NICU and Infant Feeding Assessment and Treatment Flashcards
1
Q
SLPs role in the NICU
A
- focus on entire role not just heavy focus on dysphagia and feeding
- how is the SLP part of the interdisciplinary team?
- overview of the factors specific to the NICU setting that SLPs should understand
2
Q
the NICU
A
ICU for neonates, including premature infants
3
Q
extremely preterm
A
born before 25 weeks
4
Q
very preterm
A
born 25-32 weeks
5
Q
moderately preterm
A
born 32-34 weeks
6
Q
late preterm
A
born 34-36 weeks
7
Q
assessment in the NICU: want to know
A
- born early? if yes, how many weeks? need to know how that affects the infant (earlier born, higher risk of comorbidities and respiratory complications)
- what development processes occurred outside of the womb that for a typical pregnancy would’ve occurred within the womb
8
Q
classification by birth weight
A
if they are bigger, that is typically good for being preterm
9
Q
extremely low birth weight (ELBW)
A
less than 1,000 grams
10
Q
very low birth weight (VLBW)
A
less than 1,500 grams
11
Q
low birth weight (LBW)
A
less than 2,500 grams
12
Q
small gestational age (SGA)
A
for their gestational age, less than 10th percentile of their weight
13
Q
large gestational age (LGA)
A
for their gestational age, more than 90th percentile of their weight
14
Q
preterm infants are more at risk for
A
- motor impairment
- sensory impairment
- cognitive deficits
- behavioral/mental health disorders
15
Q
NICU-specialized area of practice: NANT and ASHA endorse that NICU is a specialized area of practice that requires knowledge, skills, and training specific to the neonatal population
A
- embryo, brain, feeding/swallowing, motor development
- know typical patterns for premature neonate versus atypical patterns
- look at the whole baby
- neuroprotection
- parents and the baby are key to effective neonatal therapy
- culture shift
16
Q
ASHA knowledge and skills for SLPs in the NICU: knowledge required
A
- normal embryology, perinatal, and postnatal infant development
- understanding of current research in neurobiology, physiology, and genetics as they relate to infant behavior
- atypical infant development which includes theories and research findings, risk factors in prenatal and perinatal development, etiologies, and medical conditions
- family-centered practices including the impact of the NICU experience on family dynamics and function, information about family systems, parent-infant interactions, parent empowerment, and meaningful professional alliances
- team-based processes that involve ethical decision-making, interactions with multiple disciplines, and legal issues
17
Q
ASHA knowledge and skills for SLPs in the NICU: specialized knowledge is also needed in the following areas
A
- foundations of developmentally supportive care (e.g. synactive theory, behavioral state organization)
- medical complications affecting infants as well as the medical equipment and procedures used in the NICU
- staffing patterns in the NICU
- ecology of the NICU
- parenting in the NICU
18
Q
neonatal therapist
A
OT, PT, or SLP who provides direct patient care and/ore consultative services for the premature and/or medically complex infants in a NICU
19
Q
neonatal therapy strives to maximize developmental outcomes, support infant mental health, and facilitate family interaction
A
- this specialized field of therapy therefore contributes to the optimization of each infant’s development at the earliest point in the lifespan
- focus is on neuroprotective care, preventing negative developmental outcome, minimize impact of NICU on development
- normalization, minimization, prevention
20
Q
SLPs in neonatal therapy
A
- specialists in infant communication
- crucial in all infant driven interventions
21
Q
SLPs in neonatal therapy: can be part of the care team during heel sticks/procedures, baths in the NICU serving as the role of the minimizing negative impact and serving as communication specialists
A
see infant stress cues –> respond to help them cope and provide support and positive interactions to support positive touch/experiences and enhance
22
Q
SLPs in neonatal therapy: goals of interaction are…
A
- normalize development
- conserve energy
- facilitate organization
- recognize stressors
- encourage self-consoling
23
Q
NICU team: primary team
A
- neonatologistas
- APRN, physician assistant
- nurse
- respiratory therapist
- PT, OT, SLP
- music therapist
- child life specialist
- radiologist technologist
- nutritionist
- social worker
24
Q
NICU team: special consultants
A
- otolaryngologists
- audiologists
- pulmonologists
- neurologists
- neonatal surgeons
- cardiologists
- gastroenterologists
- developmental pediatricians
- and much much more…
25
interprofessional practice (IPP)
- occurs when multiple service providers from different professional backgrounds provide comprehensive healthcare or educational services by working with individuals and their families, caregivers, and communities to deliver the highest quality of care across settings
- set up for success in the NICU but also when discharged, next steps!
26
neuroprotective care goal of neonatal therapy: definition
strategies capable of preventing neuronal cell death, result of apnea or hypoxia which occurs with increased frequency in the NICU
27
neuroprotective care goal of neonatal therapy
- interventions used to support the developing brain or to facilitate the brain after a neuronal injury in a way that decreases neuronal cell death and allows it to heal through developing new connections and pathways for functionality
- assists in integration of input in an adaptive, positive manner
28
neuroprotective care goal of neonatal therapy: family integrated, developmentally supportive care
- healing environment that manages stress and pain
- offers a calm and soothing approach with involvement of the entire family
- improves health outcomes, lengths of stay, and decrease cost associated
29
protective/preventative vs. reactive intervention
- goal of NICU interventions is protective
- consults before problems arrive vs. problem-based consult
- preventative medicine vs. waiting for a problem to arise
- neuroprotective care purpose of therapy in the NICU
- much of how the infant responds is nonverbal communication and we are experts in that!
