feeding and swallowing

Problem Solving: Preterms with possible tongue tie

Catherine Shaker Seminars Leave a comment

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

 

Research Corner: Sensory Processing Disorders and Former Preterms

Catherine Shaker Seminars Leave a comment

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.

 

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

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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.

 

Problem Solving: Torticollis, GER and Feeding

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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

Catherine Shaker Seminars Leave a comment

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

The Early Feeding Skills Assessment Tool (EFS) now available

Catherine Shaker Seminars Leave a comment

I am pleased to announce that through my collaboration with Suzanne Thoyre, RN, PhD The Early Feeding Skills Assessment Tool (EFS) is now available for download and use with you babies in the NICU and through adjusted age 6 months.

The EFS is a tool to help us:

The EFS has evolved over the years as a wonderful guide to cue-based feeding in the NICU. I especially am proud of it because it looks at feeding from the infant’s perspective and is grounded in physiology. It reflects how I conceptualize feeding in the NICU, which I refer to as “infant-guided”, i.e., a dynamic approach based on contingent co-regulation between infant and caregiver. That maybe a parent/family member, a nurse, or a therapist.

The tool is also based on dynamic systems theory (that multiple systems synergistically affect each other during feeding) and these systems are assessed dynamically throughout an entire feeding, to arrive at a gestalt. Capturing variability across the entire feeding is a critical part of the analysis/integration of information. The items are designed to capture the variability in the infant’s learning of the foundational components of feeding skills, the continuum of that learning, and the emergence of skills; so it assesses  whether component skills are not observed, are emerging, or are indeed consistently expressed. It is often used serially to capture developmental progress in feeding over time.

The EFS leads the caregiver, by the nature of how it is designed, to the interventions that naturally flow from the results of the assessment. It profiles interventions to support adaptive function during feeding and swallowing, and therefore interventions for safety.

The EFS is user friendly in that it is not focused on understanding and identifying only isolated oral-motor components but rather making sense of what all caregivers “see” every day when they feed preterm infants–the infant’s communication/cues during feeding. It provides a common language about feeding terminology (such as what do we mean by an infant is “pacing” himself, or what is “coordinated”, for example) to help all team members, including families, get on the same page, so conversations and report have common meaning. Psychometrics have been completed and published soon.

Join us in Atlanta on August 15-16, 2018 for a live learning event on utilizing the EFS in support of Cue-Based Feeding in the NICU. Stay tuned for details on my website soon!

Use this link to register and download the EFS
http://feedingflock.web.unc.edu

Problem Solving: NICU Graduate with Down Syndrome and CHD

Catherine Shaker Seminars Leave a comment

Question: I have been treating a 24-month-old little girl that has had a complicated medical past including prematurity (27 weeks gestation with a birth weight of 2.2 lbs. oz..), Down syndrome, AV canal defect, ventricular septal defect, duodenal atresia s/p repair, and respiratory distress in newborn requiring intubation at birth. Additional diagnoses included: bilateral sensorineural hearing loss, GERD, VUR/urinary reflux, anemia, and hypothyroidism.  I started seeing her nearly a year ago and referred her for an OPMS due to frequent upper respiratory illness although she had no outward signs/symptoms of aspiration.  She was found to be aspirating thin liquids and the recommendation was for honey thick liquids and fast flow nipple.  She has done well in therapy and has transitioned to a variety of table with liquids by cup and bottle.  She is returning to pulmonology soon and the doctor wanted to know how she is doing with thin liquids.  I’ve been hesitant to recommend going back to thin liquid without a follow up due to the history of silent aspiration.  Do I try distilled water with nursing to check of O2 saturations to give the doctor feedback? I think I would still want a repeat instrumental since the history of silent aspiration and respiratory illness. Any other thoughts or possible suggestions?  Parents are very nervous with feeding although she has done very well in treatment and the overall frequency of respiratory illness has decreased.

