NICU

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

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

Catherine Shaker Seminars Leave a comment

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

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

Question:

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

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

Answer:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Problem Solving: Late Preterm Weaning Breast to Bottle

Catherine Shaker Seminars Leave a comment

Question:

The parent of a client approached me about a three-month baby refusing bottle feeds. Baby had some issues at birth with feeding and was in NICU for one week due to respiratory insufficiency, born at 36 weeks. Since 37 weeks, baby has been exclusively breastfed with no issues and appropriate weight gain. Does anyone have any techniques to facilitate transition to bottle with pumped breast milk? Any bottles that you have found to work better than others

Answer:

There is likely a myriad of factors that likely are combining to result in this former late preterm’s difficulty transitioning from breast to bottle.

Because she is a former late preterm, it opens up so many possible interacting etiologies that need to be peeled apart and looked at in dynamic relationship with each other. Why she is “refusing” bottle feedings is the key to how we intervene.

Most late preterms born at 36 weeks are in the newborn nursery. The fact that she required neonatal intensive care and had respiratory insufficiency suggests that respiratory co-morbidities were significant. There may have been other co-morbdities, which are not uncommon for late preterms, but we do not know that.

The typical approaches for a healthy term infant with the same challenges cannot be applied to a former late preterm. While she is now 3 months, she is a little over 2 months adjusted age, and that difference is essential to consider, as it provides the context in which we interpret her behaviors. Born 3 weeks early, her sensory-motor experiences early-on were different. Her postural integrity may still be lagging somewhat and may predispose her to more readily breastfeed because less adaptations are required posturally at breast. Because the unique and exquisite physiology of breastfeeding creates ” islands of stability” for breathing for preterms, her preferences for breastfeeding may indeed be physiologic – i.e., at breast she can control the flow to create “windows of opportunity” to integrate breathing with sucking. That isn’t possible with most mad-made nipples. Man-made nipples not only often flow faster, but the infant cannot control the flow from a man-made nipple. It flows based on what nipple the caregiver chooses and the infant can only “respond” to what flow has been selected. The flowrate differences may be part of the picture.

Based on that, I would likely not consider alternative feeding procedure that require this former late preterm to manage a less controllable flow from a Medella Soft Feeder, syringe, cup, straws. While that may be supportive in a former healthy term infant, it may create more struggle for this infant given her history.

I would suggest swaddled sidelying, a slow flow nipple (perhaps Dr. Brown’s preemie flow), ad infant-guided co-regulated pacing to support the kind of flow rate control that this infant has learned and appreciated at the breast. Always offer the nipple via her rooting response, as she is used to rooting actively with breastfeeding, versus” placing the nipple” in her mouth or” putting it in her mouth”. I would also avoid any tendency to prod with the bottle, as she is not prodded at breast. The less adaptability required when she goes from breast to bottle, and the more physiologic stability we create by supporting breathing, the more likely we will be to see progress. We also want to foster a positive feeding experience versus focusing on how much the infant takes, i.e., emptying the bottle, which may unfortunately come into play as bottle feeding is offered. Supporting maintaining the mother-infant relationship will be essential.

I hope this is helpful.

Catherine

Problem Solving: Poor Feeding Post Jejunal Atresia Repair

Catherine Shaker Seminars Leave a comment

Question:

I was just consulted on an infant with a history of jejunal atresia with repair. He was born at 33 weeks GA and is now 41 weeks. He reportedly has consumed 50-90mL adlib on demand per physician of breast milk via bottle. Mother reports feeding every 3-4 hours. The OT that has been working with this little one has incorporated use of a slow flow nipple and external pacing which reportedly assists with coordination and reduces frequency of adverse events but the infant continues to demonstrate physiological instability. During some feedings he demonstrates coughing within a few minutes of onset of feeding. Mother reports that any change or disruption of coordination results in change of physiological stability. These episodes occur during as well as after feeding in which he is demonstrating coughing, occasional color change, desaturation, and bradycardia (both during and after feeds). The RN and mother indicate that on a couple of occasions at night, he has required blow-by. No significant spit ups noted, however, RN reports that on one occasion, small amount observed on external nares. They have reportedly attempted various nipples, positioning, and have also tried breast feeding (which resulted in a significant episode). Reflux strategies/precautions have already been implemented but without much improvement.

Reduced coordination is an issue, however, also suspect EER as piece to this. I am trying to determine differential and plan on completing MBS to get a better idea of swallow physiology. Does anyone have any experience with children with this particular diagnosis or thoughts on this case?

