NICUMary Ewing M.A., CCC-SLP, CLC, BCS-S

Catherine Seitz M.A., CCC-SLP, BCS-S ISHA Fall Conference 2014

mjewing@bsu.educseitz1@iuhealth.org

Role of the Therapist in the NICU

ASHA statement

“Speech-Language Pathologist who practice independently in the NICU environment and provide service to infants and families are required to hold the Clinical Competence in Speech-Language Pathology and abide by the ASHA Code of Ethics (2003), including Principle of Ethics II Rule B, which stated: “individuals shall engage in only those aspects of profession that are within the scope of their competence, considering their level of education, training, and experience.”

Role of Therapist

Determined by need of NICU

Team approach to ensure successful feedings

Promote developmental care, positioning, infant massage and positive feeding

Help ensure long term developmental maturation

Provide education to hospital staff

Empower Families through education, demonstration

Babies in NICU

35 weeks gestation or less

Ill newborn

Respiratory distress

Cardiac Issues

Congenital Anomalies

Prenatal exposure to narcotics

Difficult Delivery

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Brain Development at 36 Weeks Gestation

Motor Variety resting posturesFlexor tone extremitiesReflexes present

StateWake on ownAlert for up to 30 min.

FeedingActive root1 suck, 1 swallow, several breaths (immature pattern)Mildly consistent burst-pause patternConsistent compression, but variable suctionFeeding completed in 30 min.

.Kinney HC. Semin Perinatol. 2006;30:81-88.

Intra-Uterine Development of Feeding

Sucking develops around 15 to 16 weeks gestation

Swallowing develops around 14 to 17 weeks gestation and can be observed during ultrasound at 28 to 29 weeks gestation

A fetus swallows approximately 15 oz of amniotic fluid per day The coordination of suck:swallow:breathe pattern evolves around 31 to 33 weeks and is mature around 37 to 38 weeks gestation

NewbornNewborns demonstrate a coordinated suck:swallow:breathe pattern with 1 suck, 1 swallow and 1 breath throughout the feeding

A consistent burst-pause pattern should be evident throughout the feeding

Newborns exhibit a more efficient sucking pattern that has consistent suction along with compression

Ability to exhibit feeding cues and demonstrate state regulation

A newborn should be able to complete a feeding within 20 to 25 minutes

Development of Feeding

InfantSuckling is demonstrated by an infant up until around 6 months of ageSucking begins around 6 months until weaned from bottle/breast feedingOral skills for spoon feedings develop around 6 months of ageOpen cup may be introduced around 6 months of ageStraw drinking may be introduced around 6 to 7 months of age.Finger foods may be appropriate around 8 to 9 months

Dissolvable solids introduced when infant on hands and kneesChewy solids when infant is walking

Development of Feeding

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Development of Feeding

Must consider corrected age for premature infants for initiation of each diet levelNew studies and AAP recommend waiting until 6 months to initiate solids to reduce allergies and childhood obesity

immature digestive system poor head and trunk stability for safe swallowreflexes versus volitional movements

~continued

Interventions Within NICU

Indirect/Decreased lighting

Monitoring of noise levels

Pain management

Odor neutral environment

Positioning and positioning aids

Baby Friendly which promotes breast-feeding

Developmental Care

Sensory System

Tactile

Visual

Vestibular

Olfactory

Taste

Kangaroo Care

An evidence based practice involving skin to skin contact with mother/father of baby.

Benefits include, but not limited to, increased bonding, feeding success, temperature/sleep regulation, and pain management.

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Infant MassageBenefits include improved:

Circulation, skin integrity, skin tone, weight gain, digestion, pain tolerance, and alert states for the neonatesAttachment, interaction, and communication with parentsParental understanding of infant cuesProlactin levels in mothersOxytocin levels in babies to promote growth, circulation, and decrease stress

What can complicate early feeding success?

Multiple caregivers

Prolonged use of OG/NG tubes

O2 nasal cannula

Bili lights

Suctioning and intubation

Preterm infants have to deal with a lot of sensory input.