Catherine’s Answer: Sounds like a child with multiple complex co-morbidities that are likely combining to create the etiology for her feeding challenges. From what we understand about her, we don’t know what the etiology of the silent aspiration events was. Without the etiology(ies) and understanding her swallowing pathophysiology, it must be hard to fully understand what to work on to improve her swallow function. That also would inform our problem-solving as to the contributing factors, the nature of the swallowing impairment and potential for improvement, in the context of her medical co-morbidities and multi-system differences. Contributing factors seem to be cardio-respiratory and GI, as well as postural tone, oral-motor and sensory. These likely combine to create risk for uncoupling of swallowing and breathing. The lack of clinical suspicion prior to the original instrumental assessment followed by silent aspiration creates increase risk for her, given her pulmonary status. So, your concerns are appreciated. I think it is uncommon to have infant on honey thick liquids because the risk to aspirate, given such impaired physiology, remains, despite the thickening to honey. And if she does aspirate honey thick liquids, that may create significant challenges for her lungs, given the history we know. That said, she has been on thickened liquids of a year. We typically reassess physiology much sooner in the developing infant with multiple co-morbidities.

Depending on the original data gleaned in radiology, at that time pacifier dips of thin liquid would have been an avenue to allow for purposeful swallows that activate the fast twitch fibers and promote interval sensory-motor learning with tiny amounts of thin liquids. That way when she returned to radiology to relook at physiology, we would be less likely to have an artifact -i.e., lack of careful recent sensory-motor experience with thin liquids that can create a predisposition perhaps to mis-direct the thin liquid. So, dipping the spoon in thin liquids for some tiny tastes may help at this point to safely prepare her while minimizing risk. Of course, there is risk to aspirate the trace tastes used for purposeful swallows, but one must weigh the need to set her up for success with recent sensory-motor experience for a brief period and then take her very soon for a repeat instrumental assessment. With a focus on physiology during the swallow study, and not just whether she aspirates, current data can be provided to guide her treatment. Hopefully interval improvements in the underlying co-morbidities and your good intervention may allow for safe advancement of her liquid diet, even if only in a therapeutic situation, A year is a long time to be on honey thick liquids., and that is not without its own attendant sequelae. You are asking good questions. Keep us posted.

 

I hope this is helpful.

Research Corner: Outcomes of Congenital Heart Disease

Catherine Shaker Seminars Leave a comment

For those of you who provide support to a pediatric cardiovascular intensive care unit, I wanted share this insightful article on outcomes for this unique and special population. It reinforces the breadth of services that as SLPs we can provide and the critical nature of our broad assessment post-op and careful follow-up. I hope it informs your practice as much as it has mine. A fascinating read. Please share it with your cardiologists.

Excerpt: “The risk factors for poor outcome include type of CHD; presence of genetic conditions; fetal and neonatal neuroimaging abnormalities; pre-, peri-, and postoperative factors associated with hypoxia and hemodynamic instability; prematurity; male sex; and family socioeconomic status and resilience. In utero, CHD may affect cerebral blood flow and oxygenation with resultant slower brain growth, delayed brain maturation, and white matter vulnerability. Pre- and peri-operative instability may cause brain injury, such as white matter injury, microhemorrhages, and stroke. Operative factors, such as deep hypothermic cardiac arrest and cardiopulmonary bypass, played a minor role in determining long-term outcomes. Postoperatively, prolonged hospital stay and severity of illness were predictors of worse outcome.”

 Anne Synnes, M. D. C. M. (2017). Neurodevelopmental Outcomes of Congenital Heart Disease: Impact, Risk Factors, and Pathophysiology. Journal of Pediatric Cardiology and Cardiac Surgery, 1(1), 28-36.

I hope this is helpful.

Catherine

Problem Solving: Oxygen with PO in the NICU

Catherine Shaker Seminars Leave a comment

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

 

 

Problem Solving: Rice Cereal does not thicken breastmilk

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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.

 

Resources for Practice in the PCVICU

Catherine Shaker Seminars Leave a comment

One of my SLP colleagues was kind enough to share these excellent resources for those of us who work with infants and children S/P surgery for Congenital Heart Disease. Very informative for my practice.

