Problem-Solving: NICU Safety Concern

Question: I work in a NICU and am having difficulty with one of the Neonatologists. He changes nipple flow rates to see if volume will improve despite detailed documentation from therapists and nurses related to poor feeding quality, liquid loss, disengagement, occasional coughing and wet breathing with the faster flow nipple. Orders are changed requiring caregivers to use the faster nipple basically tying their hands behind their back regarding following the infants lead. I still use the slower nipple regardless and try to educate. Last time this happened, we spoke to the ‘head physician’ and were told that although my services were consulted, it’s is the physician’s decision to make. The question I want to throw out is…. In this case, is it expected that I sign off as the recommendations are not followed after education and discussions? Do I stay on to provide quality oral experiences 3-5 feedings per week, only? Not sure what the expectation is at this point.

Answer: This is unfortunately a more common situation than one might think. As I travel to teach about the NICU across the US and beyond, all too often this is a topic of discussion, as many SLPs who are part of NICU teams experience such a dilemma. Volume driven feeding in the NICU continues to be a challenge to neuroprotection and swallowing safety, and creates not only concerns for airway invasion but also learned aversions and maladaptive behaviors. The push to “get babies out”, lack of awareness and/or understanding of current research, combined with old habits of “getting it in”, combine to make our work in the NICU both challenging, at times disheartening and at times exhausting. Continuing to bring the research, using each consult as an opportunity to dialogue and letting the medical team “think along with you” about physiology, medical co-morbidities in the NICU and their relationship to feeding/swallowing, using guided participation with nurses and partnering with RNs who “get it” continue to be ways we can articulate our value. But in these situations as you describe, there is no clear answer. One option is to sign off, but then we cannot even advocate to protect the infant, support parent learning and reconsideration of their infant’s communication, identify onset of resulting aversions, or try to optimize safety with interventions. And we often cannot continue the dialogue about that infant and his response to the faster flow that may continue to go unrecognized by well-intentioned caregivers. And we lose an opportunity to turn the tide. I recognize it is a high and strong tide, one I have been dealing with since 1985 when I first set foot in a neonatal intensive care unit. Our resilience matters for the preterm and sick term infants in our care in the NICU, and their futures. Working in the NICU is indeed a step at a time each day, and requires much of those who choose to be there. The changes one can see over time keep us going and we support each other to have the courage and confidence to do so. I hope this helps

Problem-Solving: 9 month old with poor feeding and NGT

This interesting pediatric patient was sent to me for problem-solving. Thought I’d share, since it is an opportunity to build our clinical reasoning in pediatrics:

Question My patient is almost 9 months old s/p bilateral strokes. Has only breast fed, no bottle feeding experience. Has NGT in place. Head control is an issue but getting better and can maintain in Rifton chair/supported high chair when awake, alert. Currently breast feeding without aspiration related issues, although latch and strength of suck appear to be reduced and mom reports subjective difference. Main issue is moms reduced production of milk at this time, also baby has always been a “grazer” so not a good combo I have tried a dr brown level 1 and used smaller volufeeders; he can’t latch at all and he does not non nutritive on pacifier either. I’ve tried the bottle for over a week at my supervisors recommendation that we should “desensitize him” to the bottle. I am considering using a breast feeding trainer cup such as Mam or NUK simply natural to pursue any bottle feeding route. My understanding is that the neurolearning threshold for transitioning may be pretty tough as this point since sucking isn’t reflexive anymore and he has no prior experience with this skill- but I am open to hearing about others experiences and best practices. He is taking small volumes of purée via spoon and honey bear straw cup. I suspect he may need more time w ngt to build oral motor skills and then wean off ngt. Catherine, can you offer any suggestions for either improving bottle feeding transition ?

