: cardio-respiratory, neurologic, neuromotor, sensory, sensory-motor/postural , airway, gastrointestinal, and oral-sensory/oral-motor, as well as the feeding “environment” (such as mother’s milk supply, milk flow rate, the caregiver’s perception of her role as a feeder and her experience, position utilized, and for bottle fed babies – nipple choice, as well as response to apparent infant stress and communication throughout the feeding). In addition, how the caregiver defines “successful” can be enlightening (e.g., volume, amount of stress observed, how soon infant disengages, feeding with or without apparent incoordination). Sometimes, infant behaviors interpreted as leading to an  “unsuccessful” feeding may be purposeful on the infant’s part to protect his airway or to signal stress (i.e., use of a compression-only sucking pattern, no longer rooting, letting go of the latch, loose latch). Sometimes what can look  like an oral-motor problem may be the infant being “smart”. It is important to ask that question. Again, think of dynamic systems theory.

You can see how if we, unfortunately, view one system as the focal point and don’t consider the bigger picture of  the context  of the other relevant systems for that particular infant, our differential about the problems observed will be sorely lacking, and our plan of care, therefore, ineffective. From this informed perspective, the SLP can present impressions and recommend further consults and diagnostic workups  thoughtfully to the physician.

An evaluation by a skilled pediatric therapist who looks at all the systems that underlie function, and their interaction, in the setting of the infant’s history, will best help to answer the “why” that can then guide the infant toward more consistency “successful ” feeding  —-  which to me, means infant-guided pleasurable safe feeding with an engaged infant and a caregiver who provides contingent responses to infant communication during feeding.

I hope this is helpful.

 

Research Corner: Non-nutritive sucking in the preterm infant

Pineda, R., Dewey, K., Jacobsen, A., & Smith, J. (2018). Non-Nutritive Sucking in the Preterm Infant. American journal of perinatology.

Objective To identify the progression of non-nutritive sucking (NNS) across postmenstrual age (PMA) and to investigate the relationship of NNS with medical and social factors and oral feeding.

Study Design Fifty preterm infants born at ≤32 weeks gestation had NNS assessed weekly starting at 32 weeks PMA. Oral feeding was assessed at 38 weeks PMA.

Results There were increases in NNS bursts per minute (p = 0.005), NNS per minute (p < 0.0001), NNS per burst (p < 0.001), and peak pressure (p = 0.0003) with advancing PMA. Level of immaturity and medical complications were related to NNS measures (p < 0.05). NNS measures were not related to Neonatal Oral Motor Assessment Scale scores. Smaller weekly change in NNS peak pressure (p = 0.03; β = –1.4) was related to feeding success at 38 weeks PMA.

Conclusion Infants demonstrated NNS early in gestation. Variability in NNS scores could reflect medical complications and immaturity. More stable sucking pressure across time was related to feeding success at 38 weeks PMA.

Commentary from Catherine:  Co-morbidities matter in every facet of the preterm infant’s development and skill progression. The emergence of non-nutritive sucking, its quality, and its interface with swallowing and breathing,  is clearly affected by the nature of and interaction among the infant’s co-morbidities. Take time to carefully consider this in your assessments and ongoing interventions with our  ones in  the NICU. Remember, sucking does not occur in isolation –  it is part of a dynamic interactive system.

 

 

 

 

Research Corner: Characteristics of children at risk of aspiration pneumonia

Pavithran, J., Puthiyottil, I. V., Narayan, M., Vidhyadharan, S., Menon, J. R., & Iyer, S. (2018). Observations from a pediatric dysphagia clinic: Characteristics of children at risk of aspiration pneumonia. The Laryngoscope.

Methods: A retrospective analysis of medical records of 88 children referred to the dysphagia clinic who had undergone videofluroscopic swallow study (VFSS).

 Results: Oropharyngeal dysphagia was found in 61.3% (54 of 88). Incidence of aspiration pneumonia was 39.8% (35 of 88).

Conclusion: Respiratory symptoms such as cough, choking, excessive secretions, and pharyngeal dysmotility other than aspiration in VFSS were not predictors of pneumonia. Infants and children with laryngotracheal anomalies, demonstrable aspiration in VFSS, and major cardiac illness are at risk of presenting with aspiration pneumonia. Whether gastroesophageal reflux disease (GERD) or esophageal dysmotility are causative of aspiration in the rest of the population needs to be investigated by future prospective studies.

 

Problem-Solving: Aspiration of EBM

Question: I was curious if there is any research out there regarding the effects of breastmilk on the lungs if aspirating small amounts? 

