QUESTION: I am posting this for a colleague that works in our NICU department, we’d appreciate any insight you might have!

“Can there be significance to infant’s with tongue tip elevation as the preferred position while at rest?  We currently have two infants on our NICU caseload that consistently hold this position.  It is interfering with feeding as the infants both root but will infrequently bring their tongues down for nipple acceptance.  They are both from a twin gestation and were born between 28-30 weeks.  Neither have an oxygen need.  Any thoughts?”

ANSWER
This is an adaptive or compensatory behavior often seen in preterms, especially those born <28 weeks, but even in late preterms. It is associated with increased WOB and/or an increased respiratory rate. One of my favorite neonatologists, Dr. Ragatz, who was my mentor almost 30 years ago, loved to “think along with” me about how respiratory co-morbidities affect breathing. As a marathon runner, too, he concurred with me on this. Placing the tongue tip on the alveolar ridge provides the infant with  a point of stability for the tongue, and has an  impact on many of the muscles of the head/neck, including those that stabilize the shoulder girdle. This biomechanically creates the feeling of a more open airway.  No one has studied this phenomenon but a pulmonologist and several skilled neonatal OTs and PTs have agreed with this hypothesis. Our infants find ways to help themselves without someone telling them; this is an example, as is the spontaneous use of pursed lip breathing by preterms who need to blow off C02; adults with COPD are often taught this by RTs. Dr. Ragatz found it fascinating that what he reported experiencing while running the Boston Marathon was what we see some of preemies do.

When we see this behavior, it is communication to us that the infant is choosing to pause his sucking to breathe. And so we respect this, allow him the pause as long as he wishes, letting him signal his readiness to return to sucking via his active rooting on the nipple which is kept touching the corner of his lip during the pause. We then create a feeding “environment” that reduces his need to recruit this adaptive behavior. We do this by utilizing a swaddled elevated sidelying position, a slower flow nipple, and contingent co-regulated pacing to support a frequent series of deep breaths.

Think about the infant’s behavior not as “interfering” with feeding, but as the infant guiding you as the caregiver. When feeding the infant is perceived and valued as a relationship between the infant and the caregiver, the feeding experience builds trust and positive sensory-motor learning for the infant. This is the way we improve post-NICU feeding outcomes and support the parent-infant relationship in ways that have long-lasting effects.

I hope this is helpful.

Catherine

Question:
I have performed a swallow evaluation on a 36 week preterm on supplemental O2 1L 21%Fio2 almost a week ago ( he was 35 at the time). The report I received was that the baby was not interested in PO. However, my assessment with slow flow nipple with the use of side lying and strict external pacing. 1 suck one swallow / cough and choke followed by desaturation to low 80s. Recover in 20 seconds. The next two sessions Dr. Brown preemie with 5 minutes of short sucking bursts with pacing every suck with desaturation to 50%!!! Self-corrected with some external help after almost 30 second. My recommendation is to hold PO feed until next week, RNs did not like that and told me today that they tried last night and he took 11 mL and choked and desaturated several times. My question is: is it really worth it? I don’t plan on doing a video swallow study because I know he aspirates, I am just waiting for him to May be mature a little bit and hopefully with time his swallow function and respiratory status will improve. Other than slow flow nipple/ external pacing and side lying, what other strategies we can implement to help this little guy?
He does very well in NNS via pacifier.

Answer:

We need to know more about his history, especially his GA and his co-morbidities, respiratory hx and behaviors (hx of ventilation?  Progression to low flow nasal cannulae – was it difficult for him to wean? Baseline RR and WOB at rest, WOB with pacifier? is he on any diuretics? hx of PDA ligation?), his postural control and state regulation, for example, to problem-solve.

Knowing he is 36 weeks PMA and having adverse overt events is indeed concerning. Without the bigger context of his hx, it makes it challenging to complete a differential. A set of data in the context of a different history and a different set of co-morbidities will often yield a different POC.

In my experience it is not typical or a variant of maturity at 36 weeks PMA to display the physiologic decompensation you and RNs report, especially given the interventions described. If they are going to continue to feed him we need to objectify the swallowing physiology. A swallow study would not be to see if he aspirates. It should allow us, as Jim Coyle has taught us, to look for a biomechanical impairment and any form of bolus mis-direction, not just airway mis-direction, that may lead to the decompensation observed and then allow us to objectify the impact of carefully titrated interventions, and to determine the etiolog(ies) for bolus mis-direction or perhaps prolonged breath holding.

Tell us more 🙂
I hope this is helpful.

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Follow up response from therapist:

Thank you so much Catherine for responding to my post. Here is more information:

His GA 27/ 2 days with RDS with APGAR 1 minute 8 – 5 minutes 9 He  was placed on NCPAP  for a week then followed by HFNC for a couple of more weeks. This last month, he has been on O2 NC ( 1L / FIO2 21 %. ECHO was done 3 weeks ago with small PDA. Baby is also SGA.  Chest X-ray about two weeks ago : moderate diffuse interstitial and airspace disease. last week, improved resolution of the bilateral pulmonary opacities.  They just started him on Diuretics on May 28th. He had two HUS that were normal. This baby is in a very calm state, does not show hunger cues and/or hand to mouth exploration. He does have a root reflex. He is alert the entire feed, not very engaged though. He has very short sucking bursts 2-3  this poor thing is very cautious with his sucking as  if he knows it is not going to go well. So he is not really that eager feeder that goes to town and forgets to breathe. His suck strength and length with a pacifier is excellent. And state regulation is normal with the pacifier. Oral exam is unremarkable. About the formal swallow study, your point is reasonable. However from my previous experience in this NICU. The information that I get from the study is oftentimes misinterpreted and used against my judgment. I had a baby in the past that I did a video swallow study on and he had consistent penetration 50% of the time with the slow flow nipple / 10 % of the time with Dr. Brown preemie and my recommendations was to use Dr. Brown Preemie with side lying and provide 5 minutes break before resuming the last 10 ccs (because that is when the baby gets disorganized and start choking) and the baby ended up NPO for PEG placement. They concluded that the baby is micro aspirating and no matter what I say and how I explain it. RNs just would not feed him. I would see him for his AM feed and that is about all he got all week long until he was transferred to a different hospital for the PEG placement. I tried to contact the mother to educate her about her son’s condition and how he can still bottle feed and she was so busy, would not return my call.  I might sound unreasonable but I am considering the study as the last resort, perhaps after a couple of more weeks when I know that that is as good as it gets!

