Question: Is there a pediatric algorithm or current guidelines/best practices for feeding pediatric patients on high volumes of HFNC? We’re frequently being asked to conduct Bedside swallowing assessments on pediatric patients who are respiratory compromised on 10-12L of HFNC. I’m very uncomfortable with this for several reasons. Our Intensivists are open to having conversations but are asking for the EBP. Any input would be greatly appreciated! Thanks in advance!
Catherine’s Answer: Our current research-based evidence on PO feeding while requiring CPAP or HFNC is only emerging and is limited. It is not sufficient at this time to allow us to create an generic algorithm in which we can have confidence to guide the team. It underscores the high importance of our clinical wisdom —-clinical reasoning and critical thinking —- for this fragile population, whether a neonate or a pediatric patient. The plan for each patient must be considered in the context of unique history, co-morbidities, premorbid status, acuity of illness, presenting clinical course and progress, trajectory of the respiratory course (weaning support vs. need for escalation), clinical impressions and differential, and current risks to health due to potential airway invasion, as each of my colleagues has so well reinforced.
In the neonatal period, with the guiding input of the SLP, the goals would be to minimize airway invasion, avoid onset of maladaptive feeding behaviors, minimize further respiratory system morbidity and avert the adverse short and long-term effects of stress (both physiologic and behavioral), and to support the parent-infant feeding relationship. Carolyn’s 2023 publication (see below) is an excellent resource for this question regarding our NICU population. The data documenting the high risk for silent aspiration among NICU infants is quite worrisome. Our only objective research data on safety of PO feeding for those infants requiring Non-Invasive Ventilation (NIV) –is from Ferrara (2017) looking at PO feeding on CPAP; the neonatologists conducting the study halted it due to safety concerns. One of the key takeaways for me from Ferrara’s work was the need for objective data regarding the impact of NIV on the swallowing physiology of neonates being asked to PO feed on NIV. Not just whether aspiration is witnessed but the impact on swallowing physiology even in the absence of witnessed aspiration. “Tolerance” for PO on NIV in neonates has been based in most studies only on subjective data, and as such the conclusions appear tenuous. Multiple studies have shown the limitations of clinical judgement regarding airway protection during PO feeding on much less complex neonates and pediatric patients – so our NICU infants with complex respiratory co-morbidities requiring NIV very likely present added risk for silent airway invasion.
For our pediatric patients in PICU, their premorbid history and co-morbidities, and reason for admission are part of the unique problem-solving required. Otherwise- normally-developing children who are admitted with respiratory illness, or a viral process may be expected to follow a different trajectory toward recovery and may be able to take a different path toward return to PO feeding than those with premorbid feeding/swallowing problems or a complex history. There is not an algorithm of which I am aware that can confidently discern those differences and their impact, at this time. Hema’s Desai’s 2022 publication with Jennifer Raminick (see below) is an excellent resource for considerations regarding PO feeding in the pediatric population requiring high flow oxygen therapy. Rice and Lefton-Greif (2022) also reinforce a focus on patient factors in the problem-solving process about HFNC in pediatric patients, especially the setting of the trajectory of the child’s course (weaning support vs. need for escalation), and the interaction with clinical impressions and the potential risk that airway invasion may impact recovery; there is also a lit review current at that time. Our pediatric patients are also worrisome due to the added complications of a high incidence of post- extubation dysphagia, estimated to be as high as 69% in a study by DaSilva et al (2023) see below.
Cross-fertilization of knowledge through patient-specific collaboration with the team (whether in NICU or PICU) is essential. I agree this can best be accomplished by Laura’s and Hema’s suggestion to advocate for SLP consult as the starting point for patients on respiratory support so that we can help guide the PO plan case by case, via ongoing collaboration. Of note, SLP consults in PICU according to Santiago et al (2023)- who noted a decrease in SLP involvement in the PICU (at three well-respected pediatric hospitals) among patients ages 7-12 y/o with a h/o mechanical ventilation, which may reflect a trend, pending further data. While this is not the situation in all PICUs, I hear from colleagues in some that the value-added by an SLP consult is not consistently recognized and a consult is sometimes perceived as likely to “hold the patient back” or delay discharge. This can unfortunately sometimes then provoke readmissions, prolong LOS and/or adversely affect outcomes.
From my networking nationally, a dilemma is not uncommon in many pediatric hospitals across the US. The unfortunate influence of applying adult-based data to pediatric practice, a scarcity of research on neonatal and pediatric patients, an often less-than-optimal acute care SLP consult practice —that would optimally support interdisciplinary problem-solving and care —and the increasing complexity of the patients we see across the continuum of pediatric acute care, all combine to create the perfect storm. We are all in this together.
Barnes, C., Herbert, T. L., & Bonilha, H. S. (2023). Parameters for Orally Feeding Neonates Who Require Noninvasive Ventilation: A Systematic Review. American Journal of Speech-Language Pathology, 1-20.
da Silva, P. S., Reis, M. E., Fonseca, T. S., Kubo, E. Y., & Fonseca, M. C. (2023). Postextubation dysphagia in critically ill children: A prospective cohort study. Pediatric Pulmonology, 58(1), 315-324.
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.
Santiago, R., Gorenberg, B., Hurtubise, C., Senekki-Florent, P., & Kudchadkar, S. (2023). Speech pathologist involvement in the pediatric ICU. Critical Care Medicine, 51(1), 353