- much of what we do is based on counseling
30
why neuroprotective care?
- most infants admitted to NICU here, look how much brain growth is left!
- end of neuronal migration, 3rd stage of CNS development
- proliferation exceptional neuronal growth, interrupted in NICU
31
neonatal sensory development: tactile
- 7-18 weeks
- heel sticks, IV
32
neonatal sensory development: vestibular
- 14-16 weeks
- movement during cares
33
neonatal sensory development: olfactory gustatory
- 12-14 weeks
- chemicals, emesis
34
neonatal sensory development: auditory
- 18-35 weeks
- alarms, CPAP oscillatory
35
neonatal sensory development: visual
- 38 weeks-term
- lights, phototherapy
36
infant communication, synactive theory of development
how to understand infant's behavior as communication (infant's body system is constantly interacting with its environment)
37
interdependence of systems
- autonomic
- motor
- state
38
autonomic system: signs and symptoms of stability
- color: pink over the entire body
- respiratory pattern/breathing: regular, 40-60 breaths/minute
-visceral signs: stable digestion with appropriate burping, regular elimination of abdominal wastes
39
autonomic system: signs and symptoms of stress
- color: pale, red, dusky, or mottled color changes on part or whole body
- respiratory pattern/breathing: uneven intervals, > 60 or < 40 breaths/minute, pauses > or equal to 2 seconds, gasps, yawns, coughs
- visceral signs: regurgitation, hiccups, gagging, excessive drooling, diarrhea, gases
40
motor system: signs and symptoms of stability
- tone and posture: arms, legs, and body well rounded and softly flexed
- movement: smooth movements of arms, trunk, and face
- self-regulatory behaviors: holding hands to face, mouthing/sucking on hands, adjusting posture
41
motor system: signs and symptoms of stress
- tone and posture: flat limbs, face, or body, extended limbs or fingers, arching of the neck or back, excessive tucking of body
- movement: movements jerky, frantic flailing movements, repetitive behaviors that interrupt organization and stability
- self-regulatory behaviors: not successful at all
42
state system: signs and symptoms of stability
- sleep or fully awake is clearly defined
- smooth transition
- appropriate state for the situation
- stable, predictable cycles (e.g. schedule)
- control and not overwhelmed by stimuli
43
state system: signs and symptoms of stress
- states not easily defined
- rapid changes
- inappropriate of state to time
- unpredictable cycles
- overwhelmed by stimuli
44
additional stress cues: autonomic signs of stress
- color changes (pallor, flushing/turning red, and cyanosis/turning blue)
- changes in vital signs (heart rate, respiratory rate, blood pressure/BP, pulse ox rate)
- visceral (vomiting, gagging, hiccups, passing gas)
- sneezing
- yawning
45
additional stress cues: motor signs of stress
- generalized hypotonia (limp, decreased resistance to moving of the infant's extremities)
- frantic flailing movements
- finger splaying (holding fingers spread wide apart)
- hyperextension of extremities (arms or legs extended straight out almost in a locked position)
46
additional stress cues: state signs of stress
- diffuse sleep states (lots of twitching, grimacing, not resting peacefully)
- glassy-eyed (appears to be "tuning out")
- gaze aversion (cuts eyes to the side trying not to look at what is in front of them)
- staring (a locked gaze, usually wide-open eyes)
- panicked look
- irritability (hard to console)
47
additional stress cues: attention/interaction signs of stress
- infant will demonstrate stress signals of the autonomic, motor, and state systems
- inability to integrate with other sensory input (can't look and face, listen to talking and suck a bottle at the same time)
48
additional stress cues: self-regulatory behaviors
attempts to deal with stress and regain control
- change in position
- hand-to-mouth
- grasping
- sucking
- visual locking
- hand clasping
49
in NICU sleep =
growth and development
50
newborn states and caregiver considerations
1. deep/quiet or non-REM sleep
2. light/active or REM sleep
3. drowsiness
4. quiet alert
5. active alert
6. crying
51
deep/quiet or non-REM sleep: baby's behavior
- no movement, only occasional jerks
- eyes closed, no eye movements
- startles with delay, suppresses quickly
- regular breathing
- lowest oxygen consumption
- low resting HR in some term infants
52
deep/quiet or non-REM sleep: caregiver considerations
- difficult or impossible to arouse
- no interest in feeding at this time
- not receptive to social interaction
53
light/active or REM sleep: baby's behavior
- random movements and startles
- eyes closed, rapid eye movements
- irregular respirations
- higher oxygen consumption
54
light/active or REM sleep: caregiver considerations
- term infants start and finish sleep cycles in active sleep
- preterms react more to stimuli at this time than term infants
- may fuss briefly, and be awakened before truly awake and ready to eat
- lower, more variable O2 saturations
55
drowsiness: baby's behavior
- eyes open (dazed) or closed
- respirations more rapid and shallow
- intermittent startless
- slow response to sensory stimulation
- smooth state change after stimulation
56
drowsiness: caregiver considerations
- may awake further or may return to sleep (if left alone)
- talking quietly to infant may arouse infant to a quiet alert state
57
quiet alert: baby's behavior
- eyes open wide, face is bright
- focused attention
- body is quiet with minimal movement
58
quiet alert: caregiver considerations
- best state for learning because infant focuses all attention on visual, auditory, tactile, or sucking stimuli
- best for interaction with peers
59
active alert: baby's behavior
- eyes open and alert
- actively moving extremities
- reactive to external stimuli
- irregular respirations
- may or may not be fussy
60
active alert: caregiver considerations
- infant has increased sensitivity to internal (hungry, tired) and external (wet, handling, noise) stimuli
- unable to fully attend to caregiver or environment because of increased sensitivity and motor activity
61
crying: baby's behavior
- cries, possibly intense
- may be difficult to console
- respirations rapid, shallow, irregular
62
crying: caregiver considerations
- indicates that individual tolerance limits have been met or exceeded
- not receptive to learning
63
neonatal integrative developmental care model: 6 lotus flower petals
1. partnering with families
2. positioning and handling
3. safeguarding sleep
4. minimizing stress and pain
5. protecting skin
6. optimizing nutrition
64
neonatal integrative developmental care model
outlines what NICU care teams focus on not just medical outcomes or feeding
65
neonatal integrative developmental care model: what are our services aimed to support?