Answer:

The jejunal atresia repair in and of itself does not explain the decompensation you report. All we know about history is the infant is a preterm born at 33 weeks. Are there any other co-morbidities such as Neuro or respiratory? Post-op he may have some lower branch of the Vagus-driven atypical sensory GI responses but that would not typically lead to the clinical behaviors you describe. What is his WOB like at baseline and how does it vary with the aerobic demands of feeding? Does the infant otherwise present as a typical former 33 weaker at his current adjusted age? Can the events appear to be averted by co-regulated pacing that is more strict with an Ultra-preemie nipple? Without knowing the answers to these questions, I would be asking to complete an instrumental assessment to objectify swallowing physiology and determine if there is normal physiology which is being altered under certain conditions or if physiology is impaired, what the etiology is (or etiologies are) that lead to bolus mid-direction. The clinical behaviors you describe in this neonate are ones I typically see associated with aspiration. To continue to feed the infant despite volumes ingested given these adverse overt events does not support neuroprotection and may lead to feeding refusals.

I do not think the thermal stimulation suggested would be advisable as we have at this point no known etiology for the events observed. Every intervention should be thoughtfully matched with clinical behaviors and etiology, and used within an evidence-based framework. At this juncture in your differential, the data don’t lead us in that direction.

Of course EER (Extra Esophageal Reflux) may indeed be part of what is happening but we cannot assume that. It is possible that EER events are co-occurring during swallowing, which could result in bolus mis-direction if the infant’s swallowing physiology is indeed altered in the moment by the EER. It is possible the decompensation observed during PO feeding is due solely to EER events (bolus mis-direction from below) that is occurring both during feeding and at non-feeding times. Hopefully an incidental finding of EER would then be captured by the radiologist during the swallow study. Alternatively, the events of decompensation observed clinically may indeed reflect a true dysphagia –but if so, the etiology (or etiologies) can then be determined during the swallow study. An instrumental assessment will give us an impression of the possibly multiple factors impacting the dynamic swallow pathway. This then can inform the differential and then guide both the SLP and the entire team in terms of next steps for intervention as well as further diagnostic workup.

I hope this is helpful.

Catherine

Problem-Solving: Trach and Vent

Catherine Shaker Seminars Leave a comment

QUESTION: Hello! I work in a residential home with medically fragile infants. We currently have an 11 month old (7months adjusted). He is trach and vent dependent with many diagnosis’ due to prematurity including: pulmonary hypertension CLD, PIE

We are having many debates (speech/ nurses) on respiratory rates that are appropriate for feeding. Can anyone provide some guidelines that are based on research as the nurses are stating that his resting respiratory rate is in the 50’s therefore it is ok for his RR to be elevated during feedings… Help!!! I am on an island!!!

ANSWER: Given this was a 28 weeker based on his adjusted age, his longstanding respiratory co-morbidities from the NICU are most likely the biggest part of the picture still, even though now 7 months adjusted age. Did he indeed get the trach in NICU due to need for long-term ventilation, or were there any airway pathologies that might now preclude tolerance of an in-line PMV? When was the last time ENT saw him to assess airway integrity?
Often infants with a history like his may have multiple issues/co-morbidities that need to be considered regarding readiness to feed. I like to start with a recent airway assessment as I mentioned so you can discuss with the ENT his perspective on readiness to trial a PMV in line and to secure an order if team agrees. If his co-morbidities do not preclude a PMV trial, experience shows us that the inline valve can typically help wean vent settings in infants, and of course could also contribute to restoring subglottic pressure (for improved pressure gradients for swallowing – a key component of infant swallowing). It would also help him manage his secretions as he could then “feel”/sense the secretions. You don’t mention anything regarding his secretion management, which is a factor to consider, but I find it is often improved by a PMV if tolerated. Just feeling his secretions and then swallowing his secretions is a big learning curve for an infant like this and is a critical step along the way.
He has no taste and smell right now, which most likely he actually has never experienced, given that he most likely was vented and trached in the NICU. This is a big void for infants with his history. Being able to use his sensory system (taste, smell, touch/tactile) to “guide” the swallow will be critical for this infant whose oral-sensory-motor system has been altered for some time. Indeed, when he is truly ready (from multiple perspectives of readiness) to trial some tiny PO tastes (most likely of puree), my experience suggests the entire swallow pathway will be better supported via use of a PMV. Again if he tolerates a PMV, based on the original etiolog(ies) for the trach and current airway integrity. I always look to partner with ENT, Pulmonology and my RTs.
Regarding respiratory rate (RR), our RTs tell us that focusing on RR as a primary indicator is quiet limiting and does not take into account the infant as a whole, in particular both his current level of respiratory support (vent settings, Fi02 needs, ability to wean settings, trends over the last month or so, overall progression toward weaning, for example) and his work of breathing (WOB) both at rest and with activity. By WOB, I mean breathing effort – it is often a better overall indicator of physiologic stress than RR alone. WOB would include for example: nasal flaring/blanching, chin tugging, retractions (suprasternal, clavicular, pharyngeal, intercostal, substernal) – this increased respiratory effort, if present at baseline, suggests the “workload” required with breathing, even despite respiratory support, may indeed render the ability to organize breathing even with non-nutritive sucking precarious; the attendant “aerobic workload” is something he needs time to work through and learn to modulate with help during therapy. Being able to “feel” oral-pharyngeal airflow during non-nutritive sucking or oral play is in itself a step along the way to future PO.
Too often, well-intentioned caregivers who think PO feeding will be “fun” are not appreciating the complexity of the task with an altered airway, being hooked up to a vent, not being able to taste or smell (which they often don’t understand as sequelae from tracheostomy) and having a long history of altered oral-sensory-motor experiences, as well as other developmental concerns related to the need for a trach (i.e., gross and fine motor delays, altered postural control, especially in the head and neck, which can affect ability to feed), and other co-morbidities associated with being born so extremely preterm that can alter his overall developmental trajectory.
I know this response is much deeper than you expected, but so much to consider – RR is just the tip of the iceberg so to speak. You aren’t really on an island because we are all out here, each of us learning and at times struggling with similar issues, perhaps with similar patients or clinical questions. I actually like being in the “gray zone”, as I like to call it, where the answers are not clear but the questions often are. That is of course how we grow.
He is lucky to have you in his corner as you try to both protect him and offer him opportunities to grow and develop. I hope this gives you food for thought as you consider next steps. Your population of medically fragile infants is one of the most challenging.
Catherine

