Research Corner: Therapy Usage in the NICU

Therapy Usage in the NICU

Ross, K., Heiny, E., Conner, S., Spener, P., & Pineda, R. (2017). Occupational therapy, physical therapy and speech-language pathology in the neonatal intensive care unit: Patterns of therapy usage in a level IV NICU. Research in developmental disabilities, 64, 108-117.

This article by Bobbi Pineda OTR and her colleagues provides valuable information about utilization of therapy services in a large NICU. It provides insight into referral patterns and supports the concept of early and continued therapy services throughout the NICU stay to optimize outcomes. While their findings are not necessarily generalizable to other NICUs, this is the first attempt to gather such data.

It is worrisome to me that for those NICUs in which SLPs support feeding, referrals are often not received until > 36 weeks PMA. By that time, many of our fragile preterms (with complex co-morbidities) have already struggled learning to feed and may be referred at that time for extra support to “fix them”. In NICUs where PT/OT support feeding, they are typically already following the infants when feeding readiness is a focus, so for those infants whose team is likely to require extra support for feeding, it is already in place. My hope is that there will be greater recognition of the importance of early additional feeding support to the team for those preterm infants at the highest risk for enduring feeding problems, as profiled in the literature. The complex nature of their poor feeding often requires a team approach to avoid maladaptive behaviors and airway invasion. More research is needed to explore this concept and articulate infant needs for support related to co-morbidities.

Research Corner: Tube Fed Children….Management, Weaning and Emotional Considerations

Tube Fed Children: Management, Weaning and Emotional Considerations

Edwards, S., Davis, A. M., Bruce, A., Mousa, H., Lyman, B., Cocjin, J., … & Hyman, P. (2016). Caring for tube-fed children: a review of management, tube weaning, and emotional considerations. Journal of Parenteral and Enteral Nutrition, 40(5), 616-622.

Working with our infants and children who are tube fed can be challenging. This more recent article by a well-respected interdisciplinary team highlights some key perspectives and current data that can inform your therapy practice. Hope you enjoy it as much as I did.

Catherine

Research Corner: Feeding Problems from the Parents’ Perspective

Feeding Problems from the Parents’ Perspective

Estrem, H. H., Pados, B. F., Thoyre, S., Knafl, K., McComish, C., & Park, J. (2016). Concept of pediatric feeding problems from the parent perspective. MCN: The American Journal of Maternal/Child Nursing, 41(4), 212-220.

Wanted to share this recent article that so well captures the importance of the family as the most important part of our therapy with their child. As the authors state: “A child and their family have a feeding problem; they experience this journey together. It is more inclusive to consider this issue in the context of the child’s natural environment with the people who are most familiar and invested. A shared conceptualization that families can relate to (without perceived stigma), and that providers could use to classify pediatric feeding problems, would improve potential for early feeding assessment, referral, and for feeding intervention efficacy to last long term.”

Research Corner: Brain Oriented Care in the NICU

Brain Oriented Care in the NICU 

I wanted to share with those of you who are part of an NICU team or provide services for NICU graduates an article that, while 4 years old, is still so applicable as we support change from a volume-driven to an infant-guided feeding culture in the NICU. Those of you have an interest in neuroprotection for fragile adults will also find it interesting.

Bader, L. (2014) Brain-Oriented Care in the NICU: A Case Study. Neonatal Network Sept/Oct 2014, 263-267

Brain-oriented care, or neuroprotection, is often thought of as “new” to the NICU, yet as the author states, neuroprotection encompasses all the interventions that promote development of the brain. Because our NICU infants are wiring their brains outside the womb, every experience matters. Especially when it comes to feeding. The author makes the connection to infant-guided feeding, an approach we all need to advocate minimizing the physiologic stress associated with learning to feed in the NICU, and indeed after discharge. Unfortunately, the physiologic stress that many NICU infants experience when fed using a volume-driven approach instead, can wire the brain away from feeding. The feeding outcomes of NICU infants, which are poor, make it imperative that we be a part of the change in our NICUs to listen to the infant’s communication and provide the relationship-based care, especially with feeding, that allows the preterm infant’s brain to wire in an adaptive not a maladaptive way.

I hope you find this informative.