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Follow-up response from Catherine:

Thanks for the great detailed history. This helps me focus and use the infant’s specific history and co-morbidities to guide my thoughts. I find that every day in the NICU this is the process that best supports my critical thinking 🙂

I am not surprised that he is under 28 weeks given the complex clinical presentation you described in your original post. His respiratory course described and the fact that he still requires flow and is on chronic diuretics suggest that respiratory co-morbidities are paramount; he may indeed have met the criteria for CLD. The PDA, though it is small is also likely driving increased WOB.

Some of his disengagement you describe (“not showing hunger cues) may be due to WOB , even if it appears somewhat subtle at times, which can often inhibit the  drive to suck. This is a likely etiology given that his non-nutritive suck is described as well-developed and effective. I find this is often the case with our infants with significant respiratory co-morbidities and often our “healthy preterms” as well. Sometimes “sucking skill” can actually predispose such infants to bolus mis-direction. That is why focusing on the suck as the focal point for a feeding assessment can be limiting, or even cause one to label a pattern such as “wide jaw excursions with sucking”  as arbitrarily “pathologic/abnormal” when it is actually may be for that infant, an  adaptive/purposeful behavior that the infant uses in response to swallow-breathe incoordination. You make  a great example of the short sucking bursts you describe that he uses — he is “very cautious with his sucking as  if he knows it is not going to go well”–that is, the short sucking bursts do not reflect pathology –i.e.,  the inability to sustain a long sucking burst–though some may think it is pathology if they just focus on his sucking without looking at the context/co-morbidities. Actually for him, the short sucking bursts reflect “good thinking” on his part, as I say, to parents 🙂

I was especially impressed by the fact that despite your interventions, he continues to have adverse overt events. For many preterms, slow flow rate with contingent co-regulated pacing as you describe can avert decompensation. We always as NICU SLPs use those interventions, and don’t rush to radiology, but when the fundamental interventions do not ameliorate the decompensation, that is highly concerning, as you undoubtedly told your NICU staff. Every experience the infant has matters. So if they continue to feed him and each time he experiences negative learning, he is wiring his brain away from eating. We know the neurons that fire together wire together. It is highly likely that continued feeding under these “conditions” can be a pathway to aversions down the road. that’s where some  researchers are focusing:

Smith G.C., Gutovich, J. et al (2011) Neonatal intensive care unit stress is associated with brain development in preterm infants .Annals of Neurology. 70(4), 541-549.

Thoyre, S.M. (2007) Feeding outcomes of extremely premature infants after neonatal intensive care. JOGNN, 36(4): 366-375.

By advocating to obtain objective data via an instrumental assessment, you will have more information to rule in or rule out what the possible etiologies might be, what specifically may be happening to predispose him to bolus mis-direction and then observe if any further interventions (e.g., maybe only single sucks at a time for now?) serve to avert the negative experiences. If we do not advocate for further workup, they will likely continue to feed him as they are, and at what cost to the infant, and we don’t fully understand his physiology. Sometime s infants with this presentation are purposefully using a delay in swallow initiation to get that last breath in, much like COPD-ers. Knowing that, i.e., why the events might be occurring, is important and guides interventions.

I so understand your frustration with the responses we sometimes received to our recommendations after both clinical and instrumental assessments. But the only way we change that is to keep having dialogue and trying our best for each patient as you are trying to do. it is always a journey working in the NICU, I say, not a destination -)  I have these same struggles every day. I worry for him that if you wait to sort this out until  “after a couple of more weeks”, his learning and outcomes could be altered quite adversely.

Thanks so much for your thoughtfulness and this interesting but unfortunately too common dilemma. I hope this is helpful and apologize it is so long! As you can see, the NICU is my passion and I love problem-solving.

Catherine

Question: I completed a new eval on a newborn infant, 7 weeks old.  PMH: NAS likely, looks/acts premature, removed from parents at 3 weeks and is in foster home, dehydrated upon custody, limited history.  Intake is great and she is growing/gaining since in foster home.  Last week she started struggling with feeding.  Her tongue tip remains elevated with nipple presentation.  This was present in eval.  Once she drops her tongue and accepts the nipple she will drink very well.  Great suck and coordination.  Jaw opening is limited with nipple stim to lip.  Seems like she is anchoring her tongue to stabilize her jaw.  Is this correct?  If so, what approach is needed to assist with feeding?  And what can foster mother do at home?  Various feeding positions do not assist to extend her trunk.  Stim with soft gum massager does not assist.  Her mouth is very tiny (weighs ~6 lbs.).  Suggestions, please!

Answer: 
Good problem-solving and asking questions!

