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

 

This question was posted on my colleague Krisi Brackett’s blog http://pediatricfeedingnews.com/ and I thought my response might be helpful to my readers as well.

Question: My observation, like other therapists, is that many of the micro preemies and/or babies that have had very involved respiratory issues and complex treatment needs because of these issue, often require increased sensory input related to feeding (temperature variance, thickened consistency).  What we have observed is that these babies often benefit from increased FIO2 during feeds despite having adequate O2 levels.  Do you have any thoughts on this matter?  Our primary Neonatologist says that there is no physiological reason that this rational would be helpful.  I believe the extra flow provides the sensory input that these babies often need, especially while learning to feed.

A few thoughts. “Flow ” and Fi02″ are two different parameters. Due to the concern for the potential adverse effects of oxygen (Fi02), many NICU infants in need of increased respiratory support are weaned to 21% Fi02 with flow. That flow can be delivered via NCPAP, HHFNC, and low flow nasal cannulae. The flow rate itself (PEEP or LPM), has been shown to often help prevent pharyngeal collapse and facilitate maintenance of functional residual capacity (FRC). These two parameters to some extent are likely part of the underpinnings for effective feeding, when WOB and respiratory stability permit PO. However, when an infant is requiring significant Fi02 at baseline, one might question his/her readiness for the aerobic demands of feeding. Depending on the “extra flow” you describe (typically that means for example, PEEP or LPM), it may also create possibly an unsafe feeding environment, as what a conclusion of the recent study by Ferrara et al.   See Ferrara, L., et al. “Effect of nasal continuous positive airway pressure on the pharyngeal swallow in neonates.” Journal of Perinatology 37.4 (2017): 398-403. The answers are not fully in but this well-done paper suggests certain flow may clearly be worrisome for infants requiring intensive care.

Regarding thickening feedings in the NICU –  As I travel and teach across the US about feeding preemies, I am consistently finding that thickened feedings are viewed only as the final consideration after position change, further slowing the flow rate and use of increasing strict co-regulated pacing. The potential adverse effects of thickened feedings are many, and require us as to be “clinical scientists”, i.e., carefully weigh the risk-benefit ratio for each preterm infant, and create a unique algorithm for that infant’s plan of care, in collaboration with the NICU team. Each infant’s history, co–morbidities, respiratory history, and current clinical picture and as well as the impact on the infant’s swallowing physiology, must be carefully considered and weighed. We have suck a complex job when it comes to supporting safe and neuroprotective feeding. We lack the research to fully guide us, so in addition to evolving research, I think our critical thinking, living in the “grey zone”(having more questions than answers) and dialogue with the medical team are our current optimal strategies.

I hope this is helpful.

Catherine

 

 

Question:

I have heard that rice cereal is not good to thicken with breast milk. Do you have  research or articles we could use for a discussion with our neonatologists because they prefer we use it as they do not want commercial thickeners at all. We have discussed gel mix but they do not want us to use it. Any suggestions?

Answer:

The many dieticians I have met have explained it to me as follows. It is the enzymes (such as Amylase, Lipase and Protease). The enzymes in breast milk serve a variety of functions, some of which we do not even know yet. Some enzymes are necessary for the function of the breasts and the production of breast milk, some enzymes help a baby with digestion, and some are essential a child’s development. Amylase is the main polysaccharide-digesting enzyme in MBM and it  digests starch.  So it averts binding of the MBM with rice cereal. Our MDs don’t allow commercial thickeners, either and gel mix is not approved by FDA for preterm in NICU. However some NICUs do.

Doesn’t leave a lot of options so one must look individually with the team at each infant, based on history, whether he can breastfeed (which is typically safer for most preterms unless there is a structural airway problem – and then  breastfeeding  not necessarily more protective). Depending on the etiology of the aspiration, plan will be different. Some infants may have a period of PO feeding formula (which has increased viscosity compared to MBM) or slightly thickened formula with rice cereal – not ideal ever,  but may need to balance multiple factors and utilize as an interim plan related to likelihood of, and timing of,  etiology for bolus mis-direction resolving.

 

Question: Our department is rolling out a new oral care protocol.  I am “on the fence” about this and I am worried that this practice may create more harm than good.  However, we have lots of little ones on vents, HFNC and many “gut” babies that will be NPO long term.  Many of these kiddos are at very high risk for infection and I think anything that can be done to prevent infection would be extremely beneficial.  I have been asked to assist in developing the protocol and giving input as to how to go about delivering the colostrum w/o inflicting negative stimuli to oral cavity (this was my hesitation w/ the program).  I am thinking perhaps the program should only include kiddos 30+ weeks as they may be more tolerant of oral stimuli. I thought maybe attempting to find a silicone swab of sorts to deliver colostrum via oral massage to gum ridge/buccal cavity may be appropriate.  Any thoughts?   Thank you!

