Problem-Solving: Infants with HIE in NICU

Question from SLP:


The LC (from a nursing background) and I don’t seem to agree. Particularly with an grade 2 HIE infant we weren’t in agreement but it I think it is applicable beyond. For complex or fragile infants learning to breast feed, when they begin falling into the sleep state and reflexively sucking but holding onto the nipple would you tend to a) break the latch and discontinue the feed? Or b) would you do this after a certain amount of time – eg 45 minutes to an hour after waking the infant or c) let them go until they let go of the nipple.Thanks for your help,

Catherine’s Answer:


Can you tell us more about the infants skills, course and history? Altered state regulation for goal directed behavior for feeding is worrisome in the setting of HIE, to which you allude. It may predispose some infants post HIE to silent aspiration, if indeed swallowing and oral-motor integrity are altered. This is often the case with HIE, depending on the bigger picture of co-morbidities,  neurologic data/MRI, WOB and postural/sensory-motor integrity, and how their developmental trajectory is emerging post event. Quiet alert state in this population is typically critical for safe feeding and for actively learning and establishing neural motor maps for safe feeding. What impact do tactile/vestibular re-alerting techniques, f/b secure swaddling to promote postural stability and alignment have?

Response from SLP:

So the main question is whether you allow neonates for keep sucking at the breast when they are not in a quiet alert or even drowsy state. The LC does not think it’s appropriate to cut off a breast feed unless the infant is overtly not tolerating. And she would I say if they still are holding onto the nipple they are still engaged in the feed. The particular infant we were disagreeing about was cooled 72 hrs, seizures initially, rescued tone, suck present but initially weak. He was only 1 day post rewarming when the LC and I assessed jointly. He struggled to rouse for the feed but following cares and some non-nutritive sucking on the pacifier, he was offered the breast – demonstrated active rooting and immediate initiation of strong sucking. He changed sides and again strong root and suck. A few audible swallows but not much as milk supply was limited. When he fell more into a drowsy and then light sleep I thought we should remove him from the breast, especially as it had been nearly an hour since they had first started trying to wake him. But she disagreed and it created a very awkward situation in front of a parent and one that we have gone round and round on since without agreeing. Just finding my therapy lens and her lactation lens are not seeing the same thing or able to come to an agreement.

Catherine’s response:

It is challenging to answer regarding all neonates, as not all neonates, as you know, are the same. There isn’t of course a one size fits all answer, which you recognize but she may not. The co-morbidities you describe are, for me, a critical part of problem-solving how to proceed during a breastfeeding session for this particular infant .

For this infant, in the setting of his co-morbidities, I would not allow him to suck “on automatic pilot” the way that mothers of healthy infants might. Healthy infants without co-morbidities, like LC might see in NB nursery, will still learn when breastfeeding in drowsy or light sleep state and are typically quite safe. The healthy NB might rest without fully maintaining latch and then re-engage smoothly when hunger provokes return of drive.

This is very different than the situation for the infant you describe. Having required cooling/therapeutic hypothermia for 72 hours, with altered postural and oral/facial tone (likely leading to the weak suck) is at high risk for airway invasion. Most infants with his history and a weak suck also have alterations in their swallowing integrity because the neural underpinnings for sucking and swallowing have overlapping function.

After an hour of efforts at breastfeeding, 1-day post-rewarming, his disengagement needs to be respected. The integrity of his likely already fragile swallow will be less reliable and less timely with the onset of fatigue. That is so different than a healthy NB. Perhaps focusing on his unique history and co-morbidities as the basis for your wanting to rest and protect him, as contrasted with acknowledgement of how you would agree that with a healthy NB the session would be different, would be a starting point for collegial conversation over coffee.

The lens through which she is looking at the skills he brings to his breastfeeding may not readily include full awareness of the adverse effects of HIE on those critical underpinnings as they relate to safety. But we recognize her good intentions. Continued dialogue is the key. You can offer a perspective that is probably different from hers and could “round out ” her perspective,  and reframe his behaviors with new meaning.

