Research Corner: GE Reflux and NG Tubes in Infants

Take a look at this article hot off the press:

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

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

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

Hope you enjoy it as much as I did.

 

Shaker ASHA Blog: Preparing for the NICU

Do you hope to get a coveted pediatric placement during graduate school or for your clinical fellowship experience? Are you interested in an even more specialized subset of pediatrics? Working as a speech-language pathologist in the neonatal intensive care unit (NICU) requires many specific skills. These tiny patients and their families are fragile. The family-centered care we provide as SLPs, in support of neuroprotection, communication and safe feeding, create the foundation for a thriving parent-infant relationship.

Read more here: Preparing For Grad School or CF Placement In The NICU: Part One 

Ankyloglossia Resources

Here are some excellent resources for ankyloglossia.  I am also attaching an article regarding why reflux is often an associated co-morbidity. These sites add to our understanding of posterior tongue tie, anterior tongue tie, as well as lip and cheek ties. Dr. Ghaheri has wonderful videos and pictures. I hope these resources inform your practice!

 http://tonguetie.net

 http://www.brianpalmerdds.com

 http://www.drghaheri.com/resources

 http://www.kiddsteeth.com/

 http://www.cwgenna.com

 Assessment Tool for Lingual Frenulum Function developed by Alison Hazelbaker

 

Steehler, M. W., Steehler, M. K., & Harley, E. H. (2012). A retrospective review of frenotomy in neonates and infants with feeding difficulties. Int J Pediatr Otorhinolaryngol. doi: 10.1016/j.ijporl.2012.05.00

Problem Solving: Supporting PCVICU infants

Question

Our hospital is working on creating a neurodevelopmental care team to implement in our CVICU. We are thankful to be involved and are working to gather research based evidence for what we do. We need research articles regarding the benefits of:

pacing
side-lying
breastfeeding with cardiac dysfunction (any guidelines you are using?)
vocal cord dysfunction/aspiration following arch advancement/coarcs (any protocols you are using with ENT/VFSS/FEES?)

We have found some articles but would love to hear your thoughts/get additional research to support our cause 🙂

Thank you so much!

Answer

You mention many of the critical areas of consideration when working in the PCVICU (pediatric cardiovascular intensive care unit), as many infants and children with congenital heart disease have feeding/swallowing problems secondary to their cardio-respiratory co-morbidities as well as other associated co-morbidities. This population is at high risk for genetic syndromes, which opens an even wider potential for co-morbid conditions. Post-arch repair increases risk for left VCP and post-ECMO infants in PCVICU are also at risk for right VCP; early scoping by ENT and early ST involvement prior to resuming/initiating PO is essential.

Because many of the feeding/swallowing issues specific to prematurity involve respiratory co-morbidities, much of the literature on preterm infant feeding and NICU intervention will inform your practice in cardiac.

Search the ASHA list serve archive for past posts from many contributors regarding NICU feeding, pediatric cardiac feeding issues and feeding on high flow cannulae for some excellent considerations and references. You will also find applicable information on my website including my publications with extensive bibliographies of pertinent references that address co-regulated pacing, sidelying and other interventions. A literature search will also yield several recent helpful papers (on VCP associated with cardiac repair, benefits of breastfeeding, feeding challenges post cardiac repair etc.), and a search through ASHA will yield pertinent Division 13 CE articles as well as post-convention papers, for example from a presentation by SLPs from Boston Children’s regarding their work and my past NICU-related presentations as well as those of others pertinent to NICU and PCVICU practice.

Working in PCVICU provides an amazing environment for learning from both nurses cardiologists, intensivists and respiratory therapists. I absolutely love it there, although I think the well-intentioned goal of getting these infants/children discharged after surgery can lead to challenges such consistency of feeding approach, following a plan, not focusing on just intake but also positive learning and its impact on long-term feeding outcomes. I found that starting by learning from them, having collegial conversations that enlighten them about our perspectives, the research and our clinical problem-solving, all helped to open doors for professional respect, collaboration and partnership, and for engaging in the difficult conversations with nurses and physicians when  a well-intentioned volume-driven approach becomes the problematic issue. Families are so grateful for the individualized infant-guided and child-guided approach we can share with them, as it allows them to build or rebuild a relationship with their sick child through positive feeding.