Problem Solving: Vomiting in three year old NICU graduate

Catherine Shaker Seminars Leave a comment

Question: I need help brainstorming possible etiologies for chronic vomiting/regurgitation with a 3 year old.

Medical hx is significant for 36 week prematurity, hypoplastic left heart syndrome now s/p Fontan on 6/16. On 6/18, pt w/new onset left side weakness; imaging found hypoxic injury and watershed infarct. PMH also significant for submucosal cleft palate and GT dependence. Chart review revealed ongoing ST to address feeding issues from infancy, including oral aversion and decreased oral motor development, both now resolved. Parents report pt is interested in PO feeding and will put all textures in his mouth but chews them and pockets rather than swallowing because he is afraid of vomiting. Assessment revealed mild OM weakness but adequate lingual lateralization and chewing skills. Initial PO trials were with preferred foods (smooth puree and water via straw). After very small volumes (less than a teaspoon of each), pt regurgitated the food/liquid which subsequently expelled everything else he had “eaten” via GT up to 2.5 hours earlier. The gag did not happen until after pt had safely swallowed on both trials (separate events with puree and liquid). Parents report that this happens several times a day and that pt also vomits without PO intake (just GT feeds) but that is less common. Pt has had several MBSS which revealed functional pharyngeal skills (oral skills were lacking in one but that was some time ago). The only UGI pt has had was when he was an infant, as part of the work up for GT but they presented contrast via NGT and only viewed stomach and beyond. Therefore, today, I asked for an esophagram to rule out structural or functional issues in the upper GI sections. This test was negative.

These parents are so frustrated and don’t know why their son is vomiting all the time. What I witnessed did not appear to be related to sensory/behavioral (texture aversion) or swallow dysfunction. I was wondering about UES dysfunction or esophageal pouch/diverticulum but the radiologist did not see evidence of those today. Any suggestions??

Answer:
There may be a variety of GI issues to consider as part of the differential. You don’ t mention if he also received a Nissen at the time in infancy when his G-Tube was placed; if so this may be part of the puzzle, especially considering the vomiting after G-Tube feedings. His diagnosis of HLHS and multiple surgeries, and subsequent post-cardiac surgery GI complications are quite common, as Shaunda suggested. The lower branch of the vagus can wreak havoc with many of our babies and children post-op. Given his history and pre-morbid feeding challenges (oral aversion, oral-motor problems), there may now be an exacerbation of those premorbid challenges. Given that he must have had some kind of post-op event on or prior to 6/18 that resulted in a documented hypoxic injury and watershed infarct, I wonder if there may also be some alterations in pharyngeal and/or upper esophageal function that may be also part of the etiology. What I mean is that even though there is a strong case for GI issues as a part of your differential, there are apparent recent neuro ones too that, along the swallow pathway, may alter both pharyngeal and upper esophageal (especially UES) swallow function. You mentioned he has had several swallow studies but has there been once since the onset of left sided weakness and the watershed infarct and cardiac repair? This would be a great opportunity to objectify both pharyngeal and upper esophageal swallowing physiology with at least the puree and liquid he clinically appeared to swallow well. His complex history and the recent post-op event suggest to me the need for a current instrumental assessment. Because the UGI is a moment in time, and that his is such a complex presentation, a test result such as a “negative UGI” may not tell the whole story. Perhaps during the swallow study, you may also capture an incidental finding related to GI function, and given the focus on dynamic swallowing in the swallow study (versus what they may focus on in an UGI), you may be able to gather needed data about both pharyngeal and upper esophageal function. The combination of his multiple co-morbidities, and their interaction, is likely quite complex, and the data from a swallow study may help inform the entire team’s perspectives.
Catherine

Problem Solving: Therapeutic taste trials in NICU

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Question:

What are your thoughts therapeutic taste trials? We are a level 3b NICU. And
have many babies with multiple medical complexities. We are beginning a
therapeutic taste trial protocol for babies who are over 32 weeks PMA, have
a nonnutritive suck, and physiological stability. The idea behind this is
practice swallowing for babies who are yet able to bottle feed due to a
number of factors but mostly babies who are on too much oxygen support (1.5
liters of hi Flow or greater)