Common reasons SLP is consulted:Difficulty coordinating breathing with eating or drinkingDifficulty sucking from a bottle and/or breastWhen stress signs are noted/observedConcern for possible aspirationRecurrent pneumonia or respiratory infectionsFeeding periods longer than 30-40 minutesSustained drooling with open mouth posturing not associated with teethingIncrease in work of breathing with feeding or breathing disruptions during feedingExcessive/consistent spitting up after feedingCraniofacial anomaliesWeak suckUnexplained food refusal or failure to accept different textures of foodFailure to thriveChoking, coughing, gagging, vomitingIf alternative feeding methods are being considered.

Dysphagia clinical evaluation

What the SLP assessesBirth HistoryOral structures/oral phase of feeding/swallowingInitiation of the pharyngeal phase of swallowRespiration/Work of breathingSensory SystemState RegulationReflexesNon-nutritive vs. Nutritive suckingStress signsGross motorRisk for aspirationDetermine safest diet levelDetermine need for VFSS

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How Feeding Works

Oral Phase

Pharyngeal Phase

Esophageal Phase

infant anatomy

Work of Breathing✦ Respiration is foremost a survival function!!!!

✦ Feeding is an infant’s aerobic exercise and physiologic work (running a marathon every time they eat)

✦ Sucking may override breathing to the point of apnea.

✦ Increased work of breathing can lead to respiratory fatigue, shutdown and excessive burning of calories resulting in weight loss

✦ Always need to consider the impact of work of breathing on child’s ability to be a successful oral feeder

✦ Increased work of breathing may delay gastric emptying resulting in reflux

✦ If an infant is not actively swallowing then the airway is open!!!

Respiratory SystemHistory and length of intubation and ventilation

History of prematurity

Post-conceptual age

Length of hospitalization

Need for oxygen

During hospitalization/after discharge

History of respiratory infections

Bronchitis

RSV

Pneumonia

Chronic upper respiratory infection

Current respiratory diagnosis or issues

Asthma

Allergies

Non-nutritive versus Nutritive sucking

Non-nutritive

2 sucks per second

Involves only the sucking component

Can be elicited in all states except deep sleep and crying

Suck:swallow:breathe ratio- at least 6 to 8 sucks prior to swallow

Not necessarily a predictor of feeding success

May increase the work of breathing and fatigue the infant prior to po feedings.

Nutritive

1 suck per second

Involves the coordination of suck:swallow:breathe

Most efficient in awake/alert state

Suck:swallow:breathe pattern 1:1:1 ratio (preterm infants demonstrate difficulty with this coordination)

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Oral Stimulation

Need to monitor stress signs during all stimulation activities to maintain positive experienceHands to faceOral exploration of hands and/or pacifierPositive touch when oral gastric (OG), nasal gastric (NG) tube or oral ventilator tube presentTactile stimulation to cheeks and lips

sustained touch/pressurestroking/movement

PositioningMaintain postural control

Hands midline Swaddle

Left/Right sidelying versus uprightHead elevated above hips

angle of elevation dependent on nasal regurgitation

Air way stability ear, shoulder, hip in straight lineconsider laryngo/tracheomalacia

Transition to supine/upright as appropriate2 to 4 months in preparation for anatomical changes and spoon

PacingWhy pace?

Teaches the infant an organized pattern for safe feedingAllows infant to coordinate breathing during nutritive sucking

How to pace?To teach coordinated suck:swallow:breathe

Pre-term: 3 sucks then tip nipple downward for 3 second break for breathing for first 1 to 2 minutes of feeding or until infant begins to self paceTerm: 5-10 suck:swallow:breathe patterns then tip nipple downward to allow for catch-up breathingBaby will show signs of when to resume feeding!!!

Cervical auscultationUse as a clinical tool to help determine S:S:B in infants and trigger of swallow in all age groups

Swallowing is lower frequency and respiration is high frequency

Use bell side of stethoscope to laryngeal area for swallow and diaphragm side for respirations

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Videofluoroscopy Swallow Study

View anatomical structures during dynamic swallow

Determine severity of penetration/aspiration episodes and/or rule out silent aspiration

Effectiveness of therapeutic/compensatory strategies

Make suggestions/recommendations for direction of skilled therapy

When appropriate establish goals

Provide thorough description of swallow deficits to aid in safe progression of diet in treatment

VFSS Clips

Work of BreathingNasal Regurgitation

VFSS Clips

Aspiration Thickened Liquids

Difficulty with Breast/Bottle Feeding

What to look for:

Increased feeding time (longer than 20-30 minutes)