Given that the infant can actively lower her tongue to the floor of the mouth and establish an effective latch, tongue-palate seal and coordinated sucking pattern, this is likely a compensation (i.e., an adaptive behavior). I see it most often in infants due to  increased work of breathing. Infants will often elevate the tongue tip to the alveolar ridge when the work of breathing creates challenges for suck-swallow-breathe. I suspect the contact/pressure of the tongue tip at the alveolus may help to stabilize the tongue in such a way that it give the feeling of a more open pharyngeal airway. This may sound funny, but one of my favorite neonatologists at my old NICU, who is a marathon runner, told me that when he runs in marathons, he often places his tongue tip at the alveolus to get through the respiratory work during the run. Knowing my great interest in the pathophysiology and co-morbidities of infants with CLD (Chronic Lung Disease,) he postulated the reason as I stated above. It make sense to me (and did to him!) , as we knew we had often seen this behavior co-occur in infants with extra breathing effort during feeding (and at rest too). Though the WOB may be slight, it can interfere with the fine coordination of swallowing and breathing, and infants make adaptations, i.e. use compensatory or adaptive behaviors to “get them through” the feeding or in an attempt to ease stress associated with breathing. Unfortunately , some of the adaptations they use can become maladaptive behaviors if the underlying issue causing the need to adapt is not addressed and rectified.

This would make sense for this infant, given his known/suspected co-morbidities, i.e. being a preterm (which would account for the increase in WOB) and NAS/Neonatal Abstinence Syndrome (which can result in frantic disorganized approach to feeding that leads to an increase in work of breathing).

The “closed jaw” is likely another adaptive behavior — the infant does not actively open her mouth until she is done breathing; when she is  done breathing, she roots, opens her mouth actively and latches. She is communicating by her behavior, as infants do, to you and to mom, and telling you how to help her. So continue to use her rooting reflex to initiate the feeding; if she does not open her mouth and root, then wait  a few  seconds and re-root her; don’t put the nipple in passively or pry her mouth open. She knows how to open her mouth when she wants to, right? 🙂  Just be patient and listen to her:-)

A swaddled elevated sidelying position with her head higher than her hips will help ease WOB and facilitate organization as well. I’d also suggest you consider a controllable flow rate (slow flow rate) as that may indirectly also help the infant manage optimally if there are even subtle breathing issues, likely with his co-morbidities. Dr. Brown’s preemie (slow flow) nipple has worked well with similar infants in my experience.

Take a look at my article “Reading the Feeding” in the ASHA leader archives or you can find it on my website http://www.shaker4swallowingandfeeding.com under the publications tab. It details infant breathing behaviors/cues that guide the feeder to understand what is happening and why.

I hope this is helpful.

Catherine

Question:  I work in a Level 2 special care nursery; it is staffed with PRN OTs and PTs who specialize here. A nurse on the unit has asked me for a guide to knowing when to refer for therapy services, based on evidence based research. She would like us to present this to the RN practice council at our hospital. I am wondering, do you use any guide, or know of research supporting when to refer, other than state requirements (i.e. LBW or drug exposed)?  I am very appreciative of your response in advance!  I really enjoy your Q and A series!!!

 

Answer: See the guidelines in my 2007 article “An Evidence-based Approach to Nipple Feeding” available on my website. Recent papers by Jadcherla et al (2010), Kirk et al (2007) also profile what I like to call the “high-risk fragile feeder” that would benefit from support by therapy. You also should consider adding those infants who continue to require ventilation or HFNC when approaching 34 weeks PMA, as their respiratory co-morbidities are readily supported by both Kirk and Jadcherla’s findings.

Shaker, C.S. & Woida, A.M. (2007) An evidence-based approach to nipple feeding in a level III NICU: Nurse autonomy, developmental support and teamwork. Neonatal Network, 26:2, 77-83.

Jadcherla, S. R., Wang, M., Vijayapal, A. S., & Leuthner, S. R. (2010). Impact of prematurity and co-morbidities on feeding milestones in neonates: a retrospective study. Journal of Perinatology, 30(3), 201-208.

Kirk, A.T., Alder, S.C. and King, J.D. (2007) Cue-based oral feeding clinical pathway results in earlier attainment of full oral feeding in premature infants. Journal of Perinatology 27(9): 572-8.

I hope this is helpful.

Catherine

Question:

If an infant has an inefficient suck because of lack of buccal fat pads and often slightly low tone the combination can result in too wide a jaw excursion and a very inefficient suck. Why would you not give jaw and cheek support (as needed) to make the whole coordination process easier and less fatiguing? If the baby’s resulting suck then is strong enough to receive too fast a flow, I would think that the solution would be to use a nipple with a slower flow rate, not eliminate the support that improved the suck. If nurses are giving too much support, it would also help to provide the training to create guidelines for the amount of support that is just right for each infant.

Answer
With all of our NICU babies, the value or adverse effect of strategies requires consideration of a number of underlying and related issues. One must consider the whole infant, i.e. co-morbidities (respiratory, airway, sensory-motor, and GI) when looking at supportive/compensatory techniques for feeding/swallowing.

Sucking pads are believed to develop in the last month of intrauterine life, so approximately 36 weeks in utero. So they are not available to many preterms. In normal postural/oral-motor development, the cheeks and lips are not active (i.e. not used) for feeding in the normal newborn until he is 3-4 months of life. Prior to that time, the cheeks/lips (they work as a system) posture on the nipple/breast for stability–they do not actively form an anterior seal to obtain the fluid bolus. As a result, the nutritive suck is achieved through a strong “tongue-palate” seal. I have seen a couple newborns and preterms with, unfortunately, multiple hemangiomas that eroded the cheeks and lips right after birth; each was able to feed effectively (no cheek support needed) due to an intact tongue and palate, and, therefore, a tongue-palate seal.