You will likely work with your own team to best create pathways and protocols that your team develops, once you have your feet on the ground and have a better understanding of your unique PCVICU population and your team’s preferences and past experiences utilizing therapy services in PCVICU. Once I had a sense of this and had built relationships, I provided an in-service to all PCVICU team members (and am set to repeat it d/t staff turnover) that allowed us to set the stage for their understanding of the unique considerations for return to feeding function, swallowing physiology, critical interventions, safe feeding, avoiding volume driven feeding, the high potential for feeding aversions, and the fragile nature of skills in this population.

Building relationships and bringing data seem to best go hand in hand when we start any new program. How wonderful they have asked you to be a part of their team. Know up front there will be daily struggles, just like in NICU, but they are all worth it at the end of the day. All the best to you in this endeavor!

Catherine

 

 

Research Corner: Dysphagia Treatment for School-Aged Children

For those of you who service school-aged children, Dysphagia Café has a thoughtful post by Emily Homer, a recognized leader in school-based services.

 

Click on the link below to inform your practice!

https://dysphagiacafe.com/2017/06/16/dysphagia-cafeteria-navigating-school-based-dysph

Catherine

Shaker 2017 Publications on Infant-Guided Co-Regulated Feeding in the NICU

I am proud to announce the publication of my two new manuscripts devoted to Infant-Guided Feeding in the NICU. I was invited to contribute regarding the NICU for the 25th anniversary edition of Seminars in Speech and Language, dedicated to Pediatric Feeding and Swallowing. I am humbled to be one author amongst colleagues well-respected in pediatric dysphagia. My goal was to share the science and art that underlies our role as skilled and thoughtful neonatal therapists. A sequel to my previous papers on using the infant’s communication as a guide during feeding and supporting parents in feeding their preterm infant, these contributions are designed to provide the theoretical underpinnings and interventions that are foundational in the Neonatal Intensive Care Unit. Support of an infant guided, co-regulated feeding approach is essential to both neuroprotection and safety for these infants who are entrusted to our care. I hope they inform your practice and extend your critical thinking with our tiniest and most fragile patients.

Below are the citations and abstracts:

Shaker CS. Infant-Guided, Co-Regulated Feeding in the Neonatal Intensive Care Unit. Part I: Theoretical Underpinnings for Neuroprotection and Safety. Semin Speech Lang. 2017 Apr;38(2):96-105. doi: 10.1055/s-0037-1599107. Epub 2017 Mar 21.

Abstract: The rapid progress in medical and technical innovations in the neonatal intensive care unit (NICU) has been accompanied by concern for outcomes of NICU graduates. Although advances in neonatal care have led to significant changes in survival rates of very small and extremely preterm neonates, early feeding difficulties with the transition from tube feeding to oral feeding are prominent and often persist beyond discharge to home. Progress in learning to feed in the NICU and continued growth in feeding skills after the NICU may be closely tied to fostering neuroprotection and safety. The experience of learning to feed in the NICU may predispose preterm neonates to feeding problems that persist. Neonatal feeding as an area of specialized clinical practice has grown considerably in the last decade. This article is the first in a two-part series devoted to neonatal feeding. Part 1 explores factors in NICU feeding experiences that may serve to constrain or promote feeding skill development, not only in the NICU but long after discharge to home. Part II describes approaches to intervention that support neuroprotection and safety.

Shaker CS. Infant-Guided, Co-Regulated Feeding in the Neonatal Intensive Care Unit. Part II: Interventions to Promote Neuroprotection and Safety. Semin Speech Lang. 2017 Apr;38(2):106-115. Epub 2017 Mar 21.

