Question: During rounds there was a question around whether there were any benefits to providing oral stimulation for our intubated NICU infants. I did a quick search to see if there was any literature out there but did not find anything specific to intubated infants. Interested in your insights and experiences.

Catherine’s Answer:

Early oral cares are often provided by bedside RNs in this fragile population of intubated infants, and research documents multiple benefits. A few added thoughts related to our clinical wisdom. The population of “intubated infants” in the NICU as you know encompasses such a wide range of GA, PMA, co-morbidities and levels of physiologic stability and tolerance to interventions.

These indeed are often our most fragile NICU infants. Each one is typically unique, so I always start with understanding that infant’s co-morbidities that led to the need for ventilation. For example, PPHN, CLD, CHD, congenital malformations, neuromuscular disorders, and structural airway alterations, or multiple complex co-occurring co-morbidities, which then often create an even higher risk for adverse feeding outcomes.

Bobbi Pineda in her most recent contribution to our knowledge base reminds us that in the NICU we must be thoughtful and cautious, as we can inadvertently cause harm—- “Careful consideration as to whether each intervention can be done for most infants at a given PMA is complex, and vulnerability of infants in the real-world context must be carefully evaluated.”  To her nugget of wisdom, I would add “the infant’s unique co-morbidities” as critical considerations. They often profile relative overall medical complexity, medical acuity and risk for instability, adverse outcomes, and delays in progression to full PO feeding.  Research has shown that prolonged need for ventilation in preterm infants is a significant predictor for feeding outcomes (Malkar, et al 2015).  We may follow those preterm infants with prolonged need for intubation (greater than 30 days), those intubated stable preterms  approaching the PMA when feeding readiness might be considered, those with prolonged intubation waiting for placement of a tracheostomy for long term ventilation. We may also follow intubated early term, full-term and post-term infants, with their attendant sequalae secondary to co-morbidities leading to admission to the NICU, who are therefore at risk for altered progression to PO feeding.

Fragile preterms if not born early would be fetuses experiencing motor learning and oral-motor learning in utero; their oral-motor movement patterns would be evolving in the context of the containment provided by the uterus, with hands on their face and in their mouth (and alternating touching the placenta per research).The risks for our sick newborns are likely related to altered motor learning (extrauterine and potentially intrauterine) and nosocomial and developmentally-related environmental differences specific to that NICU that may support, or not support, the early oral-sensorimotor underpinnings for eventual PO feeding.

Ideally the neonatal therapist would have standing orders in a level III and Level IV and collaboratively work with the team, especially the bedside nurse, which would then best allow for this dynamic individualized, at times necessarily episodic, intervention —to support those underpinnings.

We then recognize that what interventions are offered, and what are not offered will both be critical—and be unique to that infant’s bigger picture, and the ongoing tolerance of that infant in our hands.

Interventions will involve infant-guided structuring of experiences that most closely align with the optimal oral-sensory-motor environment, which mimics to some extent a variation of those in the intrauterine space (for preterms) and those typical of early life (for sick newborns), laying the groundwork for caregivers’ embracing the complexity of the prerequisites for potential future PO feeding, and building the appreciation for the small steps that are designed to build forward in a thoughtful individualized way—which is key.

While we do not to my knowledge have RCTs to support intervention with these fragile infants, our clinical wisdom and experience clearly support that beginning to unfold this pathway to optimize outcomes has been beneficial.

Almost 15 years ago, one of our APRNs asked me to follow a former 24-week infant with CLD and PPHN, then 45 weeks adjusted age with protracted ventilator dependence. She said, “I hope you don’t think I am crazy since he is still on the vent, but I want to give him every chance to be ready and do his best if he is able to PO in the future. I think you could give him the best chance.” I recall telling her, “Thank you so much for being so proactive and seeing the possibilities to build his oral-sensorimotor readiness and minimize maladaptive behaviors. I’ll be careful every step of the way”. And she said, “Just what I thought.” That is team collaboration on the infant’s behalf.

While we don’t always have published research for what we do in the NICU, we do have our critical thinking, and the cross-fertilization of knowledge through collaboration with a thoughtful NICU team.

I hope this is helpful.

Pineda, R., Kellner, P., Guth, R. et al. NICU sensory experiences associated with positive outcomes: an integrative review of evidence from 2015–2020. J Perinatol (2023)

Malkar et al (2015) Antecedent predictors of feeding outcomes in premature infants with protracted mechanical ventilation. Journal of Pediatric Gastroenterology and Nutrition, 61(5), 591-595).