Even with a slow flow/controlled flow nipple, our vulnerable preterms can get too much flow, too large a bolus. When we add cheek support, we will increase the flow rate and the bolus size. Because most preterms have very strong sucks, often too strong for their own good, and are “stuck in sucking” much of the time, as Pamela Lemons wrote, caregivers must look at the dynamic, or synactive, impact of all interventions on each other. So if cheek support is used, it affects more than the suck, in other words. Increasing the flow rate, or doing so inadvertently through cheek support, is not supportive for preterms’ swallowing safety. While it will increase intake (efficiency of feeding), it is likely to result in physiologic instability. This may or may not be apparent as aspiration events in preterms are most often silent in my clinical experience. The anatomy of the preterm and the physiology of the swallow predispose the infant to easily overfill the valleculae; this, combined with a tendency toward increased work of breathing and an increased respiratory rate, along with neuromotor and neurologic immaturity, can render the airway unsafe. The preterm is unlikely to be able to make the dynamic adjustments required as the pharynx reconfigures itself from a respiratory tract to an alimentary tract and back to a respiratory tract with each swallow, especially if it occurs in the presence of flow that may readily move to a rate beyond his capacity.

We can provide the postural stability to offset lack of sucking pads through effective swaddling with limbs to the body midline, elbows inside the blanket, a sidelying position, neutral head neck flexion with slight tilting down of the chin, and offer effective external pacing based on the infant’s continuous feedback to help suck, swallow and breathing remain coupled and synchronous.

Over the last 25+ years working in Level III NICUs, I have rarely needed cheek support to facilitate safe and effective feeding; those occasions have been with sick newborns, not preterms.

I have also observed preterms offered cheek support during a Video Swallow Study (to assess its impact on the swallow, as it was being used at bedside by well-intentioned caregivers), overfill the valleculae and penetrate or aspirate as a result. Matthews wrote years ago that, with preterms, it is not the work of “sucking” that makes feeding challenging but the work of trying to “breathe” in the presence of a flow they cannot manage safely, which in turn then inhibits/disrupts breathing.

If volume is the overriding goal, cheek support may be viewed as a critical tool by some caregivers, and often unfortunately is. As there is hopefully a paradigm shift from “Volume Driven” to “Infant Driven” feeding in NICUs, the reasoning behind not using cheek support for preterms will hopefully be more readily understood by our nursing colleagues. Until then, helping our nursing colleagues understand the “why” behind our protective strategies, and the why behind strategies that are not viewed as supportive, is a good interim step.

Question: There are several different hospitals with NICU’s in my general area and many of our nurses float between hospitals. Periodically one will question the differences in speech services in the different NICU’s. In particular one NICU has a plethora of SLP’s who work there full time (contracted in) and typically feed a majority of the babies every day (or so I am told). Comparatively, our NICU has one SLP (me) where I typically feed the babies on my list once every 1-2 weeks  – with a tx focus more on sensory stim, tongue thrust reversal, NNS and oral reflex stim. I am wondering what other NICU’s are doing around the country? How often do you see each baby and is feeding part of your tx at each visit? Thank you in advance,

Answer:
Roles of the SLP in the NICU vary depending on the particular NICU, and, of course, on the SLPs perspective, expertise and passion, as well as logistics of budget, staffing and training.
Some NICUs are much farther along in the transformation from volume-driven to infant-driven feeding. As such, they can more readily benefit from a more consultative model similar to what you describe you describe. Even so, typically, our presence on a regular basis is critical and builds the relationships necessary to give us value in the NICU as a resource for research, the latest information about swallowing/feeding and outcomes, guiding parents, providing in-services, and having “casual” conversations with staff (both MDs and RNs) as colleagues, which provide a basis for mutual respect and problem-solving together both in the present and the future. This provides the basis for “belonging” to the team. It does not happen overnight but it is a journey every NICU therapist, I believe, mustembrace.

Due to the positive influence of maturation, as well as the adverse effects of changes in medical status (i.e., decline,weaning of supports, fluctuations in the influence of current and new-onset co-morbidities etc.), a frequency of every 1-2 weeks would be very limiting. It doesn’t typically allow for the collaboration from day to day with RNs/Neonatologists, problem-solving, parent teaching and guided participation, updating of suggestions, as well as actual therapy to improve function, be it for feeding readiness or safe and efficient swallowing/feeding. Preterms and often sick newborns in NICU change daily; our input is critical regarding resulting changes in  recommendations/suggestions, progression to PO, and for advocating for neuro-protection for the developing preterm, for whom the “work” of feeding may present new and perhaps more concerning safety issues over time. Nothing in NICU is static. Each day, each session, each interaction with caregivers/staff brings a new perspective and perhaps a different level of support needed from day to day.

I hope this is helpful.

Catherine
Catherine S. Shaker, MS/CCC-SLP, BRS-S
Board Recognized Specialist – Swallowing and Swallowing Disorders
http://www.Shaker4SwallowingandFeeding.com

Question:

This week I had a baby who was only 34 wks, 1 day (born at 29 wks) and doctors were pushing PO feeding and discharge (because I have a magic wand that can get a baby feeding in 24 hrs- sarcasm noted :). With a slow flow nipple, pacing to 3, and inclined/sidelying position, the baby had 3 episodes of desaturations and one episode of bradycardia. So, I talked with the doctors about trying the Bionix Controlled Flow nipple. I have used it 2 consecutive days, and baby’s intake was 6 cc’s on the first day with advancement to setting “2” and 11 cc’s on the second day, with advancement of setting “3”. No more episodes of bradycardia/desaturations. Pt does have some stress noted as I advance settings, but I normally will stop advancing if pt shows signs of stress and he has seemed to tolerate it as we keep going. I’ve also implement pacing to help.
My question was, what types of patients benefit best from using these bottles? It seems as if it’s a good way to work on swallowing on the young babies (34-35 wks) without going quickly to a MBSS and giving them time to grow. If pt was 36+wks I would be quicker to move towards a MBSS, but bc of his age, I kind of want to give him time and practice before I radiate him so young. Does that line of thinking make sense? This is only my 2nd time using the bottle and it seems to be working well- giving the baby practice every day without overloading him. Any other specific cases in which this bottle worked well? Thanks in advance for your input! Sorry such a long post!