Anterior loss

Noisy feedings

Demonstrates 2 or more stress signs

Increased work of breathing

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Breast and Bottle Feeding

Infant is able to control the rate of milkMultiple streams which coat oral cavityMore stability for tongue and jawInfant able to pace betterBetter body positionMother may need to pump until let down occursSuck:Swallow:Breathe coordination for breast feeding is earlier than for bottle feeding

Breastfeeding Bottle FeedingInfant unable to control the rate of milkSteady stream from single hole nipple directed at posterior pharyngeal wallLess stability for tongue and jawMore difficulty self-pacingMore difficulty to positionNot nipple confusion but flow confusionStudies indicate increased obesity linked to bottle fed infants

BMH Feeding ProtocolPre-oral stage

NPO/NG feeding only

Non-Nutritive Suckling Stage

NPO/NG feedings only

Nutritive Sucking Stage I (critical stage)

Minimal oral intake <10%

Nutritive Sucking Stage II

Mod. Oral intake > 10% to <80% 9Oral/NG)

Nutritive Sucking Stage III

Full oral intake >80% oral/24hours

Feeding Readiness Scale

Use in overall evaluation to initiate oral feedings (1, 2 good)

Used with each individualized assessment

Used with cue based feeding practices

Assess & document feedings

Evaluate infant behavior: maturity, stability, interest in feeding

Implementation per “Oral Feeding Pathway”

Consistent scores of 4 or 5 referral to SLP

Quality of Nippling ScaleFocuses on safe feedings

Encourages observation of infant’s feeding behavior

Documentation of behavior

Assist caregiver in necessary techniques needed for oral feeding

Evaluates fatigue, coordination, swallow, etc.

Consistent scores of 4 or 5 referral to SLP

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Initial/Early Stress Signs

Occur prior to feeding or early in feeding

Are subtle and may be easily missed

May occur due to difficulties with reflexes, state regulation, sensory information, respiration and/or coordination/abnormalities of oral structures

Infant is telling us “this does not feel good”

Tongue thrust

Tongue elevated to alveolar ridge

Lip pursing

Finger splaying

Furrowed brow

Raised eye brows

Eye blinking

Moderate Feeding Stress Signs

Occur when infant is pushed through a negative feeding experience

The body begins to react to the negative event

May occur due to difficulty with bolus flow rate, respiration, oral motor skills and/or coordination of suck:swallow:breathe

Infant is telling us that the airway is compromised

Squirming

Head turning

Averting eye gaze

Falling asleep

Increased hypertonicity/hypotonicity

Jaw/limb trembling

Gasping

Straining/bearing down/bowel movement

Sweating

Major Feeding Stress Signs

Occur when infant is no longer able to maintain adequate airway protection

May occur in attempt to prevent aspiration or following an aspiration or penetration event

Coughing

Choking

Congestion during and/or after feeding

Wet breathing

Wet/gurgly vocal quality

Things to ConsiderFat from breastmilk and formula provide energy for continued brain growth and cognitive development

Between 3 to 6 months of age children may begin to refuse to eat or demonstrate more difficulties

Around 6 months of age the nervous system matures and the sucking reflex fades. Feeding then becomes a volitional act

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Bottles/Nipples

Wide base/narrow base

Tip to phlange

Material

Levels/flow

standard, slit, y-cut, cross cut

Venting system

Flow rateNot all slow flow nipples are created equal

Each manufacturer has their own rating and can not be compared with other brands. A slow flow in one brand may be equivalent to a medium in another brand.Turn bottle upside down and watch the size and rate of drip.Utilize cervical auscultation during feedings

Flow rate of common nipple

Nipple Brand

Dr. Brown preemie

Dr. Brown level 1

Enfamil green

TommeeTippee

Enfamil blue

Ross yellow

Ross red

Avent #1

Medela Breast

cc per 60 sec

7.3

7.7

8.8

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12.3

13.5

15.3

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16.3Kelli Tracy Jackman, MPT

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Why we like Dr. BrownPros

Laser cutShape and material promotes appropriate latchVariety of levels

Ultra-PreemiePreemieLevel 1-4Y cut

Able to use with multiple populationsAble to use with multiple thickening methodsOther hospitals using Dr. Brown bottles?

ConsMultiple partsCost/price?