I have some concerns especially regarding babies who are post PDA ligation
and we are receiving “encouragement” from physicians to begin this protocol
on babies on bubble CPAP. My obvious concerns with PDA ligation is the
incidence of paresis to left vocal fold and CPAP from my understanding
maintains positive pressure for open airway which worries me for poor airway
protection/open airway during the swallow. The bolus give is .05ml-.2 ml
increments. Also what are your thoughts on using sterilized water vs
breastmilk/formula? we seem to be giving them less than what they get from
“oral care”. Any help will be greatly appreciated!

Answer:

I think this could be supportive provided the therapist drives the plan
(once the consult is ordered), and that careful attention is given to
physiologic stability and infant engagement during all oral-sensory-motor
experiences and with pacifier dips. I would in general not be offering
“nipple” delivered boluses at 32 weeks PMA; however, even at 33-34 weeks
PMA, each infant’s unique history, co-morbidities postural control and
current level of support needed, as well as baseline WOB and RR would all
together best determine relative risk and how to best proceed. Many positive
experiences for readiness can be part of therapeutic interventions prior to
offering a nipple for PO feeding.

Infants s/p PDA ligation are highly at risk d/t the typical respiratory
sequelae associated with having required a ligation. A scope by ENT has been
advocated in some recent papers (search Google Scholar) suggesting many
infants are asymptomatic post-PDA ligation surgery despite having true vocal
cord motility sequelae and therefore scoping should be considered to assess
the airway integrity.

I think MBM is always better than sterile water or formula – more sensory
load than sterile water and a more normal oral-sensory-motor experience. No
one has studied it to my knowledge but I suspect that if traces of MBM are
micro aspirated, perhaps the lungs will better tolerate MBM than formula.

I hope this is helpful.

Catherine

Problem Solving: Thickening with NICU Graduate

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Question:
I have not yet personally seen this baby (he’s 2-3 months old), but got some background info from our NICU ST. I’m trying to brainstorm before he sees me for a follow up appointment. Baby had VFSS in NICU and was safe on thickened formula (nectar, I believe) with baby oatmeal. Baby never took off with feeding while in the NICU and was d/c with NG and doing 1-2 bottles/day. As baby has been home he’s having painful constipation issues and thickened feeds have stopped. Baby is to have follow up with GI, but will end up seeing me before them.
He’s coming back as an outpatient for a repeat VFSS. Now, in a perfect world he’ll pass without thickener… but if not, I’m wondering what my options are for thickening feeds? Has anyone thickened for infants with something other than baby oatmeal/rice cereal? Is there another option besides cereal and NG tube?

Answer:
Late responding to this thread. You may have already seen this infant for the repeat VFSS by now. We don’t know much about his history except that he was in NICU, which leaves a wide potential for possible co-morbidities that would be important to your differential in radiology. The GI discomfort you mention makes EER/GER a possible co-mrobidities but there are likely others that you will want to both peel apart and consider together “synactively” to better understand his dynamic swallow and its function during feeding given what you find out about his feeding “environment”, i.e., how he is fed, bottle used, his clinical presentation while he feeds and post-feeding behaviors

Hopefully you were able to get more information about why he was placed on nectar thick liquids post-NICU VFSS – the etiology for the apparent bolus mis-direction should guide you in the follow up study and help you problem-solve as well as look at optimal interventions to address that etiology –sometimes thickening is viewed as a solution but it is not, as you know. As Suzanne Evans Morris said years ago, it is merely a step along the way to improved swallowing. When the VFSS analysis and synthesis of information informs our understanding of the infant’s physiology, we can then develop a plan of care to address both the etiology as well as an interim plan to optimize safety.

We try both in the NICU and with infants either post-NICU, or who were never in NICU, to avoid thickening whenever possible. Because toady we have so many flow controlled nipple options, we are much more able in radiology to find a nipple flow rate combined with co-regulated pacing that optimizes bolus size and enhances timing of the suck-swallow-breathe sequence. There aren’t many options to thicken for infants. Our GI docs have concern for grain allergy in infants, increased constipation, and other MD specialist often have their own concerns (altering of caloric density and nutrients, electrolyte balance, free water etc.) Gel Mix is a newer carob bean based thickening product developed by a GI doc that some hospitals are using for some post-term infants. You can find more information on the internet or by talking to its developer. It is often helpful to partner with the attending, in this case likely a pediatrician, to ask, if thickening appears to be the least problematic option, what would he prefer his patient receive. As many previous list serve threads have expressed, the answers for each patient must be individualized, be the product of a team’s perspectives, and its effects be assessed in an on-going manner. It is challenging to live in the “gray” zone where the answers are not black and white nor are they immediately clear, but require deliberate and reflective thinking. Each of us in radiology is faced daily with this dilemma, and I think it makes us better clinicians at the end of the day. Our physician colleagues have always considered risk-benefit ratios for their patients regarding multiple options, and we can do no less, considering all levels of evidence and family/team input.