- all tied to reduced negative effects of stay
- neurological protection
- developmental skill development along expected continuum
66
healing environment
- infants have improved outcomes when environmental stress caused by overstimulation is reduced
- focus on family presence/reunification (positive family experiences)
- limit extraneous sound, light, smell
- single room set up but not isolation
67
healing environment: cycled lighting
- on day/off night
- eye covers vs. room light
- improved weight gain, shorter stay, increased O2
- decreased ROP, better growth
68
healing environment: sound reduction
- the sound levels in NICUs range from 7 dB to 120 dB, often exceeding the maximum acceptable level of 45 dB, recommended by the American Academy of Pediatrics
- HL increased in premature infants: 2%-10%
- quiet time (lights + noise reduction)
- decrease alarm volumes
- floors to absorb sounds
- isolettes/incubators to filter noise
- rubber wheeled carts
- cluster care
69
healing environment: smell/taste
- oral colostrum care
- limit procedural smell
- cloth/hearts with smell of parents in isolette with infant (STS)
- limit adult smell (lotions, aftershave, etc.)
70
oral colostrum care
- taste of mom, improved immune response, positive early oral experiences
- best oral care intervention
71
supporting families
- essential to optimize developmental outcomes
- trauma-informed care
- give shared attention to the infant, parent, and early developing attachment relationships
- reunification and zero separation are ultimate goal
72
supporting families: trauma-informed care
- NICU is traumatic, psychosocial support for the parents
- infants experience a number of threats, activate fight or flight, disrupted establishment of nurturing and secure parental relationships (altered relationships/social interactions of infant/caregivers)
- early family stress can impact a child's behavior long term
73
supporting families: reunification and zero separation are ultimate goal
- secure attachment, emotional connections
- STS/Kangaroo care improves maternal responsiveness and infant attachment, improved development outcomes/brain development
- limited quality or quantity of parent care results in negative changes in brain structure and function
74
proper positioning
- neutral head position
- rounded shoulders
- hips and knees flexed
- toes pointed straight
- hands to mouth
- boundaries provided appropriately (mimic the fetal position in utero)
- eyes, knees, and toes in all same direction
75
proper handling
- infants can feel effects of their vestibular movement when quickly turned
- quick turning, known as a "preemie flip", has been said to cause disorganization in an infant's system modulation for up to 20 minutes
- smooth, slow modulated movement light touch or gentle stroking can seem over-stimulating and irritating (gentle but firm "static containment" such as "quiet hands" or "hand hugs")
76
positive touch
- STS/Kangaroo care
- hand hugs
- infant massage
77
STS/Kangaroo care
- more intent gave and developmental outcomes for infant
- better mood for parents
- infants receiving kangaroo care looked more intently at a stimulus with less gaze aversion (46-48) and demonstrated better mental development at 6, 12, and 24 months as well as better cognitive development at 5 and 10 years
- 47 parents who participated in kangaroo care demonstrated fewer depressive symptoms and a better mood
- some decreases in measures of stress, better mother--infant interaction and better maternal self-esteem
78
negative touch/procedural touch results in
- hypoxia
- bradycardia
- sleep disruptions
- increased intracranial pressure (ICP)
- repeated episodes of hypoxia and increased ICP may place preterm infants at increased risk of complications such as intraventricular hemorrhage (IVH) and subsequent neurodevelopmental delays (oral aversion, SPD later)
79
protect sleep because sleep =
brain development in the NICU
80
protect sleep: quiet (deep sleep)
energy restoration, bodily homeostasis
81
protect sleep: active (light sleep)
sensory input processing, memory encoding, and learning
82
protect sleep: at 28 weeks you get emergence of sleep patterns of REM and NREM (active and quiet sleep)
- the cycle between sleep states is important for neurosensory development, learning, and memory and preservation of brain plasticity (ability to change its structure and function in response to environmental changes)
- less plasticity --> smaller brains, altered learning, long term effects on behavior and brain function
83
cortical production increased in children with VLBW infants (associated with pain): results in
- decreases synapses and affects attachment
- increased arousal puts infant on high trigger alert
- may lead to long term hyperactivity, anxiety, and impulsive behavior
- later problems with attention regulation and self-control
84
2 person care help mitigate pain/stress, help infant cope
- help support families to know how to calm/soothe infant during unpleasant interventions and "read" cues
85
optimizing nutrition
- not just oral feeding, but also tube feeding consider NNS during tube feeding, oral colostrum care, preventative feeding interventions
- supporting practices that facilitate infant driven and responsive feeding practices
86
EBM is what is best tolerated by tube feeding
- decreased NEC, sepsis, and ROP
- LT: EBM in NICU --> deeper grey matter brain volume, better IQ, and better neurodevelopmental outcomes
87
infant drive feeding
- responsive feeding by SLP/family members/all members of team
- use practices that address feeding readiness and family support
- physiological and behavioral cues are the NICU infants communication, be responsive!
