Question: I am seeing a newborn at 38 weeks now day of life # 31 baby. Has weak suck. Is able to bring liquid into mouth but no coordination. to swallow. Most liquid pools in mouth and is spit out. Baby tires quickly. Baby has many other health issues including predominant extensor tone, cardiac, chromosomal abnormality-only 50 cases known-life expectancy is very low). I would appreciate any suggestions re: stimulation of swallow, feeding intervention.

Answer: This certainly appears to be a challenging newborn. From what you describe, there appear to be significant issues for swallowing safety and oral feeding may not be indicated right now.

Many sick infants with such a presentation actually have underlying low tone proximally. Thus the hypotonia that likely exists in the head/neck provides a poor base of support for the trachea and for the swallowing mechanism. It is likely that both the intrinsic and extrinsic tongue muscles are hypotonic. As a result not only will the suck be weak, but the swallow will be affected (decreased BOT for posterior propulsion, decreased pharyngeal compression and motility related to reduced control of the constrictors, etc.). Due to underlying low tone throughout the upper body, it is likely that there are respiratory issues that may result in increased work of breathing, that might compromise timing of the swallow-breathe sequence.

What is his actual diagnosis? What are his pharyngeal reflexes like? Often in such babies those reflexes are unreliable. Does he swallow his saliva? Sounds like it may also pool as does fluid offered. What is his state regulation like? What about work of breathing? What is the status of his airway —is there any auditory suggestion that he is not maintaining it? Not uncommon with such a postural presentation.

Given what we know, I’d suggest a swallow study. It is likely there is a delay in the initiation of the swallow, along with reduced pharyngeal motility and clearing, and the risk for silent aspiration, given what you describe, is high. This information about his swallow will be important to your intervention plan and for the discharge plan, especially since he has already been hospitalized a month.
I’d also recommend to the neo that we limit to gavage feedings only, with swallowing trials (as safety permits) by the SLP. Intervention would include a good postural base (via swaddling and positioning–well-supported side lying may help tremendously; check with OT/PT as needed), work on the intrinsic and extrinsic tongue muscles (via deep pressure input, direct and indirect tapping, direct NDT techniques to the muscle groups of the tongue to improve stability and control); the cheek/lip muscles may benefit from direct input as well, as they are likely also to be hypotonic given what we know. This is not to say that the cheeks/lips need to be active (they are not active in normal infants until 3-4 months of age) but they do provide postural stability for the tongue during young infant feeding. If the pharyngeal responses are diminished, again likely with this presentation, I have found some direct sensory-motor input can be helpful. Depending upon results/impressions from the swallow study, one might consider, after providing the sensory-motor preparation just described, offering trace amounts (single sucks at best) of fluid via a slow flow nipple, which would have been trailed in Radiology (Dr. Brown’s Premie Flow level P or Enfamil slow flow) and observe.
The other issues are of course ethical and quality of life if indeed life expectancy is limited with his diagnosis. So close collaboration with the neos and nurses, and family, regarding safety issues and impact is essential. Volume won’t be the goal if swallowing trials are initiated. He will need some form of tube feeding for his nutrition. Likely this would be an NG if life expectancy is short and prognosis overall is poor, but in some cases a PEG is placed. On-going therapy that may eventually be more monitoring or episodic, is typically provided after discharge.

Problem-Solving with Catherine
Question: Apparently our hospital has a new grant for ‘Music Therapy’. I thought it was for the Pedi cancer patients, but I see one of my NICU babies is on their list. Someone comes twice a day and has a pacifier connected to a machine that plays music when the infant sucks hard enough. Per the nurses report, the music therapist said the infant was ‘getting better’ w his sucking (stronger? longer? NNS?). This particular baby is a 48 wk., 4 month old (born at 32 weeks/twin). He is still <5 lbs. and has BPD, no endurance, reflux and an aversion to nipple feeding (GT was planned for this past Monday, but he has a UTI). I feel like this topic has been address before here, but I am just not capable of figuring out how to find it. I was wondering what the feeling is from our community – helpful and good, tiring and bad, case by case?

Also, I am not sure how pt.’s are chosen to participate in the music therapy and I only became aware of it yesterday because infants father thinks it tires baby out and “Nobody cares what (he) thinks.” I have a call out to the music therapist herself too. Any input would be appreciated! Danielle
Answer:
 Music Therapy in the NICU often includes PALS (Pacifier Assisted Lullaby) as you mentioned below, though it may include only the playing of music and singing while the infant is held by the Music Therapist.