Answer:

You don’t mention much about his history except that he was a 29 week GA infant. As a former 29 weeker, this infant likely has respiratory co-morbidities. I suspect he is in RA as you don’t mention any NC02. Not sure how early your NICU typically discharges but for a 29 weeker, discharging at 34-35 weeks PMA is not typical; an infant with his history is unlikely to be even a marginally-skilled feeder by that post menstrual age (PMA). He likely needs careful co-regulated pacing to support coordinated swallows.

It is true that swaddled sidelying and limiting the bolus size are  key interventions with preterms, as is using a slow/controllable flow rate.

A couple thoughts for you.

The external pacing you report providing with the slow flow nipple every 3 sucks may not have been a match for his needs. What I think of as providing  “pacing” is to  impose breaks from sucking to facilitate a pause in sucking, to allow for swallowing without delay, and then support the immediate initiation of several deep breaths. If the caregiver arbitrarily imposes a break in sucking at predetermined junctures, i.e. every 3 sucks, we take the infant’s communication from moment to moment out of the equation. The infants communication tells the caregiver when to impose a break, That is why I like the term “co-regulated pacing”–that means the infant and the caregiver have a reciprocity during feeding such that one guides the other. For a description of  the communication signals the infant uses to guide the feeder, you can look at the ASHA Leader February edition 2013 for the article I wrote entitled “Reading the Feeding”  in the NICU. You can also find it on my website www.Shaker4SwallowingandFeeding.com under the TAB “publications”. If we use the infant’s communication to guide the pacing, you then don’t arbitrarily pace at 3-5 sucks for example. You support the infant from moment to moment. So maybe with a slow flow nipple, i.e. Enfamil’s, you might see he showed you cues after one suck or two sucks; if so, waiting until 3 sucks may have given him a bolus that was too large, or that delayed the re-initiation of breathing too long, and caused swallowing and breathing to become uncoupled.

The Bionix bottle/nipple can also limit bolus size but I find the design of the nipple is not developmentally-supportive for the oral-sensory-motor system of the preterm. While its shape is consistent with what the evidence-base suggest is optimal, the hard tubing running down the center of the nipple (which is necessary to regulate flow in Bionix design) provides an atypical stimulus for the tongue, not like the breast certainly (which is soft and moldable during breastfeeding) and not like a typical bottle nipple (which can be compressed with no “hard” input).

For preemies, who already are in an altered sensory environment and are wiring their brains outside the uterus, we must all be thoughtful about any sensory input we provide/offer. Every experience matters in the NICU, especially with feeding. So I encourage you to look at Reading the Feeding, go back to the slow flow nipple and use all the other good interventions you mentioned. Watch the baby; let him guide you about what he needs and co-regulate the feeding. You don’t need the Bionix bottle in my experience.

I agree that going to radiology is not the next step given what you have told us.
I hope this is helpful

Catherine
 

Question: It seems as if our NICU has had an influx lately of infants whose mothers were diabetic. I have found these babies to be very poor feeders. I am sure those of you who work in the NICU have had these babies also. I want to get some feedback from my colleagues about treatment techniques with these infants. Besides pacing and using slow flow nipples are there any other techniques you use with these babies?

Answer:  I agree that Infants of Diabetic Mothers (IDMs) are a challenging population. Due to the high sugar environment in utero, their blood sugars are initially off, and as a result they are very sleepy. Poor state regulation with the resulting inability to sustain alertness and drive/stamina for feeding is common; as their sugars normalize, we expect their state regulation to begin to normalize. They often also have increased WOB and intermittent tachypnea. This not only affects safety of suck-swallow-breathe coordination, but also stamina secondary to respiratory fatigue. Unfortunately, these infants are often term or near term, though not always. They can look “bigger” though they are often a bit low tone, most often described as being “doughy” as this is not typically true hypotonia  (i.e., with a neurological etiology) but can be more transient. That said, if an IDM makes slow progress in feeding skills, neonatologists will often study the infant’s head, as these infants are at high risk for brain malformations due to the intrauterine environment.

Most helpful interventions include: alerting techniques, re-alerting when infant becomes passive (so he is active with the feeding); avoiding any prodding or passive manipulation of the nipple/bottle/infant’s cheek or jaw–these interventions increase flow passively and can create safety issues and lead to feeding refusals; swaddling securely in flexion for feeding, supporting all limbs to body midline, hands near face–and re-swaddling after alerting infant versus feeding him “unswaddled”; use of a slow flow nipple to optimize swallow-breathe coordination–avoiding medium and high flow nipples that empty the bottle but are not supportive of coordinated feeding; I tend to not use chin/cheek support, as it increases flow rate and bolus size, which is often problematic if there is truly low tone. Also helpful is co-regulated pacing based on the infant’s continuous feedback regarding swallow-breathe timing and physiologic stability; concentrating the formula to increase caloric density so infant does not have to take as much volume while he is learning; respecting the infant’s signs of disengagement and not steering them back to sucking when they disengage; providing thoughtful and consistent anticipatory guidance and guided participation for all caregivers and especially families so they can understand and support the infant’s developmental strivings and emerging skills.