88
oral feeding: success is if the infant...
- has had the opportunity for positive feeding experience
- looks comfortable throughout the feeding with minimal signs of distress
- maintains an oxygen saturation near pre-feeding level throughout the feeding and quickly recovers to baseline after feeding
- finishes the feeding with midline flexed body posturing (overall stability during feeding)
89
nutrition considerations in the NICU
- not just oral feeding
- can work on pre-feeding/readiness and this usually occurs during tube feedings (non-nutritive sucking)
- cue based (rooted in communication)
- feeding/dysphagia is just a piece of the larger puzzle of SLPs in the NICU
- it's all inter-related
90
nutrition considerations in the NICU: resources for assessment
- NOMAS (requires training)
- EFS
- Brite Pados- Infant Feeding Care resources and go with the flow article
- SOFFI
91
primary goal for swallowing
- bolus efficiency
- the tongue provides the initial positive driving force, as its posterior deflection provides the basis for laryngeal elevation by applying traction to the hyoid bone
- stasis or residue occurs when a negative zone is now a high pressure zone, which could be related to acute illness, mechanical, or progressive neurological disease
- airway protection
92
bolus efficiency definition
moving the bolus into the esophagus in a timely manner without residue, effort, pain, or repeats swallow
93
bolus efficiency: more info
- efficient bolus movement is accomplished when coordinated neuromuscular contractions and relaxations create zones of high pressure below the level of the bolus
- this creation of high and negative pressure zones is created by timing/coordination of the lips, velum, laryngeal vestibule closure, and the upper esophageal sphincter
94
the tongue provides the initial positive driving force, as its posterior deflection provides the basis for laryngeal elevation by applying traction to the hyoid bone
laryngeal elevation helps create a negative zone of the pressure in the pharynx which allows the bolus to move fast and safely
95
airway protection
preventing bolus from entering the larynx or trachea
96
primary goal for feeding
mother-baby dyad, brain, growth, learn and sense experiences
97
when experiences are prolonged or missed due to a medical co-morbidity, there are...
sensory and motoric skills that can be learned incorrectly, promoting negative relationships to food, including all the senses (seeing food, smelling [olfactory], feeling, and tasting)
- this is how a pediatric feeding disorder is born
98
pediatric feeding disorder (PFD)
impaired oral intake that is not age-appropriate and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction
99
for infants and children with PFDs...
every bite of food can be painful, scary, or impossible, potentially impeding nutrition, development, growth, and overall well-being
100
feeding skill factors
- oral sensory functioning
- oral motor functioning
- pharyngeal and function
- pharyngeal sensation
- skilled-based dysfunction
101
feeding skill factors: oral sensory functioning
- limits/inhibits acceptance of a variety of foods acceptance and tolerance of different textures (liquids/solids) that are expected for the child's developmental age
- temperature, texture, taste, bolus size/amount, sight, smell, touch (how it feels on their hands)
102
feeding skill factors: oral motor functioning
bolus control, bolus manipulation, which could appear to the person as sloppy eating, messy, slow oral feeder, extended period of time to complete meals
103
feeding skill factors: pharyngeal anatomy and function
- have to look to know what is going on, and must get imaging (FEED, VFSS); do not thicken blindly
- have to see anatomy to diagnose structural differences, imaging is not pass/fail, tells us physiology and structure and gives us information about compensatory strategies and impact on swallow physiology
104
feeding skill factors: pharyngeal sensation
- normal to silently aspirate in infants/premies have to interpret and infer pharyngeal sensation based on the physiological functions you observe particularly in a VFSS study or FEES (a bit more direct assessment in a FEES, but still cannot untangle the interplay of sensorimotor loop)
- consideration of the entire system, timing coordination strength, in the context of normal swallowing, which admittedly is poorly understood and not well defined in pediatrics due to lack of high level evidence
105
feeding skill factors: skilled-based dysfunction
- unsafe oral feeding
- delayed feeding skills
- inefficient oral feeding
106
unsafe oral feeding
clinical s/s of aspiration, "As and Bs", gagging, vomiting
107
delayed feeding skills
does not accept or consume foods that are considered age appropriate, do they need adaptive feeding equipment
108
inefficient oral feeding
duration of meal times over 30 minutes, extensive coaxing to be an efficient oral feeder, do they need adaptive feeding equipment
109
psychosocial factors: developmental
- delays in motor skills, language socialization, or cognition may impact
- think postural stability or self feeding
- we know there is an increase in prevalence with those with ID/DD
- mismatch of parent expectation and child ability (want child to consume a texture they cannot chew for example) may contribute to aversive experiences (reinforcement of negative feelings towards feeding), think ability level, not CA
110
psychosocial factors: mental and behavioral health
- child, caregiver, or the dyad can influence feeding
- social emotional dysregulation
- caregiver stress (high degree or caregivers of children with PFDs)
- mental health status of caregivers can influence mealtime interactions
- over or under control of mealtime experience
- have to consider things like Ellyn Sater division of responsibility, responsive feeding practices, rapport, relationship, trust, and impact on feeding experiences
111
psychosocial factors: social influences
- caregiver-child interactions
