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).

 

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.

Question:

I have a baby who was born around 38 weeks GA, now about 3 weeks old (I can confirm when I’m at work tomorrow if needed). Attempted vaginal delivery, but baby began having HR decels. Emergent C-section, mother’s uterus ruptured, and infant was free floating in the abdominal cavity. Coded at 10 min life, resuscitated. Whole body hypothermia protocol for 3 days, then re-warmed. Inconsistent gag reflex, poor secretion management (although improved significantly), no rooting reflex, no sucking reflex. Now on RA. With the exception of improved secretion management and stability on RA, there has been no improvement. Received G-tube yesterday. Likely will go home later this week.

Parents are amazing and I’m wanting to give them everything I can. I’m putting together a packet of information on including tube fed children in family meals and preventing oral aversion, things like that.

I’m just looking for any good handouts or information anyone may have that I can use. He’ll be set up with outpatient, but the family will do anything that may help at all.

This is the first baby I’ve worked with that has had absent rooting and sucking, so I feel stuck on how to treat.

Catherine’s Answer: 

In my experience, sounds like moderate-severe HIE given the impact on oral-pharyngeal reflexes. What did MRI Brain show? That is essential to our differential. What does OT say about postural tone and movement since it is a base for oral-motor control? Likely diffuse postural hypotonia but may be starting to show some atypical movement patterns and an abnormal increase in tone, depending on MRI. In the setting of neurologic co-morbidities as devastating as this appears to be, the diminished pharyngeal responses (i.e., inconsistent gag response) reflects pathology. Would suspect that if pharyngeal responses are inconsistent, there is a co-occurring impact on pharyngeal constriction, and saliva swallows are impaired to some extent. Remember that the suck, swallow, and pharyngeal responses are underpinned by cranial nerves with overlapping function —so most often, the suck, swallow and pharyngeal are impacted to a similar extent. There is a good chance he is aspirating his saliva silently, as he may lack the sensory registration and motor responses to elicit a timely and effective cough. Sounds like you been seeing the infant in the NICU, and he is being discharged to EI/home? These infants with this level of neurologic insult are so sad and are so complex. I remember the first one I was consulted on way back in the early 90s – we did not call it HIE back then but that is what it was. Despite 10 years in EI at that time with complex infants, no one knew how to help these infants that started to survive a difficult perinatal course. That is one of the reasons that I later developed my NICU Swallowing and Feeding and After Discharge seminar, and my Advanced Infant/Pediatric Dysphagia seminar —-to share my discoveries and support clinical problem-solving of our complex patients, across the age span. The aberrant oral-pharyngeal reflexes and facilitating the sensory-motor components that will support eventual function become the focus both in NICU and EI. For parents right now, it’s all about providing motor learning during their interactions —provide infant with good postural support and midline stability with UE/hip/knee flexion, chin tilting down, via very very secure swaddle; elevated sidelying cradle turned toward caregiver with hands supported near face; facilitate rooting response on own hands and via mother’s finger using deep pressure (not expecting him to respond but focusing on providing input for the brain); firm deep pressure to blade of tongue in rhythmical one per second pattern to provide motor learning for future sucking (using his own fist, mother’s finger, firm pacifier). Lots that we can then offer as therapists via NDT, sensory-motor learning, oral-sensory interventions for developing underpinnings for rooting, non-nutritive sucking, effective saliva swallows and state regulation. These babies are complex and teach us so much! Hope this gives you a place to start. I look forward to seeing you at one of my seminars, where I can expand on these interventions.