The biggest challenge as I see it with these infants in the NICU is getting everyone on the same page so we all let the infant guide us, via his communication, versus doing whatever is necessary to empty the bottle.

QUESTION:

I have been using the Ross (cleft palate) nipple most recently with my newborn cleft babies. It seems to be working really well. I feel pressure to use the Habermann since we have a few boxes in stock but I never seem to have luck with that bottle. Does anyone else seem to have trouble with the Habermann, or is there something that I could possibly be doing wrong?

ANSWER:

Over tightening can “crimp” the disk and obstruct flow and collapse the nipple. Just gently hand-tighten the ring, don’t turn it hard. It gets easier to do the more you use it 🙂

Also the Habermann can be used very effectively without squeezing of the teat. I have had newborns with complete cleft of the soft and hard palate, such that all that was left was the boney nasal septum; they can effectively get flow via their using only their own active compression.

Know that when we squeeze to deliver flow it is likely very challenging to deliver the right amount, even with attending very carefully to the infant’s cues to guide us. That makes it hard to avoid “overfilling the valleculae” and increases risk for bolus mis-direction toward the airway. The long soft palate of the newborn actually sits in the vallecular space, to help create a “bolus accumulation” site that helps “contain” the fluid which, in the normal newborn, is actively “driven” into the valleculae. When the soft palate is cleft, that “seal” is breeched and squeezed flow has the great potential to be beyond the infant’s capacity and to move toward the airway. This has the potential to occur even when we try our best to limit the squeeze/bolus size, since we cannot “see” in the valleculae at bedside to objectively know that the valecullae are getting too full. Let the infant self-limit the flow rate by not squeezing. You can then use co-regulated pacing as needed if the infant “gets ahead of himself”. One of the benefits of the Habermann is that when baby stops sucking, there is no flow.

The Dr. Brown’s Specialty feeder is beneficial as it allows the infant to regulate the flow, provided the caregiver selects a proper nipple flow rate to start with ( typically premie or  level 1, for example)

Safety is always enhanced with infant-guided regulation of flow rate.

Question:

I am wondering if any NICU therapists are familiar with or are using the PAL (Pacifier Activated Lullaby). It is supposed to stimulate NNS by playing music while the infant sucks. One of our nurses recently met with the company and is interested in learning more about it. I have not heard of it before this and after looking at their website am not convinced it is worth pursuing. I just wanted to see if anyone else out there has heard of this or has any thoughts. Any input would be greatly appreciated. Thanks!

Answer:
We must all be thoughtful as we evaluate devices that are designed or marketed to develop a skill. It is the thoughtful use of a modality, or the thoughtful decision not use it, based on the clinical assessment of our patient and the evidence, that should be our guide, both in the NICU or in any other level of care in which SLPs are a part of the team.

My NICU clinical experience for over 28 years suggests that PAL (Pacifier Assisted Lullaby)  is not an answer for the feeding/swallowing problems preterm infants present, and may actually inhibit functional skill (i.e., feeding). The issue for preterm infants is more complex than a “sucking problem.” Feeding problems in the NICU are rarely so simple, though sometimes a “poor suck” is unfortunately perceived as the reason for many of them. Learning to feed, both effectively and safely, is a complex, multifaceted challenge for preterm infants.¹

I have been part of the team in two large level III NICUs, and many of those babies have been extremely preterm. Many have respiratory distress syndrome (RDS) or CLD (Chronic Lung Disease), requiring intubation and ventilation, and/or need supplemental oxygen in the course of their recovery. We have not observed a direct detrimental effect on non-nutritive suck (NNS). These infants typically demonstrate effective non-nutritive sucking when ready to initiate bottle feeding, with respiratory issues being the paramount barriers. We have found that the NNS typically emerges with development and positive support during care. For all infants, our nurses provide excellent oral care, including developmentally appropriate hand-to-mouth, rooting and pacifier activities, to support development of non-nutritive sucking. For infants with delays in onset of oral feeding due to medical status or those profiled as likely to be high-risk fragile feeders, the speech-language pathologist is added to the team to provide positive early pre-feeding and graded swallowing experiences. This helps the infant make the transition to nutritive sucking more safely and effectively.²

The challenges preterms encounter in learning to feed are most often the direct sequelae of residual respiratory problems. These problems (e.g., tachypnea, increased work of breathing, compensatory breathing behaviors, breath-holding) jeopardize the coordination of sucking, swallowing and breathing. ¹  This can lead to respiratory fatigue and incoordination, or indeed adverse events such as choking, coughing and color change. Even infants with excellent NNS can have significant problems learning to suck nutritively because their drive to suck is often stronger than their physiologic sense of oxygenation.³

Very often the co-morbidities of early gestation, lower birth weight and attendant respiratory sequelae make feeding a challenge. The NNS, for which PAL was developed, has not been the issue delaying discharge.

It is also  important to recognize that the NNS and the nutritive suck are very different in their rate and rhythm due to the addition of fluid with nutritive sucking. This renders non-nutritive and nutritive sucking different developmental skills. Lingual patterns on ultrasound have shown significantly greater displacements and excursions when a preterm infant was sucking nutritively vs. non-nutritively on a pacifier.⁴

The NNS is not in itself a predictor of nutritive success (i.e., bottle feeding), research has found.⁵
NNS is just one of several domains that require consideration when contemplating the introduction of oral feeding. While found to be helpful, typical non-nutritive interventions have not been shown to decrease length of stay.⁶

A recent study reported that a non-nutritive stimulation program in an NICU did not result in earlier weaning from an nasogastric (NG) tube or earlier discharge when compared to similar infants without that intervention.⁷

In addition, PAL is designed to foster, and has as its outcomes, longer sucking bursts. Longer sucking bursts are problematic for the preterm. Longer sucking bursts may inadvertently, and likely do, increase WOB and overall respiratory effort. This “drain” on the infant’s respiratory reserves can have detrimental effects on the functional skill of feeding,⁸   as PAL is often provided just prior to a feeding.