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

My NICU clinical experience for almost 30 years suggests that PAL (Pacifier Assisted Lullaby)  is not an answer for the feeding/swallowing problems preterm infants present, and may actually inhibit functional skill (i.e., feeding). The issue for preterm infants is more complex than a “sucking problem.” Feeding problems in the NICU are rarely so simple, though sometimes a “poor suck” is unfortunately perceived as the reason for many of them. Learning to feed, both effectively and safely, is a complex, multifaceted challenge for preterm infants.1

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

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

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

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

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

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

In addition, PAL is designed to foster, and has as its outcomes, longer sucking bursts. Longer sucking bursts are problematic for the preterm. Longer sucking bursts may inadvertently, and often do,  result in respiratory decompensation, increase in  WOB and overall respiratory effort. This “drain” on the infant’s respiratory reserves can have detrimental effects on the functional skill of feeding,8 as PAL is often provided just prior to a feeding. During PALS, the focus  by the Music Therapist is only on sucking, and as a result, the infant’s communication about its effects on breathing may not be recognized or understood by the Music Therapist

.

Also, during PAL, it is likely at the preterm infant is not able to stop on his own at the appropriate junctures to take a series of deep breaths. This is directly related to immaturity, i.e. the drive to suck can inhibit the drive to breathe in the preterm, as he cannot register changes in CO2 versus O2, which can be a by-product of continuous sucking. So we often see a continuous sucking pattern with the pacifier and with PO feeding.9

While continuous sucking may sound like a hallmark of skill, in the preterm infant it can destabilize the autonomic system, lead to breath-holding or insufficient breaths, which can lead to desaturation, and potentially a cascade of events leading to decompensation.

So sucking, faster sucking or engaging in longer sucking bursts, is not necessarily good for the preterm and typically is not. Sucking can’t be looked at in isolation, as it is part of a dynamic physiologic event that has multiple system implications/effects. 10

When the focus is on sucking itself, i.e. with PAL, we are not providing the preterm with the careful support required to integrate breathing with sucking. Then sucking activities provided can actually be detrimental to motor-learning, and potentially increase stress on a physiologic level.11  This can then lay down neural pathways that, instead of facilitating positive learning, may move the infant away from learning to feed.12

While it may seem to some that enhancing sucking can be the answer for feeding issues that delay discharge, it is just not that simple. NICU infants learning to feed require dynamic, infant-guided supportive strategies during both pacifier sucking and during feeding, based on watchful vigilance and continuous feedback from the infant. The focus is on physiologic stability, active participation of the infant, and coordination of sucking with swallowing and breathing.5

This approach is more likely to promote readiness for  and eventual swallowing safety, support adequate nutrition, and result in the earlier discharges we have seen in the NICUs I have been fortunate to work in.

As you know, supporting successful feeding for preterm infants goes way beyond sucking. For those infants who indeed do have “sucking” problems, then the involvement of the SLP, who can problem-solve with reflective/critical thinking, and support the integration of sucking with breathing, in preparation for eventual PO feeding,  is more supportive and more beneficial for sensory-motor learning than a referral for PAL, in my opinion.

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

I hope this is helpful. Good critical thinking on your part!

Catherine
Catherine S. Shaker, MS/CCC-SLP, BCS-S
Board Certified Specialist – Swallowing and Swallowing Disorders
Florida Hospital for Children
Orlando, FL

www.Shaker4SwallowingandFeeding.com

Question:
Just curious, what is the practice of your acute care facility when it comes to silencing/pausing monitors? Are SLPs permitted to silence or pause the alarms in your facility? Is there a policy on this in your facility? I am interested in all populations, but particularly interested in hearing from NICU therapists.  I’ve done a lit search on this and have come up empty.
Answer: This is a complex question. As therapists in the NICU, we have the potential to cause harm, as the infant whom we are treating, by the nature of his need for intensive care, can indeed exhibit significant physiologic instability both during feeding readiness interventions and during attempts to coordinate sucking, swallowing and breathing. The neonatal nurse who is caring for/”assigned to” the infant you are treating is responsible for his medical stability. As therapists, we need to foster strong relationships with, and respect for, the bedside RN. She is your partner in care and there to both guide you, inform you, and intervene to support the infant with whom you are interacting. Your conversations with her should include how the infant has been doing, which will include his recent (~24 hour) and baseline physiologic stability and any concerns she may have about how fragile he might be, what conservative measures you might need to take during you treatment. That conversation should also include making a plan with her, should the infant show signs of impending or indeed acute instability. Be sure you know what those signs might be for that infant; if you are not sure, don’t hesitate to ask for her guidance and teaching. I learned long ago (YIKES! almost 30 years now) that asking questions or for guidance in the NICU is critical for learning about this unique environment and fragile population, as well as the complex (and ever changing!)medical information that impacts our care. We gain the respect of our neonatology and nursing colleagues by never hesitating to ask their input and guidance; if we don’t ask the questions or have the conversations we should, to build this partnership, we place the infant at undue risk, and we also risk respect that can be afforded to our profession. Each interaction with nursing prior to seeing the infant should be of the utmost importance. The nurse can clarify when to notify/call her, what objective parameters are ordered for that infant’s vital signs (HR, RR, saturations), what are the normal ranges for those parameters for him, what physiologic changes warrant her immediate notification so she can assess the infant. When the infant alarms, there is a reason; maybe it is an simple as the equipment is not picking up the signals, but most often it can reflect impending decompensation or indeed an acute event. The alarms, which “sound” often up to 15 seconds after vital signs actually have started changing, mean the infant requires immediate and accurate assessment and likely intervention. Your learning as an NICU team member and your conversation with that bedside nurse before that session should guide you. Never hesitate to ask for help when the infant alarms. Your understanding of why the infant alarmed, what to then assess, what to do, when to stop doing it and when, despite what the monitor says, the infant is not responding, are skills not quickly learned in the NICU. After all these years and so many wonderful nurses mentoring me and helping me hone my skills, many of the nurses trust me implicitly to support the infant. I still look to them to guide me, and respect their value from moment to moment, as the infant’s safety is at stake. With each and every nurse whose infant I work with on a given day, we have the conversations I described above, before I ever lay hands on that infant. The conversations reinforce our partnership, our mutual respect and regard, and offer me so many opportunities to learn and grow every day.
I hope this is helpful.