Answer:
The benefits of mother’s milk (MBM) 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 and to 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.

The key is that this 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 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. Practice of course, 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. So yes, there is potential for this initiative to do more harm than good.

I would avoid “oral-motor work” designed to focus on jaw work or 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 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). 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 and help caregivers embrace the critical impact this intervention can have if offered in a neuro-protective infant-guided way.

I hope this is helpful.




Catherine


Problem-Solving Cardiac Babies: Slow Flow vs Standard Nipple?

I answered this question for Krisi Brackett’s blog and wanted to share it with all of you!

Question:

I’m a nurse in a pediatric cardiac ICU. There is a debate within our unit about whether slow flow nipples, or standard nipples are best for feeding our complex kids.  There is a belief among some of the staff that using a slow flow nipple makes the baby have to work harder to get the milk, thus tiring them out.  Most of the studies I found about slow flow nipples don’t directly address whether they cause the baby to “work harder”/expend more calories, and many of the studies that

I found are over 10 years old. I was wondering if you could advise me on what is the current, evidence based best practice.

Answer:

Many preterm infants in the NICU and the vast majority of our infants in pediatric cardiac intensive care have a baseline increase in WOB and often intermittent if not frequent tachypnea related to their cardiac pathology. Clearly our HLHS infants are among the most fragile, but not unlike many of our NICU infants with CLD and typical cardiac infants, it is their baseline respiratory work that creates both endurance and safety concerns during PO feeding (Jadcherla, 2009). Our cardiac infants who are also former preterms have then an added co-morbidity that typically increases cardio-respiratory workload.

In addition, any cardiac surgery that involves the aortic arch (reconstruction, dissection nearby, the ductus arteriosus or L pulmonary artery; S/P Norwood procedure) presents a high risk for post-surgical LVCP (Averin et al, 2012) This then can add another level of concern for safety during PO feeding.

The aerobic demands of feeding superimposed on a baseline of increased cardiorespiratory work serve to increase the risk for aspiration in the pediatric cardiac.
Yet there is pressure sometimes on professional caregivers to “get our cardiac infants to eat”, with a well-intentioned goal of getting them home. Indeed, well-intentioned strategies, which are volume-driven, may include increasing the flow rate to empty the bottle, which can cause the infant to “fight the flow” to breathe. While medium and high flow nipples help to “empty the bottle”, there is no evidence that increasing the flow facilitates a safe swallow or promotes cardio-respiratory stability.

A faster flow rate can result in both physiologic stress and negative feeding behaviors for the infant, who may struggle to breathe when swallowing and breathing compete. It can lead to learned feeding refusals to feed and long-term feeding aversions.  How often we observe feeding refusals and aversions in cardiac infants. This indeed may be a direct result of struggling to feed, given the inherent aerobic demands of feeding. Respiratory fatigue then sets in and compounds the negative experience.  In addition, unfortunately, a well-intentioned caregiver may steer the infant back to sucking and ask him to continue, when he has disengaged. The risk then to aspirate increases.
Clearly our cardiac infants require instead an “infant-guided” approach to feeding, which optimizes respiratory stability, swallowing safety and positive learning experiences for the infant. This supports our long-term goal of good growth with a lifelong joy in eating.
There has been minimal research regarding flow rate and cardiac infants per se. Much of our understanding of flow rate and its impact on both intake and cardio-respiratory workload comes from research regarding preterm infants, who by their nature, typically have respiratory co-morbidities.