Question from another SLP in response:

We have a very similar infant in our level 3 NICU…36 weeks, HIE, cooled for 72 hours, seizure activity. He survived re-warming, does have white matter damage per MRI but no infarct. He is currently on a CPAP of 6 and tolerating for the most part although RR is often well over 70. With cares he does demonstrate some nice periods of quiet alertness, will bring his hands and fingers to his mouth, and suck on a pacifier. He does a lot of tongue thrusting.. perhaps related to the placement of the OG but also ? if there is more of a neurologic component . Mom also would like to breast feed although with other children at home I’m not sure he will be a sole breast feeder. He has a very wet productive sounding cough at times with cares which concerns me a little bit…question possibility of silent aspiration with own secretions. He has not started to PO yet given respiratory status but I’d love to have any insight into this situation as well. I am very concerned about the risk for aspiration. Being a level 3 NICU, many of our babies on cool cap end up being transferred to a level 4 NICU for higher level care so I just want to make sure we are taking all necessary precautions when this infant does start to PO feed. Thank you so much

Catherine’s response:

I agree that his current clinical presentation and history are worrisome for ability to be a safe PO feeder, given what we know right now. His risk for altered swallowing function seems quite high, and a wet cough at rest, increased WOB and intermittent tachypnea. I would suspect that the altered oral -motor integrity you describe is likely neuro-related as opposed to the presence of an OGT in situ, as  it is not a typically co-occurring variance with typical  late preterms without his neurologic co-morbidities . As respiratory support is weaned, and he has an opportunity to fully exhibit the range of behaviors (or lack thereof) prerequisite to PO feeding, you can help the parents learn along with you about the complexity of swallowing for late preterm infants,  prerequisites for PO, his skills and challenges given history ad know diagnoses/test results,  a focus on the little steps toward readiness to feed. As you build the  relationship of trust , you can come from a for a perspective of knowing they want the best for their infant; you can help mother learn along with you through your offering pacifier dips of mother’s milk for purposeful swallows and reflect to her what that suggests to you about suck-swallow-breathe function, before actual PO is on the horizon. You will be learning about him and so will she, so when the team considers an order for nuzzling at breast, a foundation of teamwork and mutual problem-solving will have been established. That will be a good place from  which to have continued conversations.




Problem-Solving: Fluoro Time for Neonates

Question:

At the hospitals that I work at we have outdated machines that only capture video swallow studies at 6 frames per second. Are the restrictions the same for fluoro time (I think it’s about 2 min recommended fluoro time at 30 frames per second for peds and neos)?

Catherine’s Answer:

The low frame rate will of course limit the objectification of swallowing physiology, unfortunately, and sometimes can lead to the need for increased exposure time. Multiple citations by Heather Bonilha Shaw would be helpful as you advocate, along with your radiologists, for equipment that provides 30 fps.  Given your situation, ALARA (as low as reasonably achievable) should remain your guide. That said, as I teach across the US and survey attends at my swallow study seminars, is most typical that with neonates, the aim is the least amount necessary but less than 2 minutes; with pediatric patients, less than 5 minutes. Of course, co-morbidities, compliance, previous exposure to x-ray/radiation, and clinical impressions about physiology as your go along in the study, all must be considered.

Our tech tracks the exposure time as we go along, the rad and I are very aware, and at each juncture I am asking myself “have I objectified physiology sufficiently? Do I need more time?” and if so I am very thoughtful about continuing or not. if I need a few more swallows to better elucidate physiology or complete a differential, or to objectify the likely positive impact of an intervention, I usually discuss it with the rad and we agree on further time based on a determined required need. Most infant studies are less than 2 minutes exposure and most of our pediatric patients less than 3 minutes, at 30 fps.

At the end of each study, I think always ask myself, ” is there anything I could have done differently to reduce exposure time?” Maybe not but it keeps my always trying to do better for my little patients. Heather is on the ASHA list serve, and, I am sure, can add her always appreciated thoughts. Her recent commentary (see list serve archives) on a paper suggesting 15 fps in pediatrics so eloquently explained issues even in 15 fps for our population that may also be useful in helping to make the case for equipment that provides 30 fps.

Problem-Solving: Respiratory rates in neonates

Question:
Hot topic and in need of evidence based research regarding bottle feeding the premature infant (or term infant) with tachypnea.

What is everyone’s practice?  No PO feeding if respiratory rate above 60? 70?  Would appreciate research articles and your hospitals guidelines!

Catherine’s answer:

To my knowledge, there is no research to guide practice but rather the it is often neonatologist training,  preference and the extent to which intake is a key driver in a particular NICU. Neina Ferguson published an informative paper in 2015 about preterm infants in  the NICU that correlated tachypnea during PO with subsequent aspiration in radiology.

Ferguson, N. F., Estis, J., Evans, K., Dagenais, P. A., & VanHangehan, J. (2015). A retrospective examination of prandial aspiration in preterm infants. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 24(4), 162-174.