Pediatric patients with congenital heart defects have their own set of challenges such as heavy amounts of sedation, bypass, pain from surgical incision, and weakness from recovery. A good resource is the National Pediatric Cardiology Quality Improvement Collaborative Website. This group is studying a specific cardiac population HLHS (Hypoplastic Left Heart Syndrome) but there are some good resources. Another website to look for information in regards to neurodevelopment specifically with congenital heart patients is the Cardiac Neurodevelopmental Outcome Collaborative (CNOC) website. These two groups are looking at standard practices in regards to feeding and nutrition. Best practices sometimes come within your unit and your team. Find a physician champion, provide in-services to staff, develop protocols that promote safe and effective feeding practices for your patients. And try to get involved in small research studies or PDSA cycles, (Plan, Do, Study, Act) and share your experiences with other clinicians. Use the basics that you know about feeding safety but be creative with your feeding plans for families when feeding is so important to them.

Research Corner: Feeding Outcomes After the NICU

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Abstract:

Optimal growth and successful feeding in the neonatal intensive care unit (NICU) are difficult to achieve, and data indicate premature infants continue to struggle after discharge. The purpose of this systematic review was to identify growth and feeding outcomes in the NICU published within the last 10 years. Available evidence suggests weight-for-age decreases between birth and discharge from the NICU, and continues to lag behind expectations after discharge. Prevalence rates of breastfeeding differ across countries, with declining rates after discharge from the NICU. Interventions focused on increasing breastfeeding rates are effective. Most healthy preterm infants successfully nipple feed at a gestational age ≥ 36 weeks, but infants may be discharged prior to achieving full oral feeding, or eating with poor coordination. Earlier born preterm infants are later at achieving full oral feedings. After discharge, preterm infants are slower to develop eating skills, parental reports of feeding problems are prevalent, and parents introduce solids to their infants earlier than recommended. This review enhances professionals’ understanding of the difficulties of feeding and growth in preterm born infants that are faced by parents.

 

Ross, E. S., & Browne, J. V. (2013). Feeding outcomes in preterm infants after discharge from the neonatal intensive care unit (NICU): A systematic review. Newborn and Infant Nursing Reviews, 13(2), 87-93.

 

 

Problem Solving: NICU Feeding Readiness

Catherine Shaker Seminars Leave a comment

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


PO Feeding on NCPAP and/or HFNC: The Dilemma

Catherine Shaker Seminars Leave a comment

This is a practice dilemma for all NICU SLPs. The pressure to get infants out of the NICU often drives care decisions, especially when it comes to PO feeding.

Many neonatologists incorrectly assume that there is a window within which our preterms must “experience” PO feeding or they will “miss that critical window and never learn”. So, despite co-morbidities and often respiratory needs that are paramount, infants are being asked to feed. That well-intentioned paradigm is based on writings from Gesell back in the 60s that talked about a “critical window” for learning to eat. Those times were different in many ways as was the population being described. Early intervention now in NICUs to support readiness, neonatal care that is neuro-protective and promotes positive overcomes, and recognition of safety issues inherent in the complex task of PO feeding even when weaned from CPAP and HFNC clearly call for reconsideration of that paradigm, which, perhaps to a large part, underlies the thinking that leads to “pushing PO” and orders to PO on CPAP and HFNC. Many of our former preterms do indeed learn to feed orally at later ages, once weaned, and from my experience do so with much less stress and much more safely.

Advocating for safety for these infants is a critical one for SLPs in the NICU and PICU. Current NICU technology has advanced to the point that more infants are surviving and yet many are requiring extended periods of CPAP and HFNC. Many extremely preterm infants in our NICU with CLD at post-term (41 weeks PMA +) remain dependent on CPAP or HFNC. MY NICU team has had good collaborative conversations about the benefits of ST being involved to maintain a positive oral-sensory environment, promoting the oral-sensory-motor components that are the underpinnings for future PO feeding, beginning early to foreshadow for parents the swallowing, breathing and postural skills needed, and helping families also support those components, versus attempting PO feeding when the infant clearly is struggling with respiratory stability. Clearly, medical co-morbidities predispose an infant in the NICU to PO feeding problems. Multiple papers have studied that. Those infants with the greatest respiratory comorbidities, often those born < 28 weeks’ gestation and BW < 1000 grams, are most likely to require CPAP and/or HFNC at those post-menstrual ages when PO feeding is often attempted. Sick newborns may also present similar issues, secondary to their co-morbidities.