Abstract: Feeding skills of preterm neonates in a neonatal intensive care unit are in an emergent phase of development and require careful support to minimize stress. The underpinnings that influence and enhance both neuroprotection and safety were discussed in Part I. An infant-guided, co-regulated approach to feeding can protect the vulnerable neonate’s neurologic development, support the parent-infant relationship, and prevent feeding problems that may endure. Contingent interventions are used to maintain subsystem stability and enhance self-regulation, development, and coping skills. This co-regulation between caregiver and neonate forms the foundation for a positive infant-guided feeding experience. Caregivers select evidence-based interventions contingent to the newborn’s communication. When these interventions are then titrated from moment to moment, neuroprotection and safety are fostered.

 

Catherine

Developing NICU Competencies

Just a few thoughts. Those developing the NICU competency will benefit from a period of reflective thinking to avoid the tendency to look for something already done or a cookbook, though guidelines can clearly guide and inform our own key learnings and formalized competencies. My dear friend and SLP colleague, Bob Beecher, from Children’s Hospital of Wisconsin used to say: “Cookbooks are made for cooking not for eating…use them wisely.”

SLPs mentoring new colleagues can develop very meaningful mentorship plans and identify objective SLP clinical skills for “check off” through careful reflection and application of current literature. This includes drawing from their own mentorship in the past (what worked, what was missing), or if you were not fortunate to have a mentor and came from the ground up alone, like I did in 1985 – what you now know is essential). Consider the current mentorship process in place (and feedback from recent staff mentored). Compile current literature that is essential as a foundation for NICU practice. Throughout the mentoring, it is critical to reflect that being part of an NICU is a journey, not a destination. Both the NICU’s evolution from a medical and technology perspective, as well as our own need to continue learning and growing in this rapidly changing clinical environment, are essential to an NICU practice that thrives and does so with respect and professional integrity.

Focus on providing the mentee with guided participation with and then assessing objectively (while supervised) their competency related to verbalizing and/or demonstrating the underpinnings of NICU practice during both evaluations and treatments. Even today these are rarely discussed in graduate school), and include: neuroprotection, medical co-morbdities and current technologies and their typical impact on feeding/swallowing, developmental progression of the dynamic systems (postural , state, oral-sensory-motor, respiratory, GI) that underlie feeding/swallowing for sick term infants versus preterm infants, guidelines for referral to ST (who, when, why, how to advocate), readiness factors for PO feeding and how SLP can support the progression to PO feeding (as co-morbidities permit), parameters for physiologic stability and indications of decompensation as well as how to avert and/or respond, the components of evaluation and completing a differential utilizing a wide range of data, explaining one’s differential to others (MD versus RN versus the family), instrumental assessment of swallowing physiology (why, when, how, potential intervention strategies and their benefits/risks), documenting to assist the team via your impression and plan versus only checking off boxes, strategies to support safety and their evidence-base (co-regulated pacing, resting, positioning, swaddling, state modulation, nipple selection), infant communication (signs of stress versus stability, signs of disengagement versus engagement), NICU equipment (what, why, application to SLP practice, progression of respiratory support, lines and their risks), team relationships (learning from other team members, bringing the evidence-base, difficult but respectful conversations, controversies due to the emerging evidence-base, supporting families), breastfeeding (physiology and relationship to bottle feeding, how to support as an SLP), common medications and potential impact of PO feeding. I am sure I am leaving something out but this is hopefully a start.

The depth and complexity of our work in the NICU, and the potential for these often fragile infants to decompensate, demand that both mentorship and competency assessment be carefully structured and supported. Our profession and our families deserve no less.

I hope this is helpful.
Catherine

Problem Solving: Late Preterm Weaning Breast to Bottle

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: Therapeutic taste trials in NICU

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: Complex 15 month old with aspiration

Question:
I’ve been seeing a 15-month old female pt. for feeding therapy for almost one year (coming up on annual). She’s diagnosed with microcephaly & pharyngeal dysphagia. She came to me on a 5.0 oz. honey thick soy formula diet after a swallow study revealed aspiration.

She’s always sick (snotty, congested, had CDIFF 2x) and presents with a snorty quality when eating. ENT reports clear, but narrow canals. She’s been cleared by GI, passed thyroid testing, had genetic testing revealing no abnormalities, and PCP not too concerned for her development. Therapy tools & techniques have included facial and oral massage, flavored gloves, Z vibe, Nuk brush, flat maroon spoons, chewy tubes for chewing, trialing different temperatures & flavors, etc. She clears spoon adequately, doesn’t lose food, sits upright in a high chair, and gains weight appropriately.