- cultural responsiveness and competence by the SLP
- ex: general behavior management (time out punishment) may not be a good match for mealtime management
112
psychosocial factors: environmental
- distracting environment (TV electronics)
- sleep feeding/drowsy feeding
- impacts social relationship, may be well meaning but negatively reinforce mealtime behaviors that did not promote success
- schedules that are inconsistent impact hunger, or constant grazing
- availability of food resources impact variety and amount offered, can impact ability to explore new food
113
psychosocial factors: grazing
- false sense of fullness, reduces intake
- disruptive behavior
114
psychosocial factors: grazing, disruptive behavior
refusing to self feed, learned feeling aversions due to reinforcement of udx medical etiologies or punishment associated with meals
115
all behavior is communication...
just have to explore why
116
intake
improve weight gain --> need RD to determine what foods to target and how to enhance caloric value to what they eat
117
intake: what is the end goal?
- safety
- oral motor/sensory development
- developmental skills necessary for intake
- thrive and stay alive! nutritional for growth!
118
airway safety (safety at all costs)
- prolonged intubation due to prematurity or medical co-morbidities such as CHD
- upper airway differences
119
upper airway differences
vocal cord paresis, intubation trauma, subglottic stenosis, laryngomalacia
120
how can we compensate in the NICU for airway safety impairments?
- preventive lens
- compensatory lens
- habilitation lens
121
preventive lens
NPO, non-nutritive stimulation only, milk drops
122
compensatory lens
positioning to maximize airway protection, left side down for right VC paresis, flow rate, pacing
123
habilitation lens
- supporting parents/caregivers to habilitate normal development
- thus when we are treating from a rehabilitative lens, we should never touch the infant without the parent present
124
nutrition
- brain growth
- weight gain
- skin
125
nutrition: brain growth
- is the baby on breast milk, formula, etc.?
- what is the recipe for their nutrition impacting the quality of their oral feeding?
- often adding extra calories and additives
126
nutrition: weight gain
GERD? milk protein allergy, prolonged PO intake
127
nutrition: skin
wound healing, diaper rashes, things to think about
128
oral feeding development (developmental milestones for feeding, oral motor, oral sensory)
- feeding difficulties are commonly found in premature infants and term infants who are critically sick due to many factors
- the severity of illness can also impact feeding as serious medical conditions can lead to delayed introduction of oral feeding
129
the infant's level of maturation can impact feeding abilities
- neurobehavioral maturation is the precise coordination of autonomic, motoric, nad behavioral state organization
- it requires the development of the nervous system to support the integration and smooth coordination of sucking, swallowing, and breathing required for bottle feeding
130
the infant's enteral tolerance can vary
this refer to the preterm infant's ability to establish and maintain successful oral feeding related to the degree of structural and functional development of the GI system
131
the infant must demonstrate physiological stability
- immature feeding abilities are often displayed as physiologic and motoric signs of distress, such as bradycardia, irregular cardiac rhythms, apnea, nasal flaring, and changes in respiratory patterns such as periodic or labored breathing
- infants with poorer control often display increased signs of distress, such as irritability, inconsolable crying, rapid state changes, sleepiness, color changes, and respiratory pauses with stimulation
132
the infant must demonstrate behavioral state organization for successful feeding
- if the preterm infant is fully alert for feeding, there is greater potential for active participation and less time is needed to complete the feeding
- infants fed in a drowsy state are not as actively involved in sucking and are at greater risk for choking and aspiration
133
hunger cues can also impact feeding
- demand or self-regulatory feeding provides the infant with opportunities to demonstrate hunger cues and alertness behaviors appropriately before the oral feeding
- the rooting reflex is present by 28 to 30 weeks, becoming more vigorous and sustained by 36 weeks
134
SSB coordination is an essential part of infant feeding
- if an infant cannot sustain regular breathing patterns and oxygenation during NNS, most likely they will not be able to manage oral feedings
- in a coordinate cycle of nutritive sucking, the 1:1:1 relational pattern among sucking, swallowing, and breathing creates a rhythmic unit of repetition in which breathing seems uninterrupted
- during less coordinated feeding, breathing is regularly interrupted by swallowing and may be secondary to it
- the preterm infants' immature CNS may cause them exhibit weak movement patterns, disorganized states, and inability to integrate the sucking, swallowing, and breathing coordination necessary for bottle feeding
135
the infant must have control of tone
- oral-motor control is affected significantly by and is dependent on general body muscle tone and control
- if a preterm infant does not have enough physiological flexion for proper feeding positioning, they will be unable to keep limits in a close and flexed position
- the combined effects inadequate physiological flexion and gravity contribute to the more extended posture of premature infants, which, according to neurodevelopmental principles, does not provide an adequate base for feeding
136
responsive feeding
- "during the first year, infants and caregivers learn to recognize and interpret both verbal and nonverbal communication signals from one another. this reciprocal process forms a basis for the emotional bonding or attachment between infants and caregivers that is essential to healthy social-emotional functioning."