If the infant has such respiratory needs that he requires CPAP, or a HFNC, one must ask if PO feeding is really a priority for that infant at that time. The ability to reconfigure the pharynx from a respiratory tract and back to an alimentary tract with precise timing and coordination surrounding each swallow is a concern. When we look objectively in radiology during an instrumental assessment of swallowing physiology, even infants with CLD stable on RA have altered or impaired swallowing physiology as a direct result of their CLD. The bolus mis-direction and resulting aspiration we often observe is typically silent. In the adult population in the most recent information I have seen (Garon et al, 2009 Journal of Neuroscience Nursing) reported that of 2000 adults studied with a variety of co-morbid conditions, including COPD, 54.5% of those who aspirated did so silently. The data I have collected thus far for NICU infants suggests strongly to me that even the data from Arvedson et al in 1994 likely underestimated the tendency for infants to silently aspirate. In addition, her study population was not only less involved from a respiratory perspective back in 1994 than the population we see today, but it also was a population composed of not just infants. The need for an “urgent breath” often can predispose an infant with increased work of breathing to silently mis-direct the bolus into the airway during the swallow. The ability of the infant to close the glottis against the driving force of the respiratory support, while breathing with increased effort or with an increased respiratory rate, which effectively creates air hunger, and yet still maintain glottic closure throughout the duration of the swallow, would likely be precarious. Given the infant’s likelihood of baseline tachypnea and increased WOB, the dynamic adjustments of the airway surrounding the swallow are likely to be disrupted, and create uncoupling of swallowing and breathing. Without objective data on the impact of CPAP or HFNC on swallowing physiology we cannot conclude that feeding under these conditions is “safe”. Indeed, infants for whom we do not necessarily capture aspiration during a dynamic swallow study may indeed show alterations in swallowing physiology that may indeed predispose them to aspiration under “the right conditions” during PO feeding (changes in nipple flow, changes in position, changes in respiratory support for example) so it isn’t even just about aspiration but the potential impact of CPAP and HFNC on swallowing physiology. The fact that the infants “eat” and “are fed” and “transferred volume” does not equate to “safe feeding”.

We must of course consider the physiologic stress likely to occur when the infant experiences “feeding” when they still require NCPAP and or HFNC. It is highly possible the stress of trying to breathe and coordinate a swallow may lay down neural pathways that move the infant away from wanting to eat, by wiring those sensory-motor pathways that lead to current and/or future maladaptive feeding behaviors. We know that studies looking at stress in preterms have shown an association with adverse changes in brain structure on MRIs.

In the NICU seminars I teach, this body of evidence and our dilemma are always part of our problem-solving discussions. I am fortunate after 32 years in the NICU to be part of a team that is looking beyond “getting them to eat” and looking to partner with ST to guide practice while the evidence-base is emerging. NICU SLPs are in a key role to dialogue, problem-solve and focus on safety and neuroprotection as essential part of this practice issue which confronts every neonatal team.

Jim Coyle has said: “There is one rule of thumb: there is no single parameter that qualifies or disqualifies a patient for anything or that confirms or refutes risk in and of itself. It is the combination of parameters that the clinician uses to estimate risk and to form a diagnostic impression and complete a differential. That is what we teach students and trained clinicians should be emphasizing. Grab your water bottle and go for a 2-3-mile run. After 15 minutes when at your aerobic steady state and RR is up, try to take a drink of water and observe what you need to do to orchestrate the whole thing. Yet you are healthy and mature and not recovering from respiratory issues. Very illuminating.”

The dialogue needs to continue and we need measures of oral feeding that go beyond intake, and methods of assessment that capture critical variables, including objective assessment of physiology.

I hope this is helpful.

Catherine