Also, during PAL, it is likely at the preterm infant is not able to stop on his own at the appropriate junctures to take a series of deep breaths. This is directly related to immaturity, i.e. the drive to suck can inhibit the drive to breathe in the preterm, as he cannot register changes in CO2 versus O2, which can be a by-product of continuous sucking. So we often see a continuous sucking pattern with the pacifier and with PO feeding.⁹  While continuous sucking may sound like a hallmark of skill, in the preterm infant it can destabilize the autonomic system, lead to breath-holding or insufficient breaths, which can lead to desaturation, and potentially a cascade of events leading to decompensation. So sucking, faster sucking or engaging in longer sucking bursts, is not necessarily good for the preterm and typically is not. Sucking can’t be looked at in isolation, as it is part of a dynamic physiologic event that has multiple system implications/effects. ¹⁰   When the focus is on sucking itself, i.e. with PAL, we are not providing the preterm with the careful support required to integrate breathing with sucking. Then sucking activities provided can actually be detrimental to motor-learning, and potentially increase stress on a physiologic level.¹¹  This can then lay down neural pathways that, instead of facilitating positive learning, may move the infant away from learning to feed.¹²

While it may seem to some that enhancing sucking can be the answer for feeding issues that delay discharge, it is just not that simple. NICU infants learning to feed require dynamic, infant-guided supportive strategies during both pacifier sucking and during feeding, based on watchful vigilance and continuous feedback from the infant. The focus is on physiologic stability, active participation of the infant, and coordination of sucking with swallowing and breathing.⁵   This approach is more likely to promote readiness for  and eventual swallowing safety, support adequate nutrition, and result in the earlier discharges we have seen in the NICUs I have been fortunate to work in.

As you are undoubtedly aware of, supporting successful feeding for preterm infants goes way beyond sucking. For those infants who indeed do have “sucking” problems, then the involvement of the SLP, who can problem-solve with reflective/critical thinking, is far better than a referral for PAL, in my opinion.

References

1. 1. Shaker, C.S. (2013) Reading the Feeding. The ASHA Leader – American Speech-Language-Hearing Association.
2. 2. Shaker, C.S. (2013) Cue-Based Co-regulated Feeding in the NICU: Supporting Parents in Learning to Feed Their Preterm Infant. Newborn and Infant Nursing Reviews (2013) 13 (1): 51-5
3. Shaker, C.S. (2012) Feed Me Only When I’m Cueing: Moving Away From a Volume Driven Culture in the NICU. Neonatal Intensive Care, Journal of Perinatology-Neonatology, 25 (3) May-June, 27-32.
4. Miller, J.L., Kang, S.M. (2007).Preliminary ultrasound observation of lingual movement patterns during non-nutritive versus non-nutritive sucking in a premature infant. Dysphagia, 22: 150-60.
5. Lau, C., Kusnierczyk, I. (2001). Quantitative evaluation of infants’ non-nutritive and nutritive sucking. Dysphagia, 16: 58-67.
6. Fucile, S., Gisel, E.G., Lau, C. (2002). Oral stimulation accelerates the transition from tube to oral feeding in pre-term infants. Journal of Pediatrics, 141: 230-36.
7. Bragelian, R., Rokke, W., Markestad, T. (2007). Stimulation of sucking and swallowing to promote oral feeding in premature infants. Acta Paediatrica, 96: 1430-32.
8. Thoyre, S.M., Shaker, C.S., Pridham, K.F. (2005). The early feeding skills assessment for preterm infants. Neonatal Network, 24: 7-16.
9. Shaker, C.S. (2010) Improving Feeding Outcomes in the NICU: Moving from a Volume-Driven to an Infant-Driven Approach. American Speech, Language, Hearing Association. Swallowing Disorders Division 13 Perspectives – Oct
10. Shaker, C.S. (1999) Nipple feeding preterm infants: An individualized, developmentally supportive approach. Neonatal Network, 18(3), 15-22.
11. Smith G.C., Gutovich, J. et al (2011) Neonatal intensive care unit stress is associated with brain development in preterm infants .Annals of Neurology. 70(4), 541-549.
12. Browne, J. V., & Ross, E. S. (2011). Eating as a neurodevelopmental process for high-risk newborns. Clinics in Perinatology, 38(4), 731.

Catherine
 

Question: We are currently devising an Infant-Driven Feeding Protocol for our level 3 NICU and have come across some differing opinions regarding our definitions of what are and are not significant episodes (or events) for RNs to be noting and charting. Nursing in our NICU feels that 02 desaturations should only be documented if they are below 85% AND lasting 20 seconds. This seems like a fairly long amount of time to the speech-pathology staff. By not charting shorter events, we are concerned that nursing will not recognize the need for intervention in infants who are experiencing incoordination of their suck-swallow-breathe or who may be aspirating. I am curious what other NICU’s use and qualify as “significant feeding events” as well as if you differentiate between feeding-related oxygen desaturation/apnea/bradycardia and other A/B/Ds. Most literature I have been reviewing regarding 02 desaturations only states the % as a requirement.

Answer:
Your frustration is shared by many I suspect. There are multiple levels to this concern, and that it is often a challenge for SLPs as we try to build the culture of feeding that creates a level of concern for all physiologic instability, even those events that don’t “last as long” as that NICU’s criteria, or those more subtle behaviors during feeding whose early onset signals an imminent event of physiologic decompensation.