- "responsive feeding is an active and also an interactive process: paying attention to the baby while offering food, watching her reaction, learning cues, and responding promptly and supportive to her needs."
137
responsive feeding: bidirectional
- parent notices readiness cues for feeding, offers food, infant response, parent response and adjusts based on infant responses and infant responds again
- establishes attachment and trust for relationship
138
feeding assessment and interventions and the NICU
1. coordinated ability to suck-swallow-breathe is crucial for independent oral feeding
2. immature oral feeding ability hinders the development of preterm infants and increases the morbidity of aspiration, hypoxemia, bradycardia, pneumonia, and even mortality
3. delay in the transition from tube feeding to full oral feeding may slow preterm infants' growth and development, leading to feeding disorders, prolonged hospital stay, low motor-infant interaction, and increased hospital cost
139
first, are they ready to PO?
- rough age guidance: around 34 weeks GA (not a firm date/age but consider the norms for sucking and SSB from a neuroembryological development lens)
- not intubated
- degree of respiratory support is "acceptable"
- show readiness cues
140
first, are they ready to PO?: degree of respiratory support is "acceptable"
O2 via NC ok, but HFNC is debated
141
first, are they ready to PO?: show readiness cues
- stability: think synactive theory
- interest/hunger
- NNS assessment
142
SOFFI method: guide E-1 movement (ready)
- general stirring (movement of extremities and head)
- moving hands onto face or mouth
- moving the face against bed linens or hands
- mouthing or sucking movements
143
SOFFI method: guide E-1 movement (not ready)
- very little or no facial movement
- very little or no movement of extremities or trunk
- shallow, irregular breathing
144
SOFFI method: guide E-2 behavioral state
crying from hunger indicates readiness to feed but increases the difficulty of feeding with necessary self-regulation, raises heart and respiratory rates, and wastes energy (it is nearly always preceded by earlier signs of hunger)
145
SOFFI method: guide E-2 behavioral state (ready)
- light sleep, drowsy, or awake
- mild fussing from hunger that is calmed with holding and preparations to feed
- begin feeding before an infant is crying from hunger
- however, if more subtle feeding cues are missed, calm a crying baby before starting to feed (e.g. withholding, movement/gentle vestibular stimulation, pacifier, etc.)
- stabilize infant as needed (guide C: stabilizing/reinstating stability/calming)
146
SOFFI method: guide E-2 behavioral state (not ready)
- infant is asleep
- avoid vigorously stimulating a sleeping infant to awaken in order to feed
- avoid starting to feed an infant that is sleeping (rather than drowsy)
- avoid waiting until the exactly scheduled feeding time if the infant is clearly hungry before then
- avoid feeding a crying infant
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are they showing readiness + hunger cues?
- quiet alert, drowsy or more alert/aroused starting to fuss (may need to calm first)
- mouth opening
- rooting, turning head
- increased movement
- mouthing hands
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SOFFI method: guide F-1 approaching the infant (ready)
- whether drowsy or awake, approach the infant by first providing an "acoustic distance alerting" of a few moments of quiet speech directed to the baby
- this is followed by the "proximal alerting" of a light hand swaddle or light touch on head and body while speech is continued
- these "alerts" use natural biological functions to ready all systems for an event
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SOFFI method: guide F-1 approaching the infant (not ready)
avoid activity that arouses an infant suddenly (e.g. abrupt touching, handling) or that elicits a startle
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SOFFI method: guide F-2 holding in arms (ready)
- wrap infant securely (not tightly) with extremities flexed in midline, shoulders and back of head supported inside the blanket, and hands near face/mouth as infant's own movement indicates
- hold infant arms
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SOFFI method: guide F-2 holding in arms (not ready)
- avoid omitting this assessment
- the infant is not ready to feed if he remains asleep or becomes unstable or does not take the pacifier voluntarily or if sucking is weak and intermittent
- avoid pushing the pacifier in the infant's mouth or inserting it when mouth is open (as in a yawn) but infant is not showing interest in it
- avoid picking up a sleeping baby and stimulating to an awake state in order to start a feeding
- avoid advising parents to initiate a feeding by these methods
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SOFFI method: guide F-3 offer pacifier and observe (ready)
- offer pacifier by brushing it against lips or cheek (to elicit rooting)
- wait for infant to show interest (turn toward, mouthing movement, opening mouth) or accept the pacifier
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SOFFI method: guide F-3 offer pacifier and observe (not ready)
