Question:  On our Pediatric Unit (age Newborn to 18 years), particularly Pediatric Intensive Care, our physicians are not on the same page as to WHEN to start PO trials for Peds patients, when on HFNC.  One Intensivist has ordered Eval on kids at 8L and wants us to proceed.  Other Intensivists are stating 6L or less, and our pediatricians want 4L or less.  I want an evidence-based guide for ALL STAFF to be on the same page, including the nursing staff. With a high level of admissions in PICU for this current Respiratory Season, this is coming up way too often.   Most of our nurses prefer the 4L or less, and really trust and allow Speech to make the call on appropriate level, considering the whole evaluation process.  I have one ROUGE nurse, however, that follows infant “cues” only, and doesn’t seem to consider other contributing factors; thus, she just loves when ST is not around and she will get the MD to order a Nurse Swallow Screen, and plop them on the bottle or breast, no matter what the mechanism or Level of O2 support.  I want to establish a more “black and white” approach, or perhaps at least an algorithm or flowchart for reference for ST to use in our decision making.

Catherine’s Answer:  This dilemma is a common and daily challenge for those of us who work in a Children’s Hospital, both in PICU, our peds units, Pediatric Cardiac Intensive Care and the NICU.

The evolving science about the impact of respiratory support on the swallow-breathe interface is sparse and more robust for our NICU population, yet that too is actually still in its infancy, as a guide for our clinical practice. To some extent, the NICU population has more common etiologies and co-morbidities that may allow some guiding tenets to assist us, but even so, each infant is an individual patient for whom algorithms, without carefully considering the unique nuances of that infant, can lead us down a pathway that may inadvertently be problematic and unsafe.  In addition, we have multiple caregivers in PICU both within physician specialties and our nursing colleagues who bring their unique experiences, training, and perspectives on the critical factors essential to optimize the safety PO intake in children requiring intensive care.

For each patient in PICU, multiple factors will influence our impressions, our recommendations and our thoughtful conversations with the team—-i.e., the nature of our PICU patients –with their often multiple complex co-morbidities (or lack of premorbid co-morbidities when otherwise normally developing), whether they have a history of previous hospitalization and why, their varying reasons for admission, their different trajectories in terms of where they are at in recovery from (or resolution of) the event or events that provoked admission, their respiratory history, their feeding history; the need for early yet well-timed instrumental assessment for objective data about the impact of respiratory support on swallowing physiology—avoiding a study executed too early that may create and artifact in the data set. These factors that underpin critical thinking, and our differential and plan, are not easily mapped into an algorithm. One of my neonatology colleagues refers to this as the art and science of medicine, and I suspect the consideration includes the work we do as well. A gifted caregiver, he always says we have algorithms but remember to pause to really “look” at your patient every step of the way. I love that mantra and use it every day.

A focus on patient specific factors will be key: premorbid and current co-morbidities, acuity of illness, trajectory of their medical course (are they weaning support? How smooth has weaning been thus far? Has there been need for escalation? What about the last 48 hours?), your clinical impression of prerequisites for tastes or PO trials – or current resolution of interval clinical concerns—that underpin readiness to PO), the potential risk for that child if aspiration occurs and how that might impact overall recovery. Then we have to use a dynamic cautious co-regulated approach at all ages with continuous multisystem analysis and collaboration with the team.

There will always be those caregivers in any discipline who choose to operate outside the team, whom you described as rogue; rules and algorithms likely won’t change their ways of interaction. While it may seem a black and white process would be a good fix, it doesn’t allow for the required daily dynamic thinking unique to caring for a PICU patient that is changing and whose course is evolving. I think the thoughtful “cross fertilization of knowledge” as I like to call it, among team members caring for that patient via dialogue at Rounds and at each consult and, most importantly, in our many casual conversations with our PICU colleagues in between patients, that builds a foundation for caring for each patient uniquely every time. That can still be evidence-based, which of course includes the professional knowledge base each discipline brings to the conversation but allows room for a dynamic approach to each patient moment to moment, and collaboration. That way, through this cross fertilization of knowledge each of us grows and learns, and our combined perspectives can be mulled over and considered in concert with each other. Once a patient care process such as this is set in motion, it is amazing how it fosters collaboration, partnership, and professional courtesy that then can lead to optimal outcomes for the child and family.

An algorithm cannot encompass all components of a patient’s gestalt nor consider all the potential “whys” that might be relevant to that unique PICU patient. We out of necessity need to leave some room in our dynamic plan of care to accommodate that and build on the team’s joint perspective. It’s no different that our PICU Intensivists who likely have some guiding tenets for caring for a child with TBI, but the dynamic treatment will be carefully adjusted day by day based on the current data set —there is no one algorithm for intensive care processes with a TBI, as that may be an infant post shaken baby event, or a previously normal 10-year-old, or a toddler with premorbid ASD. We do often find that those children who have been otherwise normally developing prior to being admitted, for example with an acute respiratory illness or a viral process, may experience more rapid resolution and follow the trajectory for recovery of an acute process. Those with premorbid co-morbidities or with an acute on chronic respiratory process will typically take a different path and require more caution and deliberation along the way.

Part of the passion for PICU care for all disciplines comes from the deliberation, the joint attention, the learning from each other, the discussions and the incidental learning that takes place every day. Living in the “grey zone” where the answers are not black and white, and the path is built on asking questions, and follow-up questions, not having immediate answers, is what brings us back each day to grow and learn along with our colleagues, and from each patient collaboration, and then the team takes away “key learnings” to build the clinical reasoning for the next patient.

Two recent references:

Rice, J. L., & Lefton-Greif, M. A. (2022). Treatment of pediatric patients with high-flow nasal cannula and considerations for oral feeding: a review of the literature. Perspectives of the ASHA special interest groups, 7(2), 543-552.

Raminick, J., & Desai, H. (2020). High Flow Oxygen Therapy and the Pressure to Feed Infants with Acute Respiratory Illness. Perspectives of the ASHA Special Interest Groups, 5(4), 1006-1010.