Each NICU will have its standards about how the significance of an event (apnea, bradycardia, desaturation) is defined. Depending on the prescribed range of saturations tolerated/accepted for a particular infant (usually its specified in an order), a particular saturation value will have different meaning. Most often as I teach  across the US and consult at NICUs,  85% is most typically the lower limit acceptable. Issues of probe placement, correlation of HR with pulse rate reading, and symmetry of the saturation wave, are all important variables when determining if a saturation level displayed is “real”.

Most NICU charting requires that the desaturation charted includes context of the event (i.e. sleeping, feeding, being held, during another type of procedure). By the time the saturation registers on the monitor, time has already lapsed from the time the event occurred to when the monitor captures it and then the number you see is an average over that time period. In the context of feeding, whether it is apnea, bradycardia or destauration, the infant will have given cues or shown behaviors that reflect the beginning of decompensation long before the monitor registers it. So the monitor read-out becomes a confirmation, with objective specificity (i.e., how low the HR dropped, how low the sats dropped, how long the infant held his breath), of what we are already observing while watching the infant feed. That is why we discourage RNs from watching the monitor while they feed infants and encourage all feeders to watch the infant. By the time the monitor tells you there is a problem, the infant is already in trouble.

That said, the objective information from the monitor helps to put the event in perspective, and is thus valuable. Even if the sats don’t “stay down” 15 seconds, the fact that something caused them to drift down during feeding warrants further consideration, such as why did that happen? what might be the etiology (i.e. obstruction of the airway with part of the bolus, laryngospasm due  to EER during feeding, a low hematocrit that resulted in desaturation with the aerobic demands of  feeding etc.). So you see the bigger question or challenge in this scenario is helping the staff embrace the bigger concept that the infant’s experience of feeding  is closely tied at a fundamental level to the infant’s physiologic stability, and that swallowing and breathing, and the extent to which they stay coupled or become uncoupled, has the potential to result in bolus mis-direction of many types and indeed airway compromise.

The physiologic impact of feeding which results in A/B/Ds is concerning to SLPs in and of itself, regardless of the lowest numbers or the length of the event. That is because we are tuning in clinically to what the infant is doing at that moment, during the event and after the event (i.e. tuning in to color, respiration, WOB, suggestion of bolus mis-direction, swallow-breathe coordination etc.) and using all the information the infant gives us, including his non-physiologic stress behaviors, to then prophylactically and contingently respond with interventions to help the infant maintain or re-gain stability during feeding.

Many wonderful neonatal nurses also use the paradigm I just delineated when they provide watchful vigilance during PO feedings with preterms. There are likely some of these RNs in your unit and they should be a part of developing/refining/implementing your infant-driven feeding protocol. Perhaps think of forming a feeding council to bring this forward as a team, and seek out a neonatologist as your champion to be a part of the group as well. The change away from a volume-driven NICU brings forth many issues, and more of them are likely ahead as you tackle this change in feeding culture. Having a feeding council or committee to begin the collegial discussions is essential for buy in, for re-looking at “old ways” or less helpful ways of doing things, and for discussing your NICU’s guidelines for events, their current significance and their possible significance in an infant-driven culture.

Changing the culture of feeding, which goes hand in hand with implementing cue-based feeding, is a process that takes time and requires interdisciplinary collaboration and much  thoughtful reflection. This question and others that arise during this process, and how they are considered and determined, will drive how well your  NICU evolves and how readily they implement feeding focused on the infant and include you in this journey.

 

Question: Recently I have accepted a new and exciting position at a specialty hospital where I am one of 2 SLPs working solely in the NICU. The rest of the NICU therapy team is composed of OTs. Both OT and Speech provide feeding and swallowing assessment and treatment. Speech interprets the MBSs while OT provides the feeding during these studies, which works great! The potential challenge we see is how do both therapies provide services to an infant and her caregivers without creating a duplication of service when both disciplines treat feeding and swallowing? Does Speech take certain diagnoses, such as all clefts, craniofacial anomalies, etc. and OT the “feeders and growers?” Or do we divide the new orders in half? Has anyone else dealt with, or are you dealing with this? What solutions have you found?

Answer: Actually, all staff in the NICU either support or do not optimally support feeding/swallowing in the NICU, from the first day of life. To the extent that self-regulation is supported during all activities and interactions, the infant wires his brain and entrains the sensory motor system optimally. This then supports the integration of subsystems that underlie safe and effective feeding. Through co-regulation with the infant, i.e., contingent responsiveness by the feeder to the infant’s continuous feedback during feeding, the infant’s self-regulation and therefore physiologic stability, and safe swallowing, can be optimized.

Swallowing and feeding are viewed and supported within the context of the whole infant, the entire team, including the family, and the medical complexities/co-morbidities. A focus on infant-guided versus volume-driven feeding is essential to minimizing stress during feeding. Recent studies have shown that stress in preterms is associated with changes in the structure of the brain. So all of us in the NICU have the potential to either support or constrain the infant’s development, through feeding, both in the short-term in the NICU and in the long-term.

The science and evidence-base regarding neonatal swallowing, its relationship to physiologic stability and postural control, the influence of flow rate on airway protection, the relationship of sucking rate, bolus size and respiratory pattern to safe swallowing must be well understood. Recognizing the uniqueness of the preterm’s anatomy and swallowing physiology, his signs of engagement and disengagement that signal stability versus disruption of the swallow-breathe sequence, awareness of adaptive/compensatory behaviors during feeding, and what are supportive versus non-supportive interventions, are all essential.

Those who support feeding/swallowing in the NICU have the responsibility to bring this level of information-base to the infant and his family, in order to guide the entire team toward infant-guided co-regulated feeding.