Catherine

Problem Solving: Feeding Readiness in the NICU

Question: Non-nutritive oral motor therapy in NICU – when do you use it and why and what result do you see? As a warm up to oral feeding to help organize? In 30-32 weekers to prepare for oral feeding? In patients who would be nil by mouth for an extended time? Patients who are not able to feed orally due to severe aversion (usually due to gastro issues)? What is the latest research on this? I’ve read articles for and against.

Answer: A few thoughts for you. I don’t conceptualize what I think you are describing as oral motor but rather “feeding readiness”, which encompasses a different concept, a much broader, yet more defined, infant-guided approach in the context of the preterm’s unique co-morbidities.

Conceptualizing the feeding-related services we provide in the NICU as “feeding readiness” and “supporting safe/functional PO feeding” can help neonatal nurses and neonatologists better understand the value we add to the NICU team. Unfortunately, well-intentioned but stressful cares and/or feedings may wire the infant’s brain away from eating, and indeed lead to later feeding aversions. The literature on feeding outcomes in former preterms includes reflections on the high percentage of former preemies with enduring feeding problems, far beyond the NICU. It impacts the infant-parent relationship and multiple domains.

I would avoid “oral-motor work” designed to focus on oral-motor skills per se at this juncture as it would be too invasive and not appropriate. You are describing preterms who are both fragile and still many weeks prior to term. Were they not born too soon, they 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). Careful attention must be paid to physiologic stability, especially its impact on WOB and RR., during all infant-guided readiness experiences Progression to pacifier offered via rooting response for sucking with co-regulated pacing, f/b tiny droplets of EBM on a pacifier offered via rooting response for purposeful swallows They would be integrating their structurally-intact aero-digestive system by 17 weeks of life, swallowing several ounces of amniotic fluid each day.

Focus on structuring experiences outside of the uterus that most closely align with the ideal sensory-motor environment (intrauterine)and help caregivers embrace the critical impact this intervention can have if offered in a neuroprotective infant-guided way.

Also, know that in addition the benefits of mother’s milk (EBM) to the mucosa via tiny trace droplets that may promote purposeful swallows and oral-sensory-motor mapping is being considered by many NICUs as an early approach to supporting readiness for infant-guided feeding in the future prime the sensory-motor system along with nuzzling at the breast (kangaroo mother care). There is a very tiny “paintbrush” one of the reps has (sorry I cannot recall which) that can support a very gentle limited offering of MBM to the lips or this could be offered via very gentle well-graded touch. But one can do this with gentle infant-guided touch via a caregiver’s gloved finger as well.

The key is that any feeding readiness experiences should be offered when infant is at his best respiratory wise (both in terms of respiratory support being required and his WOB and RR), he is actively engaged and maintains physiologic stability, and should be offered using infant-guided principles of interaction. Resting the infant and use of co-regulated pacing to assure that respiratory stability is fostered from moment to moment, are essential to support a neuro-protective experience that promotes both safety and positive learning. Some NICU caregivers offering EBM may need guidance to view this experience in such a light, as opposed to a “task” that one “must complete as a part of cares” .
We recognize that, in the NICU, “practice” is not the key, but what is, is the experience, and how it is both offered and received by the immature emerging neuronal pathways and oral-sensory-motor system.

In the NICU, every experience matters, as I like to say. Practice in and of itself, only makes permanent the neuronal pathways that are recruited and mapped; it does not in and of itself create the pathways that underlie function or skill; it can unfortunately lead to maladaptive behavior and stress if done as a task and/or offered in a programmed way. Infant-guided experiences are essential to neuroprotection.

I teach these concepts and their underpinnings in my NICU seminar and cite relevant research, but I have yet to find anything published or researched specific to what I am describing, which provides the supported oral-sensory-motor learning I find so beneficial to our preterms. Its evolution is a part of my practice since 1985 in Level IV NICUs.
I hope this is helpful.

Catherine

 

Research Corner: GER/EER in the NICU

Schurr, P., & Findlater, C. (2012). Neonatal Mythbusters: Evaluating the Evidence For and Against Pharmacologic and Nonpharmacologic Management of Gastroesophageal Reflux. Neonatal Network, 31(4), 229-241.