- avoid forcing pacifier into the infant's mouth
- avoid considering the infant ready to feed even if the pacifier is not accepted voluntarily
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SOFFI method: guide F-4 assess ability and readiness (ready)
the infant is ready to feed if he attains or maintains a drowsy or awake behavioral state and maintains physiologic stability and shows spontaneous interest in the pacifier, and if sucks vigorously in a series of sucking bursts and pauses
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SOFFI method: guide F-4 assess ability and readiness (not ready)
- the infant is not ready to feed if he remains asleep or becomes unstable or does not take the pacifier voluntarily or if sucking is weak and intermittent
- avoid pushing the pacifier in the infant's mouth or inserting it when mouth is open (as in a yawn) but infant is not showing interest in it
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external supports for state regulation: if a baby is not calm, feeding can be difficult, especially in preterm infant
- skin to skin
- swaddling and positioning
- sway and shush
- lights
- bum pats
- be careful with motion, calming to some, overstimulating for others
- hand hugs
- STS
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assess and use as intervention
- pumped breast
- pacifier
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non-nutritive stimulation (NNS)
early sensorimotor interventions may improve oral feeding skills in preterm infants
- we know that often, these infants are missing the opportunity/experience to practice purposeful sucking which is an organized in a burst-pause pattern
- when administered before bottle-feedings, NNS provides behavioral stability throughout the feeding, decreases restless states, and increases quiet alert states
- tube fed and are kept in hospital until they are able to safely meet their nutritional requirements orally, while maintaining adequate daily weight gain without cardiorespiratory compromise
- not all pacifiers and breasts are created equal, thus what does this sensorimotor feeding intervention look like and when do we introduce it?
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NNS: tube fed and are kept in hospital until they are able to safely meet their nutritional requirements orally, while maintaining adequate daily weight gain without cardiorespiratory compromise
our studies suggest that early sensorimotor interventions may improve oral feeding skills and facilitate SSB in preterm infants
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NNS: what are our goals?
- infants' jaw and cheek development
- their behavioral state
- sucking efficiency
- sucking patterns
- transition to oral intake volume intake and/or quality of oral intake
- sensory experiences
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assessment considerations for NNS
- do they root and latch on pacifier?
- can they keep it in their mouth?
- do they calm?
- look for some tongue cupping (NICU and up)
- watch for stability during NNS (vitals, color, etc.)
- if you pull back on it, do you feel the suction?
- can they manage their secretions?
- if unstable, averse or doesn't have strong skills --> may try paci dips --> if not tolerated we stay here (give interventions to promote PO readiness)
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treatment considerations for NNS
- pre-feeding oral stimulation (OS), NNS, improve oral feeding skills and the transition to independent oral feeding
- NNS interventions help support transition to oral feeding and have a positive impact on transition to oral feeding time
- support readiness to PO feed
- helps swallow small amount of saliva
- can help pull against provider tastes but not demand of managing flow
- positive touch/infant massage around the face
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feeding interventions to promote PO readiness: milk drops
- safe/immunity
- oral enjoyment
- intervention starts at 3 days of age
- infants were given normal bedside care except after they had been nested in, and stable given a droplet or 2 of milk
- if the infant licked their lips offered a swab or pacifier
- if the infant accepts either, they are given more - a droplet at a time - based on the infant's cues
- swab or pacifier remained in place as the droplets were given
- volume limited by gestational age (literally just little drops)
- milk drops with cares or gavage feedings as oral attempts were considered the oral enjoyment
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SOFFI
quanlity vs. quantity, motor stability, autonomic stability, behavioral stability
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Support of Oral Feeding for Fragile Infants (SOFFI)
- this feeding intervention is designed to promote the development of component quality PO feeding from the infant
- it is not focused on volume or quantity consumed
- it's a systematic algorithm that provides guidance to clinicians and caregivers about how to promote a good quality feeding - and not to be consumed by quantity of PO feeding
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SOFFI: a good quality feeding is defined by...