I hope this is helpful. Keep us posted on what the repeat VFSS suggested.

Catherine

Research Corner: High Flow Cannulae

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Article Review

Leder SB, Siner JM, Bizzarro MJ, McGinley BM, Lefton-Greif MA.

Oral alimentation in neonatal and adult populations requiring high-flow oxygen via nasal cannula. Dysphagia 2016, 31;154-159.

article available through Google Scholar

I am quite concerned by the conclusions of Leder et al regarding safety of oral feeding for preterm infants requiring CPAP.

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. Our 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 underpinning’s 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 co-morbidities, 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. This is quite concerning given the conclusion from Leder et al’s study does not even mention this possibility. 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. Should the potential for silent aspiration not at least be mentioned? 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 “ate” and “were fed” and “transferred volume” does not equate to “safe feeding”. Leder et al’s conclusions don’t unfortunately take this into account.

We must of course consider as well the physiologic stress likely to occur when the infant experiences “feeding” under such circumstances. It is highly possible the stress of trying to breathe and coordinate a swallow may actually 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.

My colleague, Dr. Suzanne Thoyre, a neonatal nurse feeding researcher, raised some excellent questions about the study design some of which I will try to share in my own words, as she is not a part of our list serve

What did Leder et al deem for inclusion criteria that would be “stable respiratory status” and “Cardio-respiratory stability”? Typically, infants requiring CPAP or HFNC have both increased WOB and increased RR. RR may appear artificially low when rates are captured by a monitor for example that does not sense shallow rapid breaths. Was WOB a consideration? This is a key component of infant clinical assessment of breathing in preparation for attempting as well as during PO feeding. Excessive WOB even in the presence of a less elevated RR can alter timing of swallowing and breathing and often lead to silent bolus mis-direction in the NICU population, much as it might in adults with respiratory work. It is common that infants requiring even low flow oxygen cannot feed without a co-occurring increase in their work of breathing. Two of my OT colleagues in NICUs out East who each observed MD-directed RNs feeding infants on CPAP and HFNC reported seeing significant increase in WOB, RR and signs of behavioral stress.

How was successful oral feeding measured? Did they collect physiologic and behavioral data that demonstrated no indicators of stress, change in oxygen saturation, change in HR, change in respiratory status? The tool they used to measure this needs to be provided. If the feeder simply filled out a checklist, it would be important to know how those observers were trained, how all of these parameters were described and what definitions were used for change in these parameters.
Are the infants in the study on CPAP and HFNC truly being PO fed at 32 weeks PMA? Or is the term “corrected GA” being used incorrectly? I ask because typically even healthy preterms without co-morbidities stable in RA are not being fed PO in most NICUs, with some rare exception. This needs clarification and perhaps makes the conclusions even more concerning.

Unfortunately, Leder et al’s paper will reinforce an incorrect not uncommon assumption. 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 learn to feed orally at later ages, once weaned, and from my experience do so with much less stress and much more safely.

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

I hope this is helpful.

Problem Solving: Feeding and the parent-infant relationship

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Question: I work in EI, in a primary-service provider, parent-coaching model doing home visits, and am considering taking courses to get an Infant/Toddler Mental Health certificate. Since strong relationships really provide the foundation for so many early communication foundations, I think this would be a beneficial area in which to learn more, but would love some feedback/input from other SLPs in the EI world.

Answer: I agree that the parent-infant relationship is best used to guide and inform our SLP practice, whether it’s supporting early communication in EI, or indeed in the NICU, while supporting the early communication that takes place first through the feeding relationship. Feeding isn’t a task of course, it is, when it is at its best, relationship-based.

As an NICU SLP, this is the heart of my daily practice as I empower parents to understand their infant’s communication during feeding, and let the infant guide them in providing a positive safe feeding experience. I call this “infant-guided” feeding. It fits so well with the concept of infant mental health, I thought I would share it with you.

Interaction between infant and parent is the mechanism through which the infant’s development ultimately occurs. Feeding is not solely a task of nutritional intake, but also has many social correlates in infancy and throughout the lifespan. Interaction during infant feeding aids the development of social interaction, communication and being responsive to others among both parents and the infant. Parents of healthy term infants regulate the environment and any stressful events for the infant through bonding and attachment. This “dance of attachment” between parents and the infant creates a blueprint for the infant’s future well-being, including brain development, nervous system regulation, ability to manage stress and sense of security. In the NICU, however, parents may experience the loss of their own homeostasis due to the stress of having a preterm infant. Parental anxiety, depression, and the sense of a loss of autonomy are common. The dissonance between the parents’ expectations and the reality of parenting an infant born early is often particularly stressful. Parents may perceive themselves as outsiders in the NICU and there may be difficulties for parents in developing relationships with their infant and staff. Therefore, empowering parents in the NICU is very important.