Catherine
Catherine S Shaker, MS/CCC-SLP, BRS-S

Question:

I am seeing an infant born at  38 weeks now  day of life # 31 baby. Has weak suck. Is able to bring liquid into mouth but no coordination. to swallow. Most liquid pools in mouth and is spit out. Baby tires quickly. Baby has many other health issues including predominant extensor tone, cardiac, chromosomal abnormality-only 50 cases known  -life expectancy is very low). I would appreciate any suggestions re: stimulation of swallow, feeding intervention.

Answer:

This certainly appears to be a challenging newborn. From what you describe, there appear to be significant issues for swallowing safety and oral feeding may not be indicated right now.

Many sick infants with such a presentation actually have underlying low tone proximally. Thus the hypotonia that likely exists in the head/neck provides a poor base of support for the trachea and for the swallowing mechanism.  It is likely that both the intrinsic and extrinsic tongue muscles are hypotonic. As a result not only will the suck be weak, but the swallow will be affected (decreased BOT for posterior propulsion, decreased pharyngeal compression and motility related to reduced control of the constrictors, etc.). Due to underlying low tone throughout the upper body, it is likely that there are respiratory issues that may result in increased work of breathing, that might compromise timing of the swallow-breathe sequence.

What is his actual diagnosis? What are his pharyngeal reflexes like? Often in such babies those reflexes are unreliable. Does he swallow his saliva? Sounds like it may also pool as does fluid offered. What is his state regulation like? What about work of breathing? What is the status of his airway —is there any auditory suggestion that he is not maintaining it? Not uncommon with such a postural presentation.

Given what we know, I’d suggest a swallow study. It is likely there is a delay in the initiation of the swallow, along with reduced pharyngeal motility and clearing, and the risk for silent aspiration, given what you describe, is high. This information about his swallow will be important to your intervention plan and for the discharge plan,especially since he has already been hospitalized a month.

I’d also recommend to the neo that we limit to gavage feedings only, with swallowing trials (as safety permits) by the SLP. Intervention would include a good postural base (via swaddling and positioning–well-supported sidelying may help tremendously; check with OT/PT as needed), work on the intrinsic and extrinsic tongue muscles (via deep pressure input, direct and indirect tapping, direct NDT techniques to the muscle groups of the tongue to improve stability and control); the cheek/lip muscles may benefit from direct input as well, as they are likely also to be hypotonic given what we know. This is not to say that the cheeks/lips need to be active (they are not active in normal infants  until 3-4 months of age) but they do provide postural stability for the tongue during young infant feeding. If the pharyngeal responses are diminished, again likely with this presentation, I have found some direct sensory-motor input can be helpful. Depending upon results/impressions from the swallow study, one might consider, after providing the sensory-motor preparation just described, offering  trace amounts (single sucks at best) of fluid via a slow flow nipple, which would have been trialed in Radiology (Dr. Brown’s Premie Flow level P or Enfamil slow flow) and observe.

The other issues are of course ethical and quality of life if indeed life expectancy is limited with his diagnosis. So close collaboration with the neos and nurses, and family, regarding safety issues and impact is essential. Volume won’t be the goal if swallowing trials are initiated. He will need some form of tube feeding for his nutrition.

Likely this would be an NG if life expectancy is short and prognosis overall is poor, but in some cases a PEG is placed. On-going therapy that may eventually be more monitoring or episodic, is typically provided after discharge.

Catherine