We currently have an ex 25 week infant who is now corrected to 40 weeks.  Infant has CLD, currently on LFNC 2.5 LPM 100% Fi02.  Infant is s/p PDA ligation with L vocal cord paresis.  He also had delayed start to feeds due to medical NEC x2.  We started conservative PO trials with him 2 weeks ago-offering 10cc via Dr brown ultra-preemie nipple in R sidelying.  He built stamina and was appropriate for a VFSS this past week.  Results were as expected.  Infant had 2 episodes of gross aspiration- 1 with thin barium via ultra-preemie nipple and 1 with ½ strength nectar thick barium via preemie nipple.  1 was silent and the other resulted in a brady/desat.  However, he demonstrated several consecutive safe swallows during the length of the study.  We decided to allow him to continue to BF on a pumped breast and have been also contemplating allowing him 5cc of straight breastmilk 1-2x/day via ultra-preemie nipple for ongoing practice.  Some of our practitioners would like to allow him these PO bottle trials while others would prefer to keep it at just breast feeding with the pumped breast and allowing some pacifier dips during PG feeds.  I am torn between what would be best for this medical complex infant.  I work frequently with adults as well and have thought about the Frazier Free Water Protocol with some of our patients.  Given that breastmilk seems to be a fairly benign liquid, would it be similar?

Answer:

I know of nothing published but my pulmonologist colleague has told me that she believes EBM is likely tolerated much better by the lungs if aspirated, compared to  formula or thickened formula.

Aspiration is of course especially worrisome, though,  in the setting of CLD and a continued  need for respiratory support, L vocal cord paresis. You dont’ t mention the etiology for the aspiration events but I suspect an altered swallow-breathe interface,  and likely ineffective and/or incomplete airway closure, are probable etiologies.

Because we are not always fortunate to actually witness aspiration during the brief moment in radiology,  when there is indeed gross aspiration, at times silent, it confirms swallowing physiology is impaired.  Based on the data you provided,  I would not PO feed by bottle,  as “practice” as suggested by some practitioners, is not the answer. It is highly likely that resolution of CLD and vocal cord paresis are the answer,  both f which will take time. Pacifier dips of EBM, a GTube and repeat swallow study in 2 months has been a successful plan for our babies who present similarly.

The pacifier dips are like a free water protocol for infants and also perhaps limit the risk while allowing for purposeful swallows. PO feeding silent aspirators, especially those with the history and multiple complex co-morbidities you present, is worrisome to me. “Pratice”, which actually involves recruiting impaired physiology,  would, for me, weigh heavily against this option for this infant. While breastflow is likely more protective than flow from a man-mande rubber nipple, especially in the setting of CLD, breastfeeding may not be more protective  if there is a primary airway problem as you describe.

I hope this is  helpful.

Problem-Solving: Stridor in preterm infant with trouble breastfeeding

Question:

I am seeing a 5 week old tomorrow morning, born at 35 weeks. I will be looking at fat pads and tethered oral tissues. Mom reports breastfeeding is very painful. Mom just sent a video and I am hearing a lot of stridor.  I am also seeing a very shallow latch. we will explore a Dancer hold tomorrow as well. I attached a video clip.

Thoughts on the stridor?

Answer:

ENT is a very important consult for which to advocate. I have been fortunate over the years to be mentored by some fabulous neonatologists (who love the airway like I do!), RTs, pulmonologists and pediatric ENTs who have kindly allowed me to ask a million questions and who kindly have helped me think about the airway from their perspectives — but very “simplified” so I could start to make sense out of what  I am seeing and hearing clinically.

We don’t know much about history and co-morbidities for this IUGR-appearing infant except she was 35 weeks GA and is now 40 weeks adjusted age. So much possibility for why we are hearing stridor. Knowing more may assist with our problem-solving on the list serve, and as the SLP seeing the infant, inform a initial differential that allows the SLP to advocate from an informed perspective.

The shallow latch may be purposeful to limit flow in order to protect the airway, or it may be due to tethered oral tissues, or it may be purposeful due to the need to prioritize breathing. Or a combination of any of these etiologies.

Is there apparent mandibular hypoplasia that might be leading to an ineffective tongue-palate seal and poorly controlled bolus? That can lead to stridor.

Be thoughtful with a dancer hold as it will inadvertently increase flow rate, which may not be what the infant wants. If when you offer the dancer hold, you hear increased stridor, or infants pulls away or changes facial expression to a “worried” look, or increases breathing rate or effort, the infant will be “telling you” the dancer hold is not helpful for him right now. Infant guided interventions and the infant’s responses always inform our differential.