Research has shown that the ability to feed well is closely related to the caregiver’s ability to understand and sensitively respond to the infant’s physiology and behavioral communication. Depending on the perspective of the professional caregiver, however, feeding may be viewed as either supporting the infant in a positive learning opportunity or as emptying the bottle. Infant cues of stress may not be recognized by professional caregivers who remain focused on “getting it in” the infant. They may feed past the infant’s communicative “stop signs” in an effort to assure volume is ingested, using well-intentioned strategies that actually result in stress for the infant and often, incoordination. These volume-driven strategies, may include: increasing the flow rate to empty the bottle, which can cause the infant to “fight the flow” to breathe; prodding the infant, which takes away the infant’s active sensory-motor control over feeding, and delivers unanticipated flow into the infant’s oral cavity and/or pharynx; putting the infant’s head back to use gravity to help empty the bottle, which increases risk for bolus misdirection and airway compromise; unswaddling the infant to “keep him awake”, which actually takes away critical postural support for the swallowing mechanism. The infant may be expected to continue feeding, despite subtle signs of physiologic instability, behaviors that suggest swallowing and breathing are starting to uncouple, for example: drooling, gulping, nasal flaring and blanching, the lack of a regular series of deep breaths, chin tugging, and changes in eye gaze pattern. Communicative signs of disengagement may not be given meaning. These signs may include pushing the nipple out, pulling off the nipple, no active rooting or sucking, arching, shutting down/inability to re-alert, or purposeful use of a weak suck on the infant’s part to signal a preference for return to only pacifier sucking. If the role model provided for parents is volume-driven, parents may see their role as emptying the bottle or “getting it in” the infant. They may not correlate feeding behaviors with co-occurring physiologic instability, may not identify adverse events as problematic, and may not recognize and respond to infant “stop signs” during feeding. They may learn to view feeding a something they do “to their infant” not “with their infant “. Reducing stress for the infant promotes neuroprotection and reducing stress empowers the parents.

Parents observe and learn they can communicate back and forth with their infant during feeding, and that this conversation allows their infant to guide them. This co-regulated approach to feeding recognizes the impact of the caregiver on the infant’s experience of feeding and views the infant as a co-regulatory partner with his own agenda and emerging feeding skills. This co-regulation between parent and preterm becomes the foundation for strong parent-infant attachment and is formed most often during feeding experiences in the NICU. When the unique behavior of an infant is understood as a communicative attempt, and parents know how to respond to it effectively, feeding is both more successful and less stressful, and the attachment relationship tends to strengthen, while parental anxiety tends to diminish. Infant-guided feeding early on is the foundation for a strong parent-child-relationship that supports long-term positive outcomes a cross so many domains.

I hope this is helpful to embracing infant-guided feeding as a critical component of infant mental health. As you are able to incorporate this perspective into your work, both infants and caregivers benefit.

Catherine
Catherine S. Shaker, MS/CCC-SLP, BCS-S
http://www.Shaker4SwallowingandFeeding.com

Problem Solving: Impact of Prematurity on Feeding

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QUESTION:
My niece, on 2/4/16, birthed by c-section a 5#1oz boy with perfect latch and sucking but is labeled a preemie as his due date was 3/7
My grandson was born 5 weeks pre-term, 5#3oz and had a weak suck and labeled preemie.  Required facilitation for increasing sucking strength and became an efficient breast feeder after a month.
Is a preemie determined by the amount of weeks gestation or maturity at birth?
The new boy is doing everything a newborn does…good latching, sucking, eliminating, etc….
I have worked with some infants and young ones with gtubes, but haven’t thought about this question when a “preemie” has developed and appropriate feeding skills since I have never seen a preemie with good sucking!
Anyone?
Thank you…
ANSWER:
I can see how this might seem confusing to you. One of the babies was 36 weeks gestation, which means he is a late preterm infant. The other was 35 weeks gestation, and he is also considered a late preterm infant.

GA (gestational age) is a way of classifying preterms, and can give us insight into potential risk for developmental challenges and potential for associated medical issues. The lower the GA (infant may be as early as 23 weeks), the more likely for both associated medical co-morbidities and the more likely there will be feeding difficulties. The research profiles this correlation, which is most compelling for those infants born at or under 28 weeks GA.

Your little guys are both late preterms so in a group profiled with less risk overall but none the less, some risk d/t been born, in this case, 4-5 weeks early. Every day in the womb is one more day for intrauterine sensory-motor learning to occur, and so even a week longer inside mom can make an amazing difference in how the infant presents and progresses. In addition, other factors come to bear on the infant’s progression to feeding, including components of mom’s own pregnancy and medical issues during that time, the quality of the new infant’s transition to extrauterine life in the delivery room, whether he was delivered at a hospital that is experienced in delivering preterms, whether he was transported to an NICU after birth or was born at a hospital with its own NICU, for example.