Reflux is a common issue in the NICU and with many of our pediatric patients. The evidence-base for effective interventions continues to  emerge related to preterm infants in the NICU. This paper by an NICU nurse published in 2012 is a fabulous resource. It does not just provide strategies but looks at the current evidence base as of its publication and explains so well the “whys” behind the interventions. It is so easy to join a bandwagon and support the latest idea but having the rationale and the data to titrate the interventions based on the unique issues and co-morbidities of a specific population, such as the NICU, is essential. It will inform your practice!

Problem Solving: Preterms with possible tongue tie

Question:

I am feeding a bit frustrated and just curious what others are thinking. I recently worked with twins in the NICU:  born at 24 + 6, BPD, one with history of bowel perforation and IVH grade II and the other with PVL. Both had G tubes placed while in NICU.  I did VFSS on both while in NICU. One did well with small volumes; she was able to DC home with small amounts of thin liquids via preemie nipple and small amounts of breast feeding. She was making slow but steady gains and showed good comfort.   The other one had some difficulty with swallow safety with abnormal VFSS.  He DC to home on small volumes thickened liquids via bottle and mom was also working on small trials of breast feeding with him as well.  Wonderful parents.  The babies had fantastic and very consistent RNs during their NICU stay; it was one of those times where you felt like everything was working well for these babies with histories of extremely preterm births and multiple co-morbidities.  The parents set up OP therapy services right away; they were told fairly quickly that both babies had tongue / lip / cheek ties and would benefit from a consult with a dentist to do the releases. The RN and neonatology staff came to me immediately and questioned this as the parents had reached out to them with concern.  I advised then to suggest the parents get a second opinion from one our ENTs who routinely work with our NICU babies during their stays and on follow up.  Thoughts?

Answer:

We do see preterm infants with lip and tongue ties that can adversely affect lingual thinning and cupping and effectiveness of tongue-palate seal. This in turn can lead to diminished volume transfer and lead to early fatigue, as the ineffective effort yields less than ideal intake and tires the infant. The infants you describe however also clearly have additional/other potential etiologies for their limited PO intake (24 weeks, CLD, GI and neuro co-morbidities).

The possible restrictions as identified by the OP SLP, if they are indeed present, could further contribute to their feeding challenges. However, the ties in and of themselves, if they are present, are likely not the reason these infants required G-Tubes, rather, their co-morbidities were. The ties would create further struggle.

Unfortunately, depending on how the OP SLP explained her concerns to the parents and how much she considered the co-morbidities these twins present (which are known to highly influence feeding success), there may have been the impression created that the G-Tubes were “not necessary”. The OP SLP may have been clear that the ties would create further challenges and weren’t the primary problem, yet the family, wanting to hear the G-Tubes were “never necessary”, took away a much different message. The NICU team (who hopefully recognizes the co-morbidities these twins presented are associated with increased G-Tube requirements), had an obligation to explain (or re-explain) the bigger picture to the family –i.e., co-morbidities matter when it comes to feeding (research shows that), and,  if there are indeed ties, which can unfortunately be missed at times, then correcting the ties, if ENT chooses to do so, would not change the need for the G-Tubes.

It is all too easy to instead assume that missing the ties, if they indeed exist, is why the infants received G-Tubes. Well-intentioned NICU staff may have reacted without understanding that “co-morbidities matter” (this is my most-used mantra during my NICU work and teaching) — but they do! Too often it seems co-morbidities don’t matter, as decisions/prognoses/plans about feeding are made by the medical team without regard to the infant’s co-morbidities. I find if we follow the co-morbidities, then our differential, prognosis and plans for these infants are likely to be appropriate.

I would reach out to the OP SLP, find out what she noted as indications of ties exist that might have been missed, share insights regarding the stamina and co-morbidities that created the need for GTube while you followed them in the NICU, and build a relationship through which there can be sharing and learning.  

I would also follow-up with my NICU colleagues to continue the conversation and reinforce the bigger picture that I referenced above. Too often SLPs can become the “reason” a preemie gets a GTube, or so it seems. This notion, which can discredit us as a profession or as individuals unfortunately in the eyes (and voices!) of some team members, and then by connection, some families, will change only with continued conversations. This is one of those times, Linda. Your likely recommendation for a GTube during their NICU stay wasn’t made lightly and I am confident was appropriate. The dialogue you have now is important for you, your team and for families fortunate to have your care in the future.