Answer: Don’t know a lot about his birth history, developmental history and co-morbidities that would help to problem-solve and to put into context the nature of his feeding/swallowing problems, since they sound like they are part of a bigger picture, as is often the case. I suspect his birth history would inform our differential. Multiple systems can be and often are synactively affected by each other and create a complex puzzle that needs to be solved to guide our plan of care. Wondering why still an NGT at 9 months instead of a GTube, given longstanding poor feeding, to support growth and avoid aversions that can result secondary to prolonged NGT in situ? Sounds like at least hypotonia and reduced postural stability are contributing to poor feeding, and are unlikely to resolve the short term, given apparent neuro comorbidities. Wondering about integrity of saliva swallows. If suck is that poor, swallowing physiology is likely also altered, if not impaired given poor head/neck control. Postural issues described suggest there may also be respiratory considerations. Not sure we can conclude there are no aspiration issues as he is more likely to silently aspirate given hypotonia, if he does invade his airway. Or he may misdirect the bolus toward the nasopharynx and adversely affect his nasal airway patency. Other relevant systems could be airway, respiration and GI co-morbidities that need to be considered in your differential, in the setting of his medical history. That should help guide you to workups to request and what interventions are indicated or might help at this juncture. Not sure about the rationale for the reported need to “desensitize”? Normalizing oral sensitivity sometimes needs to be part of the process but doesn’t sound like it for him, based on what you have mentioned. The latch is not likely refusal from what you have told me but rather altered sucking integrity or perhaps flow rate challenges that result in adaptive behavior that then becomes maladaptive. If the suck is poor, as you describe, a MAM or NUK breastfeeding training cup may not help or may create more challenges. Try to figure out why he is having trouble, first, then consider what interventions might best address that problem. The problem is likely not the feeding utensil but lack of the oral-sensory motor- underpinnings for effective feeding or other factors which I cannot sort out based on what I know thus far. An instrumental assessment of swallowing physiology with the purees and honey bear straw cup you are using with him would help define physiology, and you might also be able to observe some swallows with bottle feeding as well. I hope this is helpful. What a complex little guy.

Problem- Solving: Milk drop intervention for feeding readiness

Barbara O’Rourke, NICU RN, read my post on pacifier dips in the NICU, and is sharing the infant-guided neuroprotective “milk drop intervention” being used in her intensive care unit, and its positive outcomes. Thank  you, Barbara! 

Three years ago, our NICU launched an approved IRB research project of giving milk drops to our infants. The project was initiated due to an increase in our VLBW and LBW of oral aversion and the inability to take full oral feedings at 40-44 weeks CGA. We sought the guidance of our medical team, who requested that the project focus on 23 week to 33+6 week gestational age at birth infants. Although our only hypothesis was that “the infants who received milk drops would have a shorter length of stay (LOS) than infants who did not”, we also assessed and collected data for our knowledge regarding their HR, RR, oxygenation, color, state, tone, respiratory support, and response to the milk drops. The intervention would start at 3 days of age, and the infants were to be given normal bedside care except after they had been nested in, we would give a droplet or two of milk – if the infant licked their lips we would offer a swab or pacifier – if the infant accepted we would give more – a droplet at a time – based on the infant’s cues. The swab or pacifier remained in place as the droplets were given. The volume was limited by gestational age, and just like a feeding, sometimes the infants would not respond, however most of the time the infant did respond. As they matured they would often awaken before cares, sucking their fingers, looking around, and “waiting” for their milk drops. The process often took 10-15 minutes as we paced the infant allowing the infant to guide us. We only gave milk drops with cares or gavage feedings as oral attempts were considered the oral enjoyment for that set of cares. 100 subject infants were matched with 100 control infants who were discharged from our NICU before the study began. The data of the one 23 week infant in the project was pulled since the infant was transferred to another facility. The remaining 99 subject infants were matched only on gender and gestational age at birth with control infants. The average LOS for the subject group was 44.11 days versus the control group 49.30 days. The most significant difference in LOS being seen in the infants 24-30weeks. When costs were assessed, it saved our unit over $660,000.00 on these 99 infants. Our medical team requested the milk drop intervention become a standard of care for all infants in our NICU. The nurses document the infant’s response to milk drops in EPIC with the therapists and neonatologists often including the infant’s response to milk drops when they are assessing for oral feeding readiness. It is not unusual for our VLBW and LBW infants to go home at 35-36 weeks, some exclusively breastfeeding.