She’s transitioned from thickened milk–to thickened stage 1 & 2 foods–to non-thickened stage 1 & 2 foods (cleared by Dr and follow up swallow study revealed aspiration on liquids only). And we are stuck here. There were two instances when mom forgot to pack food so she was given stage 3 lasagna bc ironically, that’s all I had at the clinic. She tolerated the chunks and ate the food w/ no problem. She never did this at home for mom or ever again for me. One time, in preparation for her 1st birthday, we tried sneaking tiny pieces of cupcakes in her food. She tolerated this and even ate bites of it without baby food altogether by the end of the session! She never did eat it again. Lately she’s taking 1-2 containers of 4.0 oz. stage 2 baby food during her sessions lasting 30-60 minutes. Once a solid (tiny cereal piece, yogurt meltable, chunks in stage 3 food) of any kind enters her mouth, she’s choking, crying, and trying to get it out. She’s not into the oral motor stuff anymore. She turns her head away, she just wants to eat. Help! Where should I go next with my re-eval as far as testing, other referrals (allergy?) and new goals?

Answer:
Sounds like a complex child. Her microcephaly is likely a clear influence on her skill progression and at least part of the reason for her feeding/swallowing difficulties. As Heidi suggested, her sensory-motor system is likely not going to process information in the typical way, and that may be the underlying reason for her variability in skills and her dysphagia. From the information so far, I don’t know anything about her early history which often helps to sort out what might be going on and why. It helps to now she aspirated but that is so limiting in helping us understand the bigger picture. Sometimes swallow study reports unfortunately only tell us aspiration occurred. If we could understand why the events occurred, what the child’s response was, and what specifically then might improve physiology, it allows our therapy approach to be more directed.

The always getting sick and congestion may sequelae of dysphagia and/or reflux. If there is a delay in swallow initiation, some of the bolus may be inadvertently mis-directed in to the nasopharynx and create the sound you hear. She may have more chronic congestion because refluxed material is entering the hypopharynx, some of it is being swallowed down but some “hangs up” along the

pharyngeal or nasopharyngeal wall.
Sounds like you have utilized many of the typical therapy tools to enhance function and she’s made progress. Her inconsistent ability to manage texture change may indeed be sensory-motor and/or trouble preparing and managing (i.e., fully chewing, reforming a bolus and effectively swallowing the bolus. Again, not knowing the etiology for and timing of for the current liquid aspiration reported, that remains a missing piece of our problem-solving puzzle that might help us better understand her challenges with her solid diet as well. Sometimes children with microcephaly may have diminished sensory registration throughout the entire oral-pharyngeal system that can at any moment alter processing of information along the swallow pathway. This places her at risk of mis-interpreting sensory data as she east/drinks, so she will bear watchful, vigilance during meals to monitor rate of eating and bolus size. The food chaining Heidi referenced might indeed be helpful and you can incorporate continued work on further improving oral-motor integrity as you go along. Given her microcephaly, the quality of her oral-motor skills may be a continued issue, although they may be functional. The clarity and variety of her spontaneous speech/sounds and her imitative skills may provide some indirect insights for you.

Perhaps you can talk with the therapist who did the study to find out more about physiology and have her suggest next steps, since she has seen the child clinically. I would also find out more about the reported liquid aspiration, so you know what you can be working on to enhance her liquid swallows, with the goal of eventually not needing thickening as safety permits. While we may need to thicken liquids for some children when there are no alternatives, our goal as you know id to work on the underlying components of the swallow that will support safe tolerance of less thickened and hopefully eventually unthickened liquids. Also is she in OT and PT? She may benefit from sensory integration and sensory motor treatment that may actually further support your progress with her.

I hope this is helpful. You are asking such good questions and she is making progress. Keep up the good work!

Problem Solving: Feeding and the parent-infant relationship

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
www.Shaker4SwallowingandFeeding.com

Problem Solving: Impact of Prematurity on Feeding

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.

Research Corner: Reflection in the NICU

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