Being even “only” 4-5 weeks early of course affects messaging from the brain to the muscles, timeliness of airway opening/closing, and also integrity of musculoskeletal movement, each to a varying degree for each preterm, as each one is unique in his presentation. For late preterms, there is an increased risk for hypoglycemia and hyperbilirubinemia, increased WOB, and intermittent tachypnea.  Each of these can affect drive to feed and coordination of breathing with swallowing, and the drive to suck (i.e., because breathing takes precedence). Sometimes reduced drive to feed (d/t respiratory issues common to late preterms) can be mistakenly perceived as poor sucking, when most topically the suck is fine and the infant is choosing to suck less (or less strongly) so he can focus on breathing.

In addition, there is also the influence of the hospital staff on the infant’s feeding environment, i.e., is the hospital staff volume-driven or infant-guided in their feeding approach? That “approach” is the lens through which the staff then interprets, or misinterprets, infant feeding behavior to families, and then in turn teaches families how to feed their infant,  either in a volume driven way (“he has a poor suck, give him help to suck”) or “he has less drive (due to perhaps hyperbilirubernemia and hypoglycemia and/or just being early) and has increased breathing effort, so we need to re-alert him, rest him intermittently during feeding, offer co-regulated pacing based on his communication and slow the flow rate so he does not fight the flow to breathe.” So the quality of the feeding experience is a part of the picture too.

So many factors go into the feeding experience for each preterm infant. I hope this helps make sense of the multiple reasons for the apparent variability you report. Glad to hear they are both doing well now.

Problem Solving: Swallow Studies in the NICU

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I recently received an email with questions from an experienced SLP posed by the neonatologists at her large level IV NICU regarding swallow studies. There are of course no black and white answers, and the evidence-base is lacking, we know, but thought I’d share my comments/perspectives.

Her questions follow. My responses are in italics:

” A lot of concern has come to light regarding how we perform MBSS.  The physicians feel it is not a fair assessment given altered positioning, transport to the fluoroscopy suite which may negatively impact regulation and physiology of these infants, and strategies used.  The swallow study is only a moment in time and looks at physiology not just aspiration (or bolus mis-direction), so, given that, the data we can extrapolate during an instrumental assessment may be more useful, than they realize, to help complete a differential and develop a plan of care. 

Would you mind answering the following:

1. Do you always assess in sidelying?  If semi-reclined, do you start that way and transition into sidelying routinely or if you feel this position may change outcomes? If swaddled elevated sidelying is the typical positon the infant is fed in, yes; if not, I would look at typical position, and then determine if objectifying sidelying as a helpful intervention is indeed justified by the added exposure, based on physiology observed, co-morbidities and interventions trialed.

  2. Do you feed for a certain time frame or percentage of the volume that infant consumes bedside, prior to the study To build in a fatigue factor, I would observe briefly under fluoroscopy at the start of feeding and then feed off line with periodic imaging as indicated for that infant’s differential and based on what is typical for him. That way we see physiology at the start and then intermittently to objectify impact of fatigue on physiology over time.

3. Are there parameters for duration between studies if you note significant clinical improvements during bedside feeds? I typically image as infrequently as possible. If we are not chasing the ‘aspiration” event but rather assessing physiology in radiology, my sense is we then focus on and ask ourselves what component(s) of the etiology (or etiologies) observed on the previous study may have changed in the interim. And if the etiology or etiologies have not resolved, why radiate the infant again with little potential for change in physiology? Too many MDs want us to keep repeating studies to “look for aspiration” and therefore if we “just do one more study” maybe we won’t capture aspiration, right? And then we don’t “capture aspiration” in that moment, and someone concludes incorrectly, therefore, that the infant “passes”, is “safe to feed”, is “cleared to eat”?? That is the thinking I believe that incorrectly follows when the procedure is inadvertently presented as such or viewed as such. That is not the best use of the procedure nor in the infant’s best interest when we look at the “cost ” long-term of added radiation (which we know the AAP is quiet concerned about, especially with infants). The type of “revised” thinking that I am advocating for is often out of the box for many of our neonatologists, but I find that once we have this level of critical reflective thinking and dialogue with neonatologists, then they better understand the role of physiology (normal versus altered versus impaired) and the judicious use of video fluoroscopic swallowing studies in the NICU. They too can learn to look beyond aspiration if we guide them. But it starts with us and these conversations. The dynamic nature of swallowing in the context of the infant’s co-morbidities must always ground us and guide our clinical reasoning.

I hope this is helpful to my NICU colleagues!

Catherine

http://www.Shaker4SwallowingandFeeding.com

Research Corner: Reflection in the NICU

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Thoyre, S., Park, J., Pados, B., & Hubbard, C. (2013). Developing a co-regulated, cue-based feeding practice: The critical role of assessment and reflection. Journal of Neonatal Nursing, 19(4), 139-148.

 

Those of you who practice in the NICU will enjoy this article by my colleague, Suzanne Thoyre PhD RN, on the use of reflection during the assessment of feeding in the NICU. Together we developed the Early Feeding Skills Assessment Tool (EFS) which is referenced at the end of this article.  The focus herein is viewing an assessment as providing opportunities for infant communication.

