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.

Leave a Reply