Offering a flow rate that is manageable promotes what Goldfield (2007) calls “islands of stability” for breathing and avoids the need for an urgent breath. The need for an urgent breath can be due to sucking too fast and then “running out of air”, which can in turn lead to desaturation, apnea, bradycardia and a cascade of physiologic decompensation; swallowing and its integrity will “defer” if you will, to breathing, and result in movement of the bolus into/toward the airway with that breath, leading to either symptomatic or silent aspiration.  A flow which is not manageable inhibits “windows of opportunity” (Goldfield et al, 2006) to breathe, and thus the infant has to fight the flow” to breathe. Sucking, swallowing and breathing are complex processes even when considered separately. When an infant is fed, these processes must act together, working smoothly and efficiently, with highly accurate timing and coordination, to result in safe and efficient feeding. When both breathing frequency and depth are not optimally supported because too much time is spent in swallowing a larger volume of fluid delivered by a faster flowing nipple, ventilation is adversely affected. Al-Sayed and colleagues (1994) showed that slowing the rate of milk flow reduced ventilatory compromise. They reported that in term infants, taking more with a faster flow was at the cost of ventilation. An increased rate of consumption typical with a faster flow required an increased metabolic rate and increased swallowing frequency, which reduced ventilation. There work suggests that any feeding strategy that maintains intake with reduced frequency of swallowing (such as with a slow flow nipple) is likely to be ventilatory sparing. This is a critical component for our cardiac infants and can avoid the onset of respiratory fatigue and its attendant sequelae

A recent article by Pados and colleagues (2016) looks at effects of milk flow on the physiologic and behavioral responses to feeding in infants with HLHS (Hypoplastic Left Heart Syndrome). They remind us that feeding is a physiologically stressful event due to the need to coordinate suck-swallow-breathe and maintain adequate oxygenation during those aerobic demands. From their baseline, which often includes increased WOB and intermittent tachypnea, our cardiac infants have limited tolerance for further aerobic “work” that adversely affects ventilation. During frequent swallows, there is a repeated and prolonged disruption in ventilation during the time the airway is closed for swallowing. This may result in considerable physiologic distress for the cardiac baby with limited respiratory reserves, and may lead to disengagement, apnea, bradycardia and inadvertent bolus mis-direction leading to aspiration. A slower flow rate may assist the cardiac infant with maintaining baseline respiratory reserves and timing of the dynamic adjustments of airway opening and closing that surround the actual swallow. In their study, Pados et al observed physiologic and behavioral responses to a standard flow (Dr. Brown’s level 2) and a slow flow (Dr. Brown’s preemie). Results included the finding that the slower flow allowed the infant to maintain heart rate closest to baseline, and indeed a lower heart rate overall compared to the standard flow rate, suggesting the slow flow feeding was less physiologically stressful. Respiratory rate was significantly higher during slow flow feedings and change from baseline to feeding was greatest for the standard flow feedings. They suggest that the higher respiratory rate during slow flow feedings may be interpreted as being an indicator that slow flow feedings are more supportive, as the infant is able to breathe more often and more readily during feeding. Yet the infant’s average respiratory rate of 72 across all (both standard and slow flow) feedings is still worrisome. Given that integrating a pharyngeal swallow, which takes an average of one second, creates concern for inherent risk for airway protection, despite the flow rate offered. Because the study infant experienced adverse events with both flow rates, it reminds us that safe feeding for our cardiac infants is about much more than just a manageable flow rate. It takes understanding the physiology of infant swallowing, considering pertinent research that considers flow rate and physiologic stability, and then learning from the “communication” of our cardiac infants when they feed with a slow flow nipple and we provide co-regulated pacing and resting – how much calmer they look, how less excessive their WOB is, and how their volumes actually do increase (Shaker, 2013a).

Lau et al (1997, 2000) hypothesized in her study that preterm infants would feed more if the flow rate was unrestricted versus if milk flow occurred only when the infant was sucking. This was a great way to look at the difference in intake when flow was faster (less controllable) compared to a slower, more manageable “infant-guided” flow rate. Oral feeding performance was documented when milk delivery was “unrestricted”, as routinely administered in nurseries, versus “restricted” when milk flow occurred only when the infant was sucking. Proficiency (% volume transferred during first 5 minutes of a feeding/total volume ordered), efficiency (volume transferred per unit time) and overall transfer (% volume transferred) were calculated. Restricted flow rate enhanced all three parameters. With a slower flow rate, infants were less likely to have to struggle with milk flow when they need to pause to breathe. This is what Goldfield postulates is essential to coordinated swallowing with breathing. The infant’s ability to take more with a slower flow rate reflects how a manageable flow rate enhances intake. It promotes the essential respiratory reserves to “go the distance” like marathon runners, as it allows for frequent and deep breaths.
Although increasing the flow rate is considered a way to help a preterm infant ingest more volume, flow rate is actually negatively correlated with feeding efficiency. Using a randomized controlled trial, Chang and colleagues (2007) evaluated the effects of a crosscut nipple (faster flow) versus a single-hole nipple (slower flow rate) on feeding ability and stability. Preterm infants were more physiologically stable and used a more efficient sucking pattern with the slower flowing nipple than with the crosscut nipple. The infants ingested a greater volume with the slower flowing nipple as well (Chang et al, 2007).

