QUESTION: Does your unit use a protocol similar to the one in this article (dropping kids who are typically on 3-4L to 2L to feed). If so do you have any thoughts or feedback?
Yildiz Atar, H., Ryan, R. M., Ricciardi, S., Nauman, C., Pihlblad, M., Forsythe, T., & Bhola, M. (2024). Introduction of oral feeding in premature infants on high flow nasal cannula in a level IV neonatal intensive care unit: a quality improvement initiative. Journal of Perinatology, 1-8.
https://pubmed.ncbi.nlm.nih.gov/38714842/
CATHERINE’S ANSWER: I am not aware of any other similar published protocols with a wean of respiratory support. The NICU OT at Rainbow Babies Level IV who co-authored, Sheri Ricciardi, is thoughtful. When I spoke with her about the protocol and its development, the careful infusion of a sound therapeutic perspective into the operationalizing of the protocol every step of the way is evident and sets it apart in my mind. The article describes this as a “very safety-focused protocol”, which has not been stated in previous published protocols I recall reading regarding PO feeding on CPAP and/or HFNC.
That said, I think the “wean” during PO to less respiratory support seems to come only from the “informal” guideline in many NICUs to “PO at no greater than 2 LPM support” without other evidence-based rationale. It seems to me counterintuitive that the infant can indeed be weaned during the aerobic demands of PO feeding to less respiratory support than “required” at baseline…… from a cardiopulmonary perspective, given that these are often our most fragile infants with CLD, that doesn’t make sense.
Is the level of tolerance by the “weaned” infant subject to less restrictive parameters? Often the monitors don’t tell the whole story during PO feeding, and our infants can ride under the radar. How often we see in radiology they infant continues to suck and swallow despite the trachea invaded by barium, in the absence of an A/B/D.
Given that some well-intentioned caregivers may respond in the NICU to our worry about WOB during PO by remarking “oh that’s how he always breathes, keep feeding”…when in actuality the “cost” of the wean to the infant may be more significant than might be apparent..? Subtle increases in WOB, subtle changes in engagement, change in motor control that may be subtle, need for more resting, slight delays in swallow initiation and/or airway closing or re-opening surrounding the swallow—these data points matter.
I wonder what a pulmonologist would say about the increased physiologic burden with the wean and the implications for function at a physiologic level, even at the level of the alveoli. Just thinking out loud.
If we have no objective data about the impact of the wean on swallowing physiology, we are basing our impressions on clinical data only. Yet these are are most fragile feeders who are the ones for whom we most often need a VFSS. Data from Duncan et al 2018 (out of Boston Children’s) reinforced that clinical impressions about airway protection have poor sensitivity. I worry for these fragile little ones for whom the noble and well-intentioned goals of PO feeding and getting home may not be without their own attendant sequalae for the infant. All of the answers are not in and in the interim we must proceed with caution on behalf of our little ones.
Neuroprotection is best supported with a focus on the “continuum” , which starts with individualized feeding readiness intervention. We follow our infants once stable on nCPAP, each with an individualized plan along this continuum. As Bobbi Gittens Pineda, OTR has said “vulnerability of infants in the real world context must be carefully evaluated” when we plan our interventions. A wonderful relevant reference is the publication by our colleague Rachel Scandiffio Selman OTR (2025). An on going encumbrance is that for some well-intentioned Neos, there may not even be a continuum that includes a period of pacifier dips in readiness to begin establishing the motor maps required. I suspect that is due, at least in part, to a lack of full appreciation for the complex underpinnings required for PO feeding and the abundant research that correlates co-morbidities with PO feeding difficulties and profiles infants at highest risk.