Consistency

Ultra-thinThin1/2 nectarThin-nectarNectarThin-honeyHoney

Thickening?Any patient on thickened liquids for swallowing difficulties needs to be followed by their physician and a certified feeding therapist

Consider when infant on increased calorie formula with added scoops and the impact of thickening on digestive process including kidneys

Consider type of bottle/nipple for thickened liquids that continue to promote age appropriate oral motor skills

standard versus cross cut

Why complete VFSS/MBS

Is thicker always better?

Type of thickeners

applesauce, yogurt, pudding, rice, oatmeal, Thik and Clear, Simply Thick

Types of ThickenersStarch based

Rice cereal--no age restriction

Thick-it--37 week gestation or older with need to be followed by a physician

Thicken up/Thicken up clear--3 years or older

Gum based

Thik n Clear--currently no age restriction

Simply Thick--12 months or older and 12 years with a history NEC

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Thickened Liquids

Rice/oatmeal

Pros

Cost

Ease of purchase

Cons

Does not thicken breastmilk because of the amylase

Does not maintain consistency throughout feeding

Constipation (which can cause or worsen reflux)

Obesity versus growth

Thickens differently dependent on brand and method

Thickened Liquids

Thik and Clear

Pros

Prepackaged for easy measuring

Used by many children’s hospitals around the country

Mixes with variety of liquids including breastmilk

Cons

No research

Can clump during mixing

May cause increased gas in GI system

Thickened LiquidsSimply Thick

Pro

Maintains consistency

Mixes easily

Has more research within pediatric realm

Cons

FDA warning for use in premature infants and more recently in infants

May cause increased gas in GI tract

Gastrointestinal DevelopmentDevelopment

Develops based on input

GI system provides sensory feedback

Food acceptance, feeding schedules, amounts consumed are adjusted in response to this feedback

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Normal Reflux–Infants and Children50% of 0-3 month olds regurgitate 2 or more times per day

70% of 4-6 month olds

25% of 7-9 month olds

Less than 10% of 10-12 month olds Archives of Pediatric and Adolescent Medicine, 1997

~continuedGastrointestinal

Successful FeedingVolume vs. Experience

When an infant is learning to oral feed, the experience is more important than the volume of P.O. intake

Perfect practice makes perfect

Feeding is a developmental skill.

Slow and Steady WINS the race.

Evidence Based Feeding Goals for Discharge

Preterm Infants demonstrate competent oral feeding skills prior to hospital discharge

Infant driven model (cue based)

Feedings are safe,functional, nurturing, individualized and developmentally appropriate

PO all prescribed volume in 15 to 20 min

Maintain steady weight gain

Precise coordination of S:S:B maintaining physiologic stability

Parents comfortable and ready

Appropriate follow-up with SLP if warranted

Improved communication between providers

When to refer for outpatient feeding evaluation

Difficulty with or late initiation of oral feeding Inability for child to breastfeedPoor transition to bottle feedings from breast feedingDifficulty transitioning to spoon feedingsAny use of thickened liquidsFood preferences or avoidance

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Things to consider during treatment after NICU

Birth Trauma-nerve damage, neurological damageHeart defects-can affect respiration and stamina Premature lungs- asthma, respiratory infections, respiratory diseasePrenatal exposure-withdrawalWeight and growth-growth chart percentiles, FTTSleep habits-snoring, frequent wakingVoiding-frequencyReflux-amount, frequencyRespiratory system-has a significant impact on feeding for all ages

Question Time????

?References

Breton. S, & Steinwedner, S. (2008). Timing Introduction and Transition to Oral Feeding in Preterm Infants: Current Trends & Practice. Newborn & Infant Nursing Reviews, vol. 8 (3); pp. 153-158.

California Perinatal Quality Care Collaborative (2008)> Quality Improvement Toolkit.

Chang, Y., Chun-Ping, L., Lin, Y. et al. (2007). Effects of Single-Hole and Cross-Cut Nipple Unit on Feeding Efficiency and Physiological Parameters in Premature Infants. Journal of Nursing Research. vol. 15 (3); pp. 215-222.