I hope this is helpful.

Catherine

 

Problem Solving: Reflux in the NICU

Question:

Regarding NICU preemies/infants, what are recommendations/guidelines utilized for concern with reflux (e.g., thickener, rice)? Are more behavioral and positioning strategies utilized first (e.g., HOB elevation, hold upright 30 min after feed) or is initiation of formula change/diagnostic imaging (MBSS) preferred? Also, if thickening, is there another approved way besides rice?

Answer:

I am responding specifically to preterms in the NICU. Those discharged to home may have GI follow and/or pediatricians manage their care, which allows for more options and perhaps even more variation in practice. There are no agreed upon guidelines from NICU to NICU, often there is variability even among your group of neonatologists. Let me share what they and my GI friends have kindly taught me over the years along with what I have learned along the way.

They tell me that the lack of agreement is d/t the absence of compelling literature that clearly guides them, especially when it comes to use of medications for EERD/GERD. That said, a recent study brought to our team by our pharmacist concluded that PPIs can cause significant problems for preterms (increased risk of NEC, sepsis/bacteremia, PNA and GI infections; decreased absorption of nutrients such a calcium, iron, zinc, magnesium, B12 –and zinc is essential to function of their immune system). While use of medications has typically been infrequent and a last resort approach in the Level IV NICUs I have been a part of, evidence such as this has further decrease their use, understandably so. When risk benefit ratio is not clear, physicians will be cautious. There is risk with thickened feedings as well (such as adverse effect on GI emptying which can worsen reflux, constipation, increased risk for NEC, alterations in C02); if thickening for reflux, what is used and how much is quiet variable again r/t MD differences. Most often rice is utilized but it too can have attendant sequelae as mentioned previously, as well as potential allergenic responses and concerns for arsenic.

Instead reflux precautions are typically the first line of defense (elevating head of bed, L side down post feeding for the first hour, R side down for the second hour and beyond – when monitored; upright carry position on caregiver’s shoulder post feeding when held); avoid medium or fast flow nipples that might lead to air swallowing and exacerbate EERD/GERD, utilize co-regulated pacing to avoid air swallowing, frequent gentle burps, use of elevated elongated sidelying position for feeding (to minimize pressure gradients throughout the abdominal area that might inadvertently increase propensity for reflux).

Pump feedings that allow a slower delivery of feedings via NGT or OGT over time have been used but the literature is actually inconclusive as to its benefit, and there may be adverse effects especially on gall bladder function.

Concentrating formula so less volume is required to get the same calories is an option. However, this can backfire as the increased caloric density can actually create GI discomfort in preterms.

Change in formula to Gentle or Sensitive formulas (Enfamil Gentle Ease, Similac Sensitive, Good Start Gentle), low lactose formula (Similac Spit Up, Gerber Good Start), possibly Soy based formula (if tolerance to cow milk protein is in question), possibly Extensively Hydrolyzed formulas in which proteins are mostly broken down (Nutramigen, Alimentum, Pregestimil), or possibly Elemental formulas which contain 100% broken down proteins if suspected milk protein allergy (Neocate, Elecare). Such decisions may be made with GI or by neonatology alone.

Imaging typically starts with and UGI to look at structural integrity and if the structures are in proper rotation. An UGI is not a test for reflux; radiologists will tell you that if they do not capture reflux in the moment in radiology, that does not mean the infant does not reflux, but if they DO capture reflux on an UGI, it is such a brief and minimal volume procedure that reflux is likely a key issue for that infant. While other types of imaging are possible in a workup for GERD/EERD (Ph probe studies, reflux scans, MII), they are not typical in the NICU.

A swallow study would not be a test to assess for reflux though we may capture EER as an incidental finding during an instrumental assessment of swallowing physiology.

So, as you can see the neonatologists must weigh so many critical factors. Work with your team and their thinking, be present and learn their rationales, read the research they are discussing, contribute what you can, especially clinical interventions that are often first line. There is an evolving science and practice and being part of the team is ho we both learn and add value.