I believe that when we conceptualize feeding as a relationship–based experience, we then see our role during feeding as dynamically attending to infant communication from moment to moment, responding contingently to support physiologic and behavioral stability, and therefore averting stress for the infant. This then supports neuroprotection, which is our ultimate goal with both preterm and sick newborns in intensive care. Dr. Thoyre does a wonderful job capturing this concept. Because it is written by an NICU RNs, it is information that will likely be helpful to you in your conversations about cue-based feeding with your nursing colleagues.

“The feeder maintains a goal to optimize the feeding through assessment of infant cues. Assessment skills are deepened through a process of focused observation and reflection on what is being learned (from the infant).  The feeder uses all modalities available to observe and interpret infant communication (both physiologic and behavioral), and reflects on the meaning of the infant’s cues. Cue-based feeding is therefore more than learning to respond to infant distress; it is also learning from the infant how to anticipate what they will need and providing appropriate support so they can have as successful a feeding experience as is possible. Through this process, the feeder supports and strengthens the infant’s efforts, and respects and protects their limits. Assessment of the skills an infant brings to the feeding is essential if we are to provide feeding support that meets the infant’s needs.

Catherine

Problem Solving: Breastfeeding and Swallowing Dysfunction

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Question:
Hello!  I work in a children’s hospital with a level 4 NICU.  Our SLPs know that thickening is our last resort, so to speak, in terms of interventions that we provide for these infants (positioning, nipple flow rate, etc.)  Our hospital is currently using rice cereal to thicken feedings if needed based on MBS.  We are exploring GelMix as an option, but this hasn’t been cleared by our Neos or GIs.  Does anyone have any evidence/research to support using a combination of 50/50 breast milk and formula and thickening with rice cereal?  We know that rice is broken down in breast milk, but if we do a 50/50 mix, is that enough for the rice to bind and maintain a thicker consistency?  Do any of you have protocols for those infants with swallow dysfunction in terms of breast-feeding?  Thank you so much for any feedback!!

Answer:

At the end of that post you asked about protocols for “infants with swallowing dysfunction in terms of breastfeeding”.

I am assuming you are asking about infants who are bottle-feeding and breastfeeding and had a swallow study done that showed an impairment or alteration in swallowing physiology with bottle-feeding that resulted in bolus- misdirection and potentially aspiration?

An infant may indeed have an alteration or impairment in his underlying swallowing physiology that will adversely affect the biomechanics of swallowing and lead to bolus mis-direction both toward/into the laryngeal and/or nasopharyngeal airway. In infants of course, who are by nature obligate nasal breathers, the mis-direction and its etiolog(ies) must be carefully considered.

Because of the unique physiology of breastfeeding, it is uncommon that infants will show overt decompensation with breastfeeding but possible. I have found clinically that those infants who decompensate during breastfeeding often have a true alteration or impairment in swallowing physiology. Breastfeeding is actually easier than bottle feeding, even for preemies, so it is possible an infant may not experience an alteration or impairment of swallowing physiology at breast though it was observed in radiology with bottle-feeding. Take a look at the multiple “gold standard’ writings of Paula Meier, Goldfield and Nyqvist regarding the unique physiology of breastfeeding suggesting it is likely most supportive of airway protection for infants.

My clinical experience and reading of the literature has lead me to hypothesize  that those infants whose etiology for impaired swallowing physiology is flow rate and/or coordination of suck-swallow-breathe, in the presence of normal structural integrity of the airway and oral-pharyngeal mechanism, may do quite well with breastfeeding. Breastfeeding optimizes flow rate regulation and provides “windows of opportunity” for breathing so well described by Goldfield; it is this then that likely optimizes bolus control. However when there are issues with structural integrity of the airway (i.e. vocal cord paresis/paralysis, laryngomalacia, tracheomalacia) the “protective nature” of breastfeeding may no longer be realized, if you will.

There is no way to study my hypothesis since we cannot observe breastfeeding under fluoroscopy. However, working closely with pulmonologists, ENTs and neonatologist’s, we have together carefully considered each infant, his co-morbidities and what we know from the science of breastfeeding to inform our decisions about breastfeeding given objective data obtained during bottle-feeding.

I suspect your question, which is a good one, may have been prompted by infants who had a swallow study with the bottle from which “aspiration” findings are being generalized to breastfeeding. I don’t think its that simple, as I hope my thoughts above suggest.
Unfortunately the complexity of the infants we follow requires us to pause at each juncture in the clinical process, and allow ourselves to think in the “gray zone” as I like to call it. Not expecting quick answers but rather allowing reflection, carefully weighing that infant’s history, co-morbidities, clinical and instrumental findings and the evidence-base to complete a solid differential. From there, we dialogue with the team to develop a plan of care and interventions to hopefully minimize risk while optimizing both neuroprotection, skill progression and the infant-mother relationship. It is a challenging balancing act every day for us and so we keep asking questions and learning.

I hope this provides some food for thought and is helpful.

Catherine