a stable, self-regulated infant and a caregiver who sensitivity (responsively) adjusts to the infant's physiology and behavior to realize a feeding experience in which the infant remains comfortable and competent while using feeding abilities achieved to that point
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SOFFI: synactive theory is the framework
- posits that infants are biologically striving, throughout development, toward the self-regulation of increasingly complex abilities
- caregivers can support this emerging competence by attentively and knowledgeably responding to each, individual infant's autonomic neurophysiology, behavioral state, and motor (or movement) behavior so that the infant remains functionally organized and self-regulated
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positioning and feeding
- consider elevated side-lying position
- easier anterior-posterior rib cage movement
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consider elevated side-lying position
- similar to football or cross-cradle position at breast
- infants are in physiological flexion (fetal position)
- most comfortable and neutral position for their body
- muscles are totally relaxed
- easier to maintain head and trunk alignment
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easier anterior-posterior rib cage movement
- increases lung compliance
- decreases airway resistance/work of breathing
- horizontal milk flow
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pacing intervention
- compensatory technique that can be used across all feeding (e.g. breast, bottle)
- babies had to suck and swallow sometimes to breath (when you notice apnea)
- can tilt bottle down (point nipple up to palate and break seal with lips but leave in the mouth
- can move bottle laterally
- can remove fully (last resort)
- pace to cue them to breath, allow catch up breathing, then resume
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feeding intervention
flow rate
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flow rate: modify it
- not all flow rates the same...can't rely on packaging
- good for safety (aspiration or when having difficulty coordinating SSB)
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flow rate: components
- autonomy: feeding readiness
- competence: quality, efficiency, safety
- relatedness: reading the feeding, what is your infant's communication telling you about the flow rate
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IDF: Britt Pado has done all of the heavy lifting for us on this topic
- she is a nurse researcher who has spent the past few years studying flow rate of common commercial nipples and how it impacts the quality and safety of oral feeding
- current research suggests that the physiologic stress, behavioral distress, and fatigue related to feeding in infants with practiced in the infant critical cause units and community providers - where faster flow rate was considered better - why, they saw the infant was too tired when bottle feeding thus assumed they would need a faster nipple to help them finish
- that is volume drive practice, which is what we have learned from Dr. Pados research
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IDF: by utilizing a responsive feeding approach, we are able to identify the following
- stop feeding when infant's communication demonstrates that flow is too fast (what does this look like, feeding refusal, pulling away, pushing nipple out, turning head)
- safety: is the infant's swallowing frequency able to accommodate the flow of the nipple, if the infant can not clear the milk from the oropharynx, then infant is at increased risk for airway compromise (i.e. aspiration)
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IDF safety: is the infant's swallowing frequency able to accommodate the flow of the nipple, if the infant can not clear the milk from the oropharynx, then infant is at increased risk for airway compromise (i.e. aspiration)
we know infant's do not present with the same signs/symptoms of aspiration as adults, thus we need to be able to respond/identify how the infant is presenting
- pooling milk in buccal space
- significant anterior spillage in an attempt to divert milk from airway
- gulping
- sequential repetitive swallows
- tachypnea
- desatuation
- bradycardia
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IDF: collapsing nipples were another clinically relevant incidental finding in early testing
- a collapses nipple is often interpreted as the nipple being of too slow a flow for the infant's suck strength
- what is actually happening when a nipple collapses is that the mechanism for releasing suction pressure within the bottle has been disrupted and is not tightened onto the bottle too tightly, disrupting the mechanism that allows suction pressure within the bottle to release
- to keep this from happening, the collar should be tightened just a little more than is necessary to keep from leaking
- if a nipple collapses during feeding, the nipple and collar should be removed from the bottle to allow pressure to equilibrate
- the nipple and collar can then be screwed back on, with care taken not to overtighten
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consider bolus temperature
- pilot studies have shown that cold bolus have improved airway protection for infants (preterm) with dysphagia when compared to room temperature liquids
- considerations of temperature of liquid as a variable to manipulate to improve airway protection may be a useful consideration (look at via imaging, thin of sensory properties of cold liquids)
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when to thicken?
not until after 40 weeks (after term)
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thicken with caution
when putting thickener into formula, parts of the GI tract die
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thickening: here is why
- try not to thicken under 1 year old
- when using breastmilk, can only use gel-based thickeners to thicken it
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parents/caregivers read infant's cues and respond
- parent and caregivers understand when and how to offer
- differences between being "fed" and being "supported to feed" through infant-guided
- co-regulation
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parent and caregivers understand when and how to offer
- state regulation, physiologic stability, behavioral cues
- hunger, satiety cues
- modifications as appropriate
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cue-based feeding, aka IDF
this model identifies that infant matures at a different rate, previous research suggests that the ability to coordinate the necessary reflexes, suck, swallow, and breathe commences at 33 weeks gestation
- therefore, this feeding method initiates an assessment of feeding readiness beginning at 33 weeks gestation and continues the assessment prior to each feeding experience
- once the infant begins to orally feed, the clinician assesses the infant utilizing the quality of feeding assessment and the type of caregiver supports needed for a safe feeding experience
- the psychometric testing of the IDF method is limited to 1 validation study utilizing the Delphi method
- however, there is evidence that supports the readiness behaviors, quality of feeding, and caregiver supports
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IDF similar to SOFFI less "decision making trees": in regards to breastfeeding
- successful breastfeeding is baby-led, following the infants' cues of hunger and satiety to promote milk supply
- breastfeeding provides increased skin-to-skin contact for the mother-infant dyad
- skin-to-skin contact increases in maternal responsivity and bonding
- being responsive may include infant led attachment
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family-centered care
- build strong therapeutic relationship
- recognize parent as the expert
- bring all caregiver into the process
- support parent's ability to reflect
- referral to mental health support
- ideally part of initial assessment
- requires parent education regarding reason for referral
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considering the level of respiratory support in the NICU and impacts on feeding
- respiratory rate
- 1 SSB sequences takes 1 second
- if RR is 60 or greater --> tachypnea
- how can the time SSB appropriately?
- HFNC typically associated with taxed respiratory system, need for more support
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consider IDF principles and SOFFI
- can they tolerate aspiration and negative consequence?
- look at RR
- some conflicting research, some see no risk to feed using strict criteria with higher levels of respiratory support (not just nasal cannula) some found significant risk