I hope this is helpful. See Dupont, C. (2017). Gastroesophageal Reflux (GER) in the Preterm Baby. In Gastroesophageal Reflux in Children (pp. 111-124). Springer. It is quite informative though there are multiple other articles. DOI https://doi.org/10.1007/978-3-319-60678-1_8

I hope this is helpful.

Catherine

Research Corner: Sensory Processing Disorders and Former Preterms

Researchers at Washington University in St. Louis conducted a study to describe the incidence of sensory processing disorder in former preterm infants at age 4-6 years. They also sought to define medical and socioeconomic factors associated with sensory processing disorder and examine relationships between neurobehavior at term and later sensory processing disorder. The study enrolled thirty-two preterm infants born <30 weeks and conducted neurobehavioral assessment using the NICU Network Neurobehavioral Scale (NNNS) at term equivalent age, and the Sensory Processing Assessment for Young Children (SPA) at 4-6 years of age.

In this sample, 50% of children presented with a sensory processing disorder at age 4-6 years based on SPA scores. Additionally, the study did not identify any association between sensory processing disorder and medical and socioeconomic factors including gestational age at birth, sex, cerebral injury, presence of NEC or PDA, amount of respiratory support, days on TPN, surgeries, race, type of insurance, maternal age at birth, and maternal marital status. They did, however, find that more sub-optimal reflexes, and more signs of stress on the NNNS at term equivalent age was associated with having a sensory processing disorder at age 4-6 years.

The authors discuss the role of the NICU environment on the developing sensory system of the preterm infant, noting that sensory development begins in utero, but must continue to develop in the NICU, where their sensory systems can be bombarded with stimuli for which they are not developmentally prepared. They also note “it is unclear whether these early markers are indicative of the impairment that followed, or if the early impairment identified on the neurobehavioral exam resulted in altered sensory experiences, leading to subsequent sensory processing disorder.” This study demonstrates that standardized neurobehavioral testing can help identify those infants most at risk for sensory processing disorder in childhood.

Ryckman, J., Hilton, C., Rogers, C., & Pineda, R. (2017). Sensory processing disorder in preterm infants during early childhood and relationships to early neurobehavior. Early Human Development, 113, 18-22.

 

Seminar Schedule for 2018…

I am pleased to announce my Seminar Schedule for 2018. I am thrilled to be crossing the US this year again, and looking forward to meeting many new and familiar faces. All of us with one thing in common….helping our babies feed safely with infant-guided support and helping our kids eat in ways that build skill and joy in eating for a lifetime. So much exciting new research I am looking forward to sharing, and bringing my key learnings from my many patients over the past year. Our pediatric hospital continues to grow, and with it, so many opportunities for me to work with physician specialists, and infants and children through teenage years with complex feeding and swallowing problems. Many babies, kids and families touched my heart this year and I am thankful for the year ahead to continue to discover, teach and inspire.  As I celebrate 41 years as a pediatric SLP, I am grateful for you and your dedication to our kids. I hope our paths cross in 2018!

I am offering my unique and guided NICU training,  my Pediatric Feeding/Swallowing seminar that provides the essentials for practice, my Video Swallow Studies seminar that brings a dynamic approach to the pediatric swallow pathway. Also offering my Cue-based Feeding seminar which will feature a train-the-trainer focus this year with tons of infant feeding videos and discussion for learning.  New will be a one day Advance Pediatric Dysphagia seminar that brings together interactive case studies and complex problem-solving to make you a stronger clinician. Hope you can join us!

Click on the secure link below to take a peek at my 2018 Seminar Schedule.

2018 Catherine Shaker Seminars

Catherine

Research Corner: Assessment Tools for Evaluation of Oral Feeding in Infants Younger Than 6 Months

Britt F. Pados , PhD, RN, NNP-BC ; Jinhee Park , PhD, RN et Advances in Neonatal Care • Vol. 16, No. 2 • pp. 143-150 (2016)

Abstract: Eighteen assessment tools met inclusion criteria. Of these, 7 were excluded because of limited available literature or because they were intended for use with a specific diagnosis or in research only. There are 11 assessment tools available for clinical practice. Only 2 of these were intended for bottle-feeding. All 11 indicated that they were appropriate for use with breastfeeding. None of the available tools have adequate psychometric development and testing.

 Implications for Practice: All of the tools should be used with caution. The Early Feeding Skills Assessment and Bristol Breastfeeding Assessment Tool had the most supportive psychometric development and testing.

