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

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

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

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.

Catherine