Stridor may be iatrogenic (post-extubation, post-ECMO, post PDA ligation or repair to the aortic arch, post-emergent or prolonged or repeated intubation, or due to resulting subglottic stenosis, for example),or it may be congenital (r/t a vascular ring, idiopathic occurrence at birth without explanation, laryngomalacia, tracheomalacia or tracheobronchomalacia). It is surprising  how often it can go apparently unnoticed so to speak prior to our noted concerns, despite worrisome or adverse effects on feeding (intake, co-occurring physiologic stress and apparent swallowing safety). I have seen this both in NICU, PCVICU, and with admissions from home to PICU and our pediatric inpatient units at times over the years.

Cannot tell if the stridor is present at rest, as the video starts when infant is already at breast and sucking.

Cannot see if there are suprasternal and/or supraclavicular refractions present at rest or, if they are seen, are they seen during feeding only.

My mentors have taught me that:
Stridor heard frequently at rest suggests a primary airway pathology. Stridor present at rest often will be exacerbated with the aerobic demands of feeding, both at breast and bottle.

Contrast that with stridor that occurs only during feeding. That may suggest either swallow-breathe incoordination, due to  the tendency to inhale after the swallow, or indeed attempts of the airway to close in a protective maneuver due to bolus mis-direction from above and/or below.

The stridor in the video sounded biphasic, suggesting a fixed airway obstruction (subglottic stenosis, paralyzed vocal cord(s)—as the airflow moves past a constant obstruction on inhalation and on exhalation – that leads to the biphasic stridor.

Contrast that with stridor on only one phase of respiration, which is most typically associated with a dynamic airway problem – i.e., laryngomalacia – stridor is typically only inspiratory, as there is collapse on inhalation   or   tracheomalacia  – stridor is typically heard only on expiration. There may of course be a combination of airway problems, best diagnosed by ENT.

Of course we don’t diagnose airway problems as SLPs. My mentors weren’t trying to teach me to do that, but rather to think critically. I  describe what I hear,  in the setting of that infant’s/child’s unique history and comorbidities, and my ENT and neonatology friends tell me that helps them. And it helps me better consider the “whys” that underlie the feeding and swallowing challenges that result.

I hope this is helpful.

Problem-Solving: Balancing ALARA in radiology with data collection

Question

I’m relatively new to conducting pediatric MBS studies. The pediatric MBS is also a relatively new service provided at our facility. The pediatric radiologist seems extremely conservative in how many swallows/seconds he will allow for an MBS study (10 seconds/swallows total). I was trained at another facility and in talking with my peers, this is not enough swallows to get an accurate picture of an infant’s swallowing (especially if also looking at fatigue, position changes, thickeners).
I’ve been looking for research to support the amount of radiation intensity (continuous) and time (around 60 seconds total) that my peers tend to use, however there seems to be minimal literature that specifically addresses this topic.
Can you advise me as to how to advocate for a more complete study, even though this means more radiation exposure?
Thanks

 

Answer:

Rads are the ones who manage and minimize radiation exposure for patients and us too . So his caution is an attempt to protect us.

ALARA – as little as reasonably achievable – is the mantra. Work with the rad from a perspective of recognizing that and finding a common ground for gathering good data but assuring optimal protection (shielding well, time, distance all matter). Have some conversations outside of the “moment in radiology” to problem-solve.

When I teach my pediatric swallow study seminars across the US, I always survey attendees for average exposure times they use as guides, and they are typically <2 minutes for infants , and < 5 minutes for children.

This allow typically for enough data to objectify physiology and interventions usually.

If I need to watch a bit longer to complete my differential, I let the rad know and ask if we can watch just briefly and he knows I really need to see that but that I am careful to watch exposure time.

Our aim is the least dose, so if I use about more time it is only after careful thinking and when it is crucial data that is needed.

Our tech can tell us at any time the exposure time up to that point, so we know how we ear doing as we go along. Tech tells us total exposure time at the end, and I always ask myself is there anything I might have done differently to lessen the exposure time.

Usually there is not but I always try to consider that question so can become a better clinician.

Rads usually pulse the beam, we use 30 frames per second but not every hospital radiology team does. Studies have shown that less frames/sec results in less useful data and 30 fps is optimal.

If the rad pulses the beam, and he starts the beam when you say “on” , and you plan what you are going to observe to objectify physiology, carefully select interventions to objectify so you minimize radiation, then these exposure time guidelines work well.

Feeding off line for fatigue while eating/drinking materials impregnated with barium will not use up that exposure time, just the brief re-imaging post fatigue feeding , to see if there are traces in the airway , larynx, nasal airway, etc. that suggest bolus mis-direction and or residue when infant/child was feeding off line, simulating fatigue factor.

Try this approach and see if it works. It does for me.  I developed it with input from our rads, who problem-solve with us as a team and we learn from each other from a place of mutual respect for the perspectives we each bring. The rads  recognize we too will do all we can to assure safety and focus on  ALARA.

I hope this is helpful.