 Implications for Research: Feeding assessment tools need to be developed and tested to guide optimal clinical care of infants from birth through 6 months. A tool that assesses both bottle- and breastfeeding would allow for consistent assessment across feeding method.

 

Research Corner: GE Reflux and NG Tubes in Infants

Take a look at this article hot off the press:

Murthy, S. V. et al  (2017). Nasogastric Feeding Tubes May Not Contribute to Gastroesophageal Reflux in Preterm Infants. American Journal of Perinatology

Findings: The presence of a 5-French NG tube is not associated with an increase in GER or acid exposure in preterm infants. In fact, it appears that infants fed through an NG tube have fewer episodes of GER.

This is surprising to me, and brings us new information to inform our practice with infants.

Hope you enjoy it as much as I did.

 

Problem Solving: Torticollis, GER and Feeding

Question:
I had a friend send me a video of her 10 month old eating puree by spoon. The baby presents with a tongue thrust with some anterior bolus spillage. The baby is currently being treated by PT due to Torticollis, and her PT suggested an SLP feeding evaluation. I treat adult dysphagia, so this is not my area of specialty. Should this Mom seek an eval now at 10 months or wait a few months to see if the tongue thrust diminishes naturally?

Answer: An evaluation will be beneficial now, and would be concerned that without intervention, this atypical oral-motor pattern is unlikely to resolve. It is not uncommon for infants with torticollis to develop associated maladaptive oral-motor patterns and/or to have GER/EER issues that may contribute to adaptive behaviors that unfortunately become maladaptive. We don’t know anything else about this infant (possible medical co-morbidities, potentially pertinent birth or developmental history, prior/early feeding history) which would be informative. Unclear whether he accepts only purees and has this been a pattern from the beginning, how effective his oral-moor skills are with the bottle (which would provide good data to examine), whether the apparent tongue thrust is a refusal behavior (related to GER/EER) or truly a lack of oral-motor skill (perhaps use of tongue extension instead of expected thinning and cupping?) Lots of possibilities that could be explored in an evaluation. This is not typical at this age and is likely to block further development of oral-motor skills and texture progression, and reinforce maladaptive neuro-motor mapping without focused diagnostic therapy.

Keep us posted. Mom is lucky to have you in her corner!

Catherine

Research Corner: Neonatal Microbiome and Feeding Readiness in NICU

Wanted to share this fascinating article just published about the neonatal microbiome. Abstract below. Article attached. Some take a ways: Important that we advocate for and facilitate KMC ( kangaroo mother care) and use of expressed breastmilk when possible. And advocate for our involvement early on for those fragile infants for whom weaning respiratory support will  be a prominent initiative, and safe and successful feeding remain the most complex task required for discharge to home.

Hope this informs your practice like it did mine.

Nursing care of the neonate in the neonatal intensive care unit (NICU) is complex, due in large part to various physiological challenges. A newer and less well-known physiological consideration is the neonatal microbiome, the community of microorganisms, both helpful and harmful, that inhabit the human body. The neonatal microbiome is influenced by the maternal microbiome, mode of infant birth, and various aspects of NICU care such as feeding choice and use of antibiotics. The composition and diversity of the microbiome is thought to influence key health outcomes including development of necrotizing enterocolitis, late-onset sepsis, altered physical growth, and poor neurodevelopment. Nurses in the NICU play a key role in managing care that can positively influence the microbiome to promote more optimal health outcomes in this vulnerable population of newborns.

 

Rodriguez, J. et al  (2017). The Neonatal Microbiome: Implications for Neonatal Intensive Care Unit Nurses. MCN: The American Journal of Maternal/Child Nursing, 42(6), 332-337.

Catherine

Teaching at Johns Hopkins

Wrapped up a busy teaching year at Johns Hopkins in Baltimore,  where they
have an amazing inpatient team that services infants and children from
neonates to children with  burns to those admitted for psych issues. I had the opportunity to meet the staff and  tour the pediatric wards.  What a dynamic and well-integrated PT-OT-ST team!

Pediatric therapists from around the US joined me
and my colleague, Theresa for a dynamic 5 days of problem-solving,
learning and networking.

Catherine