Kenner, C., & McGrath, J. (2010). Oral Feeding and the High Risk Infant. Developmental Care of Newborns and Infants. A Guide for Health Professionals. 2nd ed.

http://nurse211w08researchfinal.blogspot.com/2008/02/roughly-12.html

http://specialneedspublications.blogspot.com/2009/07/supportingfeeding-oral.development-in.html

Ettema, Sandra, MD, PhD, CCC/SLP, Cheri Franker, MS, CCC/SLP, CLC, Laura Walbert, MS, CCC/SLP, CLC. “Pre-Chaining Programs for Infants & Children with Swallowing Disorders: Much to DO about Pediatric Dysphagia.” Indianapolis, IN. November 4&5, 2011. Conference.

ReferencesDodrill, P., McMahon, S., Ward, E., Weir, K., Donovan, T., and Riddle, B. (2004). Long-term oral sensitivity and feeding sills of low risk pre-term infants. Early Human Development, vol. 76; pp. 23-37.

Down Syndrome Ireland. Supporting Feeding & Oral Development in Young Children: Guidelines for Parents, Support Feeding & Oral Development in young children with Down Syndrome, Congenital Heart Disease and Feeding difficulties. 2009. PDF <http://specialneedspublications.blogspot.com/2009/07/supporting-feeding-oral-development-in.html>

Drenckpohl, D., MS, RD, CNSC, LDN. (2010). On Thin Rice: A therapeutic option with nutritionconsequences. Therapy Times.com .HTTP//www.threapytimes.com/0503NutF1

Fishbein, Mark, MD, Cheri Franker, MS, CCC/SLP, CLC, Laura Walbert, MS, CCC/SLP, CLC. “Food Chaining II: It Takes A Team-Dealing with Digestive Tract Disorders.” St. Louis, MO. December 2&3, 2011. Conference.

Fucile, S., Gisel, E., & Lau, C. (2002). Oral stimulation accelerates the transition from tube to oral feeding in preterm infants. The Journal of Pediatrics, vol. 141 (2); pp. 230-236.

Garcia, J., Chambers. E., Matta, Z., Clark, M. (2008). Serving Temperature Viscosity Measurements ofNectar- and Honey-Thick Liquids. Dysphagia 23; pp.p65-75.

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Referenceshealthychildren.org. American Academy of Pediatrics, 2/27/2012. Web. 4/25/2012. <http://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Switching-To-Solid-Foods.aspx>

Jackman, K.T., (2013). “Go with the Flow: Choosing a Feeding System for Infants in the Neonatal Intensive Care Unit and Beyond Based on Flow Performance” http://www.drbrownsbaby.com/medical/articles/go-flow

Ludwig, S. & Waitzman, K. (2007). Changing Feeding Documentation to Reflect Infant-Driven Feeding Practice. Newborn & Infant Nursing Review, vol. 7 (3); pp. 150-160.

McCain, G. (2003). An Evidence-Based Guideline for Introducing Oral Feeding to Healthy Preterm Infants. Neonatal Network, vol. 22 (5); pp. 45-50.

McKaig, T. Neil. “Cervical Auscultation.” Indianapolis, IN. March 31, 2011. Indiana Speech-Language Hearing Association Conference.

Quenqua, D. The New York Times, 3/25/2013. Web. 3/26/2013. Infants are Fed Solid Food Too Soon, C.D.C Finds. http://www.nytimes.com/2013/03/25/health/many-babies-fed-solid-food-too-soon-cdc-finds.html?_r=0

ReferencesShaker, Catherine, M.S. CCC-SLP. “Pediatric Swallowing and Feeding.” Lexington, KY. July 11-13, 2003. Conference.

Shaker, Catherine. “Advanced Pediatric Dysphagia.” Indianapolis, IN. July 17, 2005. Conference.

Scottland, J. (2004). The Regional Neonatal Oral Feeding Protocol. http://www.calgaryhealthregion.ca/

Shaker, C., & Woida, A. (2007). An Evidence-Based Approach to Nipple Feeding in a Level III NICU: Nurse Autonomy. Developmental Care and Teamwork. Neonatal Network, vol. 26 (2); pp 77-83.

VanDahm, K., Kern, S., Rosoff, J. (2009). The Use of Thickening Agents in the NICU. ICAN: Infant, Child, &Adolescent Nutrition, vol. 1 (2); pp 83-87

Wolf, Lynn, MOT, OTR, IBCLC and Robin Glass, MS, OTR, IBCLC. “Feeding and Swallowing Disorders in Infancy: Assessment and Management. “ Indianapolis, IN. November 12-13, 2010. Conference.

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