The paper did not look at impact on physiology in detail, but I clinically see in the NICU population that tachypnea can alter physiology without witnessed aspiration or penetration under fluoroscopy, and thereby create risk for airway invasion.

Some neos write orders to PO if infant is “comfortably tachypneic”, RR under 70.  “Comfortably tachypneic” is a almost parodical , in that tachypnea is rarely co-occurring with a comfortable looking infant, rather infants who are tachypneic may often be  exhibiting other signs of physiologic stress (e.g., nasal flaring/blanching, suprasternal and/or supraclavicular retractions, chin tugging). Increasing RR leads to more shallow insufficient respirations. The need to breathe often and rapidly will create challenges in the swallow-breathe interface, and cause breathing and swallowing to uncouple. It takes a second to complete the pharyngeal swallow, so then a RR over 60 clearly increases risk for airway invasion.

Respiratory Rate, my RT mentors tell me, doesn’t exist in isolation but is rather a part of a bigger picture. Much like, they say, level of respiratory support required does not exist in isolation. It’s each infant’s bigger picture that guides us.

As we advocate and make determinations of relative risk with PO feeding for our preterm infants, we really must look at each infant in the setting of his unique history and co-morbidities and their unique attendant sequelae. An infant post HIE just weaned or HHFNC will require a different algorithm than the former 24 weeker with CLD, contrasted with the term infant who is s/p TEF/EA repair. And, as Dr Coyle says, that is ok. One algorithm won’t work for every patient and it shouldn’t. All of my examples are infant who often have risks for airway invasion but the nuances of each infant will likely yield a slightly different profile from which to problem-solve, with the team.

That is the challenge of our work in the NICU. To look at each infant as a unique patient, and,  in the setting of what we know about him, and what we see clinically, make a well-thought out educated plan to minimize risk, articulate those risks as best we can to the team, establish interventions that optimize safety and assess their impact on an ongoing basis.

In the NICU , we are required to  live in the grey zone…no easy questions and there are no easy answers, more questions than answers, constantly thinking and re-thinking.  Just keep “listening” to each infant Tara, like you are doing, and especially partner with RTs and a neonatologist that respects the complexity of feeding and swallowing so they can think along with you.

Problem-Solving: Vocal Cord Paralysis and Sidelying

Question:

Does anyone know of any research articles regarding the effectiveness of putting an infant with a left vocal fold paralysis in a sidelying position for bottle feeds? Also, what are your thoughts about performing an MBS or FEES prior to initiation of PO feeds?

Answer:

To my knowledge there are no randomized controlled trials or research studies regarding this intervention. The pediatric ENTs who took me under their wing early on in my career suggested it and theoretically it made sense to me. While its proposed purpose (i.ie, placing infant with a left vocal cord paralysis R side down for PO feeing) is to utilize gravity to assist by passively bringing the paralyzed cord to midline, it is unlikely that can simulate true effective closure as one would observe in the setting of normal vocal cord motility.

In addition, if there are other co-occurring co-morbidities that adversely affect airway, postural or swallowing function, those most also be considered in the differential. However, combined with other interventions such as controlling flow rate, co-regulated pacing and resting, we have consistently seen improved dynamic swallowing objectified under fluoroscopy in radiology. That clinical wisdom is a level of evidence base that has helped to guide my practice.

There is also a high risk for a paralyzed R vocal cord post ECMO, so many of our cardiac infants and select preterms who require ECMO. Similarly, I have both clinically and instrumentally observed a left side down position in the setting of a R vocal cord paralysis to be a useful intervention to trial.

Once again, need to consider all co-morbidities that maybe relevant to guide us. I prefer that infants not have their first PO feeding experience in radiology. It doesn’t allow me to complete a cautious limited clinical examination of PO feeding prior to the instrumental, during which time I can begin to formulate a differential regarding the full picture (i.e., potential effects of respiration, state, and other co-morbidities on the infant’s feeding/swallowing function in the context of the infant’s history. Also, during that first feeding, when sensory-motor maps are being established and recruited, they must be on the x-ray table or in an infant seat. That said, we recognize that high risk for airway invasion in the setting of both L and/or R vocal cord motility issues. If clinically indicated, I prefer at least 1-2 very small brief PO feeding experiences with me while I trial the interventions and allow the infant to experience sensory-motor learning under optimal conditions. This can be as little as 5 mls. Because we recognize that swallowing physiology needs to be objectified to guide management for such an infant, an instrumental assessment would then follow. FEES would clearly inform our differential, and a VFSS would provide insight into the dynamic swallow pathway. I hope this is helpful.