It is important to note that any nipple ring tightened excessively will create a vacuum that does indeed require “more work” and could in effect create an artifact of fatigue. I always suggest we just “hand turn” the nipple ring to close it, but not “man turn it”. I find too tight a nipple ring is often an adverse factor when slow flow nipples are used, which does then indeed create too much “work”. But this is not flow-related, its caregiver related.
Parents of our cardiac infants need help learning to “listen” to their infant during feeding, responding sensitively to the infant’s communication during feeding about how the infant is tolerating the feeding, and titrating interventions accordingly (Shaker 2013a, Thoyre et al, 2013; Thoyre et al, 2012).  If parents are focused on volume that can then have adverse effects on the parent-infant relationship, which is established early on through co-regulated and communicative feeding interactions that build trust Shaker 2013b). This is not to say that volume is not one of the important measures of feeding integrity required for discharge. However, volume must be viewed in the context of the infant’s developmental strivings, and as the by- product of a quality feeding, in which the infant’s cues of both engagement and disengagement, despite the volume, are respected and honored (Shaker 2013a). When this happens, there is physiologic stability during feeding, and both underlying good nutrition and growth are optimized.

In both our large Level III NICU and our large cardiac surgical unit at Florida Hospital for Children in Orlando, we have started to make wonderful strides with staff and family in changing the misconception regarding slow flow nipples” making babies “work harder”. The improved feeding outcomes, more pleasant infant-guided feedings, and happier families speak for themselves.

I hope this is helpful! Thank you for asking how to best support successful feeding for our little ones in PCVICU.

Catherine
Catherine S. Shaker, MS/CCC-SLP, BCS-S
Neonatal/Pediatric Speech-Language Pathologist
Florida Hospital for Children – Orlando
http://www.Shaker4SwallowingandFeeding.com

Selected references:
Al-Sayed, L., Schrank, W., and Thach, B. (1997) Ventilatory sparing strategies and swallowing pattern during bottle feeding in human infants. Journal of Applied Physiology, 77:78-83.

Averin, K., Uzark, K., Beekman, R. H., Willging, J. P., Pratt, J., & Manning, P. B. (2012). Postoperative assessment of laryngopharyngeal dysfunction in neonates after Norwood operation. The Annals of thoracic surgery, 94(4), 1257-1261.

Chang, Y.J., Lin, C.P., Lin, Y.J. et al. (2007) Effects of single-hole and cross-cut nipple units on feeding efficiency and physiological parameters in premature infants. Journal of Nursing Research,15(3): 215-223.

Goldfield, E.C. (2007) A dynamic systems approach to infant oral feeding and dysphagia. Ecological Psychology, 19(1): 21-48.

Goldfield, E.C., Richardson, M.J. et al. (2006) Coordination of sucking, swallowing and breathing and oxygen saturation during early infant breast feeding and bottle feeding. Pediatric Research, 60(4) 450-455.

Jadcherla, S.R. et al (2009) Feeding abilities in neonates with congenital heart disease:  a retrospective study. Journal of Perinatology (29), 112-118.

Lau, C., & Schanler, R. J. (2000). Oral feeding in premature infants: advantage of a self‐paced milk flow. Acta Paediatrica, 89(4), 453-459.

Lau, C., Sheena, H.R., Shulman, R.J. and Schanler, R.J. (1997) Oral feeding in low birth weight infants. JPediatr, 130(4):561-9.

Pados, B.F, Thoyre, S.M. et al (2016). Effects of milk flow on the physiological and behavioural responses to feeding in an infant with hypoplastic left heart syndrome. Cardiology in the Young, 1-15.

Shaker, C.S. (2013a) Cue-based feeding in the NICU: Using the infant’s communication as a guide. Neonatal Network 32(6): 404-408.

Shaker, C.S. (2013b) Cue-Based Co-regulated Feeding in the NICU: Supporting Parents in Learning to Feed Their Preterm Infant. Newborn and Infant Nursing Reviews, 13 (1): 51-55

Thoyre, S., Park, J., Pados, B., & Hubbard, C. (2013). Developing a co-regulated, cue-based feeding practice: The critical role of assessment and reflection. Journal of Neonatal Nursing.

Thoyre, S. M., Holditch-Davis, D., Schwartz, T. A., Roman, C. R. M., & Nix, W. (2012). Coregulated approach to feeding preterm infants with lung disease: Effects during feeding. Nursing Research, 61(4), 242-251.