QUESTION: Anticipating the coming likely increase in RSV, we are expecting to be treating a lot of babies that are weaning from heated high flow nasal cannula on our pediatric unit. We are typically not feeding babies until they wean to 2L. Do you feed before that?

CATHERINE’S ANSWER: Such great commentary on a challenging clinical issue. For each infant, we need to develop a unique algorithm based on multiple factors. With our infants who were previously normally developing and are hospitalized for a viral process (such as RSV) or respiratory illness (such as bronchiolitis), we would anticipate their feeding challenges will be temporary, and will follow the trajectory for recovery of an acute, not chronic, process. Infant-guided interventions such as manageable flow rate, co-regulated pacing, resting, and supportive positioning that optimizes respiratory stability will be helpful, along with honoring the infant’s disengagement form feeding.

Contrast that with those infants with pre-morbid relevant diagnoses and or co-morbidities that may suggest “acute on (top of) chronic” problems. With this group, we would consider then the impact of their feeding history prior to admission (PTA), their co-morbidities PTA (very complex? moderately complex? one system only?), and aspiration risk (extremely fragile – high Fi02 versus stable with significant support- moderate Fi02 versus weaning support regularly – Fi02 21%), trajectory of their course (weaning of support versus interval escalation), and the prerequisites detailed so well by Hema, above. All of this is considered in the setting of risk to their health/recovery if that infant aspirates or micro aspirates. We might begin that continuum of return to PO feeding via pacifier dips for purposeful swallows as WOB and respiratory stability permit, working closely with RT, followed by the infant-guided guided interventions as described above, watching for subtle stress cues, infant communication and physiologic stability from moment to moment. All of this proceeds with careful attention to the on-going resolution of the viral process(es).

I hope this adds to your critical thinking. Pausing to reflect, as you did, really is the key to mitigating risk for these fragile infants.